The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: A meta-analysis

Latent trajectories of anxiety and depression among women during subsequent pregnancy following pregnancy loss

AIM

To determine the longitudinal trajectories of anxiety and depression among pregnant women who have experienced pregnancy loss, and to explore the association between post-traumatic stress symptoms (PTSS) related to pregnancy loss and these trajectories.

DESIGN

A prospective longitudinal study.

METHODS

Between October 2022 and August 2023, pregnant women with a history of pregnancy loss were recruited from four hospitals in Guangdong Province, China. Eligible participants were screened for PTSS related to pregnancy loss upon enrolment. Anxiety and depression symptoms were assessed in early, mid and late pregnancy using the Pregnancy-related Anxiety Questionnaire-Revised 2 and the Patient Health Questionnaire-9, respectively. Latent class growth analysis was employed to categorize anxiety and depression trajectories, and multinomial logistic regression analysis was conducted to examine the association between PTSS and these trajectories.

RESULTS

Of the 388 participants included in the analysis, 158 individuals (40.7%) reported high PTSS scores. The best-fitting models identified three trajectories for both anxiety and depression: low (anxiety: 35.6%, depression: 48.7%), moderate (anxiety: 44.8%, depression: 40.5%) and high (anxiety: 19.6%, depression: 10.8%). Pregnant women with high PTSS levels were significantly more likely to experience moderate-to-high trajectories of anxiety and depression compared to those with low PTSS levels.

CONCLUSION

Pregnant women who have experienced pregnancy loss exhibit higher incidences of elevated anxiety and depression trajectories. Screening for PTSS and targeted supportive care are recommended to alleviate anxiety and depressive symptoms in this population.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This study underscores the importance of early psychological screening and tailored interventions for pregnant women with a history of pregnancy loss. Trauma-informed care should be prioritized to mitigate anxiety and depression trajectories in this vulnerable population.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involvement.

Social support, temperament and previous prenatal loss interact to predict depression and anxiety during pregnancy

BACKGROUND

Pregnancy is considered a complex period in a woman's life due to the changes that occur at different levels, which increase her vulnerability to developing psychological symptoms. A woman's temperament and perceived social support may play important roles in the development of such symptomatology. The main objective of the present work was to evaluate whether social support is an effective coping resource against the development of symptoms of depression and anxiety, especially among women with certain personality types, while also considering previous prenatal losses.

METHODS

The participants were 534 pregnant women in their 26th week of gestation. They completed measures related to social support, temperament (i.e. neuroticism and extraversion) and symptoms of depression and anxiety and informed us of any previous prenatal losses.

RESULTS

The association between social support and depression was negative only for women who scored high on neuroticism. Extraversion did not interact with social support to predict depression or anxiety. Additionally, temperament interacted with previous prenatal losses, playing a relevant role in the development of anxiety symptoms. Previous losses had a greater effect on women who scored low in extraversion or high in neuroticism. Finally, a triple interaction between temperament, social support and previous prenatal loss emerged, indicating that previous prenatal loss was related to anxiety in women with low social support and low extraversion.

CONCLUSION

Pregnant women, especially those who have suffered a previous prenatal loss and score high in neuroticism or low in extraversion, may benefit from interventions that enhance social support.

The Relationship of Religious Coping with Psychological Well-being, Psychological Resilience, and Grief Severity in Women Who Had Experienced Perinatal Loss in Türkiye

The objective of this study was to investigate the relationship between religious coping strategies and three key variables: psychological well-being, psychological resilience, and grief intensity, in a sample of women who had experienced perinatal loss. The study was designed as a descriptive and correlational study. The study was completed by reaching 208 (approximately 68.1%) of the 305 women who experienced perinatal loss. Data were collected using the Personal Information Form, the Religious Coping Scale, the Psychological Well-Being Scale, the Psychological Resilience Scale, and the Perinatal Grief Scale. Bivariate analysis revealed a positive relationship of positive religious coping with psychological well-being and psychological resilience. Conversely, a negative relationship was found with perinatal grief and its sub-dimensions (p < 0.001). Furthermore, while there was negative correlation between women's negative religious coping and psychological well-being (p < 0.001), there was positive correlation between the total scale score of perinatal grief (p = 0.034) and its subscale, difficulty in coping (p = 0.003). Concurrently, the regression analysis revealed that positive religious coping was a significant predictor of enhanced psychological well-being and resilience in women, while concurrently mitigating perinatal grief (F = 281.515, p < 0.001). The study revealed that religious coping strategies employed by women who had experienced perinatal loss led to an enhancement in their psychological well-being and resilience, as well as a favorable impact on their ability to cope with perinatal grief.

The effect of nursing care during pregnancy termination on women's prenatal grief, depression, anxiety, stress and coping levels: A randomized controlled study

The termination of pregnancy is considered an emotionally devastating experience. Early intervention and counseling are essential to prevent adverse complications following pregnancy loss. This study aimed to determine the effect of nursing care based on Swanson's Theory of Caring on women's prenatal grief, depression, anxiety, stress, and coping levels during pregnancy termination. The training and counseling program, based on Swanson's Theory of Caring, included hospital care, a mobile application, and telephone follow-ups. We conducted this prospective randomized controlled experimental study in the gynecology and obstetrics clinic of a tertiary university hospital in Türkiye between September 2021 and May 2022. The study sample consisted of 50 women (intervention group: 25, control group: 25) whose pregnancy was terminated in the second trimester. The women were assigned to groups according to a randomization list created by a statistician. Data collection tools included a Personal Information Form, the Perinatal Grief Scale, the Depression, Anxiety, and Stress Scale, the Coping and Adaptation Process Scale, and the Numerical Rating Scale. We collected the data during hospitalization, between the 6th and 8thweeks after discharge, and at the 12thweek. We performed a chi-square test, a paired samples t-test, and an independent samples t-test on the IBM Statistical Package for the Social Sciences Statistics 26. The intervention group had lower mean perinatal grief (54.76 ± 19.49), depression (2.56 ± 2.39), anxiety (2.08 ± 2.10), and stress (3.52 ± 1.78) scores and higher mean coping and adjustment scores (140.48 ± 11.47) than the control group(p < .05). The intervention group also had a lower perception of labor pain, shorter discharge time, and a higher level of readiness for a new pregnancy (p < .05). The program that we applied in the study was effective in managing the pregnancy termination and post-discharge period in the population we studied.

Complicated grief following the perinatal loss: a systematic review

BACKGROUND

Perinatal loss is a severe stressor that usually triggers distressing symptoms of acute grief. Moreover, acute grief can worsen with time and become a chronic debilitating state known as complicated grief. However, there is a lack of comprehensive reviews on this topic. This systematic review aims to synthesize the existing literature on complicated grief following the perinatal loss.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, CINAHL, ProQuest, and Web of Science to identify articles on complicated grief symptoms and influencing factors following perinatal loss. We performed a comprehensive, structured evaluation in full compliance with PRISMA guidelines.

RESULTS

A systematic search produced 1163 results. Of these, 38 articles met the full-text screening criteria, and 10 pieces of literature met the inclusion criteria. Individuals may experience complicated grief following perinatal loss, manifesting in symptoms such as emotional reactions, physical responses, and social impairments. Furthermore, based on existing evidence, influencing factors include demographic characteristics, reproductive characteristics, marital relationships, social support, and coping strategies.

CONCLUSIONS

Complicated grief following perinatal loss is easily overlooked and has not been adequately studied. Further empirical research is needed to explore the symptoms and factors influencing this condition. A better understanding of complicated grief will help develop and optimize care strategies, informing future clinical practice and improving psychological support for individuals affected by perinatal loss.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023473510.

Effectiveness of Nonpharmacological Interventions for Improving the Mental Health and Other Psychosocial Outcomes of Parents with Perinatal Loss: A Systematic Review and Meta-Analysis

The objective of this study was to assess the effectiveness of nonpharmacological interventions in enhancing the mental health and psychosocial outcomes of parents who have experienced perinatal loss, in comparison to active/inactive control groups. It also sought to identify the characteristics and components of effective interventions in the included studies. A comprehensive search was conducted across seven databases from January 2008 to December 2023. The analysis included randomized controlled trials (RCTs) published in English journals and dissertations that reported at least one mental health outcome postintervention for parents with perinatal loss. Twenty-one RCTs were included. The findings demonstrated significant improvements of nonpharmacological interventions in the grief, posttraumatic stress disorder, depression, anxiety, and perceived social support of parents with perinatal loss, with moderate-to-high certainty of evidence. Optimal characteristics of nonpharmacological interventions for parents with perinatal loss were identified to inform future studies, including the intervention approaches (cognitive-based interventions), delivery modalities (face-to-face), and formats (individual-based), and a recommended number of sessions of four or fewer. To validate these findings and explore the process of nonpharmacological interventions in improving health outcomes for parents with perinatal loss from diverse backgrounds, further rigorous RCTs with larger sample sizes and longer follow-up periods are required.

