The Only Surviving Child Born After the Parental Loss of Two Children: A Case Study

Losing a child to death is heartbreaking and one of the most painful experiences for parents and living siblings [1-3]. There is an abundance of literature describing the loss of and grief associated with sibling death; however, there is limited research about children who are born after the death of their siblings. Children born after the death of a sibling are often seen as and called replacement children [4] or subsequent children [5,6]. When babies are born after the death of a child, they are also often described as rainbow babies [7]. These labels are often internalized and become part of the children’s identity for the remainder of their lives [6,8,9].

Spiegelman [10,11] detailed his experience as a replacement child for his brother, Richieu who died during the holocaust. Unbeknown to his parents, his aunt poisoned Richieu because she decided a death of this nature was better than being sent to the gas chambers. Spiegelman described Richieu’s presence in his life as that of a rival ghost who could do no wrong. A blurred picture of Richieu hung in their parents’ bedroom and even though their parents never spoke of him, the picture was a silent but strong reminder to Spiegelman that he was meant to live up to his parent’s ideal child [9]. Spiegelman felt that he was relegated to live in Richieu’s shadow. Furthermore, Mandel [12] who analyzed Maus’, the two graphic novels that Spiegelman wrote, called him a speaking corpse.

Vollmann [13] interviewed 25 adults who self-identified as replacement children. She determined that there are two types of replacement children, a positive replacement and inadequate replacement. The positive replacement children were idealized and revered. They were also seen as a gift with the power to heal the family.

Donoghue [8] conducted a case study on the replacement child, incorporating Spiegelman’s experiences as a child and her own experiences as an adopted child who replaced a daughter named Olive who died. Donoghue’s first name was also Olive. She states that themes of “rejection, alienation and haunting” (p.31) are found in her story. Like Spiegelman, she found herself battling sibling rivalry to a child who was wanted but who died. Unlike Spiegelman who did not feel guilty, Donoghue felt an “unbearable” (p. 316) sense of guilt that permeated her life. She was the focus of her parent’s worlds but knew that the first Olive was the ideal child who she needed to emulate.

Vollmann [13] interviewed 25 adults who self-identified as subsequent children. Identified themes from her interviews included impaired bonding with parents, family grief, meaning making, spiritual questioning, fantasies about the lost sibling, disenfranchised and unresolved grief, and survivor guilt.

Meyer [5] interviewed 49 adults who lost a sibling either before birth or before the age of three. Thirty-four of the 49 (69%) adults lost siblings before they were born and 15 lost siblings before the age of three. She found that the children mourned the loss of their siblings’ for years afterwards and they maintained symbolic relationships with their deceased siblings. She concluded that sibling death was instrumental in a person’s grieving process, in their growth and development and in their attempt to make meaning of the sibling’s death. Furthermore, she concluded that subsequent siblings wanted to know about the sibling(s) who died, and how their parents and other family members incorporated that experience into their own life stories.

Mandell [14] wrote a memoir detailing her experiences as a selfdescribed “replacement child.” An American Airlines plane crashed into the family home in 1952, killing her older sister, Donna. “I was conceived as the salve on the burns, to fill the abandoned chair at the grey Formica table” (p. 1). She wrote her memoir to tell the story of her family but also to tell her story, her “struggle to live up to the role burned into my psyche from the time my mother first dreamed me up as her salvation” (p.1). Her father’s last words to her on his deathbed were “be careful” (p. 3). When he was alive, he would regale her with newspaper stories about tragedies that occurred in the world. By the time she was a teenager, she “saw it as my sacred duty to prove the world was a safer place than my parents believed, that I could take risks and survive” (p. 4).

Shamir et al. (2023) introduced the concept of congenital loss, referring to the loss of a parent or a sibling(s) prior to birth. He and his team conducted a secondary data analysis using phenomenology. Of the 34 participant transcripts they analyzed, ten were sibling interviews. They analyzed the transcripts together (loss of mother, loss of father, sibling loss) and determined four themes, a non-coherent, fragmented story; lack of ownership over the loss story; an unestablished bond; and narrating an identity in the face of loss.

