Similarities and differences in couples' grief reactions following a miscarriage: results from a longitudinal study

Depression, Stress and Anxiety among Women and Men Affected by Recurrent Pregnancy Loss (RPL): A Systematic Review and Meta-Analysis

The aim of the present study is to perform a systematic review and meta-analysis on depression, stress and anxiety in women who experienced recurrent pregnancy loss (RPL) compared to controls and to men who experienced RPL. The pooled results showed a higher level of moderate/severe depression among women who experienced RPL compared to controls (5359 women, random effects model, odds ratio (OR) 3.77, 95% Confidence Interval (CI) 2.71-5.23, p < 0.00001, I² 0%). Anxiety and stress levels were also higher among women experiencing RPL compared to controls. The pooled results showed a higher level of moderate/severe depression in women who experienced RPL compared to men who underwent the same experience (113/577 (19.5%) women versus 33/446 (7%) men versus random effects model, OR 4.63; 95% CI 2.95-7.25, p < 0.00001 I² 0%). Similarly, higher levels of stress and anxiety in women experiencing RPL compared to men experiencing RPL were described. Women who experienced RPL showed higher rates of moderate-severe depression, stress and anxiety compared to both controls and men who experienced RPL. Healthcare professionals should implement screening for anxiety and depression and social support for both partners and support them in dealing with RPL according to sex-specific responses to this stressful event.

The Posttraumatic Impact of Recurrent Pregnancy Loss in Both Women and Men

Introduction Recurrent pregnancy loss is usually associated with significant psychological distress for both partners of the couple. It may act as a traumatic experience resulting in a posttraumatic stress disorder. The object of this study is to examine the posttraumatic impact of recurrent pregnancy loss on men and women and their interdependencies. Methods Cross-sectional study. All couples referred to the special unit for recurrent pregnancy loss between March 2019 and October 2020 were asked to participate with a sample size of 105 couples and 17 women. They were invited to complete a questionnaire package estimating the prevalence of posttraumatic stress, with anxiety, depression, lack of social support and dysfunctional coping strategies as contributing risk factors. Couple data were analysed with the Actor Partner Interdependence Model, taking the couple as a dyad. Results The response rate was 82.3 percent, with posttraumatic stress being measured in 13.7% of the women versus 3.9% of the men (p = 0.017). For women, number of curettages, controlled for the number of losses, correlated with the severity of posttraumatic stress (p < 0.05). Higher levels of anxiety, depression and lack of social support in women correlated positively with posttraumatic stress in their partners. The men's coping strategy "trivialization and wishful thinking" as well as "avoidance" correlated with more severe posttraumatic stress in the female partners (both p < 0.05). Conclusion The posttraumatic risks within a couple with recurrent pregnancy loss are interdependent. Recurrent pregnancy loss clinics should assess posttraumatic risks of both partners in their routine diagnostic process.

A Cross-Sectional Analysis of Intimacy Problems, Stress Levels, and Couple Satisfaction among Women with Thrombophilia Affected by Recurrent Pregnancy Loss

Recurrent pregnancy loss (RPL) is one of the most challenging and difficult areas of reproductive treatment due to the immense emotional suffering inflicted on families and couples affected by RPL. As a result, it is predicted that couples experiencing recurrent pregnancy loss would have an increase in marital problems, stress levels, and anxiety, preventing them from achieving their family goals. The current cross-sectional study aimed to target pregnant women with thrombophilia with a history of RPL to observe their intimacy problems, stress levels, and couple satisfaction by completing a series of digital questionnaires. These patients were considered as the reference group, while the control group was formed by other women with thrombophilia and a history of RPL who eventually achieved pregnancy and gave birth. A total of 238 complete questionnaires were recorded (157 in the reference group and 81 in the control group). It was observed that women in the reference group who did not give birth had a significantly higher proportion of three or more pregnancy attempts (54.1% vs. 39.5%) and a significantly higher proportion of three more pregnancy losses (68.8% vs. 55.6%). It was observed that patients in the reference group were more likely to be emotion-oriented (42.7% vs. 27.2%). Also, women in the reference group had higher levels of dissatisfaction and lower levels of self-acceptance, pleasure, and marital quality scores. The total SII and DSCS scores were significantly lower than women with thrombophilia with a history of RPL who eventually gave birth. Women from the reference group had significantly greater intimacy problems and stress levels while having lower openness scores and self-esteem scores than women in the control group. It is possible that women with thrombophilia and recurrent pregnancy loss are more dissatisfied with their marriages than those who subsequently had one child. Since the financial status of those who achieved pregnancy was observed to be higher, it is likely that they achieved pregnancy by ART interventions, as they reported in questionnaires. It is important to target families afflicted by thrombophilia and other reasons for infertility to ease their access to ART therapies. By achieving their objectives, affected families will minimize dissatisfaction, divorce rates, and stress.

Why Does Grief Hurt?