Compounding stress: A mixed-methods study on the psychological experience of miscarriage amid the COVID-19 pandemic

BACKGROUND

Experiencing a miscarriage can have profound psychological implications, and the added strain of the COVID-19 pandemic may have compounded these effects. This study aimed to explore the psychological experiences, assess the levels of psychological distress (depression, anxiety, and post-traumatic stress disorder), and examine the relationships of personal significance of miscarriage and perceived stress with psychological distress of women in North Carolina who suffered a miscarriage of a desired pregnancy between March 30, 2020, and February 24, 2021, of the COVID-19 pandemic, at 14 to 31 months after the loss.

METHODS

We conducted a cross-sectional mixed-methods study using a convergent parallel design. A total of 71 participants from North Carolina completed the online survey and 18 completed in-depth interviews. The survey assessed demographics, mental health and reproductive history, personal significance of miscarriage, perceived stress, anxiety, depression, and PTSD. Interview questions asked about the psychological experience of the miscarriage and how the COVID-19 pandemic affected them and their experience.

RESULTS

Findings indicated moderate to severe levels of depression, anxiety, and PTSD, which persisted 14 to 31 months post-miscarriage. After conducting hierarchical binary logistic regressions, we found that perceived stress and prior trauma increased the odds of depression, perceived stress increased the odds of anxiety, and personal significance and prior trauma increased the odds of PTSD symptoms 14-31 months post-miscarriage. Notably, a subsequent successful childbirth emerged as a protective factor against depression, anxiety, and PTSD. Qualitative findings depicted emotions such as profound isolation, guilt, and grief. Women noted that additional pandemic-specific stressors exacerbated their distress. The categories identified via conventional content analysis fell under five broader thematic groups: mental health disorders, negative emotions/feelings, positive emotions/feelings, thoughts, and other experiences.

CONCLUSIONS

Miscarriage during the COVID-19 pandemic intensified and added complexity to the psychological distress experienced by affected women. The study underscores the need for comprehensive mental health screenings, specialized support for vulnerable groups, and the necessity of trauma-informed care. Providers are strongly encouraged to adopt a multifaceted, individualized approach to patient care that is cognizant of the unique stressors introduced by the pandemic.

Impact of miscarriage and termination of pregnancy on subsequent pregnancies: A longitudinal study of maternal and paternal depression, anxiety and eudaimonia

BACKGROUND

Although miscarriage and termination of pregnancy affect maternal mental illnesses on subsequent pregnancies, their effects on the positive mental health (e.g., eudaimonia) of both first-time and multi-time parents have received minimal attention, especially for fathers. This longitudinal study examines the effects of experiences of miscarriage and termination on parental well-being in subsequent pregnancies from prenatal to postpartum years, while simultaneously considering parity.

METHODS

Pregnant women and their partners were recruited during early prenatal visits in Taiwan from 2011 to 2022 and were followed up from mid-pregnancy to 1 year postpartum. Six waves of self-reported assessments were employed.

RESULTS

Of 1813 women, 11.3 % and 14.7 % had experiences of miscarriage and termination, respectively. Compared with the group without experiences of miscarriage or termination, experiences of miscarriage were associated with increased risks of paternal depression (adjusted odds ratio = 1.6, 95 % confidence interval [CI] = 1.13-2.27), higher levels of anxiety (adjusted β = 1.83, 95 % CI = 0.21-3.46), and lower eudaimonia scores (adjusted β = -1.09, 95 % CI = -1.99 to -0.19) from the prenatal to postpartum years, particularly among multiparous individuals. Additionally, experiences of termination were associated with increased risks of depression in their partner.

LIMITATIONS

The experiences of miscarriage and TOP were self-reported and limited in acquiring more detailed information through questioning.

CONCLUSIONS

These findings highlight the decreased well-being of men whose partners have undergone termination of pregnancy or experienced miscarriage, and stress the importance of interventions aimed at preventing adverse consequences among these individuals.

Termination of pregnancy due to fetal anomaly: A qualitative study from Turkey on women's experiences

BACKGROUND

Termination of pregnancy due to fetal anomaly is an unexpected traumatic event for women. It can cause serious complications that can negatively affect both the physical and psychological health of women.

AIM

This study aims to examine the experiences of women who underwent medical termination for fetal anomaly in the second trimester.

METHODS

The study included 12 women whose pregnancies were terminated due to fetal anomaly. Data were collected through in-depth interviews until data sufficiency was reached. Thematic analysis method was used to analyze the data. This study was conducted using an inductive qualitative design. The women's statements were examined and double-coded. By examining the codes, main themes were created after sub-themes.

RESULTS

Women's experiences were analyzed in five themes: difficulty in decision-making (1), emotional impact (2), stigmatization (3), dilemma between hope and anxiety (4), and post-termination care and support needs (5). Participants stated that they experienced many emotions such as indecision, sadness, helplessness, guilt, and remorse during the medical termination process. Hope, anxiety, fear, social pressure and support needs were also frequently experienced in this process.

CONCLUSION

Termination of pregnancy in the second trimester due to fetal anomaly caused significant psychological symptoms. In order to prevent long-term health complications, it will be important for health professionals to provide interventions designed to meet the demands of women diagnosed with fetal anomaly.

Psychosocial intervention programme based on the needs of women undergoing termination of pregnancy for foetal anomalies: A modified Delphi study

AIM

To construct a psychosocial intervention programme for women diagnosed with foetal anomalies based on their needs in China.

DESIGN

A three round-modified Delphi survey from September to November 2020.

METHODS

In Round 1, based on literature review and qualitative interviews, a face-to-face meeting with eight taskforce members was conducted to generate the initial intervention indicators. In Round 2 and 3, 15 experts and three stakeholders (women undergoing termination of pregnancy for foetal anomalies) were invited by email to evaluate the importance of the indicators and built the final psychosocial intervention programme.

RESULTS

The response rate for both two rounds is 100%. The experts' authority coefficient was 0.86. The Kendall W value of the two rounds ranged between 0.191 and 0.339. A needs-based psychosocial intervention programme was established, including four periods (denial, confirmation, decision-making and recovery), three needs-based supports (information, social and acceptance commitment therapy) and 27 intervention indicators. The mean value of the importance of each index was 4.00-5.00. Further research is required to evaluate whether this programme is realistic and effective for the target audiences.

Perinatal grief creates vulnerability to anxiety in subsequent pregnancy: the mediating role of bereavement-related guilt

AIM

This study examines the associations among perinatal grief symptoms, bereavement-related guilt, and pregnancy-related anxiety in subsequent pregnancy within the framework of a hypothesised mourning model.

METHOD

Pregnant women with history of a perinatal loss were recruited using convenience sampling methods and completed a questionnaire set including the Perinatal Grief Scale, Bereavement Guilt Scale, and Pregnancy-related Anxiety Scale.

RESULTS

Mediation analysis was performed to evaluate the hypothesised model in a sample of pregnant women with history of a perinatal loss (N = 111). The results indicated that bereavement-related guilt functions as a mediator in the relationship between perinatal grief severity and pregnancy-related anxiety experienced in subsequent pregnancies.

CONCLUSION

These findings were evaluated in light of previous studies, providing a bereavement-based perspective on the potential transmission of the mental effects of perinatal loss to subsequent pregnancy.

Care in pregnancy after stillbirth

Pregnancy after stillbirth is associated with increased risk of stillbirth and other adverse pregnancy outcomes including fetal growth restriction, preeclampsia, and preterm birth in subsequent pregnancies. In addition, pregnancy after stillbirth is associated with emotional and psychological challenges for women and their families. This manuscript summarizes information available to guide clinicians for how to manage a pregnancy after stillbirth by appreciating the nature of the increased risk in future pregnancies, and that these are not affected by interpregnancy interval. Qualitative studies have identified clinician behaviors that women find helpful during subsequent pregnancies after loss which can be implemented into practice. The role of peer support and need for professional input from the antenatal period through to after the birth of a live baby is discussed. Finally, areas for research are highlighted to develop care further for this group of women at increased risk of medical and psychological complications.

Depression, anxiety, self-efficacy, and self-esteem in high-risk pregnancy

BACKGROUND

The aim of the study was to evaluate the levels of depression, state and trait anxiety, self-efficacy, and self-esteem among women with high-risk pregnancy due to previous adverse pregnancy outcomes (PAPOs) or prepregnancy diseases (PPD), before and after delivery, compared to controls.

METHODS

An observational longitudinal study on psychological dimensions was conducted on 86 women attending a university referral center for high-risk pregnancy, by administering the Edinburgh Postnatal Depression Scale, the State and Trait Anxiety Inventory, the General Self-Efficacy Scale, and the Self-esteem Scale. A pretest (in the third trimester of pregnancy) and a follow-up measurement session (one month after the delivery) were applied. PAPOs group, PPD group and controls were compared.

RESULTS

The PAPOs group had higher levels of depression compared to the other groups, with above-threshold levels. However, a more relevant decrease in depression was found in the PAPOs group after delivery. Levels of self-efficacy and self-esteem were unexpectedly high during and after pregnancy in all the groups.

CONCLUSIONS

A PAPO represents a risk factor for depression development during pregnancy, whereas a PPD seems to be less relevant in influencing affective dimensions. Surprisingly, all pregnant women, independently of the obstetric risk, showed high levels of self-efficacy and self-esteem.

