Predicting depressive symptoms after miscarriage: a path analysis based on the Lazarus paradigm

Effects of Person-Centered Information for Parents of Children With Cancer (the PIFBO Study): A Randomized Controlled Trial

Background: Conveying information to parents is a core part of pediatric oncology nursing; however, most published interventions do not tailor information to individual parental needs. Objective: To evaluate the effect on parental illness-related stress of person-centered information provided to parents of children with cancer. Methods: A multicenter, unblinded randomized controlled trial with two parallel arms recruiting parents of children diagnosed within the past two months from two tertiary children's cancer centers in Sweden. Parents were randomized using sealed envelopes prepared and opened by an independent person. Parents in the intervention arm met four times with experienced nurses trained in the intervention, whereas controls received standard care. The effect of the intervention was measured five times regarding parents' illness-related stress. Secondary outcomes were psychosocial states, experiences with healthcare providers, and received information. Further, we collected process data on the intervention's content and fidelity. Results: Of the 32 parents included and analyzed in the study, 16 were randomized to the intervention, which addressed a broad variety of topics. The intervention increased parents' knowledge about the biophysiological and functional aspects of their child's illness, but it had no measurable effect on their distress. Discussion: Although fidelity to the intervention protocol was sufficient, the study was flawed by recruitment difficulties, primarily due to organizational factors, which may have prevented us from observing any possible effects on psychosocial distress. Having a person-centered perspective could be promising for future studies aimed at parents of children with cancer. (Registered at Clinicaltrials.gov, number NCT02332226.).

Nursing Administration: Watson's Theory of Human Caring

Watson's human caring theory is widely used in nursing clinical practice, education, and research; however, further discussion on the application of this theory in administration is needed. The authors in this article aim to substruct Watson's theory of human caring for nursing administration. Major elements of the theory-transpersonal caring dimensions, caring competencies, and caring moments-are presented in a model of substruction that links the theoretical basis to methodology. In conclusion, this theory can be used as a framework or a conceptual model in nursing administration within an organization.

Developing a theory-informed complex intervention to improve nurse-patient therapeutic engagement employing Experience-based Co-design and the Behaviour Change Wheel: an acute mental health ward case study

OBJECTIVES

Our objectives were threefold: (1) describe a collaborative, theoretically driven approach to co-designing complex interventions; (2) demonstrate the implementation of this approach to share learning with others; and (3) develop a toolkit to enhance therapeutic engagement on acute mental health wards.

DESIGN AND PARTICIPANTS

We describe a theory-driven approach to co-designing an intervention by adapting and integrating Experience-based Co-design (EBCD) with the Behaviour Change Wheel (BCW). Our case study was informed by the results of a systematic integrative review and guided by this integrated approach. We undertook 80 hours of non-participant observations, and semistructured interviews with 14 service users (7 of which were filmed), 2 carers and 12 clinicians from the same acute ward. The facilitated intervention co-design process involved two feedback workshops, one joint co-design workshop and seven small co-design team meetings. Data analysis comprised the identification of touchpoints and use of the BCW and behaviour change technique taxonomy to inform intervention development.

SETTING

This study was conducted over 12 months at an acute mental health organisation in England.

RESULTS

The co-designed Let's Talk toolkit addressed four joint service user/clinician priorities for change: (1) improve communication with withdrawn people; (2) nurses to help service users help themselves; (3) nurses to feel confident when engaging with service users; (4) improving team relations and ward culture. Intervention functions included training, education, enablement, coercion and persuasion; 14 behaviour change techniques supported these functions. We detail how we implemented our integrated co-design-behaviour change approach with service users, carers and clinicians to develop a toolkit to improve nurse-patient therapeutic engagement.

CONCLUSIONS

Our theory-driven approach enhanced both EBCD and the BCW. It introduces a robust theoretical approach to guide intervention development within the co-design process and sets out how to meaningfully involve service users and other stakeholders when designing and implementing complex interventions.

Effect of supportive care on the psychosocial health status of women who had a miscarriage

PURPOSE

This study aims to determine the effect of individualized care provided based on Swanson's Caring Theory on the grief, depression, anxiety, and stress levels of women who had a miscarriage.

DESIGN AND METHODS

A total of 104 women who experienced a miscarriage were randomized as study (n = 52) and control (n = 52) groups.

