Pregnancy loss affects many couples every year. This is the first national study to establish that parental relationships have a higher risk of dissolving after a miscarriage or stillbirth, compared with a live birth. Although most of the effect after miscarriages was seen in the first 2 or 3 years, the effect after stillbirths persisted for nearly a decade. Although the size and duration of the effect were substantially greater for stillbirths than for miscarriages, miscarriages are quite common, and an increased hazard of 1.22 after miscarriage has important societal implications if the findings are causally related.
Although a causal mechanism cannot be assumed solely on the basis of the temporal relationship found in this observational study, there are plausible mechanisms by which miscarriage could increase relationship dissolution. The risk of relationship dissolution was appreciable in all socio-demographic groups, with >40% of relationships among women with live births dissolving within 10 years. However, fetal loss may be a significant source of additional stress in a relationship and, although the majority of couples are able to adjust to a loss and may even grow closer, there may be a subgroup whose relationships are particularly vulnerable to this major stress. Couples with an unstable relationship before the pregnancy and those with other risk factors for breaking up may find themselves unable to sustain their relationship after a miscarriage or stillbirth. It also is possible that having a live birth is protective, rather than miscarriage increasing dissolution rates.
Most of the existing research on parental risk of separation involves parents who have endured the loss of a child between birth and adulthood. However, the estimated risk of parental separation after the loss of a child has been quite controversial. Early studies reported a dramatically high risk, but others noted that those reports suffered from significant methodologic limitations, including lack of control groups, short follow-up periods, substantial study selection biases, and very small sample sizes.5
Unfortunately, many newer studies have the same limitations; therefore, it has been difficult to ascertain true risk.6
However, a recent, large, well-designed evaluation of parents surveyed nearly 20 years after their child’s death reported that bereaved parents had a 30% rate of marital disruption, compared with 24% for 428 nonbereaved control subjects, which represents a significant difference between the groups.7
In the area of pregnancy loss, researchers demonstrated substantial marital strain resulting from the loss, but the size or design of most of those studies did not allow evaluation of relationship outcomes. One large study of parents interviewed 6 to 8 months after perinatal or infant loss found that 4% of bereaved parents (N
= 428) had already experienced dissolution of their marriage or cohabitation, compared with 1% of nonbereaved control subjects (N
A survey of mothers 2 years after unexpected pregnancy loss found no difference in marital satisfaction but a higher divorce/separation rate (5.8% for parents with loss, compared with 3.7% for non-bereaved control subjects).9
However, researchers for that survey concluded that loss was not a risk factor for breaking up, presumably because of small overall numbers and the potential for response bias. A recent UK study identified pregnant women either with no children or with previous pregnancy losses after 18 weeks of gestation. At follow-up times of 6 to 8 years, 37% of women (19 of 52 women) with previous losses reported breakdown of a partnership, compared with just 12% of control mothers (6 of 51 women).10
Although our findings are based on a retrospective design and have potential recall bias, the study design does benefit from a large sample size, long follow-up periods, capture of longitudinal changes rather than cross-sectional analysis, use of a control group, and a lack of systematic selection bias.
These findings also present new information about risks to cohabitating couples. More than one-third of US births are to unmarried women, and it is estimated that one-half of unmarried parents are living together at the time of the birth; therefore, these findings apply to a significant proportion of US parents.11,12
Data have shown that cohabitating couples are at higher risk of separation in general and, in our study, cohabitating parents accounted for more than one-half of the relationship separations after fetal loss. However, it is important to note that the relative increases in relationship dissolution rates after loss were very similar for married and cohabitating couples; the absolute effect was greater for cohabitating couples because of their higher baseline risk. National data trends show younger women and black women in the general population to be at higher risk for relationship instability, and our study suggests that these risks persist in the subgroup of women with pregnancy losses.1
More study on the psychosocial impact of pregnancy losses in different populations might clarify some of these findings.