Evaluating patient experience to improve care in a specialist antenatal clinic for pregnancy after loss

In the United Kingdom, roughly 1 in 250 babies are stillborn each year. Most women who experience stillbirth become pregnant again - 80% within a year of loss. Presently, obstetric-led care is recommended; though there is a growing body of evidence to support provision of specialist services. The Rainbow Clinic is a specialist antenatal service providing care for pregnancies after loss incorporating clinical and psychological care. This study aimed to assess patient experience at the Rainbow Clinic and identify areas for clinical improvement. A 13-item questionnaire was distributed to pregnant women who attended the Rainbow Clinics at the Oxford Road and Wythenshawe sites of Saint Mary's Hospital, Manchester, UK between July 2016 and June 2021. Descriptive statistics and unpaired t-test were used for quantitative data and summative content analysis for qualitative data. Four-hundred and fifty-six women completed the questionnaire. The mean patient experience score per quarter was stable with an average of 21.1 (± 3.0) for the five years, with a maximum attainable score of 25. The COVID-19 pandemic had no effect on patient experience at the Rainbow Clinic (pre-pandemic vs. during-pandemic: mean 21.2 v 21.3; p = 0.75). Free-text responses demonstrated women felt positively about the antenatal care received. Identified areas for improvement included "more awareness of the [Rainbow] sticker" to ensure women with previous loss are identified; increased publicity of the Rainbow Clinic services; developing more clinics at different locations to improve accessibility; and continuing specialist input into intrapartum care. Specialist antenatal care provided by the Rainbow Clinic was rated as of a high standard. Potential future improvements include sticker alterations (or other mechanisms to identify women who have experienced a previous loss) and develop increased awareness of the clinic in other institutions.

Prevalence of depression and depressive symptoms in women with previous miscarriages or stillbirths - A systematic review

Women who have had miscarriages or stillbirths are known to have an elevated risk for depression. However, the prevalence of depressive disorders and/or symptoms in this group is unclear. Therefore, our aim was to estimate the corresponding prevalence of depression and depressive symptoms. A systematic literature search of the databases MEDLINE, psycINFO and PSYNDEX was conducted to consider all studies published between 2000 and 2022 in English or German on the prevalence of depression or depressive symptoms in women following miscarriages or stillbirths. Studies using valid psychiatric diagnoses or validated assessment methods regarding depression were included in the systematic review. The PRISMA guidelines were followed. Data concerning depressive symptoms were extracted from 14 studies. The range regarding prevalence of depressive symptoms in women with previous miscarriages or stillbirths was very wide (5%-91.2%). All longitudinal studies demonstrate a reduction of depressive symptoms over time. The prevalence of depressive disorders had a range of 5.4 (only for minor depression according to DSM-IV) - 18.6% (for depressive disorders according to ICD-10). The included studies are very heterogeneous considering the investigated groups, the length of pregnancies and time passed since the occurrence of miscarriages or stillbirths. Women with miscarriages or stillbirths have an elevated risk for depressive symptoms and disorders. In most affected women, depressive symptoms are most pronounced in the first months after the pregnancy loss and diminish over time.

Effect of adverse perinatal outcomes on postpartum maternal mental health in low-income and middle-income countries: a protocol for systematic review

INTRODUCTION

More than three-fourths of adverse perinatal outcomes (preterm, small for gestational age, low birth weight, congenital anomalies, stillbirth and neonatal death) occur in low-income and middle-income countries. These adverse perinatal outcomes can have both short-term and long-term consequences on maternal mental health. Even though there are few empirical studies on the effect of perinatal loss on maternal mental illness, comprehensive information on the impact of adverse perinatal outcomes in resource-limited settings is scarce. Therefore, we aim to systematically review and synthesise evidence on the effect of adverse perinatal outcomes on maternal mental health.

METHODS AND ANALYSIS

The primary outcome of our review will be postpartum maternal mental illness (anxiety, depression, post-traumatic stress disorder and postpartum psychosis) following adverse perinatal outcomes. All peer-reviewed primary studies published in English will be retrieved from databases: PubMed, MEDLINE, CINAHL Ultimate (EBSCO), PsycINFO, Embase, Scopus and Global Health through the three main searching terms-adverse perinatal outcomes, maternal mental illness and settings, with a variant of subject headings and keywords. We will follow the Joanna Briggs Institute critical appraisal checklist to assess the quality of the studies we are including. The review findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. Estimate-based meta-analysis will be performed. We will assess heterogeneity between studies using the I2 statistics and publication bias will be checked using funnel plots and Egger's test. A subgroup analysis will be conducted to explore potential sources of heterogeneity (if available). Finally, the certainty of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Since this systematic review does not involve human participants, ethical approval is not required. The review will be submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023405980.

Relationship between air pollutants and spontaneous abortion in a coal resource valley city: a retrospective cohort study

OBJECTIVE

Pollutants in the atmosphere have been linked to poor pregnancy outcomes in women. However, such investigations are scarce in metropolitan northern China. The major exposure window of air pollution affecting pregnant women is also unknown.

METHODS

For the analysis, this retrospective cohort study enrolled 6960 pregnant women recorded at Tongchuan People's Hospital from January 2018 to December 2019. Pollutant concentration values from the nearest monitoring station to the pregnant women were used to estimate exposure doses for each exposure window. Logistic regression models were created to investigate the connection between pollutants and spontaneous abortion while controlling for confounding factors.

RESULTS

PM2.5 was a risk factor for spontaneous abortion in T3 (30-60 days before the first day of the last menstrual period [LMP]), (OR: 1.305, 95% CI: 1.143-1.490) and T4 (60-90 days before the first day of the LMP),(OR: 1.450, 95% CI: 1.239-1.696) after controlling for covariates. In the same window, PM10 was a risk factor (OR: 1.308, 95% CI: 1.140-1.500), (OR: 1.386, 95% CI: 1.184-1.621). In T2 (30 days before the first day of the LMP), T3, and T4, SO2 was a risk factor for spontaneous abortion (OR: 1.185, 95% CI: 1.025-1.371), (OR: 1.219, 95% CI: 1.071-1.396), (OR: 1.202, 95% CI: 1.040-1.389). In T3 and T4, NO2 was a risk factor (OR: 1.171, 95% CI: 1.019- 1.346), (OR: 1.443, 95% CI: 1.259-1.655). In T1 (from the first day of the LMP to the date of abortion), O3 was found to be a risk factor (OR: 1.366, 95% CI: 1.226-1.521).

CONCLUSION

Exposure to high levels of air pollutants before and during pregnancy may be a risk factor for spontaneous abortion in pregnant women. This study further illustrates the importance of reducing air pollution emissions.

The needs of women experiencing perinatal loss: A qualitative systematic review and meta-synthesis

PROBLEM

There have been some studies on the needs of women experiencing perinatal loss in various socio-cultural contexts, but there is no research that systematically and comprehensively synthesizes these needs.

BACKGROUND

Perinatal loss has profound psychosocial effects. The misconceptions and prejudices existing in the public, the lack of satisfactory clinical care, and the available social support may all increase the negative impact.

AIM

To synthesize evidence for the needs of women experiencing perinatal loss, attempt to explain the findings, and provide insights into the application of evidence.

METHODS

Published papers were searched in seven electronic databases until 26 March 2022. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the methodological quality of the included studies. Through meta-aggregation, the data was extracted, rated, and synthesized, resulting in new categories and findings. The credibility and dependability of the synthesized evidence were evaluated by ConQual.

FINDINGS

Thirteen studies that fulfilled the inclusion criteria and quality assessment were included in the meta-synthesis. Five synthesized findings were identified, covering information needs, emotional needs, social needs, clinical care needs, as well as spiritual and religious needs.

CONCLUSION

Women's perinatal bereavement needs were individualized and diverse. There is a necessity to understand, identify, and respond to their needs in a sensitive and personalized way. Families, communities, healthcare institutions, and society form a coordinated whole and provide accessible resources to improve recovery from perinatal loss and a satisfactory outcome in the subsequent pregnancy.

'You're never pregnant in the same way again': prior early pregnancy loss influences need for health care and support in subsequent pregnancy

STUDY QUESTION

What are couples' needs for health care and support in a subsequent pregnancy after prior early pregnancy loss (PL) and how do needs change across the pregnancy?

SUMMARY ANSWER

Couples described unmet needs for pregnancy care in the first 20 weeks of pregnancy and were more satisfied with the care provided during the remainder of the pregnancy.

WHAT IS KNOWN ALREADY

Despite early PL being common (∼25% of pregnancies), there is a paucity of research to guide practice to optimize treatment and support future pregnancies. There has been low priority for the issue in research and a pervasive acceptance that couples should 'just try again' after experiencing PL. Women with prior PL report increased anxiety during the first trimester of pregnancy compared to those without previous PL. No longitudinal studies explore what couples' needs are throughout the pregnancy and how these needs shift across time.

STUDY DESIGN SIZE DURATION

This was a qualitative longitudinal dyadic (joint) interview study. In total, 15 couples who were pregnant after a prior PL were interviewed four times over their pregnancy. Couples were recruited from the Copenhagen Pregnancy Loss Cohort Research Programme. Interviews were held in person at the hospital or university, or online. Interviews ranged from 20 to 91 min (mean = 54 min).