FINDINGS

The women's physical, emotional, behavioral, and cognitive grief symptoms decreased after receiving Swanson's care (P < .001). Negative feelings about the future, level of depression, and anxiety levels diminished after receiving Swanson's Care (P < .001).

PRACTICE IMPLICATIONS

Supportive care and counseling provided after miscarriage were found to contribute to women's psychosocial well-being and to improve their ability to cope with psychological symptoms.

Tensions and Contradictions in Interns' Communication about Unexpected Pregnancy Loss

Early miscarriage is an unexpected pregnancy complication that affects up to 25% of pregnant women. Physicians are often tasked with delivering the bad news of a pregnancy loss to asymptomatic women while also helping them make an informed decision about managing the miscarriage. Assessing the communicative responses, particularly the discursive tensions embedded within providers' speech, offers insight into the (in)effective communication used in the delivery of bad news and the management of a potentially traumatic medical event. We observed and analyzed transcripts from 40 standardized patient encounters using Baxter's relational dialectics theory 2.0. Results indicated that interns invoked two primary distal already-spoken discourses: discourses of medicalization of miscarriage and discourses of rationality and informed consent. We contend that tensions and contradictions could affect how women respond to the news of an impending miscarriage and offer practical implications for communication skills training.

Evaluation of the impact of an augmented model of The Productive Ward: Releasing Time to Care on staff and patient outcomes: a naturalistic stepped-wedge trial

Background

Improving the quality and efficiency of healthcare is an international priority. A range of complex ward based quality initiatives have been developed over recent years, perhaps the most influential programme has been Productive Ward: Releasing Time to Care. The programme aims to improve work processes and team efficiency with the aim of ‘releasing time’, which would be used to increase time with patients ultimately improving patient care, although this does not form a specific part of the programme. This study aimed to address this and evaluate the impact using recent methodological advances in complex intervention evaluation design.

Method

The objective of this study was to assess the impact of an augmented version of The Productive Ward: Releasing Time to Care on staff and patient outcomes. The design was a naturalistic stepped-wedge trial. The setting included fifteen wards in two acute hospitals in a Scottish health board region. The intervention was the Productive Ward: Releasing Time to Care augmented with practice development transformational change methods that focused on staff caring behaviours, teamwork and patient feedback. The primary outcomes included nurses’ shared philosophy of care, nurse emotional exhaustion, and patient experience of nurse communication. Secondary outcomes covered additional key dimensions of staff and patient experience and outcomes and frequency of emergency admissions for same diagnosis within 6 months of discharge.

Results

We recruited 691 patients, 177 nurses and 14 senior charge nurses. We found statistically significant improvements in two of the study’s three primary outcomes: patients’ experiences of nurse communication (Effect size=0.15, 95% CI; 0.05 to 0.24), and nurses’ shared philosophy of care (Effect size =0.42, 95% CI; 0.14 to 0.70). There were also significant improvements in secondary outcomes: patients’ overall rating of ward quality; nurses’ positive affect; and items relating to nursing team climate. We found no change in frequency of emergency admissions within six months of discharge.

Conclusions

We found evidence that the augmented version of The Productive Ward: Releasing Time to Care Intervention was successful in improving a number of dimensions of nurse experience and ward culture, in addition to improved patient experience and evaluations of the quality of care received. Despite these positive summary findings across all wards, intervention implementation appeared to vary between wards. By addressing the contextual factors, which may influence these variations, and tailoring some elements of the intervention, it is likely that greater improvements could be achieved.

Trial registration number

UKCRN 14195.

Qualitative Assessment of Bad News Delivery Practices during Miscarriage Diagnosis

Miscarriage is one of the most common pregnancy complications health care providers discuss with patients. Previous research suggests that women's distress is compounded by ineffective communication with providers, who are usually not trained to deliver bad news using patient-centered dialogue. The purpose of this study was to use a patient-centered approach to examine women's experiences with and perspectives of communication during a miscarriage to assist in the development of communication training tools for health care providers. During focus groups, 22 women who had experienced miscarriage discussed video-recorded standardized patient-provider interactions and recalled communication during their own miscarriages. Results of a pragmatic iterative analysis of the transcripts suggest training techniques and communication behaviors that should guide education for providers to deliver the diagnosis of and treatment options for early pregnancy loss, such as demonstrating empathy, creating space for processing, checking for understanding, and avoiding medical jargon and emotionally charged language.

