Abstract
Stillbirth is a traumatic prenatal loss with personal, familial, and social implications. We explored the meaning of stillbirth for ultraorthodox Israeli women for whom grieving for prenatal loss derived from the power of faith. We conducted semistructured interviews with ten ultraorthodox women, ages 26 to 55, in a qualitative study that was focused on thematic content analysis and influenced by the phenomenological-hermeneutic tradition. The loss of the fetus was experienced as a test to the women’s belief in God, and was perceived as a way to experience God’s love. The women’s faith became stronger and provided relief, calm, and confidence in God as benefactor. The meanings they attributed to their losses enabled them to move on. Findings are discussed in the context of research and theoretical literature on coping, bereavement, and mourning processes, and meaning for pregnancy-related losses. Awareness of ethnic meanings of stillbirth promotes implementation of culture-sensitive psychosocial interventions.
Childbirth significantly influences the lives of women socially, emotionally, physiologically, and politically (Smith Armstrong, 2002). It involves cognitive, emotional, and behavioral changes through which the self converges with the self–public relationship, the public image, the ideal self, and the spouse (Stumpf, 1994). Thus, stillbirth interrupts the flow of the woman’s everyday life, especially if it occurs at the end of a prolonged period of establishing an attachment. It results in many losses: the anticipated role as a parent, hopes and dreams for the future, self-esteem, and the ability to create a new life (Brown, 1992).
In addition to intra and inter losses, stillbirth has social aspects; Scheper-Hughes (1985) argued that culture determines the meaning of mother love and child death. In Israel, where this study took place, childbirth is particularly important, mainly within the observant religious Jewish community, because the first commandment mentioned in the Bible (Genesis 1:28) is to “be fruitful and multiply.” However, Jewish law does not recognize the dead fetus as an object of mourning rituals. Jewish culture provides its adherents with a well-defined and highly sophisticated procedure for mourning that is considered obligatory by religious Jews and is also widely practiced by less-observant and nonobservant Jews. Thus, mothers and fathers who experience stillbirth are in a confused state in which their own individual sorrow is not mediated through ritualized customs of mourning because there are no formal (e.g., religious or medical) practices for working through the grief of stillbirth (Neuman, Nadav, & Bessor, 2006).
Why is there no obligation to mourn for a fetus in Judaism? Why is the fetus apparently valued less than other immediate family members, for whom mourning is obligatory? According to Rosenheim (2003), the answer is related to public involvement in the death of an infant. Involvement is determined by the baby’s degree of “fame”: “Was he recognized by many—were many involved with him, or was he not recognized by many—not many were involved with him” (Moed Katan 24:72, as cited in Rosenheim, p. 179). That is, if people recognized him outside of his home, he left a void and evoked social responses. If he was not known, there was no psychological involvement and the public was not expected to be involved in the funeral. Stav (2010) added that mourning in Judaism is not an expression of the mourners’ sadness, but rather an expression of the void that was created in the world. Thus, the laws regarding mourning apply only to a “sustainable” person who is gone and not an embryo that was created in an unsustainable form. For the parents, the child’s absence is felt, regardless of his purpose and role in the world; however, from the perspective of faith, because the soul was not intended to be part of this world, it is not lacking, and the laws of mourning do not apply.
The professional literature dealing with stillbirth includes few studies that relate to coping processes that are unique to women who experience stillbirth. Because stillbirth has been identified as a high-risk indicator for psychiatric morbidity, including posttraumatic stress disorder (PTSD; e.g., Bennet, Litz, Sarnoff, & Maguen, 2005; Radestad, Steineck, Nordian, & Sjogren, 1996), and because its impact is long-lasting (Boyle, Vance, Najman, & Thearle, 1996; DeFrain, Martens, Stork, & Stork, 1990), it is important to recognize these coping processes.