PARTICIPANTS/MATERIALS SETTING METHODS

Inclusion criteria included couples with one to two prior early PL(s) who self-reported a new pregnancy and were willing to be interviewed together and in English. Couples were interviewed four times: after a positive pregnancy test and once in each trimester. Interviews were transcribed and data were analysed using thematic analysis to compare and contrast needs of the couples at each of the four time periods in the pregnancy and across the entire pregnancy. One same-sex couple and 14 heterosexual couples participated.

MAIN RESULTS AND THE ROLE OF CHANCE

Couples' needs were categorized into two main longitudinal themes across the pregnancy, divided by the 20-week scan. Within each longitudinal theme, there were two themes to represent each time period. In the longitudinal theme 'The first 20 weeks: a 'scary' gap in care' there were two themes: Positive pregnancy test: 'Tell them it's not the same pregnancy' and First trimester: 'We craved that someone was taking care of us'. The standard pregnancy care offered in the public healthcare system in Denmark includes a scan at 12 and 20 weeks. While all couples wished for additional access to scans and monitoring of the foetus in early pregnancy to provide reassurance and detect problems early, they described considerable variation in the referrals and care they were offered. Both partners expressed a high degree of worry and anxiety about the pregnancy, with pregnant women in particular describing 'surviv[ing] from scan to scan' in the early weeks. Couples took scans wherever offered or paid for comfort scans, but this resulted in fragmented care. Instead, they wished for continuity in care, and acknowledgement and sensitivity that a pregnancy after PL is not the same as a first pregnancy. In the longitudinal theme 'The second 20 weeks: Safety in the care system' there were two themes: Second trimester: 'I think we are in good hands' and Third trimester: 'It's more of a 'nice to know' everything is OK than a 'need to know'. Couples reported their distress was lower and overall needs for care were met during this time. They expressed general satisfaction with regular or extended antenatal support although, as in the first 20 weeks, additional acknowledgement and sensitivity regarding their history of PL was desired. Couples said they felt more secure given that they had access to a 24-hour telephone support by midwife/nurse if they had any concerns or questions.

LIMITATIONS REASONS FOR CAUTION

Participants were self-selected from an ongoing cohort study of patients presenting at hospital with PL. Single women were not included in the study. This study was limited to data collection in Denmark; however, other countries with public healthcare systems may have similar offerings with regard to their provision of antenatal care, care provided in recurrent pregnancy loss (RPL) clinics and the availability of private scans.

WIDER IMPLICATIONS OF THE FINDINGS

The findings underscore that an early PL creates an increased need for monitoring and care in a subsequent pregnancy. This study highlights a gap in pregnancy care for those with a history of PL given that their need for monitoring and support is high in the early weeks of a new pregnancy before they have access to antenatal care, and before they have had multiple PLs and can be referred to the RPL unit.

STUDY FUNDING/COMPETING INTERESTS

This project has received funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 101028172 for E.K. The Copenhagen Pregnancy Loss Cohort is funded by a grant from the BioInnovation Institute Foundation. H.S.N. has received scientific grants from Freya Biosciences, Ferring Pharmaceuticals, BioInnovation Institute, Ministry of Education, Novo Nordisk Foundation, Augustinus Fonden, Oda og Hans Svenningsens Fond, Demant Fonden, Ole Kirks Fond, and Independent Research Fund Denmark. H.S.N. received personal payment or honoraria for lectures and presentations from Ferring Pharmaceuticals, Merck, Astra Zeneca, Cook Medical, Gedeon Richter, and Ibsa Nordic. All other authors declare no competing interests.

Identification of Factors Affecting Self-Efficacy in Women with Spontaneous Pregnancy Loss

Pregnancy loss is a difficult situation that can affect a woman's physical and psychological health, and thus requires appropriate management and support. An individual's sense of self-efficacy is an important factor in the process of coping with a problem. Therefore, an analysis of self-efficacy in women after spontaneous pregnancy loss is warranted, so as to establish its association with social support, socio-demographic variables, quality of care, and specific behaviors of the medical staff. The cross-sectional study was performed in a group of 610 patients hospitalized due to spontaneous pregnancy loss in hospitals in Lublin (Poland). The study used a diagnostic survey with questionnaires: Generalized Self-Efficacy Scale (GSES), the Berlin Social Support Scales (BSSS), and a standardized interview questionnaire. Post-pregnancy loss patients rated partner support highest (M = 9.25), while the best-rated category of social support was perceived available instrumental support (M = 3.78). In relation to medical personnel, the quality of care provided by midwives was rated the highest (M = 4.57). The study demonstrated a statistically significant (p < 0.05) association between the selected socio-demographic factors and the specific types and sources of support on the one hand, and generalized self-efficacy on the other, in the patients after pregnancy loss who were studied. Socio-demographic factors that affected self-efficacy in the respondents included their relationship status and socio-economic standing. Self-efficacy is positively correlated with social support in women after pregnancy loss.

Parents experiences of pregnancy following perinatal loss: An integrative review

BACKGROUND

Pregnancy following perinatal loss has a profound effect on parents and may contribute to intense psychological distress including grief, post-traumatic stress disorder, anxiety and depression. The subsequent pregnancy may also be perceived as more stressful due to the fear of recurrent loss. Midwives and other health care professionals need to be sensitive and empathetic to the needs of these parents when providing care in a pregnancy subsequent to a loss.

METHODOLOGY

The aim of this integrated literature review was to explore parents' experiences of pregnancy following a previous perinatal loss using a systematic approach. This is presented in a five-stage process that includes problem identification, literature search, data extraction and evaluation, data analysis and presentation of results. A systematic search of seven electronic databases was conducted (Jan 2009 -Jan 2023) to identify relevant primary research which addressed parents' experiences of pregnancy following a previous perinatal loss. Seven papers met the eligibility criteria and were assessed for quality using Crowe's Critical Appraisal Tool (CCAT). Thematic analysis identified two themes.

FINDINGS

The key themes identified from the literature were; the psychosocial needs and challenges faced by previously bereaved parents in subsequent pregnancies; and the need for specialist care and support in a subsequent pregnancy. Psychological needs and challenges included continued grief, depression, anxiety, and disparities in the grief process between men and women. The importance of specialist care with an increased level of support from competent, confident and compassionate health care providers was highlighted.

CONCLUSION

The experience of pregnancy following a perinatal loss can be a complex emotional experience for parents. The review identifies the need for post pregnancy loss debriefing and counselling and care pathways specific to caring for women and their partners in a pregnancy subsequent to a perinatal loss. Care in pregnancy subsequent to loss should be provided by empathetic, competent health care providers and include additional antenatal clinic appointments, pregnancy monitoring and psychological support in order to meet the needs of these expectant parents.

Alteration of the Gut Microbiota in Missed Abortion

There is a symbiotic relationship between gut microbiota and human beings. Imbalance of the gut microbiota will cause pathological damages to humans. Although many risk factors are associated with missed abortion (MA), the pathological mechanism of it is still unclear. Here, we analyzed gut flora of the patients with MA by S16 high-throughput sequencing. The possible pathogenic mechanisms of the MA were explored. Fecal samples from 14 healthy controls and 16 MA patients were collected to do 16S rRNA gene high-throughput sequencing analysis. The abundance of the Bacteroidetes, Proteobacteria, Actinobacteria, Escherichia, Streptococcus_ Salivarius, and Lactobacillus was significantly reduced in the MA group, while, the abundance of the Klebsiella was significantly increased in the MA patients. The Ruminococcaceae and [Eubacterium]_coprostanoligenes_group were found only in the specimens of the MA patients. The Fabrotax function prediction analysis showed that four photosynthesis function bacteria (cyanobateria, oxygenic_photoautotrophy, photoautotrophy, and phototrophy) only existed in the MA group. In the analysis of the BugBase microbiome function prediction, the Escherichia of the MA group is significantly reduced compared to that of the healthy controls in the items of that Contains_Mobile_Elements, Facultatively_Anaerobic, Forms_Biofilms, Potentially_Pathogenic.png, Gram_Nagative, and Stress_Tolerant_relabundance. These alterations may affect the stability of the host's immune, neural, metabolic and other systems by interfering with the balance of the gut microbiota or by the metabolites of those bacteria, causing the MA. This study explored the possible pathogenic factors of the gut microbiota of the MA. The results provide evidence to figure out the pathogenesis of the MA.

Counseling pregnant people after previous termination of pregnancy for fetal anomaly (TOPFA): the double RAINBOW approach

BACKGROUND AND OBJECTIVES

Pregnancy loss is exceptionally common, yet there exist few interventions for clinical providers to assist parents who are expecting again. Perhaps even less prevalent are practice models for parents who have terminated a pregnancy due to fetal anomaly (TOPFA). In this article, we present the "Double Rainbow" acronym, which provides evidence-supported guidance for counseling people experiencing a subsequent pregnancy after TOPFA.