Schellinski [15] states that she “was born into grief” after her brother died when her mother was three months pregnant with her. She describes feeling loss and grief her entire life. The death of a child restructures the family and the siblings born after the death of a child often experience and move through stages of grief [16].

Not all children are conceived or thought of as replacement children and it is not clear how these children incorporate the experience of losing siblings before they are born into their psychological well-being and the impact the death of their sibling(s) has on their lives. The participant in our case study was adamant that she did not feel like a replacement child, but she felt “responsible to make her parents happy.” Thus, the research questions for this case study were:
A. How did the participant incorporate the loss of her two siblings into her life?
B. How did she make meaning of the loss of her two siblings? And
C. How did her responsibility to make her parents happy affect her life?

Study design

The researcher used a single qualitative case study, based on three interviews with one participant. Qualitative case studies are used when a holistic approach is warranted. A case study provides an in-depth examination of individuals and/or groups, facilitating a comprehensive exploration of specific phenomena (Hancock & Algozzine, 2006; Merriam, 1988). A qualitative case study was chosen to answer the research questions:
A. How did the participant incorporate the loss of her two siblings into her life?
B. How did she make meaning of the loss of her two siblings? And C. How did her responsibility to make her parents happy affect her life?

Sample/participant profile

The informant, a colleague of the researchers, approached the primary researcher about a potential case study based on her life experience of being born after the deaths of two siblings. She wanted to tell her story because “it might help others to hear her story.” She asked that we present her information in a story format.

Liz was born in the late 1950’s to two middle-class parents who lived in Auburn, New York. Her father, Gordon was a carpenter and her mother, Jan worked in retail. Two sisters died before Liz was born. They both had the same name, Katie Grace. One sister died at three months and the other died at seven years of age. Liz knew about her sisters and their deaths from the time she was able to understand. “As early as I can remember my mother told me about the loss of her two daughters, my sisters.” The data from three interviews with Liz provided the findings for this case study. Liz discussed her life and how it was affected by the death of her two sisters prior to her own birth.

Data collection

A semi-structured interview guide (Table 1) with open ended questions was used to collect data through three face-to-face interviews. Interviews were audio-recorded and lasted from 30 minutes to 45 minutes. Data were collected over a three-month period (Table 1).

Ethical considerations

This study was approved by the university’s Institutional Review Board. A consent form was signed at the beginning of the first interview. The participant was informed that she could stop the interviews at any time and that she could withdraw from the study at any time without fear of penalty. Pseudonyms were used to protect the participant’s identity. The interviews and coding book are maintained in a locked file cabinet in the primary researcher’s private home office.

Data analysis

Braun and Clark’s (2006) six steps provided the framework for data analysis. The first step, familiarization, involved multiple readings of the transcripts so that the primary researcher understood the intricacies of the data. In the next step, coding, numerous handwritten codes were generated and written in the transcript margins. Initial theme generation, the third phase, began with a review of codes and the creation of potential themes and their tentative relationships. Developing and reviewing themes, the fourth phase, began with examining themes to determine if there was pattern and if the themes and relationships made sense. The themes and relationships were confirmed. The second researcher verified each step of the data analysis. After the researchers agreed on the themes, the manuscript was written.

Rigor and trustworthiness

Four concepts proposed by Lincoln and Guba [17] were used to substantiate rigor and trustworthiness in this case study. Credibility was enhanced by sending the open ended semi-structured interview questions (Table 1) to another qualitative researcher for review, and both authors reviewed and verified the transcripts. The participant also verified the findings. She asked for one change to be made because the researcher originally reported that she was married twice, but she was only married once but had a live-in boyfriend of eight years. An audit trail was maintained to ensure dependability and confirmability. A thick description provided transferability.

Table 1:Interview Questions.