In a study conducted among 20 Taiwanese mothers who had stillbirth experiences (Hsu, Tseng, & Kuo, 2002), four major themes regarding coping processes were identified: transforming the meaning of death, doing something for the deceased, anticipating another pregnancy, and rebuilding a social fabric. These findings join those of other studies of pregnancy losses in general, which have revealed coping strategies such as rearranging daily living activities (e.g., Harrigan, Naber, Jensen, Tse, & Perez 1993), expressing emotions (e.g., Franche & Bulow, 1999), attending church/seeking spiritual consolation (e.g., Thearle, Vance, Najman, Embelton, & Foster, 1995), and seeing the baby and gathering symbols that represent the baby (e.g., Rajan, 1992). Grubb-Phillips (1988) also described mothers who wished for “replacement of the infant” as a form of restitution.
Based on the assumption that loss is personally defined and uniquely attributed in every culture (Pilkington 1992), examination of the experiences of bereaved mothers in the context of their own culture might be a step toward providing better care. We explored the meaning of stillbirth among ultraorthodox Jewish women who felt obligated to fulfill the Jewish commandments relating to reproduction and family values, and attempted to gain a deeper understanding of how this meaning served as a coping strategy. It is important to note that the investigation of this subject within the ultraorthodox sector was extremely complex. Most ultraorthodox Jews prefer not to participate in research in general, particularly when the subject relates to intimate issues. Thus, with our study findings we seek to advance our professional understanding of this problem from a culture-sensitive perspective.
Method
This qualitative study was based on the phenomenological-hermeneutic concept of the human world that is composed of multiple subjective realities (Shkedi, 2005; van Manen, 1997). Hermeneutic phenomenology seeks to go beyond description to discover meanings that are not immediately apparent (Merleau-Ponty, 1996). The goal is to “reveal a totality of meaning in all its relations” (Gadamer, 1997, p. 471) through a process of interpretation that involves making manifest that which is hidden by going “beyond what is directly given” (Spiegelberg, 1982, p. 712), reading between the lines (Odman, 1988) and paying attention to what has been omitted, to the silences and the assumptions, to that which has been so taken for granted that it has not been questioned. As such, the aim of the researcher is to describe and interpret the meaning of the human phenomenon from personal consciousness without trying to refute hypotheses (McLeod, 2001; van Manen, 1997). In this study we aimed to describe and analyze the meaning ascribed to coping with stillbirth among ultraorthodox Jewish women.
Sample
The sample in a qualitative study is based on a small purposive sample of those experiencing the phenomenon studied, with the goal of fully understanding the processes (Patton, 2002). Inclusion criteria for this study were: having experienced stillbirth for the first time, age above 20 years, belonging to an ultraorthodox Jewish community, and having no psychiatric history. Potential participants were located using the clinic lists from the gynecology department of an Israeli hospital in the center of Israel that combined modern, advanced medical technology with preservation of the special character of Jewish ritual laws. Forty women met these inclusion criteria but only 10 agreed to be interviewed; 20 refused to take part in the study; another 10 had doubts regarding participation and ultimately refused. The main reasons for refusal were either their religious leaders’ instructions to distance themselves from everything related to the secular world, including research, or their desire to put the stillbirth event behind them.
Ages of participants ranged from 26 to 55 years (mean age 36.1). All of the women had experienced the loss 7 months to 13 years prior to the interview. They all had children and were all employed. Participants lived in various ultraorthodox communities in Israel that were representative of most ultraorthodox denominations.
Procedure
After receiving approval from the ethics committee of the hospital, second author Hadas Hartman, the social worker of the gynecology department, contacted the women who met the inclusion criteria. Each of the participants signed an informed consent form after reading abstracts of the study proposal. We offered to update participants with the study findings. To insure confidentiality and anonymity, we omitted private data that could identify participants from the research records; we kept raw and processed data locked and protected, and shared data only with the study team.