Abstract. Grief is a major physical and psychological health concern for adults, as well as a key risk factor for depression. The direct and indirect costs of depression in adults place heavy burdens on societal resources. Indeed, bereavement is a stressful and profound life experience, with the grieving process combining reactions to a loss that may originate in complications for bereaved individuals. The goal of this systematic review is to synthesize the findings regarding depression and grief. Studies related to the topic were obtained from multiple databases through rigorous exclusion and inclusion criteria. Only empirical studies with quantitative methodologies were included. Objectives, sample (type of sample, % male, and age), instruments, and main conclusions were extracted from each study. Overall, there are personality and contextual factors that, in addition to affecting depressive reactions following a loss, may also interface with one’s ability to grieve. Furthermore, after the patient’s death, there was a decrease in depressive symptoms over time, indicating that these symptoms are dynamic. Individuals who experience prolonged grief exhibit depressive symptoms, and those who suffer a loss may have depressive symptoms, but in a natural and non-pathological way, that is, sadness and not depression. Depression tends to decrease over time, with the existence of more children and a focus on occupation.

Advice from Bereaved Parents on Strategies to Heal After Baby Loss

With close to one in three babies dying between conception and infancy, research examining how to assist bereaved parents after loss is critical. Prior research focuses primarily on a general understanding of the journey post-loss or on a specific strategy that can be pursued to assist in healing but does not adequately provide a holistic examination of post-loss strategies nor is it from firsthand recommendations of bereaved parents. Our research addresses this gap in the literature by identifying the post-loss healing strategies recommended by bereaved parents themselves, thereby informing coping post-loss. To do this, 30 semi-structured interviews were conducted with bereaved mothers. Four themes emerged from our findings: (1) honor the deceased baby, (2) engage in helpful practices, (3) pursue healing now, and (4) embrace the post-loss journey as unique.

“A sorrow shared …”: a qualitative content analysis of what couples with recurrent miscarriages expect from one another and their families and friends

STUDY QUESTION

When couples have to face recurrent pregnancy loss (RPL), what are the partners’ wishes and needs and what is their perception of helpful and unhelpful factors with regard to their own, their partners’ and their families’ and friends’ ways of dealing with the problem?

SUMMARY ANSWER

Women and men with repeated miscarriages want open communication about their losses, but expect a sensitive and empathetic attitude from others, not pity or trivialization.

WHAT IS KNOWN ALREADY

RPL not only causes the women affected and their partners considerable emotional distress; it also has an impact on the couples’ relationships and the way they relate to their families and friends. Studies suggest that women have a greater need than their male partners to talk about their losses and that these differences may lead to dissatisfaction and cause relational tension. In addition, men often assume a ‘mainstay’ role, supporting their partners and displaying fortitude in the face of distress. As yet, however, little research has been conducted so far on the question of what the members of couples with RPL expect from one another and from their families and friends.

STUDY DESIGN, SIZE, DURATION

The study sample consisted of 147 couples and 17 women with at least 2 miscarriages attending the special unit for RPL at the University Women’s Hospital in Heidelberg (Germany) for the first time between September 2018 and October 2020 (response rate: 82.7%). The patients were asked to participate in this combined qualitative and questionnaire study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In order to explore the wishes and needs of those affected in more detail, the free text responses obtained were examined in this study by using qualitative content analysis. Categories and subcategories were created inductively to summarize and systematize content.

MAIN RESULTS AND THE ROLE OF CHANCE

Patients affected by RPL want their partners and their families and friends to deal with the topic openly and empathically. In the partnership itself, acceptance of individual grieving modes and sharing a common goal are important factors. Men, in particular, want their partners to be optimistic in facing up to the situation. Regarding communication with family and friends, it transpired that ‘good advice’, playing the matter down, inquiries about family planning, pity and special treatment are explicitly not appreciated.

LIMITATIONS, REASONS FOR CAUTION

The sample was a convenience sample, so self-selection effects cannot be excluded. In addition, the level of education in the sample was above average. Accordingly, the sample cannot be regarded as representative. The results of the content analysis are based on the respondents’ written answers to open-ended questions in the questionnaire. Unlike qualitative interview studies, further questioning was not possible in the case of ambiguities or to request more details.

WIDER IMPLICATIONS OF THE FINDINGS

Frank and sincere communication about miscarriages and about one’s own emotions and needs should be promoted both in the partnership and among family members and friends in order to strengthen the potential of social support as a resource. Open communication about the different needs of both partners is necessary to create mutual understanding. The results show the importance not only of empathy and consideration for the couples concerned but also their desire not to be pitied. Striking a fine balance between fellow-feeling and pity may also lead to tension, and this potential dilemma should be addressed in psychosocial counselling. Overall, the study contributes to a better understanding of what couples want from their families and friends when they are attempting to come to terms with RPL and highlights potential challenges in the interaction between affected couples and their families and friends.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study. None of the authors declared any conflicts of interest.

TRIAL REGISTRATION NUMBER

DRKS00014965.

Workplace experience of parents coping with perinatal loss: A scoping review

BACKGROUND

Perinatal loss affects many parents in the workforce. Yet, current knowledge about their workplace experience while facing this difficult event is sparse.

OBJECTIVES

The goal of this study was to review and synthesize the extent of scientific literature on the specific experiences of workers coping with perinatal loss and the resulting bereavement.