DESIGN AND METHODS

Using prompts of: Remember; Rehearse & Anticipate; Attach & Internalize; Interrogate decision; Neutralize; Normalize; Bond; Breathe & Observe; Optimize health; Weave and Whole story, we tie intervention techniques to evidence-based treatments and clinical practice examples.

RESULTS

Filling a gap for guidance for effective intervention with people during subsequent pregnancies after termination of pregnancy due to fetal anomaly, we aim to improve such treatment while also encouraging evaluation of the approach, encouraging evaluation of its use with broader populations.

CONCLUSIONS

The double RAINBOW approach weaves together evidence-based therapies while also attending to the work of distinguishing past losses and promoting parental attachment and caregiving systems in clients who have terminated a pregnancy due to fetal anomaly.

Anxiety and depression in pregnant women who have experienced a previous perinatal loss: a case-cohort study from Scandinavia

BACKGROUND

Perinatal loss can have long-lasting adverse effects on a woman's psychosocial health, including during subsequent pregnancies. However, maternal mental health status after perinatal loss during subsequent pregnancy is understudied with very little data available for Scandinavian populations.

AIMS

The primary aim of the study was to explore the association between previous perinatal loss and anxiety/depression symptoms of expectant mothers during the subsequent pregnancy. The secondary aim of this study was to explore possible determinants of maternal mental health during the subsequent pregnancy, independent of previous perinatal loss.

METHOD

This case-cohort study is based on primary data from Scandinavian Successive Small-for-Gestational Age Births Study (SGA Study) in Norway and Sweden. The total case-cohort sample in the current study includes 1458 women. Cases include 401 women who had reported a previous perinatal loss (spontaneous abortion, stillbirth, or neonatal death) and who responded to two mental health assessment instruments, the State-Trait Anxiety Inventory (STAI), and the Centre for Epidemiological Studies Depression (CES-D) scale. Multiple linear regression models were used to assess the association between previous perinatal loss and maternal mental health in subsequent pregnancy.

RESULTS

Scandinavian pregnant women with previous perinatal loss reported higher symptoms for both anxiety and depression during their subsequent pregnancy compared to mothers in the same cohort reported no previous perinatal loss. Multiple linear regression analyses showed a positive association between previous perinatal loss and per unit increase in both total anxiety score (β: 1.22, 95% CI: 0.49-1.95) and total depression score (β: 0.90, 95% CI: 0.06-1.74). We identified several factors associated with maternal mental health during pregnancy independent of perinatal loss, including unintended pregnancy despite 97% of our population being married/cohabitating.

CONCLUSION

Women who have experienced previous perinatal loss face a significantly higher risk of anxiety and depression symptoms in their subsequent pregnancy.

The association between history of prenatal loss and maternal psychological state in a subsequent pregnancy: an ecological momentary assessment (EMA) study

BACKGROUND

Prenatal loss which occurs in approximately 20% of pregnancies represents a well-established risk factor for anxiety and affective disorders. In the current study, we examined whether a history of prenatal loss is associated with a subsequent pregnancy with maternal psychological state using ecological momentary assessment (EMA)-based measures of pregnancy-specific distress and mood in everyday life.

METHOD

This study was conducted in a cohort of N = 155 healthy pregnant women, of which N = 40 had a history of prenatal loss. An EMA protocol was used in early and late pregnancy to collect repeated measures of maternal stress and mood, on average eight times per day over a consecutive 4-day period. The association between a history of prenatal loss and psychological state was estimated using linear mixed models.

RESULTS

Compared to women who had not experienced a prior prenatal loss, women with a history of prenatal loss reported higher levels of pregnancy-specific distress in early as well as late pregnancy and also were more nervous and tired. Furthermore, in the comparison group pregnancy-specific distress decreased and mood improved from early to late pregnancy, whereas these changes across pregnancy were not evident in women in the prenatal loss group.

CONCLUSION

Our findings suggest that prenatal loss in a prior pregnancy is associated with a subsequent pregnancy with significantly higher stress and impaired mood levels in everyday life across gestation. These findings have important implications for designing EMA-based ambulatory, personalized interventions to reduce stress during pregnancy in this high-risk group.

Anxiety of pregnant women in time of catastrophic events, including COVID-19 pandemic: a systematic review and meta-analysis

PURPOSE

In March 2020, daily life was disrupted by the new virus SARS-CoV-2, which causes COVID-19. Pandemic-related prenatal anxiety could lead to depression, a risk factor for adverse pregnancy outcomes and abnormal neonatal development. This study aimed to investigate the impact of anxiety on the mental health of pregnant women exposed to catastrophic events as compared to those without such exposure.

MATERIALS AND METHODS

PubMed/MEDLINE, Web of Science, Cochrane Library, Scopus, and EMBASE were searched for relevant studies. This study compared the prevalence of anxiety among pregnant women during a catastrophic event.

RESULTS

Fifteen full texts were assessed for inclusion, with 3 included, 10 excluded for not meeting criteria, and 2 excluded for other reasons. The included studies were published before the current COVID-19 pandemic but included the SARS 2003 outbreak. During the current COVID-19 pandemic, 10 further studies were conducted, but they failed to meet the inclusion criteria. A meta-analysis of two studies using STAI revealed that women exposed to a catastrophic event had a higher mean STAI score of 1.82 points (95% CI: 0.47-3.18 points).

CONCLUSION

Women with complications during pregnancy should be assessed for anxiety independently from catastrophic events. During financial crises, environmental or other disasters, special attention should be given to women with low risk, normal pregnancies.

Women's experiences of a pregnancy whilst attending a specialist antenatal service for pregnancies after stillbirth or neonatal death: a qualitative interview study

Aim: Pregnancy after the death of a baby is associated with numerous, varied psychological challenges for pregnant women. This study aimed to explore women's experiences of pregnancy whilst attending a specialist antenatal service for pregnancies after a perinatal death.Methods: Semi-structured interviews with twenty women in a subsequent pregnancy after a perinatal death were conducted and analyzed taking an inductive thematic analysis approach.Results: All women expressed a heightened "awareness of risk". Two subthemes demonstrated how increased awareness of risk affected their experience and their desire regarding antenatal and postnatal support. Women talked about stillbirth being a "quiet, unspoken subject" causing them internal conflict as they had an awareness of pregnancy complications that other people did not. Navigating subsequent pregnancies relied on them "expecting the worst and hoping for the best" in terms of pregnancy outcomes. Women viewed specialist antenatal care in pregnancy after perinatal loss favorably, as it enabled them to receive tailored care that met their needs stemming from their increased awareness of and personal expectations of risk.Conclusion: Women's experiences can be used to develop models of care but further studies are required to determine to identify which components are most valued.

Assessing the accuracy and quality of YouTube videos on early pregnancy loss

Objective

To assess the accuracy and quality of YouTube videos pertaining to early pregnancy loss for use as a patient education tool.

Methods

A cross-sectional study was conducted via YouTube search using the keywords "miscarriage," "spontaneous abortion," "pregnancy loss," and "pregnancy failure." The first 20 results for each keyword search, sorted by both relevance and view count, were compiled into a list. Descriptive characteristics, including the numbers of views, likes, dislikes, video length, and duration of upload were collected. All videos were independently evaluated by two physician researchers using two unique assessment tools. The Currency, Relevance, Authority, Accuracy, and Purpose (CRAAP) test was used to measure the reliability of video content. The Miscarriage-Specific Question Score (MSQS) criterion was used to objectively assess video content specific to miscarriage. Inter-rater agreement was analyzed via kappa coefficient and Pearson correlation.

Results

160 videos were screened, among which 74 videos were included for analysis. The mean CRAAP score was 8.3 out of a total possible score of 15, demonstrating good quality sources, though not of academic level. Mean MSQS score was 8.1 out of a total possible score of 24, demonstrating "fair" accuracy and comprehensiveness. Pearson correlations were 0.87 and 0.86 for CRAAP and MSQS total scores, respectively, demonstrating excellent inter-rater reliability.

Conclusion

YouTube videos related to early pregnancy loss span a wide range of quality, accuracy, and purpose. While some videos provide effective content, mean rater scores demonstrate that YouTube is not a reliable source for patient education on early pregnancy loss.

Patterns and predictors of depressive and anxiety symptoms in mothers affected by previous prenatal loss in the ALSPAC birth cohort

BACKGROUND

Studies investigating the patterns or predictors of psychological distress in expecting and postpartum mothers affected by previous prenatal loss, are limited. The study objectives were to explore longitudinal trajectory patterns of depressive and anxiety symptoms in mothers affected by previous prenatal loss from early in a subsequent pregnancy up to pre-adolescence, and to identify early factors predictive of elevated symptom trajectory patterns.

METHODS

A total of 2854 mothers from the Avon Longitudinal Study of Parents and Children self-identified as having experienced a previous prenatal loss. A latent class analysis identified trajectory patterns of symptoms across 10 timepoints from 18-weeks' gestation up to 134-months postpartum, multivariate regression analysis identified predictors of elevated symptom trajectories, and hierarchical regression analysis determined predictive accuracy between predictors and elevated trajectory patterns.