The interviews took place in the homes of the participants at predetermined times. They lasted 1.5 hours and were recorded and transcribed verbatim. Each interview included a brief sociodemographic questionnaire and open-ended questions that were based on a semistructured interview guide. The content fields included: (a) the stillbirth event (e.g., What were your reactions, emotions, thoughts when you were informed of the death of the fetus?); (b) the influence of the event on daily life (e.g., What does it mean to be a woman who experienced stillbirth?); (c) coping strategies (e.g., How do you cope with this situation? Have your coping ways changed across time?); and (d) interactions with husband, nuclear family, and community (e.g., What were the reactions of your husband, relatives, and neighbors toward you? Have they changed across time?). These fields were chosen by first author Yaira Hamama-Raz and Hartman, who are social workers and have clinical experience working with stillbirth events. In this article we focus on the stillbirth event—on the meaning of it and coping with it when the event occurred, and across time.
Data Analysis
We focused on thematic content analysis, influenced by the phenomenological-hermeneutic tradition, in three main stages. In the first stage we read the interviews several times until we felt immersed in and empathic toward the women’s experiences and complexities of coping with the loss of a fetus (Moustakas, 1994). In the second stage we focused on identifying and gathering the meaning units that were relevant to the research topic from each of the interview texts (Roulston, 2010; van Manen, 1997). The meaning units selected were recurring statements or statements that reflected the participants’ interpretations of their experiences; for example, the women described experiences that reflected their belief in the presence of God (McLeod, 2001). In the third stage, we examined the connection between meaning units that arose in the second stage in each separate interview. We focused mainly on seeking resemblances, connections, and differences and variations between the meaning units. We identified central themes that emerged from all of the interviews that characterized the phenomenon under study and represented its meaning (Smith, Flowers, & Larkin, 2009; Thorne, 2008). We connected and divided the experiences of the presence of God to a combination of two dominant themes: “test” and “love.”
According to Lincoln & Guba (1985), four issues of trustworthiness are required in qualitative studies: credibility, transferability, dependability, and confirmability. Credibility is an evaluation of whether or not the research findings represent a “credible” conceptual interpretation drawn from the original participant data (Lincoln & Guba). Transferability is the degree to which the findings of an inquiry can apply or transfer beyond the bounds of the study. Dependability is an assessment of the quality of the integrated processes of data collection, data analysis, and theory generation. Confirmability is a measure of how well the inquiry’s findings are supported by the data collected (Lincoln & Guba). In the current study, trustworthiness was enhanced through the following strategies.
To address credibility, we emphasized prolonged engagement of ongoing interviews and invested in rereading the interviews. In addition, to achieve credibility, we used triangulation; i.e., discussion of the findings with ultraorthodox people to avoid researcher bias. To address the issues of dependability and confirmability, each author performed thematic content analysis separately, both by theme content and interpretation of meaning. Subsequently, we compared our individual analyses, discussed disagreements, and looked for conformity regarding theme content, interpretation of meaning, and trustworthiness of the study. We rejected themes that we concluded made only minor contributions to understanding the examined phenomenon. Implementing systematic data analysis, grounded in participants’ narratives, increased the study’s dependability (Lincoln & Guba, 1985).
Results
Analysis of the interviews revealed two central themes which indicated that the ultraorthodox women’s coping with the loss of a fetus emanated from their faith in God. Knowing that the death of the fetus was not in vain, and that the event was a test of faith with personal significance, gave the loss meaning and significance that facilitated growth and eased the traumatic pain. In addition, the women’s belief that God is beneficent gave them a feeling that they were not alone with their loss, and provided a sense of acceptance. Owing to their faith in God’s guidance, they were relieved of agonizing questions and guilt feelings that might have accompanied the loss of the fetus.