"It's not something you expect a 15-year-old to be sad about": Sources of Uncertainty and Strategies of Uncertainty Management among Adolescent Women Who Have Experienced Miscarriage

Approximately 10%-25% of adolescent pregnancies end in miscarriage, yet we know little about the experience of miscarriage among women in this age group. To better understand the medical and psychosocial challenges faced by adolescent women who experience a miscarriage, we conducted interviews with 31 college-aged women who had experienced a miscarriage between the ages of 15 and 19. We analyzed interview transcripts using qualitative descriptive analysis and found that adolescent women experience various medical (e.g., insufficient medical knowledge, unknown etiology), personal (e.g., competing identities, lack of autonomy in decision-making), and relational (e.g., emotional invalidation, relational insecurity) sources of uncertainty in miscarriage in ways that are unique to the population of adolescent women. Women in our sample appraised their uncertainty positively and negatively (sometimes simultaneously) and reported using a variety of management strategies to facilitate their desired level of uncertainty, including information seeking, avoidance, health behavior change, and reframing the miscarriage.

Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance

Background

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships.

Objectives

We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings.

Design

Systematic literature review.

Data sources

The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted.

Review methods

Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment.

Results

Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality.

Conclusions

The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.

Does a new spatial design in psychiatric inpatient care influence patients' and staff's perception of their care/working environment? A study protocol of a pilot study using a single-system experimental design

Background

Research shows that worn-out physical environments are obstacles to psychiatric inpatient care. Patients want better relationships with staff and things to do; staff want an environment that offers hope, a calm atmosphere, and joint activities. A county council in northern Sweden and Philips Healthcare partnered to create solutions to the environmental challenges of psychiatric inpatient care. One ward at a county psychiatric clinic was selected for a pilot project to test solutions that could improve the care environment for patients, staff, and relatives. The aim of the overall project is to evaluate the effects of a newly designed psychiatric inpatient ward on patients and staff in terms of quality of care and stress. In this study, we focus on the feasibility through testing questionnaires and exploring barriers to recruiting staff and patients.

Methods

This study had a single-system experimental design, comparing a psychiatric unit pre- and post-implementation of the novel spatial design, using repeated measures with the same questionnaires twice a week during baseline and intervention phases. Primary outcomes were quality interactions (patients) and perceived stress (staff). Secondary outcomes were levels of anxiety and depression (patients), and stress of conscience (staff). A process evaluation was aimed to describe contextual factors and participant experiences of the new design. Data was collected using questionnaires and semi-structured individual interviews with patients and focus group discussions with staff. Both visual and statistical methods were used to analyse the quantitative data and content analysis for the qualitative data.

Discussion

The findings will contribute insights into whether and how a new spatial design might contribute to quality interactions and reduced stress. This is relevant both nationally and internationally, as similar interventions are needed but sparse. The findings will be disseminated through peer-reviewed publications and conference presentations.

Trial registration

ClinicalTrials.gov, NCT03140618, registered 4 May 2017

Time Together: A nursing intervention in psychiatric inpatient care: Feasibility and effects

The facilitation of quality time between patients and staff in psychiatric inpatient care is useful to promote recovery and reduce stress experienced by staff. However, interventions are reported to be complex to implement and are poorly described in the literature. This multisite study aimed to evaluate the feasibility and effects of the nursing intervention Time Together, using mixed methods. Data consisted of notes from participant observations and logs to evaluate feasibility, and questionnaires to evaluate effects. The primary outcome for patients was quality of interactions, and for staff, it was perceived stress. The secondary outcome for patients was anxiety and depression symptom levels, and for staff, it was stress of conscience. Data were analysed using visual analysis, percentage of nonoverlapping data, and qualitative content analysis. The results showed that Time Together was a feasible intervention, but measurements showed no effects on the two patient outcomes: quality of interactions and anxiety and depressive symptoms and, questionable effects on perceived stress and stress of conscience among staff. Shared responsibility, a friendly approach, and a predictable structure enabled Time Together, while a distant approach and an unpredictable structure hindered the intervention. In conclusion, the intervention proved to be feasible with potential to enable quality interactions between patients and staff using the enabling factors as supportive components. It also had some effects on perceived stress and stress of conscience among staff. Further evaluation is needed to build on the evidence for the intervention.