METHODS

A scoping review was carried out using eight different databases. A total of 15 references, all using a qualitative methodology, were identified.

RESULTS

Most of the references focused on the experience of mothers and on late perinatal loss (from the 20th week of pregnancy). All references highlighted the taboo and the non-recognition of perinatal grief and bereavement in both organizational practices and interpersonal relationships with colleagues and immediate supervisors. They also emphasized the difficulties associated with returning to work after the loss and the significant changes in the meaning attributed to work.

CONCLUSIONS

While the studies included in this review clearly indicate that perinatal loss can affect working life, larger, quantitative studies are needed to quantify this phenomenon and its impact on employees and their organizations.

Stress and depression among women and men who have experienced recurrent pregnancy loss: focusing on both sexes

RESEARCH QUESTION

Are women and men suffering from recurrent pregnancy loss (RPL) more affected by psychological stress and depression than the general population?

DESIGN

Cross-sectional study investigating the prevalence of stress and depression in women and men with RPL seen in the Danish national RPL Unit. Data were collected between 2015-2018. All newly referred couples were asked to complete the Major Depression Index (MDI) and Cohen's Perceived Stress Scale (PSS). The scores of both sexes were compared with scores from relevant cohorts of men and women from the general population.

RESULTS

In total, 412 women with RPL (82% response rate) and 281 male partners (60% response rate) were included. Depression: 5/281 (1.8%) of men with RPL had moderate/severe depression vs. 5/253 (2.0%) of men in the comparison group (relative risk (RR) 0.90; 95% CI 0.26-3.07, p=0.99). Among women with RPL, 34/412 (8.3%) had a moderate/severe depression vs. 2.2% in the comparison group (RR 3.74; 95% CI 2.40-5.83, p<0.001). High stress levels were found in 30/281 men with RPL (10.7%) vs. 15.8% in the comparison group (co-habiting men) (RR 0.67; 95% CI 0.48-0.94, p=0.017). High stress level was found among 110/384 (28.6%) of RPL-women vs. 420/1813 (23.2%) of comparison women (RR 1.24; 95% CI 1.03-1.48, p=0.026). Both MDI and PSS scores, respectively, for a woman and a man in an RPL couple were significantly correlated.

CONCLUSION

Male partners in RPL couples did not have increased prevalence of stress and depression compared with other men but we confirmed our previous finding of significantly increased frequencies among women with RPL.

Differences in post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy between women and their partners: multicenter prospective cohort study

OBJECTIVES

To investigate and compare post-traumatic stress (PTS), depression and anxiety in women and their partners over a 9-month period following miscarriage or ectopic pregnancy.

METHODS

This was a prospective cohort study. Consecutive women and their partners were approached in the early pregnancy units of three hospitals in central London. At 1, 3 and 9 months after early pregnancy loss, recruits were e-mailed links to surveys containing the Hospital Anxiety and Depression Scale and the Post-traumatic Stress Diagnostic Scale. The proportion of participants meeting the screening criteria for moderate or severe anxiety or depression and PTS was assessed. Mixed-effects logistic regression was used to analyze differences between women and their partners and their evolution over time.

RESULTS

In total, 386 partners were approached after the woman in whom the early pregnancy loss had been diagnosed consented to participate, and 192 couples were recruited. All partners were male. Response rates were 60%, 48% and 39% for partners and 78%, 70% and 59% for women, at 1, 3 and 9 months, respectively. Of the partners, 7% met the criteria for PTS at 1 month, 8% at 3 months and 4% at 9 months, compared with 34%, 26% and 21% of women, respectively. Partners also experienced lower rates of moderate/severe anxiety (6% vs 30% at 1 month, 9% vs 25% at 3 months and 6% vs 22% at 9 months) and moderate/severe depression (2% vs 10% at 1 month, 5% vs 8% at 3 months and 1% vs 7% at 9 months). The odds ratios for psychological morbidity in partners vs women after 1 month were 0.02 (95% CI, 0.004-0.12) for PTS, 0.05 (95% CI, 0.01-0.19) for moderate/severe anxiety and 0.15 (95% CI, 0.02-0.96) for moderate/severe depression. Morbidity for each outcome decreased modestly over time, without strong evidence of a different evolution between women and their partners.

CONCLUSIONS

Some partners report clinically relevant levels of PTS, anxiety and depression after pregnancy loss, though to a far lesser extent than women physically experiencing the loss. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Men living through multiple miscarriages: protocol for a qualitative exploration of experiences and support requirements

INTRODUCTION

Up to 1 in 4 pregnancies and 1 in 20 subsequent pregnancies end in miscarriage. Despite such prevalence the psychosocial effects are often unrecognised and unsupported. In the absence of any biomedical sequelae among men such marginalisation may be intensified. Men living through multiple miscarriages may also find any grief or anxiety intensified by loss of hope for future parenthood, but robust qualitative studies of these experiences are limited. We aim to rectify the deficiency.