The Test of Faith: A Force That Strengthened Coping
The meaning of the women’s coping with the death of the fetus stemmed from the notion of seeing the death as a test of personal faith. The women considered themselves to be individuals who were facing a test of faith. This meaning enabled them to garner strength and “sanctify the name of the Lord”; that is, to respond and attribute positive meaning to coping because they believed that it was God’s will. This view allowed the women to feel that they received answers to the questions of why the loss occurred and what the meaning of the loss was: I immediately knew that it was a test from God. There was nothing I could do. I had made plans, then I had to resign myself to God’s will. Things did not always go as I would have liked. Was it right to say thank you only when things went my way and to be sad when they went according to God’s plan? I remember that I didn’t scream when they told me that the fetus was dead. I quietly whispered the blessing recited when hearing that a person has died: “Blessed is the Judge of Truth.” The nurse then brought me a cup of water and I recited the blessing over water.
The women described the reciprocal relationship between the pain of the loss of the baby and the search for the meaning of the death. In their perceptions, the death expressed God’s will and was therefore accepted with understanding. The first participant quoted described her coping as a step toward understanding and preparation for life situations that reveal discrepancies between one’s desires and actual outcomes. In this situation she was required to exercise her inner strengths to realize the ideologies that she had studied and aimed to achieve.
Other participants mentioned that the loss of the fetus gave them the opportunity to reflect their faith through understanding that the loss was “from Heaven,” and according to God’s will. Accepting the loss and facing the obligations that were required of them at that time was in accordance with their faith. The first woman expressed her acceptance with her willingness to put boundaries on the sadness that was taking over her life, and the second, while still at the clinic where she was informed of the death of the fetus, turned to God with a blessing that justified the “sentence” and strengthened her acceptance of God’s decision as the absolute truth. The connection between accepting the test and coping is evident in the following comments: I caught myself and said, “Wait a minute. This was a test from God.” God gave me strength, and there were worse things. I suddenly realized that we had an opportunity to sanctify God’s name, and I turned to God and said, “Help me sanctify your name and get through this test with strength.” I then told my mother that that this was from the Blessed Lord, and that there was a reason for the stillbirth. Once I realized that, I felt much better, and much stronger.
Framing the situation as a test of faith enabled this woman to face behavioral and emotional criteria according to God’s expectations. The insight that the death of the embryo was a test of faith enabled her to extricate herself from her personal pain and to demand that her parents and children see the loss as a feeling of spiritual ascension and an act of “heroism.” This transformation allowed her to feel that she stood the test of faith and could feel “peaceful.” Standing the test of faith allowed the women to experience meanings that enabled them to see themselves as working toward “sanctifying God’s name”: It was certainly a tikun [reform]. Individuals tend to seek explanations for such events. In my reflections I could not pinpoint anything I might have done that would cause the stillbirth! But with God’s help, I was trying to improve myself, to strengthen my relationship with God.
This insight gave the participant strength, especially because she did not find a spiritual reason for the death of the baby. This situation, despite the apparent lack of meaning, caused the participant to examine her deeds and thoughts and see the death as an impetus for her to strengthen her faith. The meaning that the death of the embryo was a test of faith helped her avoid emotional turmoil and preserved her belief that the reason for her existence was to achieve God’s expectations.
Some of the participants described questions that arose concerning God’s role in the death of the fetus. These questions were in the framework of their faith: I immediately knew that it was a test from God. But I did not believe that He would do that to me. I said, “God, I don’t believe that you would do that to me.” God never did anything so bombastic to me. On the one hand it strengthened me. It was not an easy test, but I had the strength to overcome it. In terms of the test of faith and the question of how something so awful happened to me—the evil inclination played a role. It was senseless to fool around with God. I had to naively accept it.
The dialogue with God resulted from the intensity of the surprise. The questions revealed a degree of defiance concerning the intensity and intent of the test. The meaning was constructed from the knowledge that it was a test with complete faith that the questions were part of the test and that confrontation enabled coping. The meaning of the pain was also in relation to faith: We cried for three days. That’s it. We accepted that it was from God and accepted that it was what God wanted, and with the help of God we hoped that that would be the last of our troubles. We then stopped our incessant crying.