Communicated Sense-making After Miscarriage: A Dyadic Analysis of Spousal Communicated Perspective-Taking, Well-being, and Parenting Role Salience

Grounded in communicated sense-making (CSM) theorizing, we investigated communicated perspective-taking (CPT; i.e., conversational partners' attendance to and confirmation of each other's views) in association with individual and relational well-being in married couples who had miscarried (n = 183; N = 366). Actor-partner interdependence modeling revealed husbands' perceptions of wives' CPT were positively related to husbands' positive affect about the miscarriage and both spouses' relational satisfaction, as well as negatively associated with wives' positive affect. Wives' perceptions of husbands' CPT related positively to their own relational satisfaction and negatively to husbands' negative affect. Analyses revealed identification as a parent to the miscarried child (i.e., "parenting role salience") positively moderated the relationship between CPT and relational satisfaction. Implications for advancing CSM theorizing in health contexts and practical applications are explored.

Prevalence of positive depression screen among post miscarriage women- A cross sectional study

BACKGROUND

Miscarriages are a common pregnancy complication affecting about 10-15% of pregnancies. Miscarriages may be associated with a myriad of psychiatric morbidity at various timelines after the event. Depression has been shown to affect about 10-20% of all women following a miscarriage. However, no data exists in the local setting informing on the prevalence of post-miscarriage depression. We set out to determine the prevalence of positive depression screen among women who have experienced a miscarriage at the Aga Khan University hospital, Nairobi.

METHODS

The study was cross-sectional in design. Patients who had a miscarriage were recruited at the post-miscarriage clinic review at the gynecology clinics at Aga Khan University Hospital, Nairobi. The Edinburgh postpartum depression scale was used to screen for depression in the patients. Prevalence was calculated from the percentage of patients achieving the cut -off score of 13 over the total number of patients.

RESULTS

A total of 182 patients were recruited for the study. The prevalence of positive depression screen was 34.1% since 62 of the 182 patients had a positive depression screen. Moreover, of the patients who had a positive depression screen, 21(33.1%) had thoughts of self-harm.

CONCLUSION

A positive depression screen is present in 34.1% of women in our population two weeks after a miscarriage. Thoughts of self-harm are present in about a third of these women (33.1%) hence pointing out the importance of screening these women using the EPDS after a miscarriage.

Comparison of Telemedicine to Traditional Face-to-Face Care for Children with Special Needs: A Quasiexperimental Study

BACKGROUND

Services for Children with Special Healthcare Needs (CSHCN) have been challenging in terms of cost and access to appropriate healthcare services.

OBJECTIVES

The objectives of this study were to examine cost, caring, and family-centered care in relationship to pediatric specialty services integrating telemedicine visits compared to traditional face-to-face visits only for (CSHCN) in rural, remote, and medically underserved areas.

METHODS

This study used a prospective, quasiexperimental research design with 222 parents or legal guardians of CSHCN receiving pediatric specialty care. The traditional group (n = 110) included families receiving face-to-face pediatric specialty care and the telemedicine group (n = 112) included families who had telemedicine visits along with traditional face-to-face pediatric specialty care.

RESULTS

Results indicated no significant differences in family costs when the telemedicine group was compared to traditional face-to-face care. When the telemedicine group was asked to anticipate costs if telemedicine was not available, there were significant differences found across all variables, including travel miles, cost of travel, missed work hours, wages lost, child care cost, lodging cost, other costs, and total family cost (p < 0.001). There were no differences in the families' perceptions of care as caring. Parents/guardians perceived the system of care as significantly more family-centered when using telemedicine (p = 0.003).

CONCLUSIONS

The results of this study underscore the importance of facilitating access to pediatric specialty care by use of telemedicine. We endorse efforts to increase healthcare access and decrease cost for CSHCN by expanding telemedicine and shaping health policy accordingly.

Does 'Time Together' increase quality of interaction and decrease stress? A study protocol of a multisite nursing intervention in psychiatric inpatient care, using a mixed method approach

INTRODUCTION

Despite the long-known significance of the nurse-patient relationship, research in psychiatric inpatient care still reports unfulfilled expectations of, and difficulties in, interactions and relationships between patients and staff. Interventions that create structures to allow quality interactions between patients and staff are needed to solve these problems. The aim of this project is to test effects of the nursing intervention Time Together and to evaluate the intervention process.