METHODS AND ANALYSIS

Our qualitative study will adopt the sounds of silence framework designed by Serrant-Green to hear the voices of populations possibly marginalised. We will listen and learn from 30 to 50 men with a history of two or more miscarriages. The research participants will be recruited from a recurrent miscarriage clinic at a large tertiary hospital in England, and from advertisements to be disseminated by the project sponsor and miscarriage charities.Individual telephone interviews supported by a semistructured discussion guide will be audio-recorded, transcribed and anonymised. The transcriptions and any field notes will be interpreted by the framework method of Ritchie and Lewis embedded within the sounds of silence framework. Tentative findings will be presented to research participants in face-to-face focus group discussion, to enable member synthesis to enhance authenticity. The focus group discussion will be audio-recorded, transcribed, anonymised and similarly interpreted to contribute to our final synthesis.

ETHICS AND DISSEMINATION

The protocol of this project received a favourable opinion from the West Midlands South Birmingham Research Ethics Committee (16/WM/0423). Results will be submitted for publication in peer-reviewed journals and at conferences, and disseminated via newsletters and social media of our clinical collaborators and miscarriage charities. Outputs are anticipated to inform future policy and practice in the management of multiple miscarriages.

TRIAL REGISTRATION NUMBER

ISRCTN 21828561.

Stress, anxiety and depression perceived by couples with recurrent miscarriage

AIM

Recurrent miscarriage is considered a major life event. The main purposes of this study were to compare the differences in stress, anxiety, social support, sleep quality and depressive symptoms in couples experiencing recurrent miscarriage compared to peers who experience full-term normal childbirth in southern Taiwan.

METHODS

Convenience sampling and snowball sampling were used respectively to recruit 78 couples with and 80 couples without recurrent miscarriage from October 2014 to July 2015. Five structured questionnaires including Perceived Stress Scale, State- Anxiety Inventory, Interpersonal Support Evaluation List, Pittsburgh Sleep Quality Index and Edinburgh Depression Scale were administered.

RESULTS

Women who experienced recurrent miscarriage perceived significantly higher levels of stress, anxiety and depressive symptoms than their husbands. Women in the recurrent miscarriage group reported significantly greater depressive symptoms than women of the other group. A stepwise multiple regression analysis indicated key predictors of depressive symptoms among women of childbearing age, accounting for 62.9% of the variance, were anxiety, stress, social support and history of recurrent miscarriage.

CONCLUSION

Women with recurrent miscarriage suffer mild to moderate depressive symptoms and a greater incidence of depression than their peers who experienced normal childbirth. Health professionals can use the knowledge gained from these findings to evaluate women with recurrent miscarriage for stress, anxiety and depressive symptoms and develop supportive interventions.

Men's grief and support following pregnancy loss: A qualitative investigation of service providers' perspectives

This study explores service providers' experiences of supporting men following a miscarriage or stillbirth in Australia. In-depth, semi-structured interviews were completed with seven service providers including midwives, grief counselors and social workers. Participants highlighted that, despite the individual nature of men's grief, there is a need to recognize and address the additional expectations and responsibilities that may compound their experience. Within an environment focused on woman-centered care, participants described creative strategies and inclusive language to promote engagement of men. Further research exploring men's grief is needed to inform training and guidelines for healthcare professionals who work with bereaved families.

The psychological impact of early pregnancy loss

BACKGROUND

Early pregnancy loss (EPL) is a common event, with scope for long-term personal and societal impact. There are three decades worth of published evidence of profound psychological sequelae in a significant proportion of women. However, the wide variety of outcomes, screening instruments, assessment timings and geographical locations makes it challenging to form a coherent picture of the morbidity within the whole group and its subgroups.

OBJECTIVE AND RATIONALE

This review aims to investigate three questions. (1) What is the evidence for depression, anxiety and post-traumatic stress disorder (PTSD) following a miscarriage or an ectopic pregnancy in women and/or their partners? (2) What is the intensity and duration of these conditions, and how do they compare to those without losses? (3) Which patients have been found to be at highest risk of psychopathology? Answers to these questions are salient not only in day-to-day clinical interactions with those experiencing EPL, whose psychological needs may not be prioritized, but should also form the basis for tailoring healthcare policy in terms of screening for and treating the associated psychological morbidity.

SEARCH METHODS

The following databases were searched, from the start of each database up to July 2017: MEDLINE (Ovid interface, 1948 onwards), Embase classic + Embase (Ovid interface, 1947 onwards), and PsychINFO (Ovid interface, 1806 onwards). Search strategies were developed using medical subject headings (MeSH). The concepts of psychological morbidity (anxiety, depression or PTSD) and pregnancy loss (miscarriage or ectopic pregnancy) were first expanded with the Boolean operator 'or', then linked together using 'and'. Included studies were of prospective cohort design, including women or men following EPL (with the majority to have experienced losses before 24 weeks gestation), and reporting standardized psychometric measures for anxiety, depression and post-traumatic stress disorder. The timing of follow-up had to be specified and standardized across participants. Manuscript quality and risk of bias was assessed using the Newcastle-Ottawa Scale.

OUTCOMES

We found evidence of significant depression and anxiety in the first month following EPL in women. Partners were also shown to display depression and anxiety, albeit to a generally lower level. There is also evidence of post-traumatic stress symptoms relating to the EPL in three studies.