Themes

There were four themes that emerged from data analysis. These were “Heartache goes hand-in-hand with love;” “I was scared I would die too;” “I felt like I had to make my parents happy;” and “I am a chronic worrier.” The researchers included the themes in Liz’s story. Liz’s Story “I was The Only Surviving Child”.

Liz and her mom enjoyed a close relationship. Liz grew up listening to her mom talk about her sisters; their lives and death became part of her life story. “As early as I remember, my mother told me about the loss of her two daughters, my sisters. “Therefore, Liz knew the details of their lives, including specifics of their illnesses and death. “Even though I didn’t know my sisters, I felt like I knew the one who died at age 7 years.”

Liz, as the only surviving child, became the love of her parents’ lives. “My birth really helped them to overcome the grief and sadness of losing those two daughters. I brought much joy to their lives and was obviously the center of their attention.” However, Liz realizes that her parents had an underlying sadness that permeated their lives. “I always thought of my two sisters and the pain my parents must have felt.” When asked if she found meaning in her sibling’s death, Liz said it boiled down to the love that parents have for their children, living and non-living. She felt that unwavering love from her parents daily. But as Liz grew up, she also recognized that heartache went hand-in-hand with love, especially when a child dies. She also understood the unconditional love a parent has continues beyond the death of a child.

Liz noted that her mom, in her grief, took solace and comfort in eating which caused her to gain weight and experience hypertension; whereas her dad did not talk for six months after her second sister died. He “became silent.” The girls were not a welcome topic of conversation for Liz’s dad. “He would walk out of the room if they came up in conversation. He would not allow the girl’s pictures to be displayed, so my mother showed me pictures of them privately.” He built a swing for the seven-year-old and when she died, he destroyed the swing with an axe. He also tended to panic when Liz got sick as a child. “Understandably, they were so afraid that I would die too. I remember having a middle ear infection and experiencing vertigo. While I was in bed sick, I overheard my dad say to my mom ‘we are going to lose another one’. These symptoms were like what my seven-year-old sister experienced with her brain tumor so it made sense that he would be anxious.” However, her dad’s persistent anxiety and fear added to Liz’s worry that she too would die.

The fear of death was a source of constant anxiety in Liz’s life. She said she tended to “blow things out of proportion” and worried about her health, even when it was not necessary. “I always worried about dying like my sisters. This was always in the back of my mind. This was just part of my identity being the only surviving child even though they died before I was born. It shaped who I am.”

Liz felt that she “owed” her parents because, as the only surviving child, they were steadfast in their love for her and wanted only the best for her. Liz felt that she provided her parents with a lot of joy but also felt a responsibility to make her parents proud and to not worry about them. “My parents had big hopes for me to go to college and so forth. When I got pregnant at age 16 my parents were devastated and so was I. I remember telling my dad ‘Don’t worry dad I am going back to school, and you will be proud of me.’ And I did! I can remember my dad saying ‘okay, that is enough school - that occurred when I was going to my midwifery program following my doctoral education.” Liz also enrolled in the Navy and had a successful career. Liz said a career in nursing was a “natural choice; I was born to be an emotional caregiver for my parents and that just naturally played out in my choice of professions.”

Liz had two daughters and felt that they “made up for the loss of their two daughters, my two sisters.” Liz’s parents enjoyed their grandchildren; “they brought them much love, joy, and happiness. They were wonderful loving parents and grandparents. My girls were lucky to have them, as was I.” Liz’s parents helped her take care of her daughters during their childhood.

Growing up knowing that her sisters died, “impacted the way that I grew up and the way that I parented my own children. I was always worried. I was afraid terrible things were going to happen; that the other shoe was always going to drop.” One daughter was diagnosed, after a mammogram, with a .5cm mass in one of her breasts. Liz spent three weeks anxiously and worriedly waiting for the results. The mass was determined to be a cyst. Liz stated that her daughters do not worry like she does. “I’m the one who thinks the worse concerning health issues but only about myself and my family. I think more objectively and positive about others. My daughters do not worry like I do. I am glad because it is difficult to always worry.”