METHODS AND ANALYSIS

This is a multisite study with a single-system experimental design using frequent measures. The primary outcomes are quality interactions for patients and perceived stress for staff. Secondary outcomes are levels of symptoms of anxiety and depression for patients and stress of conscience for staff. A process evaluation is performed to describe contextual factors and experiences. Data are collected using questionnaires, participant observations and semistructured interviews. For analysis of quantitative data, both visual and statistical methods will be used. Qualitative data will be analysed using qualitative content analysis.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethical Review Board in the region (Dnr 2016/339-31). The findings will contribute to the development of nursing interventions in general, but more specifically to the development of the intervention. This is relevant both nationally and internationally as similar interventions are needed but sparse. The findings will be disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT02981563.

Miscarriage at advanced maternal age and the search for meaning

Although it has been documented that miscarriage is a common pregnancy outcome and more likely to happen among women aged 35 years and older, there is very little research on the quality of such a lived experience. This study features phenomenological interviews of 10 women aged 35 years and older. Theoretical frameworks of ambiguous loss and feminism guide the design and analysis. The salient themes suggest that women experience miscarriage from a physical, emotional, temporal, and social context that includes intense loss and grief, having a sense of otherness, a continuous search for meaning, and feelings of regret and self-blame.

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.

Taiwanese women's process of recovery from stillbirth: a qualitative descriptive study

The purpose of this qualitative descriptive study was to portray the recovery process of Taiwanese women after stillbirth. Data were generated through individual in-depth interviews with 21 women selected using purposeful sampling. Three stages in an emotional journey of recovery were suffering from silent grief, searching for a way out, and achieving peace of mind and mental stability. Throughout their journey, the women's overarching concern was where the deceased child had gone and whether it was well. Together these stages composed A pathway to peace of mind, a mental journey on which women struggled to spiritually connect with the lost baby and finally sought a personal pathway to emotional peace. Findings can inform healthcare providers in providing culturally sensitive care for Taiwanese women to facilitate healing after a stillbirth.

Meta-analysis to obtain a scale of psychological reaction after perinatal loss: focus on miscarriage

Pregnancy has different meanings to different women depending upon their circumstances. A number of qualitative studies have described the experience of miscarriage by women who had desired to carry their pregnancy to full term. The aim of this meta-analysis was to identify a scale of psychological reaction to miscarriage. Meta-analysis is a quantitative approach for reviewing articles from scientific journals through statistical analysis of findings from individual studies. In this review, a meta-analytic method was used to identify and analyze psychological reactions in women who have suffered a miscarriage. Different reactions to stress associated with the period following miscarriage were identified. The depression reaction had the highest average, weighted, unbiased estimate of effect (d₊ = 0.99) and was frequently associated with the experience of perinatal loss. Psychiatric morbidity was found after miscarriage in 27% of cases by a diagnostic interview ten days after miscarriage. The grief reaction had a medium d₊ of 0.56 in the studies included. However, grief after miscarriage differed from other types of grief after perinatal loss because the parents had no focus for their grief. The guilt is greater after miscarriage than after other types of perinatal loss. Measurement of the stress reaction and anxiety reaction seems to be difficult in the included studies, as evidenced by a low d₊ (0.17 and 0.16, respectively). It has been recommended that grief after perinatal loss be measured by an adapted instrument called the Perinatal Grief Scale Short Version.

Miscarriage Experiences of Lesbian Couples

This was a descriptive phenomenological study of 10 self-identified lesbian couples who had experienced miscarriage in the context of a committed relationship. Analysis of individual and joint open-ended interviews revealed that the experience of miscarriage for lesbian couples must be viewed from the perspective of the difficulties surrounding conception as well as the actual pregnancy loss. The overarching theme, "We are not in control," captures the struggles lesbian couples faced in conceiving their pregnancies and the sense of loss that accompanied miscarrying. These experiences constituted two sub-themes: "We work so hard to get a baby" and "It hurts so bad: The sorrow of miscarriage." Our results indicate that the experience of miscarriage is compounded by the complexities of planning and achieving pregnancy. Practitioners need to be aware of the unique perspectives lesbian couples have on pregnancy and miscarriage and remain sensitive to their unique needs. Findings may serve as an intervention framework for nurse midwives and others caring for lesbian couples after miscarriage.