WIDER IMPLICATIONS

In view of their high frequency, EPLs can significantly contribute to the overall burden of psychopathology within a population. Recognition of this impact is important, so that severely affected individuals may be screened and treated appropriately. Further research to establish risk factors to promptly identify and treat these patients, and to optimize their management, is crucial.

Longitudinal study of emotional experiences, grief and depressive symptoms in women and men after miscarriage

OBJECTIVE

Although miscarriage is common and affects up to 20% of pregnant women, little is known about these couples' short term and long term experiences after miscarriage. The aim of the present study was to study emotional experience, grief and depressive symptoms in women and men, one week and four months after miscarriage.

RESEARCH DESIGN /SETTING

Women, (n = 103), and their male partner (n = 78), were recruited at the gynecological clinic after miscarriage. Control women were recruited from the general population. Three validated questionnaires concerning psychological wellbeing and mental health, RIMS, PGS and MADRS-S were answered by the participants one week and four months after the miscarriage.

FINDINGS

It was shown that for women, the emotional experiences of miscarriage, grief and depressive symptoms were more pronounced than for their male partners. Grief and depressive symptoms were reduced with time, which was not the case for the emotional experiences of miscarriage. Previous children was favorable for emotional experience while previous miscarriage or infertility treatment made the emotional experience worse.

CONCLUSION

Grief and depressive symptoms is reduced over time while emotional experiences such as isolation, loss of baby and a devastating event persist for longer time than four months. Lack of previous children, previous miscarriage and infertility diagnosis could increase negative emotional experiences after miscarriage, this was especially pronounced for grief reaction. The questionnaires could be used both clinically and in research to understand the emotional experiences after miscarriage.

The impact of pregnancy loss on men's health and wellbeing: a systematic review

Background

Research indicates that men’s psychological and physical health outcomes after pregnancy loss differ from those of women. Our goal was to identify all literature with a focus on men’s experiences of pregnancy loss in order to outline current evidence concerning men’s wellbeing.

Methods

A systematic review of literature on men and pregnancy loss was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Joanna Briggs Institute (JBI) and Social Care Institute for Excellence (SCIE) guidelines. Literature was sourced from PsycINFO, PubMed, Scopus, CINAHL, and Google Scholar. Inclusion criteria were 1) studies that focused on pregnancy loss (including miscarriage, stillbirth, and ectopic pregnancy, 2) that men’s voices were specifically represented, and 3) that studies were of primary data.

Results

A final sample of 29 articles was identified, of which 16 were quantitative, 10 qualitative, and 3 mixed methods. Quantitative and mixed methods studies indicated that while men tended to have less intense and less enduring levels of negative psychological outcomes than women, they are more likely to engage in compensatory behaviours, such as increased alcohol consumption. Qualitative studies indicated that men often feel that their role is primarily as a ‘supporter’ to their female partner, and that this precludes recognition of their own loss. These studies also reported that men may feel overlooked and marginalised in comparison to their female partners, whose pain is typically more visible.

Conclusions

Further research is needed on men’s experiences of pregnancy loss, focusing on cultural differences. The experience of gay and/or transgender men who face pregnancy loss is overlooked in the literature to date.

Protocol for evaluation of the continuum of primary care in the case of a miscarriage in the emergency room: a mixed-method study

BACKGROUND

In Quebec (Canada), nearly 20,000 pregnancies end in miscarriage, and the majority of the miscarriages are dealt with in an emergency unit. Although there are studies documenting the effects of this type of grief on mental health, men's experiences are much less discussed than those of women. Similarly, no study has evaluated best practices in terms of service continuity, from emergency care to community resources. The aim of this study is to better understand the relationships that exist between the organization of emergency room and primary care health services for women presenting with miscarriage, on the one hand, and the positions and experiences of women and men within these services, on the other.

METHODS

The general objective of this mixed-method study can be broken down into three methodological sections. Focus 1. Institutional discourses and practices. This section is structured as a multiple case study of the mandates of five participant institutions. The study will involve (a) a documentary analysis; (b) a quantitative survey (N: 200) and (c) group interviews (N: 75) with caregivers and emergency unit managers. Focus 2. Women's and men's experiences of miscarriages and the institutional response. This section includes (a) a survey (N: 232) and (b) individual interviews (N: 80) designed to identify best practices in emergency involving women and their partners in each area. Focus 3. This section will integrate the information furnished by the first two sections in order to create an ethnographic overview of the situation.

DISCUSSION

This innovative project will provide answers to critical questions on how to improve the effectiveness and quality of interdisciplinary and multisectoral interventions to promote the mental health and psychosocial well-being of couples having experienced a miscarriage. It will have a material effect on the organization of emergency services and of the primary care pathway for women experiencing a miscarriage and for their partners.

TRIAL REGISTRATION

Not applicable. This study involves a retrospective view of usual health care interventions. This study is not a clinical trial that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcomes.

Experience of miscarriage: an interpretative phenomenological analysis

OBJECTIVE

The objective of the study was to explore the experiences of those who have experienced miscarriage, focusing on men's and women's accounts of miscarriage.