RESULTS

Three distinct longitudinal trajectory patterns of depressive and anxiety symptoms reflected low (54%), sub-clinical (34%), and clinical symptoms (12%). Key factors that predicted elevated symptom trajectory patterns better than increased symptom scores early in subsequent pregnancy include history of severe depression or other psychiatric problem, experiencing three or more stressful events from mid-pregnancy, inadequate social support, history of induced abortion, and history of abuse. Predictive accuracy of elevated trajectories was 0.542 (depression) and 0.432 (anxiety).

LIMITATIONS

Generalizability may be compromised by attrition, under-reporting, and recall bias.

CONCLUSION

Including factors predictive of long-term sub-clinical or clinical depressive and anxiety symptoms in early assessments will improve clinician's ability to identify mothers who may benefit from immediate and/or ongoing monitoring, and psychotherapeutic intervention after prenatal loss.

Incidence and predictors of paternal anxiety and depression following fetal abnormalities requiring pregnancy termination: a cross-sectional study in China

BACKGROUND

China is a country with a high prevalence of fetal abnormalities. Termination of pregnancy for fetal abnormalities (TOPFA) is a devastating traumatic event for parents and families, resulting in serious and lasting psychological problems. The impact of TOPFA on mothers has been extensively explored, but little research has been conducted on the resulting paternal psychological problems. This study sought to determine the prevalence and predictors of paternal anxiety and depression following TOPFA.

METHODS

We analysed cross-sectional data from 169 Chinese couples (169 mothers and 169 fathers) who experienced TOPFA. Anxiety was assessed with the Self-Rating Anxiety Scale (SAS), and depression was measured with the Self-Rating Depression Scale (SDS) for fathers and the Edinburgh Postnatal Depression Scale (EPDS) for mothers. We used the Social Support Rating Scale (SSRS) to assess levels of social support.

RESULTS

Overall, 19.5% of fathers and 24.3% of mothers had symptoms of anxiety, but there was no significant difference in the incidence of anxiety between fathers and mothers. However, depression was more common in mothers (50.3%) than in fathers (24.9%). Level of income (β = -2.945, 95% CI: -5.448 to -0.442), worry about the pregnancy (β = 3.404, 95% CI: 1.210 to 5.599) and objective support (β = -0.668, 95% CI: -1.163 to -0.173) were predictors of anxiety in fathers. Worry about the pregnancy (β = 4.022, 95% CI: 1.630 to 6.414), objective support (β = -0.652, 95% CI: -1.229 to -0.075) and maternal depression (β = 0.497, 95% CI: 0.159 to 0.836) were predictors of paternal depression.

CONCLUSION

Anxiety and depression were prevalent among parents following TOPFA in China, and fathers had similar levels of anxiety as mothers. Strategies to support fathers should consider social support and psychological interaction and draw upon father-inclusive intervention recommendations.

Neurobiology of Loneliness, Isolation, and Loss: Integrating Human and Animal Perspectives

In social species such as humans, non-human primates, and even many rodent species, social interaction and the maintenance of social bonds are necessary for mental and physical health and wellbeing. In humans, perceived isolation, or loneliness, is not only characterized by physical isolation from peers or loved ones, but also involves negative perceptions about social interactions and connectedness that reinforce the feelings of isolation and anxiety. As a complex behavioral state, it is no surprise that loneliness and isolation are associated with dysfunction within the ventral striatum and the limbic system - brain regions that regulate motivation and stress responsiveness, respectively. Accompanying these neural changes are physiological symptoms such as increased plasma and urinary cortisol levels and an increase in stress responsivity. Although studies using animal models are not perfectly analogous to the uniquely human state of loneliness, studies on the effects of social isolation in animals have observed similar physiological symptoms such as increased corticosterone, the rodent analog to human cortisol, and also display altered motivation, increased stress responsiveness, and dysregulation of the mesocortical dopamine and limbic systems. This review will discuss behavioral and neuropsychological components of loneliness in humans, social isolation in rodent models, and the neurochemical regulators of these behavioral phenotypes with a neuroanatomical focus on the corticostriatal and limbic systems. We will also discuss social loss as a unique form of social isolation, and the consequences of bond disruption on stress-related behavior and neurophysiology.

Are Mindfulness-Based Interventions as Effective as Cognitive Behavioral Therapy in Reducing Symptoms of Complicated Perinatal Grief? A Systematic Review

INTRODUCTION

Perinatal loss can be a devastating experience for parents that can result in complicated grief symptoms that include depression, anxiety, and posttraumatic stress. Perinatal bereavement care pathways have been developed internationally within health care services; however, there is an apparent lack of recommendations and guidance on grief-focused interventions specifically for complicated perinatal grief. Studies have analyzed the effectiveness of cognitive behavioral therapy (CBT) for perinatal grief, and more recent research has emerged on the use of mindfulness-based interventions (MBIs) for perinatal grief symptoms. The purpose of this study was to conduct a systematic review and present the effectiveness of CBT and MBIs for perinatal grief, to report patient experiences of the interventions, and to determine which intervention can be more effective in managing symptoms of complicated perinatal grief.

METHODS

A systematic search was conducted of 5 academic databases: PsycINFO, CINAHL, MEDLINE, Social Science, and ASSIA. No limits on publication date, language, or geographic location were set because of the paucity of research published on this subject. Quality appraisal was conducted for each included study. Findings are reported in accordance with the PRISMA statement.

RESULTS

This systematic review identified 8 eligible studies with a total of 681 bereaved participants. The results were examined for effectiveness of CBT and MBIs for grief; effectiveness of CBT and MBIs for depression, anxiety, and posttraumatic stress; and participant experiences. Both interventions produced favorable reductions of perinatal grief symptoms, depression, and posttraumatic stress. However, a true comparison between the 2 interventions' effect on complicated perinatal grief symptoms could not be made because of the limited studies in this area and the heterogeneity of the included studies' methods and outcomes.

DISCUSSION

Both MBIs and CBT interventions can be effective in reducing symptoms of complicated perinatal grief. The findings of this review are heavily weighted in quantitative outcome measurements. More qualitative research and randomized controlled trials with larger sample sizes are needed in this area of perinatal bereavement care.

A qualitative study of early career Australian midwives' encounters with perinatal grief, loss and trauma

PROBLEM

The health of women is dependent on midwifery workforce stability. Retaining new midwives is paramount, however without support, the early career can be a vulnerable time for midwives.

BACKGROUND

Midwives care for women who experience poor perinatal outcomes like stillbirth and neonatal death. Midwifery care in these sentinel events is complex. There is limited understanding of early career midwives' experiences within these encounters.

AIM

To understand the experiences of Australian early career midwives' clinical encounters with perinatal grief, loss and trauma.

METHODS

A qualitative descriptive/exploratory study using in-depth interviews.

FINDINGS

Four themes were identified from interview data: (1) all eyes on the skills; (2) support is of the essence; (3) enduring an emotional toll; (4) at all times, the woman. Most participants had minimal exposure to perinatal loss as a student. As a result, most felt unskilled and unprepared for this as a new midwife.

DISCUSSION

Types and degrees of support varied in these encounters. Early career midwives who were well supported reflected positively on working with grief and loss. In contrast, inadequate or absent support had detrimental effects on participant wellbeing. Poorly supported encounters with death (intrapartum fetal, early neonatal, and maternal) in the early career period were significantly distressful, giving rise to mental and emotional distress.

CONCLUSION

Pre-registration perinatal loss skill development and supported experiences are necessary for preparedness. Continued education, formalised debriefing and mentoring, institutional philosophies which promote collegial ethics of care, and the expansion of continuity of midwifery care models will improve new midwives' experiences.

The mental health impact of perinatal loss: A systematic review and meta-analysis

Perinatal loss can pose a significant risk to maternal mental health. There is limited data on the strength of association between perinatal loss and subsequent common mental health disorders (CMHD) such as anxiety, depression and post-traumatic symptoms (PTS). A systematic review and meta-analysis identified studies with control groups, published between January 1995 and March 2020 reporting validated mental health outcomes following perinatal loss. We identified 29 studies from 17 countries, representing a perinatal loss sample (n = 31,072) and a control group of women not experiencing loss (n = 1,261,517). We compared the likelihood of increased CMHD in both groups. Random-effects modelling on suggested that compared to controls, perinatal loss was associated with increased risk of depressive (RR = 2.14, 95% CI = 1.73-2.66, p < 0.001, k = 22) and anxiety disorders (RR = 1.75, 95% CI = 1.27-2.42, p < 0.001, k = 9). Compared to controls, Perinatal loss was also associated with increased depression (SMD = 0.34, 95% CI = 0.20-0.48, p < 0.001, k = 12) and anxiety scores (SMD = 0.35, 95% CI = 0.12-0.58, p < 0.003, k = 10). There were no significant effects for post-traumatic stress (PTS) outcomes (k = 3). Our findings confirm that anxiety and depression levels following perinatal loss are significantly elevated compared to "no loss" controls (live-births, non pregnant from community, or difficult live births). Elevated depression and anxiety rates were also reported for those who experienced loss during later stages of pregnancy. Assessing mental health following loss is a maternal health priority.