Applying Heidegger's interpretive phenomenology to women's miscarriage experience

Much has been written about measuring the feelings and impressions of women regarding their experience of miscarriage. According to the existential philosopher Heidegger life experiences such as the experience of a woman having a miscarriage can be interpreted and explained only in the context of the totality of the women’s experiences in the past, the present, and the future. Thirteen in-depth interviews with women about their experiences of miscarriage were interpreted with respect to Heidegger’s “Being and Time”. By using his interpretive phenomenology the essence of the miscarriage experience was explored and defined. The women’s feelings and impressions were influenced by past experiences of miscarriage, pregnancy, and births. Present conditions in the women’s lives contributing to the experience include their relationships, working situation, and living conditions. Each woman’s future prospects and hopes have been structurally altered with regard to their aspirations for their terminated pregnancy. The impact of miscarriage in a woman’s life was found to be more important than caregiver providers and society have previously attributed to in terms of scale. The results of the interviews reveal that the women believed that only women who had experienced their own miscarriages were able to fully understand this complex womanly experience and its effects on the woman who had miscarried.

Pregnancy loss in lesbian and bisexual women: an online survey of experiences

BACKGROUND

Although pregnancy loss is a distressing health event for many women, research typically equates women's experiences of pregnancy loss to ‘married heterosexual women's experiences of pregnancy loss’. The objective of this study was to explore lesbian and bisexual women's experiences of miscarriage, stillbirth and neonatal death.

METHODS

This study analysed predominantly qualitative online survey data from 60 non-heterosexual, mostly lesbian, women from the UK, USA, Canada and Australia. All but one of the pregnancies was planned. Most respondents had physically experienced one early miscarriage during their first pregnancy, although a third had experienced multiple losses.

RESULTS

The analysis highlights three themes: processes and practices for conception; amplification of loss; and health care and heterosexism. Of the respondents, 84% conceived using donor sperm; most used various resources to plan conception and engaged in preconception health care. The experience of loss was amplified due to contextual factors and the investment respondents reported making in impending motherhood. Most felt that their loss(es) had made a ‘significant’/‘very significant’ impact on their lives. Many respondents experienced health care during their loss. Although the majority rated the overall standard of care as ‘good’/‘very good’/‘outstanding’, a minority reported experiencing heterosexism from health professionals.

CONCLUSIONS

The implications for policy and practice are outlined. The main limitation was that the inflexibility of the methodology did not allow the specificities of women's experiences to be probed further. It is suggested that both coupled and single non-heterosexual women should be made more visible in reproductive health and pregnancy loss research.

Understanding social support and the couple's relationship among women with depressive symptoms in pregnancy

This qualitative study explored the experiences of seven couples where the female partner experienced depressive symptoms during pregnancy. Female and male partners were interviewed together and data was collected and analyzed according to Colaizzi's ( 1978 ) phenomenological research design. The interviews yielded the following themes: (a) Challenges and stressors associated with depressive symptoms during pregnancy, (b) Pregnancy's effect on mood states, (c) Relationship dynamics that influence moods, (d) Pregnancy and the influence of mood on relationship dynamics, and (e) Reliance on external sources of support. The findings extend current research and provide insight into possibilities of how to enhance assessment and intervention for women who are depressed during pregnancy by including a relational component. Findings, clinical implications, and future research are discussed.

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.

Negotiating the transition: caring for women through the experience of early miscarriage

AIM

To explore women's experiences of having an early miscarriage in a hospital gynaecological unit.

BACKGROUND

Miscarriage is a global health issue affecting significant numbers of women and is usually considered a distressing experience. This distress is often interpreted as being characteristic of grief. Nurses and other health professionals in hospital and community settings are therefore expected to provide appropriate care to meet the physical and emotional needs of the woman.

DESIGN

A qualitative, ethnographic study of a hospital gynaecological unit in the UK.

METHODS

The primary method was 20 months of part-time participant observation. Data were also collected through documentary analysis of key documents in the setting and formal interviews. These were with eight women who had an early miscarriage and 16 health professionals (nurses, doctors, ultrasonographers) working in the unit.

RESULTS

Three clear phases emerged in the women's experience of miscarriage and hospital admission; first signs and confirmation, losing the baby and the aftermath. These were interpreted as being components of a process of transition. The hospital admission emerged as vital in these early phases in which the importance of nurses and other health professionals providing sensitive, engaged care to meet the emotional and physical needs of the woman was identified.