DESIGN

This was a qualitative study using a phenomenological framework. Following in-depth semistructured interviews, analysis was undertaken in order to identify superordinate themes relating to their experience of miscarriage.

SETTING

A large tertiary-level maternity hospital in Ireland.

PARTICIPANTS

A purposive sample of 16 participants, comprising 10 women and 6 men, was recruited.

RESULTS

6 superordinate themes in relation to the participant's experience of miscarriage were identified: (1) acknowledgement of miscarriage as a valid loss; (2) misperceptions of miscarriage; (3) the hospital environment, management of miscarriage; (4) support and coping; (5) reproductive history; and (6) implications for future pregnancies.

CONCLUSIONS

One of the key findings illustrates a need for increased awareness in relation to miscarriage. The study also indicates that the experience of miscarriage has a considerable impact on men and women. This study highlights that a thorough investigation of the underlying causes of miscarriage and continuity of care in subsequent pregnancies are priorities for those who experience miscarriage. Consideration should be given to the manner in which women who have not experienced recurrent miscarriage but have other potential risk factors for miscarriage could be followed up in clinical practice.

Interpersonal psychotherapy (IPT) for major depression following perinatal loss: a pilot randomized controlled trial

This randomized controlled pilot trial examined the feasibility, acceptability, and preliminary efficacy of an adapted interpersonal psychotherapy (IPT) for major depressive disorder (MDD) following perinatal loss (miscarriage, stillbirth, or early neonatal death). Fifty women who experienced a perinatal loss within the past 18 months, whose current depressive episode onset occurred during or after the loss, were randomized to the group IPT adapted for perinatal loss (the Group IPT for Major Depression Following Perinatal Loss manual developed for this study is available at no cost by contacting either of the first two authors) or to the group Coping with Depression (CWD), a cognitive behavioral treatment which did not focus on perinatal loss nor social support. Assessments occurred at baseline, treatment weeks 4 and 8, post-treatment, and 3 and 6 months after the end of treatment. IPT was feasible and acceptable in this population. Although some participants were initially hesitant to discuss their losses in a group (as occurred in IPT but not CWD), end of treatment satisfaction scores were significantly (p = 0.001) higher in IPT than in CWD. Confidence intervals around between-groups effect sizes favored IPT for reductions in depressive symptoms during treatment as well as for improvement in mode-specific targets (social support, grief symptoms) and recovery from a post-traumatic stress disorder over follow-up. This group IPT treatment adapted for MDD after perinatal loss is feasible, acceptable, and possibly efficacious.

Support Groups Helping Women Through Pregnancies after Loss

Pregnancies following perinatal loss are full of fears and anxieties. Standards of care or interventions are not generally available, however support groups exist across the country. This study explored several pregnancy-after-loss support groups. Data were collected through participant observation of meetings, individual interviews, questionnaires, and artifacts. Five paradoxes were identified reflecting conflicts between common cultural expectations and the women’s own perspectives about pregnancy: birth/death, pregnancy equals/does not equal baby, head/heart, public/private, and hope/fear. According to participants, the groups helped members recognize their commonalities, remember their earlier babies who died, develop caring relationships, and learn new coping skills. Key outcomes included “making it through” their pregnancies, finding ways to reconcile the cultural paradoxes, and relating better with their current, live babies.

Impact of a Neonatal-Bereavement-Support DVD on Parental Grief: A Randomized Controlled Trial

This study tested the effect of a neonatal-bereavement-support DVD on parental grief after their baby's death in a Neonatal Intensive Care Unit compared with standard bereavement care (controls). Following a neonatal death, the authors measured grief change from a 3- to 12-month follow-up using a mixed-effects model. Intent-to-treat analysis was not significant, but only 18 parents selectively watched the DVD. Thus, we subsequently compared DVD viewers with DVD nonviewers and controls. DVD viewers reported higher grief at 3-month interviews compared with DVD nonviewers and controls. Higher grief at 3 months was negatively correlated with social support and spiritual/religious beliefs. These findings have implications for neonatal-bereavement care.

Measuring the Meaning of Miscarriage: Revision of the Impact of Miscarriage Scale

Background and Purpose: The purpose of this study was to determine a factor structure for the Impact of Miscarriage Scale (IMS). The 24 items comprising the IMS were originally derived from a phenomenological study of miscarriage in women. Initial psychometric properties were established based on a sample of 188 women (Swanson, 1999a). Method: Data from 341 couples were subjected to confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). Results: CFA did not confirm the original structure. EFA explained 57% of the variance through an 18-item, 4-factor structure: isolation and guilt, loss of baby, devastating event, and adjustment. Except for the Adjustment subscale, Cronbach’s alpha coefficients were ≥.78. Conclusion: Although a 3-factor solution is most defensible, with further refinement and additional items, the 4th factor (adjustment) may warrant retention.

Recurrent miscarriage clinics

A recurrent miscarriage clinic offers specialist investigation and treatment of women with recurrent first- and second-trimester miscarriages. Consultant-led clinics provide a dedicated and focused service to couples who have experienced at least two prior miscarriages. The best treatment strategy for couples with recurrent miscarriage is to discuss a treatment plan for a future pregnancy. Evidence-based up-to-date guidelines are required to reduce ineffective management of recurrent miscarriage couples, including overdiagnostics and underdiagnostics. Scientific research is necessary to study the effectiveness of new interventions, to study patient preferences, and to evaluate health care and costs or other outcomes.