This participant described the emotional pain. She and her husband stopped crying by determining that the death was caused by a force majeure. The personal meaning was their acceptance and making peace with the pain and the lack of understanding. The participant described that this was how they could put boundaries on their tears, cope with the loss, and continue living. This enabled them to face the death of the fetus in a more emotionally protective manner. Another strengthening belief was that God tests only those with the ability to cope: The moment that I made peace with the fact that I believed that God put me to the test, He knew that I could withstand it. What really happened was that I could not cope with anything else.…I cried. And I continued. I tried not to sink into self-pity or “What if?” My faith kept me together; knowing that it was God’s will helped me cope.
Two levels are apparent in this quote: a sense of concern about sinking in weakening emotions and faith that was the secure basis for coping and finding answers to questions and doubts. The participant considered the test to be God’s kindness in choosing a test appropriate to her strengths—and her capacity to bear it. This faith enabled her to cope with tormenting questions.
Faith in a Benevolent Force Strengthens Coping
The women’s faith in the omnipresence of the Lord in their lives was a significant component of their coping with the loss of the fetus. The women felt and believed that God was beneficent and was present throughout the process: in the delivery room, during contractions, and with the loss. This faith gave them a sense of comforting security that they were not alone and that God loved them, and was therefore with them. In fact, their faith in God’s love eliminated the option that God would want to harm them. This perception that emphasized God’s control over the women’s lives contributed to their coping with the loss; the women experienced relief from their misgivings and guilt feelings concerning the death of the embryo. Moreover, the women described a greater sense of closeness to the benevolent God. This feeling contributed additional meaning to the loss of the fetus: spiritual elevation.
As stated, in the interviews the women expressed their beliefs that God was with them during the process of delivering the dead fetus. The experience of that presence enabled relief from the sense of loneliness that could result following the loss: When they told me that he was not alive, I immediately felt that God was with me. I remember that during the delivery—I knew that the Divine Spirit was with me. It helped me very, very much. This birth was with God. I felt Him there. I hardly had strong contractions. The monitor did not show contractions. They didn’t think that I was progressing toward the birth. I sat up after the delivery, something I never did at any previous delivery.…I returned to myself so fast that I felt that God was there. It felt as though someone was holding me and I was not alone. I felt that I could ask anything and receive an answer, even if it was not exactly what I wanted to hear. The feeling that I could ask was enough.
The participants tangibly sensed God’s presence during the birth. The first participant noted that she experienced a feeling that the “Divine Spirit” was with her throughout the delivery of the dead fetus. This feeling created a sacred experience. The second participant brought together several different events that occurred during the birth, as proof of God’s beneficent omnipresence: few contractions and the absence of physical suffering familiar to her from previous deliveries. The third woman described a sense of being held, of closeness and containment. In addition, the knowledge that God was close and that she could turn to Him in her pain gave her a sense of comfort.
It seems that the women experienced the God figure as real, and therefore the sense of loneliness that characterizes situations of loss in general and childbearing loss in particular was not experienced. Instead, a sense of calmness and security prevailed. Faith in the omnipresent beneficent God enabled the participants to form comforting interpretations of the loss: God loved them. He guided the course of their life so that everything was for the best. This perception enabled the participants to cope with the loss with a sense of meaning: God loves me and everything that God did was for the best, and if we would know that and really see and feel it, then we would also be dancing and happy. We would make a feast…but the eyes of our corporeal and simple minds do not see far ahead, and it seemed like a great tragedy. God in heaven pondered, “When will they be able to see that it is not a tragedy? When will they understand what a favor I did for them?” The knowledge that there was someone who loved us more than we loved ourselves and wanted what was best for us gave us the strength to withstand the tests. It was like a cold, soothing compress. Praying and strengthening faith was the solution.