Women with stillbirths had a particularly high risk of relationship dissolution, and this risk persisted for up to 9 or 10 years, in contrast to miscarriages, for which the entire effect occurred over a 1.5- to 3-year period. Although it is well recognized that parents form attachments very early after conception, later losses allow for an even longer period for attachment and therefore may cause more psychological trauma and a longer duration of psychological stress.2
Unlike with most miscarriages, both mothers and fathers of stillborn children often have experienced the infant kicking and have heard fetal heart sounds, which potentially makes the infant and the anticipated birth more tangible to both parents. In addition, there are clear gender differences in how individuals cope with death, and these can be significant for couples facing a major loss; parents with significantly different grieving patterns may be at particularly high risk for subsequent marital conflict or emotional withdrawal.13–19
The finding that a previous live birth was associated with greater hazard for relationship dissolution was somewhat surprising, because previous research measuring the effect of children on relationship stability suggested that, in general, the presence of younger children improves or is neutral in the stability of marriages and cohabitations, whereas older children may represent a risk for separation.20–22
However, some studies found premarital births to be significantly disruptive to relationship stability and, in our analysis, one-fourth of women entering a marriage and one-half of women entering a cohabitation already had children, which suggests high levels of premarital births or possibly births with different partners.21
In addition, studies on longitudinal relationship stability typically relied on existing data that were retrospective, were limited to younger women, or focused on relationships that started in the 1970s or 1980s.20–22
It is likely that attitudes about marriage and cohabitation, as well as the impact of children on those relationships, have changed significantly in the preceding 2 decades.
Although these data are subject to recall bias by the mother, relying on self-reported marital status, relationship outcomes, and birth information, we have no reason to suspect systematic bias among the 3 birth-outcome groups evaluated. Although we noted a strong temporal association of greater relationship dissolution after fetal loss, the study design cannot prove that one event was the cause of the other. Although the NSFG did not identify whether subsequent marriages and cohabitations were reunions with a previous spouse or cohabitation partner, we suspect this did not occur with enough frequency to affect the results significantly. In addition, there are a number of variables that were not measured in these data that are associated with the ending of relationships. For example, lower quality of the relationship before the loss, lower parental age, and greater grief and mental distress have all been associated with reduced relationship satisfaction.9,23,24
One interesting hypothesis to consider is whether there might be characteristics that not only put a couple at risk for separation but also place their pregnancy at risk for miscarriage or stillbirth. For example, mental illness, such as depression and anxiety, has been associated with pregnancy loss and can be stressful for a relationship.25
Although we controlled for such factors in the analysis as best we could, it is plausible that, in addition to mental illness, substance abuse, domestic violence, or chronic medical diseases might pose a danger for both the couple’s relationship and the pregnancy outcome. Such influences warrant further exploration in subsequent research.
Understanding how a fetal loss affects the stability of the parental relationship has important implications for counseling and supporting couples after pregnancy loss. Although many parents find that a loss brings them closer together, the event also may create significant relationship stress. This study finds that married and cohabitating parents are at significantly greater hazard for separation after miscarriage, and this risk is even higher after stillbirth. Providers who care for bereaved families should recognize that, for some families, the stability of parental relationships may be at increased risk after loss, and they should consider whether selected parents would benefit from relationship support or counseling. Additional research is warranted to identify the specific risks and protective factors that influence relationship survival and to evaluate whether specific bereavement interventions can improve long-term marriage and cohabitation outcomes after miscarriages and stillbirths.
WHAT’S KNOWN ON THIS SUBJECT
When a child dies, parents are at slightly higher risk of divorce. Relationship outcomes for married and cohabitating parents who experience a miscarriage or stillbirth are largely unknown.
WHAT THIS STUDY ADDS
This is the first national study to establish that parental relationships have a higher risk of dissolving after miscarriage or stillbirth, compared with live birth. Given the frequency of pregnancy loss, these findings might have significant societal implications.