Pregnancy loss

Women who lose desired pregnancies by miscarriage, stillbirth, or genetic termination are at risk of suffering from grief, anxiety, guilt and self-blame that may even present in subsequent pregnancies. It is important to find effective means of helping women deal with these losses. The approach to stillbirth has shifted from immediately removing the child from the mother to encouraging the parents to view and hold the baby. This approach has been questioned as possibly causing persistent anxiety and post-traumatic stress disorder. Women who miscarry are currently encouraged to find ways to memorialise the lost fetus. Couples who decide to terminate a pregnancy after discovering a defect may deal not only with sadness but also guilt. Immediate crisis intervention and follow-up care should be available, recognising that individual women may experience different reactions and their specific post-loss needs must be assessed.

[What does a thorough personality questionnaire, the MMPI-2, tell us about psychological aspects of recurrent miscarriage?]

OBJECTIVES

Try to analyse the experience of couples undergoing repeated miscarriages by answering the following questions: what can we learn from these men and women who suffered from repeated miscarriages?

PATIENTS AND METHODS

A thorough personality questionnaire, the MMPI-2, presented to 50 couples who have had repeated miscarriages.

RESULTS

Through a hierarchical classification, different profiles appear in the men's group as well as in the women's group, revealing a somatization of psychological suffering. It is also revealing acute defensive personality profiles showing restricted affects in a lot of these men whose partners have suffered from multiple procreation failures. Such a narrower range of emotions can be a cause of additional pain for their partner and for themselves.

DISCUSSION AND CONCLUSION

We can therefore establish that, in these circumstances, the medical and/or psychological treatment should include both couple members to improve the marital adjustment and ease the couple towards another pregnancy which is always apprehended with the fear of another failure. A few etiological hypothesis may be evoked.

Miscarriage and mental health: results of two population-based studies

A miscarriage may have a sustained negative effect on mental health. Our aim was to analyze the association of the history and, if any, the number of miscarriages with mental health. The participants were women from two population-based studies, the Finnish Health 2000 survey and the National FINRISK 2002 Survey. Data were collected with a set of self-reported questionnaires, a clinical health examination and/or a home interview. A modified Beck Depression Inventory (BDI), the 12-item General Health Questionnaire (GHQ-12), the Munich-Composite International Diagnostic Interview (M-CIDI) and other non-structured interviews were used for the assessment of mental health. A diagnosis of depressive disorder and the presence of depressive symptoms were more prevalent among women with a history of miscarriage. In both datasets the higher the number of miscarriages was, the worse the current state of mood was and the higher the frequency of a psychiatric diagnosis was. These results suggest that a miscarriage, and in particular the number of miscarriages, contributes to mental health in a negative way for long.

Complicated grief after perinatal loss

The loss of an infant through stillbirth, miscarriage, or neonatal death is recognized as a traumatic life event. Predictors of development of complicated grief after prenatal loss include lack of social support, pre-existing relationship difficulties, or absence of surviving children, as well as ambivalent attitudes or heightened perception of the reality of the pregnancy. Risk of complicated grief was found to be especially high after termination of a pregnancy due to fetal abnormality. Studies have revealed that men and women show different patterns of grief, potentially exacerbating decline in a relationship. Although it is clear that prenatal loss has a large psychological impact, it is concluded that there is a substantial lack of randomized controlled studies in this field of research,

Psychological and social consequences among mothers suffering from perinatal loss: perspective from a low income country

Background

In developed countries, perinatal death is known to cause major emotional and social effects on mothers. However, little is known about these effects in low income countries which bear the brunt of perinatal mortality burden. This paper reports the impact of perinatal death on psychological status and social consequences among mothers in a rural area of Bangladesh.

Methods

A total of 476 women including 122 women with perinatal deaths were assessed with the Edinburgh Postnatal Depression Scale (EPDS-B) at 6 weeks and 6 months postpartum, and followed up for negative social consequences at 6 months postpartum. Trained female interviewers carried out structured interviews at women's home.

Results

Overall 43% (95% CI: 33.7-51.8%) of women with a perinatal loss at 6 weeks postpartum were depressed compared to 17% (95% CI: 13.7-21.9%) with healthy babies (p = < 0.001). Depression status were significantly associated with women reporting negative life changes such as worse relationships with their husband (adjusted OR = 3.89, 95% CI: 1.37-11.04) and feeling guilty (adjusted OR = 2.61, 95% CI: 1.22-5.63) following the results of their last pregnancy outcome after 6 months of childbirth.

Conclusions

This study highlights the greatly increased vulnerability of women with perinatal death to experience negative psychological and social consequences. There is an urgent need to develop appropriate mental health care services for mothers with perinatal deaths in Bangladesh, including interventions to develop positive family support.