Complicated Grief After the Loss of a Baby: A Systematic Review About Risk and Protective Factors for Bereaved Women

This study sought to identify the factors associated with the development and prevention of complicated grief in women who have lost a baby. This is a systematic review of scientific articles in the main mental health databases: MEDLINE (PubMed), EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), and APA Databases (PsycINFO). The selection and data extraction processes occurred independently and blindly by two authors, considering the eligibility criteria. The analysis included publications from 2013 to 2021 of observational studies with adult women who had experienced losing a baby (during pregnancy up to 2 years of life) and that employed standardized instruments to evaluate grief. From the 8,200 records found, 23 articles were selected for analysis. As risk factors, we identified the presence of mother’s psychopathology, history of gestational loss, and social pressure for a new pregnancy, while as protective factors, we identified the presence of another child other than the deceased one, the quality of specialized healthcare, and the social support provided by either a partner, community, or spiritual activities. Furthermore, the studies pointed to the event of losing a baby as an opportunity for posttraumatic growth. Although complicated grief is often associated with other mental health conditions, such as anxiety, depression, or posttraumatic stress, it is necessary to differentiate it for a clearer understanding of the complicated grief as a singular condition, to enable access to appropriate care for bereaved mothers and families, as well as to promote public policies which provide support to them.

Measures of anxiety, depression and stress in the antenatal and perinatal period following a stillbirth or neonatal death: a multicentre cohort study

BACKGROUND

The grief associated with the death of a baby is enduring, however most women embark on another pregnancy, many in less than a year following their loss. Symptoms of anxiety and depression are reported to be increased in pregnancies after perinatal death, although effect on maternal stress is less clear. Variation between individual studies may result from differences in gestation at sampling, the questionnaire used and the type of antecedent perinatal death. We aimed to describe quantitative measures of anxiety, depression, stress and quality of life at different timepoints in pregnancies after perinatal death and in the early postnatal period.

METHODS

Women recruited from three sites in the North-West of England. Women were asked to participate if a previous pregnancy had ended in a perinatal death. Participants completed validated measures of psychological state (Cambridge Worry Score, Edinburgh Postnatal Depression Score (EPDS), Generalized Anxiety Disorder 7-item score) and health status (EQ-5D-5L™ and EQ5D-Visual Analogue Scale) at three time points, approximately 15 weeks' and 32 weeks' gestation and 6 weeks postnatally. A sample of hair was taken at approximately 36 weeks' gestation for measurement of hair cortisol in a subgroup of women. The hair sample was divided into samples from each trimester and cortisol measured by ELISA.

RESULTS

In total 112 women participated in the study. Measures of anxiety and depressive symptoms decreased from the highest levels at 15 weeks' gestation to 6-weeks postnatal (for example mean GAD-7: 15 weeks 8.2 ± 5.5, 6 weeks postnatal 4.4 ± 5.0, p<0.001). Hair cortisol levels fell in a similar profile to anxiety and depression symptoms (p<0.05). In contrast, the median EQ-5D index, measuring health status was 0.768 at 15 weeks' gestation (Interquartile range (IQR) 0.684-0.879), 0.696 at 32 weeks' (IQR 0.637-0.768) and 0.89 (0.760-1.00) at 6 weeks postnatal. There was a negative relationship between EPDS and perceived health status.

CONCLUSIONS

This study demonstrated heightened anxiety and depressive symptoms and elevated cortisol levels in women in pregnancies after a stillbirth or neonatal death which decrease as pregnancy progresses. Further studies are needed to determine optimal care for women to address these negative psychological consequences.

Mindfulness-based intervention in Chinese pregnant women with recurrent miscarriage: A non-randomized controlled study

OBJECTIVE

Pregnant women with recurrent miscarriage have high rates of anxiety and depression. Mindfulness-based interventions have shown benefits in improving mental health in diverse populations; however, few studies have explored their efficacy in pregnant women with recurrent miscarriage, which was investigated in the present study.

DESIGN

A nonrandomized controlled study was carried out from August 2019 to November 2020.

SETTING

The study was conducted at a regional teaching hospital in Guangzhou, China that provides leading care for recurrent miscarriage.

PARTICIPANTS

A total of 158 pregnant women with recurrent miscarriage were recruited and allocated to the intervention group (n = 79) or the control group (n = 79); 131 women completed the study.

INTERVENTION

The mindfulness-based intervention consisted of a 1-h education session and daily mindfulness exercises guided by audio recordings during hospitalization.

MEASUREMENTS AND FINDINGS

Study outcomes included perceived stress measured with the Perceived Stress Scale; symptoms of anxiety and depression measured with the Self-rating Anxiety Scale and Edinburgh Postnatal Depression Scale, respectively; and positive and negative affect measured with the Positive Affect and Negative Affect Scale - Revised, respectively. Compared to the control group, participants in the intervention group showed significant decreases in perceived stress, depression symptoms, and negative affect and an increase in positive affect after the intervention. Anxiety increased significantly in the control group during the study but remained unchanged in the intervention group.

KEY CONCLUSIONS

A mindfulness-based intervention can reduce psychological symptoms and improve mental health in pregnant women with recurrent miscarriage.

IMPLICATIONS FOR PRACTICE

A mindfulness-based intervention should be incorporated into routine care to help improve the mental health of pregnant women with recurrent miscarriage.

Association Between Serious Psychological Distress and Loneliness During the COVID-19 Pandemic: A Cross-Sectional Study with Pregnant Japanese Women

Purpose

Pregnant women are vulnerable to stress. The coronavirus disease 2019 (COVID-19) has caused a global pandemic and created significant stress for many people. Social distancing to reduce the spread of COVID-19 has also reduced social interactions, which has increased social isolation and loneliness. Loneliness is thought to increase perceived stress, cause psychological distress, and increase the risk of mental illness, such as depression. This study examined the association between serious psychological distress (SPD) and loneliness during the COVID-19 pandemic in pregnant Japanese women.

Patients and Methods

An internet survey of 1022 pregnant women in Japan was conducted between June 1 and July 21, 2021. The 6-item Kessler Psychological Distress Scale, 3-item Revised UCLA Loneliness Scale, and Fear of COVID-19 Scale were used as measurement tools. The prevalence of SPD was defined as a K6 score of ≥13.

Results

The prevalence of SPD was 16.5%. Multivariate analysis revealed that the risk factors for SPD were younger age (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.01 to 1.10; p = 0.020), history of abortion or miscarriages (OR 1.56; 95% CI 1.04 to 2.36; p = 0.034), unemployment (OR 1.67; 95% CI 1.14 to 2.45; p = 0.008), fear of COVID-19 (OR, 1.12; 95% CI, 1.08 to 1.17; p < 0.001), and loneliness (OR 1.53; 95% CI 1.38 to 1.70; p < 0.001).

Conclusion

Pregnant women in Japan showed a high prevalence of SPD. Younger age, unemployment, history of abortion or miscarriages, fear of COVID-19, and loneliness were independently associated with SPD. Clinicians and health officials should pay particular attention to the psychological health of pregnant women during the COVID-19 pandemic.

The brain oxytocin and corticotropin-releasing factor systems in grieving mothers: What we know and what we need to learn

The bond between a mother and her child is the strongest bond in nature. Consequently, the loss of a child is one of the most stressful and traumatic life events that causes Prolonged Grief Disorder in up to 94 % of bereaved parents. While both parents are affected, mothers are of higher risk to develop mental health complications; yet, very little research has been done to understand the impact of the loss of a child, stillbirth and pregnancy loss on key neurobiological systems. The emotional impact of losing a child, e.g., Prolonged Grief Disorder, is likely accompanied by dysregulations in neural systems important for mental health. Among those are the neuropeptides contributing to attachment and stress processing. In this review, we present evidence for the involvement of the brain oxytocin (OXT) and corticotropin-releasing factor (CRF) systems, which both play a role in maternal behavior and the stress response, in the neurobiology of grief in mothers from a behavioral and molecular point of view. We will draw conclusions from reviewing relevant animal and human studies. However, the paucity of research on the tragic end to an integral bond in a female's life calls for the need and responsibility to conduct further studies on mothers experiencing the loss of a child both in the clinic and in appropriate animal models.

Addressing Perinatal Mental Health Risk within a Fetal Care Center

Diagnosis of a fetal anomaly in pregnancy increases the risk for perinatal mental health difficulties, including anxiety, depression, and traumatic stress among expectant parents. Common emotional challenges include uncertainty about the diagnosis/prognosis, anticipated neonatal course, fears of fetal or neonatal demise, loss of a typical, uncomplicated pregnancy and postpartum course, and disruption of family roles due to medical care-related activities and restrictions. Psychologists in multidisciplinary fetal care centers are uniquely positioned to assess mental health risks and address the needs of expectant parents. Psychologists bring additional expertise in screening and assessment, clinical interventions to promote coping and symptom reduction while preparing for birth and a complicated neonatal course, consultation and effective communication, and programmatic development. This review paper provides an overview of the challenges and behavioral health risks for expectant parents carrying a fetus with a birth defect and the unique role psychologists play to support patients and families within fetal care settings.