These participants described the dissonance between their instinctive feelings that the death of the fetus was a tragedy and what they experienced as the objective divine truth: that the death of the embryo was solely for their benefit. They both solved their questions of faith by bending their feelings to their faith: God knew what was right and good for them even before they understood it. The first participant referred to the fact that she, too, would one day be worthy of seeing and understanding what God already knows: why the death of the fetus was good for her. The second woman described how the perception that God put her to the test while guiding her life out of love and the desire for her welfare seemed to give her a feeling that there was order in the world. In addition, the participant claimed that God gave her strength to cope.
The contribution of faith in God’s guidance for coping with the loss of the fetus was also expressed in the participants’ descriptions of how they experienced relief from agonizing questions and guilt feelings about the death of the fetus: Why did it happen to me? I had four children. Did I ask why? I said, “Thank God. The Lord gave and the Lord has taken.” We are in God’s hands. He decides who will live and who will die. I am comfortable being guided, for better or worse. Hopefully there will always be only good, but I am certain that He always knows what is best for me. Faith enabled me to understand that these things were not under my control. Why did I have pangs of conscience? I did not do anything wrong. If you are not guilty, why can’t you calm down?
The first participant talked about her sense of liberation that resulted from unconditional acceptance of God’s will and decisions. The belief that life is subject to God’s navigation and procedures, together with the choice to be led by God in difficult events as well as in positive experiences, allowed her to cope with the loss with a sense of security and peace. The second participant added the absence of guilt feelings that was related to lack of control over her life and enabled coping without taking responsibility for the death of the fetus.
Another dimension of coping with the loss resulted from participants’ sense of personal growth out of the pain. This growth was based on faith in a loving God who accompanied them throughout the experience and wanted what was best. From this perception, the participants felt that the birth of the dead fetus brought them a special closeness to God that they could not have reached without the painful experience. The positive spiritual significance of the proximity of the mother to a “higher level” with God enabled containment of the loss: I felt that God said to me, “If you want, I will raise you even higher. If you make the effort, then God will help you.” I remember that in those days I felt close to God—faith, praying, and a feeling of peace. I felt that it was something that I had to undergo and that it connected me to God. It made me stronger. I remember myself praying to God and asking Him to strengthen me and take care of me because I could not face the situation alone. I felt as though we were closely acquainted, we were in continuous contact. It really kept me together.
The first participant described a relationship of give and take between herself and God. She felt that she gave God her absolute faith and in return she experienced a level of closeness to Him and unique peace. The second participant described the closeness as resulting from the significance of prayer and turning to God. She blessed the dependence on God; then she could turn to Him again. She felt as though she was in a close relationship with Him.
The concept that faith is security and that the pain did not contradict making peace and accepting God’s will was powerfully expressed in the words of the one participant, who described a confrontation with the doctor who told her that the fetus was dead: The doctor said, “Let’s go into my room.” I went into her office and she said, “It’s final. He is not alive! Good, now we have to give birth.” And I was silent. Good, give me a minute to call my husband. I called him and burst out crying.…I cried and cried. The doctor said, “It is legitimate, you are allowed to cry.” I replied, “It does not mean that I now have complaints or grievances with God. Really not. I am sure that I am allowed to cry.…I am certain that God decided what was best for me, so that is what is best for me, because he loves me most of all. He knows what is good for me.” And the doctor, who was not religious, said, “How can you say God loves you in the midst of this crisis, right after hearing of this terrible tragedy?” I told her that from age zero we know that God always does what is best for us. I was not always worthy of recognizing God’s will; God hides his face. He said. “My dear, I am doing it for you.” I know that there is a Creator of the world who knows what is best, so I totally trust Him, believe in Him, and cling to Him. I told the doctor again that it hurt, but even when it hurt, I was certain that it was best for me, and that is what kept me going. When we finished talking, the doctor said, “Listen, instead of me comforting you, you have strengthened me!”