To this day, Liz is a self-described “worrier” and has an “impaired sense of self confidence.” Her relationships with her husband, a long-time live-in partner, and boyfriends have been fraught with difficulties, and none lasted permanently. Liz feels that she “lost out being the only surviving child without living siblings.” She feels that she has “always been alone even though I have my daughters, six grandchildren, and many friends.” She is very close to her children and grandchildren; “the kids have brought so much joy; they are gifts in our lives.” Liz also “has fun and enjoys life.” She enjoys her job, her colleagues, and her family and friends. Liz has a “full life.” She readily acknowledges that the loss of her siblings impacted her life and those of her children.

The term replacement child is a term that refers to a child conceived after the death of a child [18]. Liz never felt like a replacement child. Her birth was planned, and she was embraced as a positive addition to her family and was idealized [19]. However, Liz felt she was responsible to “make them proud.” Children born after the death of a sibling(s) are often conceived as a replacement, even if this was a subconscious decision on the part of the parents [1]. Even though this is often unacknowledged by the family or living child, he/she/they may live with this psychological encumbrance for the remainder of their lives. Often replacement children live in a duality of roles; they are the replacement child, but they also are charged with maintaining their own individuality. In Liz’s case, even though she never felt like a replacement child, she felt the burden of making her parents proud, even though her parents did not verbalize her need to do so. And, even though, Liz did not associate herself as a replacement child, she verbalized that she felt as if her two daughters “made up for the loss of their two girls.”

The loss of Liz’s siblings became part of her life, her identity, and, in some ways, dictated how she lived her life, the profession she chose, her zest for more education, how she parented her children, and worried about her family members and their wellbeing. Even though she does not consider herself a replacement child, her story aligns with some of the stories told by others who were born after the death of their sibling(s). Liz’s dad refused to discuss his daughters who died. If their names were mentioned, he left the room. He never spoke their names after their death. Mandel’s [14] father never spoke his child’s name after her death. Savoie [20] knew that his brother, Andre, died prior to his own birth; “I knew what I call the headlines. I knew where’s he’s buried” (p. 3). No one talked about him, and Savoie learned major details of his life and death from people outside the family. Liz’s parents named her two deceased siblings the same name. This is analogous to Donoghue’s [8] story; she and her deceased sibling were both named Olive. Donoghue admits that this led to identity issues.

There is an abundance of literature on children who lose siblings; however, there is little research about children who are born after the death of their sibling(s). Future research is needed in this area so that health care professionals will understand the impact that the loss of siblings prior to birth. This knowledge will assist pediatric health care practitioners to refer the child/family to appropriate resources such as therapists, grief counselors, and chaplains or other spiritual support persons.

There is very little literature that specifically examines fathers’ responses to the death of children. There is scant literature that specifically investigates a brother’s perspective on the death of siblings prior to his birth. Future studies examining fathers, male siblings, and their narratives of loss will enhance the existing literature.

Liz grew up with the knowledge that her two sisters died before she was born. She remembers hearing about her sisters “when I was a little girl. I have always known about them. My mom would tell me about how much she loved them and how much she missed them. I grew up with the knowledge that my two sisters died before I was born. This impacted the way that I grew up and the way that I parented my own children.” However, Liz did not feel like a replacement child, but she felt an obligation to always make her parents proud. And, though by all accounts, she has a successful life with many personal and professional accomplishments, Liz has “down days,” is plagued with a low self-esteem, lacks confidence in herself, and is a self-described “worrier.”

This case study contributes to the literature on siblings who experience the loss of a sibling(s) prior to their own birth. Liz maintains that she did not feel like she was a replacement child, but she experienced some of the same things that people who considered themselves replacement children did. It is contradictory to think that a death that took place before one’s birth can have an impact on one’s life [13,19]. However, Liz’s story exemplifies that the death of a sibling(s) prior to one’s own birth is consequential and can govern one’s life choices. Pediatrician practitioners can use this information to refer the family to mental health practitioners and support persons, such as chaplains or other spiritual leaders.

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