Measuring Grief Following Miscarriage

Grief following miscarriage is a complex psychological response. This study was conducted to examine the psychometric properties of the Chinese version of the Perinatal Grief Scale (PGS). A total of 280 Chinese women completed the PGS immediately following a diagnosis of miscarriage (baseline) and were reassessed at 12 months follow-up. The factor structure of the Chinese PGS was explored. The convergent validity of the PGS was established by examining its correlations with the General Health Questionnaire–12 and Beck Depression Inventory at baseline. The reliability of the Chinese PGS was satisfactory. A two-factor structure accounting for 45% of the variance was identified. The Chinese PGS was positively correlated with General Health Questionnaire–12 and Beck Depression Inventory scores. The Chinese PGS was found to be a reliable and valid tool to measure grief following miscarriage.

Marriage and cohabitation outcomes after pregnancy loss

OBJECTIVE

The goal was to evaluate marriage and cohabitation outcomes for couples who experienced a live birth or fetal death at any gestational age.

METHODS

For married and cohabitating women who experienced live births, miscarriages, or stillbirths, we conducted a survival analysis (median follow-up period: 7.8 years), by using data from the National Survey of Family Growth, to examine the association between birth outcomes and subsequent relationship survival. The Cox proportional-hazards models controlled for multiple independent risk factors known to affect relationship outcomes. The main outcome measure was the proportion of intact marriages or cohabitations over time.

RESULTS

Of 7770 eligible pregnancies, 82% ended in live births, 16% in miscarriages, and 2% in stillbirths. With controlling for known risk factors, women who experienced miscarriages (hazard ratio: 1.22 [95% confidence interval: 1.08-1.38]; P = .001) or stillbirths (hazard ratio: 1.40 [95% confidence interval: 1.10-1.79]; P = .007) had a significantly greater hazard of their relationship ending, compared with women whose pregnancies ended in live births.

CONCLUSIONS

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 if causally related.

The unifying difference: dyadic coping with spontaneous abortion among religious Jewish couples

In this study we examined the meaning of abortion in the religious Jewish sector on both the individual and the couple levels. In a qualitative, descriptive, interpretive-narrative study, semistructured interviews were conducted with five religious couples. Both members of each couple were interviewed separately. The findings show that although both members of the couple experienced spontaneous abortion as a loss, each expressed it in different ways and thus perceived it differently in the couple relationship. Men who demonstrated the ability to bypass their own pain and made an effort to respond to their partners' distress motivated the women's exit from the isolation cycle, and contributed to a sense of dyadic cohesion and to creating a meaning for their "togetherness." These findings are discussed in the context of research and theoretical literature that deal with bereavement and mourning processes, and with constructing meaning for a pregnancy-related loss.

Resolution of depression and grief during the first year after miscarriage: a randomized controlled clinical trial of couples-focused interventions

AIMS

The purpose of this randomized controlled clinical trial was to examine the effects of three couples-focused interventions and a control condition on women and men's resolution of depression and grief during the first year after miscarriage.

METHODS

Three hundred forty-one couples were randomly assigned to nurse caring (NC) (three counseling sessions), self-caring (SC) (three video and workbook modules), combined caring (CC) (one counseling session plus three SC modules), or control (no treatment). Interventions, based on Swanson's Caring Theory and Meaning of Miscarriage Model, were offered 1, 5, and 11 weeks after enrollment. Outcomes included depression (CES-D) and grief, pure grief (PG) and grief-related emotions (GRE). Differences in rates of recovery were estimated via multilevel modeling conducted in a Bayesian framework.

RESULTS

Bayesian odds (BO) ranging from 3.0 to 7.9 favored NC over all other conditions for accelerating women's resolution of depression. BO of 3.2-6.6 favored NC and no treatment over SC and CC for resolving men's depression. BO of 3.1-7.0 favored all three interventions over no treatment for accelerating women's PG resolution, and BO of 18.7-22.6 favored NC and CC over SC or no treatment for resolving men's PG. BO ranging from 2.4 to 6.1 favored NC and SC over CC or no treatment for hastening women's resolution of GRE. BO from 3.5 to 17.9 favored NC, CC, and control over SC for resolving men's GRE.

CONCLUSIONS

NC had the overall broadest positive impact on couples' resolution of grief and depression. In addition, grief resolution (PG and GRE) was accelerated by SC for women and CC for men.

Shared or discordant grief in couples 2-6 years after the death of their premature baby: effects on suffering and posttraumatic growth

BACKGROUND

The loss of a baby causes severe short- and long-term distress to parents and their marital relationship, but little is known about how this distress is shared between spouses. The authors hypothesized that the grief-related concordance within a couple 2 to 6 years after the loss of a premature baby could be an indicator of shared emotional distress within a couple.

OBJECTIVE

The authors investigated the long-term grief experience among couples.

METHOD

A group of 44 parents (22 couples) were assessed by questionnaire regarding grief, suffering, posttraumatic growth, and affective symptoms, and semistructured interviews with 6 couples added qualitative information about processes within couples.

RESULTS

The extent of grief concordance was found to be related to different patterns of suffering and posttraumatic growth within couples.

CONCLUSION

The emotional exchange between partners after the loss of the child appears to be crucial for a process of concordant grief, which in turn is associated with a more synchronous process of individual posttraumatic growth.