Association of maternal exposure to ambient particulate pollution with incident spontaneous pregnancy loss

BACKGROUND

Maternal exposure to ambient fine particulate matter (PM2.5) is a potential risk factor for pregnancy loss, but the extant findings are inconsistent. One reason for the inconsistency is the difficulty of distinguishing spontaneous from induced pregnancy losses, particularly in countries with planning policies.

OBJECTIVE

To examine the association between maternal PM2.5 exposure and spontaneous incident pregnancy loss in China.

METHODS

A total of 18,513 women of reproductive age was recruited from Jiangsu Province, China, in 2007. Among them, 2451 women reported 2613 valid records of incident pregnancies from 2007 to 2010. We used Cox regression to link the outcomes (live birth, spontaneous pregnancy loss, or induced abortion) of those incident pregnancies with maternal PM2.5 exposures, assessed using well-developed estimates of historical concentrations at the county level.

RESULTS

Among the 2613 incident pregnancies, 69 spontaneous pregnancy losses, 596 induced abortions, and 1948 live births occurred. According to the adjusted model, each 10-μg/m3 increment in the average PM2.5 concentration during pregnancy was associated with a 43.3% (95% confidence interval, 6.6-92.5%) increased probability of spontaneous pregnancy loss. Advanced maternal age, a potential competing risk factor, weakened the association between PM2.5 and spontaneous pregnancy loss. The association was nonsignificant for unintended pregnancies.

CONCLUSION

Maternal PM2.5 exposure was associated significantly with incident spontaneous pregnancy loss. Our findings provide insight into the harmful effect of air pollution on human reproduction.

Anxiety, depression and social support across pregnancy in women with a history of recurrent miscarriage: A prospective study

AIM

Women with a history of recurrent miscarriage are a vulnerable population. This study aimed to examine changes and relationships among anxiety, depression and social support across three trimesters of pregnancy in women with a history of recurrent miscarriage.

METHODS

A prospective, longitudinal study was employed. A convenience sample of 166 pregnant women with a history of recurrent miscarriage completed the measures at their 6-12, 20-24 and 32-36 gestational weeks.

RESULTS

The prevalence of anxiety at early, middle and late pregnancy was 47.6%, 36.1% and 32.5%, respectively, whereas that of depression was 38%, 34.3% and 31.3%, respectively. Social support scores increased from early pregnancy to middle pregnancy then remained in late pregnancy. There were correlations among anxiety, depression and social support across pregnancy.

CONCLUSIONS

Anxiety and depression were highly prevalent in pregnant women with a history of recurrent miscarriage, especially in early pregnancy when the level of social support was the lowest. Social support is an essential buffer against anxiety and depression throughout the pregnancy.

Perinatal Grief and Post-Traumatic Stress Disorder in Pregnancy after Perinatal Loss: A Longitudinal Study Protocol

Background: Pregnancies that follow perinatal loss are often associated with mental health disorders, which are not usually treated or even identified. Objectives: The main study aim is to identify the prevalence of symptoms of post-traumatic stress disorder and complicated perinatal grief at different stages of pregnancy following a prior gestational loss. Methods: This descriptive longitudinal study will be conducted with a twelve-month follow-up. The study variables addressed will include sociodemographic data (age, sex, education, marital status, employment status and obstetric history) together with clinical data on complicated perinatal grief and post-traumatic stress disorder scores. Results: The results obtained are expected to provide a new perspective on the healthcare approach to perinatal loss and subsequent pregnancy. Conclusions: We seek to optimise comprehensive healthcare in cases of pregnancy following previous perinatal loss and to evaluate options to minimise possible risks.

History of perinatal loss: A study of psychological outcomes in mothers and fathers after subsequent healthy birth

BACKGROUND

The loss of an expected child is a psychologically difficult and potentially traumatic life event. While most women will become pregnant again within a year following the loss, data are limited regarding the mental health of parents with a history of perinatal loss, especially in the period following the birth of a subsequent healthy child. This study, therefore, investigated the relation between perinatal loss and mothers' and fathers' psychological symptoms and parenting stress 6-months after the birth of a healthy child.

METHODS

A community sample of 92 mother-father dyads living in a Canadian city and having a 6-month-old biological infant were asked to complete questionnaires measuring their history of perinatal losses (55 parents reporting at least one loss) and their psychological symptoms and parenting stress.

RESULTS

Mothers and fathers who have experienced a perinatal loss reported more psychological symptoms and parenting stress. Mothers were more likely to report psychological symptoms and parenting stress compared to fathers, but the magnitude of the relation between perinatal losses and psychological outcomes were comparable for mothers and fathers.

LIMITATIONS

Limitations of the study include the use of a small community sample with low generalizability and low levels of psychological symptoms and stress.

CONCLUSIONS

The results suggest that the experience of a perinatal loss might have negative consequences on the psychological wellbeing of parents even after the birth of a healthy child.

Quality of life, social support and self-efficacy in women after a miscarriage

Background

Pregnancy loss is typically experienced as a traumatic, critical event, which may lead to secondary psychological health disorders. Its burden involves both the experience of loss and related medical issues, which are associated with pain, hospitalization, limitation in one’s social roles, decreased sense of security, and changes in one’s perceived quality of life. The purpose of the present study was to evaluate levels of quality of life (QoL), social support and self-efficacy among women who had suffered a miscarriage.

Methods

The study was performed using a diagnostic survey method with questionnaires administered to 610 patients hospitalized due to spontaneous pregnancy loss in hospitals in Lublin (Poland). The instruments used were: the Berlin Social Support Scales (BSSS), the Generalized Self-Efficacy Scale (GSES), the WHOQoL–BREF questionnaire, and a standardized interview questionnaire.

Results

Respondents rated their overall quality of life (3.90 points) higher than their overall perceived health (3.66). In terms of social support, the highest scores were noted for perceived available instrumental support (M = 3.78), perceived available emotional support (M = 3.68) and actually received support (M = 3.60). The mean generalized self-efficacy score among the women after pregnancy loss was 30.29. Respondents’ QoL was significantly correlated with multiple social support subscales and self-efficacy (p < 0.05).

Conclusions

Women after a miscarriage perceive their overall quality of life as better than their overall health, while reporting the poorest QoL in the psychological domain. They also have a high level of self-efficacy. Regarding the types of social support, perceived available support, both instrumental and emotional, and actually received support was rated highly. Social support and self-efficacy contributed to better perceived QoL among the respondents.

Maternal and Paternal Depression During Pregnancy in China: Prevalence, Correlates, and Network Analysis

BACKGROUND

Depression is a commonly seen mental health concern for mothers and fathers during their transition to parenthood. This study aims to provide new insights into the prevalence of maternal and paternal depression, its demographic and clinical correlates, and its symptom network among Chinese pregnant women and their partners.

METHODS

In this multicenter, cross-sectional study, 769 pregnant women and their partners were assessed by Edinburgh Postnatal Depression Scale (EPDS) from June 15th to Sep 15th, 2020 in southern China. Convenient sampling method was used. Univariate analyses, multivariate logistic regression, and network analyses were conducted. Networks of maternal and paternal depression were compared.

RESULTS

In total, 60 (EPDS total score ≥13, 7.80%, 95% CI: 5.90-9.70%) women and 23 (2.99%, 95% CI: 1.78-4.20%) of these women's partners reported depression. Physical comorbidities (OR=2.664, P=0.003) was the only factor that was found to significantly correlate with maternal depression. Network analyses showed that the resulting networks were well connected and that there was significant difference of network structure between maternal and paternal depression (M=0.330, P<0.001). Centrality plot indicated that "sad or miserable" (strength=1.097) was the most central symptom in the maternal depression network, while "scared or panicky" (strength=1.091) was the most central node in the paternal network. The edge between "things have been getting on top of me" - "able to laugh and see the funny side of things" (difference: 0.153, P=0.020), and "scared or panicky" - "the thought of harming myself" (difference: 0.084, P<0.001) was significantly stronger in women's partners than that in pregnant women.

CONCLUSION

Maternal and paternal depression during pregnancy could result in significant negative consequences. Symptoms like "sad or miserable" and "scared or panicky" are critical and might be potential targets for further interventions. Evidence-based treatments, such as pharmacology, psychotherapy, community reinforcement and family training, might be beneficial for parents with depression during and after the pregnancy.

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.

The Prevalence of Depression and Its Association With Quality of Life Among Pregnant and Postnatal Women in China: A Multicenter Study

Background: This study examined the prevalence of depressive symptoms (depression hereafter) and its association with quality of life (QOL) among pregnant and postnatal women in China. Methods: In this multi-center, cross-sectional study, 1,060 pregnant and postnatal women from eight hospitals were assessed. Depression and QOL were measured using the Edinburgh Postnatal Depression Scale and the World Health Organization Quality of Life Questionnaire - brief version, respectively. Results: The prevalence of depression was 7.45% (95% CI: 5.87-9.04%) in the sample. Women with depression had lower QOL in physical, psychological, social and environmental domains compared to those without. Women with physical comorbidities were more likely to suffer from depression (OR = 2.391, 95% CI = 1.384-4.130, P = 0.002). Conclusion: Due to its negative association with QOL, increased attention should be paid to depression in pregnant and postnatal women. Regular screening assessment and preventive measures should be adopted to reduce risk of depression in this population.