CONCLUSIONS

The hospital setting emerged as highly influential in shaping the care that was given to women and influencing their experiences. Transition models were felt to be more appropriate than grief and bereavement models in guiding the psychological care given to women.

RELEVANCE TO CLINICAL PRACTICE

The experience of hospital admission and the actions of nurses and other health professionals is influential in how women negotiate the transition through miscarriage.

Psychologic Aspects of Early Pregnancy Loss

Early pregnancy loss is a complicated psychologic event that occurs in 12% to 24% of recognized pregnancies. Women who have experienced miscarriage often have common bereavement reactions and while the intensity and experience of these reactions diminishes over time for most women, a substantial minority will develop long-term psychiatric consequences. Depression, symptoms of anxiety, obsessive-compulsive disorder, and posttraumatic stress disorder are the most commonly reported psychologic reactions to miscarriage. The course and impact of these disorders on a grieving mother and her partner are discussed and treatment recommendations are made. The psychologic effects of therapeutic abortion are also be briefly discussed.

Contexts and evolution of women's responses to miscarriage during the first year after loss

Descriptions of 85 women's feelings about miscarriage at 1, 6, 16, and 52 weeks were inductively coded, rank-ordered, and clustered into 3 responses: healing, actively grieving, and overwhelmed. Women who were actively grieving or overwhelmed at 1 week experienced significantly less distress from 6 weeks on. Responses at 1 week differed with regards to those who had a history of perinatal loss or went on to experience negative life events or sexual distance after loss. One year responses differed based on who was pregnant or gave birth, miscarried again, lived through a higher number of post-loss negative life events, or experienced interpersonal or sexual distance from their mate. Responses were not influenced by gestational age at loss or having other children.

The impact of miscarriage on women's pregnancy-specific anxiety and feelings of prenatal maternal-fetal attachment during the course of a subsequent pregnancy: an exploratory follow-up study

This study assesses the implications a miscarriage history has on women's pregnancy-specific anxiety and feelings of prenatal maternal-fetal attachment during the 1st and 3rd trimesters of a subsequent pregnancy. Thirty-five pregnant women (N = 10 with a history of miscarriage) volunteered participation completing the Pregnancy Outcome Questionnaire (POQ), the Maternal Antenatal Attachment Scale (MAAS and a demographic/reproductive history questionnaire during the first trimester of pregnancy. Of these, 24 participants completed the measures again during the third trimester of pregnancy. Women with a miscarriage history reported significantly higher pregnancy-specific anxiety at trimester 1 than women with no miscarriage history; even when the effects of parity were controlled. All expectant mothers, irrespective of miscarriage history, scored similarly at trimester 1 on the MAAS scales. By the 3rd trimester, pregnancy-specific anxiety had significantly decreased for women with a miscarriage history whose mean scores on the POQ were now similar to women with no history of miscarriage. Maternal-fetal attachment had significantly risen by the 3rd trimester for all women. These findings suggest that having a miscarriage history may not have a long-lasting adverse effect on woman's psychological adaptation during the course of a subsequent pregnancy.

Social and Professional Support Needs of Families After Perinatal Loss

Perinatal loss has been associated with depression, anxiety, obsessive-compulsive disorder, suicide, marital conflict, and post-traumatic stress disorder. Nurses may provide professional support through teaching, role modeling, encouragement, counseling, problem solving, and other interventions. Nurses also may encourage more effective social support by helping significant others to provide willing, well-intentioned action that will produce a positive response in the bereaved couple. Interventions to increase professional and social support after perinatal loss are described.

Genetic Evaluation and Counseling of Couples with Recurrent Miscarriage: Recommendations of the National Society of Genetic Counselors