In these comments, the participant tried to reflect the enormity of the gap and the intensity of her faith that she tried to transmit to those outside of her religious community. The doctor, who represented the secular model of emotional expression of loss that included crying, depression, anger, and doubt concerning the meaning and logic of the loss of a fetus, tried to give the participant permission to express her feelings. This permission was perceived as a threat to her beliefs. Thus, we can understand the intensity of the participant’s attempt to prevent the doctor from interpreting her tears as an expression of weakness of faith or grievances toward God, and to clarify that her crying accompanied strength and religious beliefs. The participant continued to be strong and to cope with her belief in “loving,” beneficial, personal supervision that was exhibited through the death of the fetus. Response to God’s love was in making peace and justification of the events, which confirmed the basis of her religion.
Discussion
We attempted to understand and describe the meaning of stillbirth for ultraorthodox Jewish women. Our understanding is rooted in a dialectical perspective that relates to opposites when two or more forces or themes exist by depending on each other for their definition and existence, but also negate and oppose each other. Such opposites should be viewed from a dualistic perspective. Such opposites might never be fully reconciled, but rather might continue to produce tension and change (Baxter, 2004; Enosh & Ben Ari, 2010). There was a perception of the loss as a test of the participants’ beliefs. This might be perceived as an act of absurd, negative feelings, or even aggression by God. In contrast, there is God love. Therefore, despite their losses, ultraorthodox Jewish women’s faith became stronger and provided relief, calm, and confidence in God as benefactor. The participants reconstructed meanings to their losses that enabled them to continue in their life and maintain their religious beliefs. Further, the findings might indicate that among ultraorthodox Jewish women, the expressions of bad or harmful events, in the context of prenatal loss, can be interpreted through their beliefs that differ from those of secular/traditional individuals.
Lazarus & Folkman’s (1984) theory provides a framework for response to stressful situations using problem-focused and emotion-focused coping strategies. Emotion-focused coping tends to predominate when people feel that the stressor is something that must be endured (Lazarus & Folkman). In this context, religion is thought to have an important role in coping with stressful situations (e.g., Ano & Vasconcelles, 2005), especially in coping with all types of bereavement—including the loss of a child (Anderson, Marwith, Vanderberg, & Chibnall, 2005; Becker et al., 2007). The study findings show that the participants’ faith in God became stronger when they realized that the loss of their fetus was a test of their faith that would ultimately grant them better pain relief and fewer guilt feelings, and would hasten the “redemption of the people.”
Moreover, according to Lazarus & Folkman’s theory (1984), an individual’s coping with stress is affected not only by the objective nature of the stress, but also by the subjective meaning he or she assigns to it. More specifically, the authors claimed that persons faced with adversity make two appraisals: primary and secondary. Primary appraisal refers to the degree to which they view the situation as a challenge or a threat. Secondary appraisal refers to their assessment of their ability to handle the situation and to reduce the threat, damage, and loss it might cause. It seems that the women in our study perceived fetal loss as a challenge that helped them overcome their sorrow, and that they interpreted it as an event that empowered their level of religiosity. In this context, Tedeschi & Calhoun (2004) indicated that the possibility of growth is triggered by a highly stressful, seriously challenging event. They mentioned five categories of growth outcomes reflecting psychological, interpersonal, and life-orientation changes. One of those categories was increased spirituality or religiosity, which was also found among bereaved spouses and parents (Lehman et al., 1993).
In addition, the findings show that the participants did not direct any anger at the loss of the fetus toward God; they considered such negative feelings as threats to their faith. These findings do not correspond with previous findings from studies among women who belonged to the national religious sector of Jewish Israeli women who experienced spontaneous abortion and revealed anger toward God (Hamama-Raz, Hemmendinger, & Buchbinder, 2010). It is also not in line with the Kubler-Ross model (1969), which describes anger as a necessary stage of bereavement prior to attaining the ability to accept loss. A possible explanation stems from Janoff-Bulman’s world schema (1989). According to this notion, people believe in human nature and the nature of world schemes. These schemes are founded on basic assumptions according to which people believe in the intrinsic goodness of the world based on principles of justice, fairness, and control. According to these principles, people receive what they deserve, and if a negative experience occurs it is their responsibility, because it results from their behavior.