The objective of this document is to provide recommendations for genetic evaluation and counseling of couples with recurrent miscarriage (RM). The recommendations are the opinions of the multidisciplinary Inherited Pregnancy Loss Working Group (IPLWG), with expertise in genetic counseling, medical genetics, maternal fetal medicine, internal medicine, infectious disease, cytogenetics, and coagulation disorders. The IPLWG defines RM as three or more clinically recognized consecutive or non-consecutive pregnancy losses occurring prior to fetal viability (<24 weeks gestation). These recommendations are provided to assist genetic counselors and other health care providers in clinical decision-making, as well as to promote consistency of patient care, guide the allocation of medical resources, and increase awareness of the psychosocial and cultural issues experienced by couples with RM. The IPLWG was convened with support from the March of Dimes Western Washington State Chapter and the University of Washington Division of Medical Genetics. The recommendations are U.S. Preventive Task Force Class III, and are based on clinical experiences, review of pertinent English-language published articles, and reports of expert committees. This document reviews the suspected causes of RM, provides indications for genetic evaluation and testing, addresses psychosocial and cultural considerations, and provides professional and patient resources. These recommendations should not be construed as dictating an exclusive course of medical management, nor does the use of such recommendations guarantee a particular outcome. The professional judgment of a health care provider, familiar with the circumstances of a specific case, should always supersede these recommendations.

Pregnancy as a stressful life event

Pregnancy and childbirth typically are associated with positive emotions and with motherhood, but the reality is that this is not the case for all women or for all pregnancies. This review addresses a different aspect of these reproductive events, focusing on stressful circumstances surrounding pregnancy, as well as times when the pregnancy itself becomes a stressful life event. Pregnancy-related topics that tend to receive less attention will be emphasized. These include issues related to infertility; unplanned pregnancy; stress associated with testing and diagnosis of common medical complications; peripartum cardiomyopathy; fear of childbirth; and pregnancy loss as a risk factor for psychopathology. Epidemiologic information will be presented, as will relevant psychosocial factors related to each phenomenon. Healthcare providers should be sensitive to the distress and anxiety experienced by many women and their families as a consequence of these adverse events and the stressful challenge of any consequential decision-making, as well as stressors in their broader life context that can further exacerbate their distress, and make mental health referrals as appropriate.

Anxiety following miscarriage and the subsequent pregnancy: a review of the literature and future directions

OBJECTIVE

This is the first comprehensive review to summarize the research literature regarding anxiety symptomatology and disorders following miscarriage.

METHODS

Both "controlled" and "uncontrolled" designs are considered, with the inferential limitations of studies lacking comparison groups highlighted.

RESULTS

The limited research available suggests that miscarrying women are at increased risk for anxiety symptoms immediately following miscarriage and continuing until approximately 4 months post-loss. Beyond 4 months, reports are inconsistent. There is evidence to suggest increased risk for some anxiety disorders in the 6 months following loss; however, studies using larger sample sizes and comparison groups are needed.

CONCLUSIONS

This is the first review to consider the incidence of anxiety disorders following miscarriage, as well as the psychological impact of loss on the pregnancy subsequent to miscarriage, and the impact on partners of miscarrying women. Areas warranting further study are noted and are intended to guide future investigation.

Depressive symptoms at two months after miscarriage: interpreting study findings from an epidemiological versus clinical perspective

We identify two study designs used to investigate psychiatric symptoms following reproductive loss. One design examines psychiatric outcomes in a single cohort of bereaved women; the other compares psychiatric outcomes in bereaved and non-bereaved cohorts. We employ the findings from one study of depressive symptoms following miscarriage to exemplify these designs and inferential differences in causal inferences that can be drawn. We interviewed a cohort of 114 women at 6-8 weeks after miscarriage and a cohort of 318 community women not recently pregnant. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression (CES-D) Scale. Among miscarrying women, the mean level of depressive symptoms was substantially elevated above that in the community cohort (adjusted difference in means between cohorts, 4.9, 95% confidence interval [CI] 2.3-7.4). Among miscarrying women, 20.2% were highly symptomatic (CES-D 30+), as compared with 10.1% among community women (adjusted odds ratio [OR] 2.8, 95% CI 1.4-5.6). However, in contrast to findings from the same study concerning depressive reactions at 2 weeks after loss, the impact of miscarriage on depressive symptoms at 6-8 weeks was markedly greater for younger women and possibly for women with a history of prior reproductive loss, but otherwise did not vary with number of living children, marital status, ethnicity or educational level. We conclude that miscarrying women first seen at their 6- to 8-week post miscarriage gynecologic visit are likely to be more depressed on average than otherwise comparable women who have not experienced a recent reproductive loss. Factors that moderate the impact of miscarriage may vary with time since loss. Enhanced recognition of the implications of study design for research inferences may help bring greater clarify and uniformity to findings from future investigations in this field.