Ultraorthodox women who experienced stillbirth had no difficulty in explaining the event in terms of their negative behavior. On the contrary, according to their values, they welcomed the bad just as they welcomed the good. They believed that people do not understand God’s ways, and that what they might interpret as bad might in fact be best. This notion was expressed in Maimonides’ answer to the question, “Why is there bad in the world?” (Maimonides, 1963). He responded that bad does not exist, but in view of the comparison, what is less good appears to be bad.
Occurrences appear to be bad only when examined as isolated phenomena (Soloveitchick, 2004). Likewise, Koenig and Larson (2001) stated that the way individuals frame their worldview in a religious context can have profound implications for their mental, emotional, and physical life. Furthermore, Pargament, Smith, Koenig, and Perez (1998) proposed that religious coping (i.e., seeking support from God and/or one’s religious community; forming a partnership with God in working through difficult circumstances; attributing negative events to the will of God or to a loving God; and/or performing religious rituals) in response to crises is best understood as a two-factor model in response to stressful events, positive religious coping (e.g., forgiveness, collaborative problem-solving with God, religious purification, benevolent religious reappraisals, spiritual connection with others, and so forth), and negative religious coping (punitive religious appraisals, demonic reappraisals, spiritual discontent, self-directing coping efforts, and so forth).
This delineation has shown promise in understanding how religious faith could be associated with negative health outcomes. For instance, Ano and Vaconcelles (2005) conducted a meta-analysis of 49 studies of religious coping and found that positive forms of religious coping were related to lower levels of depression, anxiety, and distress, whereas negative forms of religious coping were associated with poorer psychological adjustment—particularly depressive symptoms. In line with this, Cowchock, Lasker, Toedter, Skumanich, and Koenig (2010) reported that women who experienced pregnancy loss, who used negative religious coping or expressed religious struggle, were at high risk of chronic or even pathological grief 1 or even 2 years after the event.
An additional explanation for the participants’ coping strategies is based on the constructivist approach offered by Neimeyer, Keesee, & Frotner (2000) and Neimeyer (2000). Under this approach, it is maintained that loss is an event that can either strengthen or weaken the individual’s constructions of meaning, and that working through bereavement is a personal process to which the people themselves ascribe interpretation and meaning. In this respect, it seems that the meaning ascribed to stillbirth by the participants in this study led them to feel that they were “the chosen”—reflecting God’s love toward them. Adopting such a view justified the tests of their faith and released them from tortuous questions and guilt feelings.
In summary, this study might contribute to a greater understanding of the meaning of stillbirth among ultraorthodox Jewish women through a cultural perspective. Therapists who are in contact with these women need to familiarize themselves with the cultural meaning of such events, and should tailor psychosocial intervention plans to the religious values and world views of their clients. For example, therapists should be careful in labeling these women who avoid expressions of negative feelings as repressive. Instead, therapists can help them create a story that promotes their adaptation and contributes to meaning in their life via their faith (Neimeyer, 2000). These women might then show less resistance, greater trust, and better cooperation with professional caregivers (Sivan & Kaplan, 2003).
The main limitation of this study relates to Guba and Lincoln’s (1989) notion of transferability or fittingness. Transferability of the findings of the present study might be only to other ultraorthodox women who experience stillbirth; however, the ultraorthodox sector in Israel is not homogeneous (Lupo & Chen, 2008). In this article we have attempted to present the voices of the various denominations of the ultraorthodox communities in Israel. Future studies should examine the meaning of stillbirth among other subgroups in the ultraorthodox sector. Moreover, since coping with stillbirth occurs not only on the intrapsychic level but also the interpsychic level, it is important to explore the meaning of stillbirth for the husbands so as to place the knowledge gained in this study in a wider context. Another limitation relates to saturation. Because many ultraorthodox women refused to take part in the study, we cannot report on saturation. During the analysis of the findings, we found that the themes recur repeatedly in the participants’ interviews.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.