Coping After Recurrent Miscarriage
Coping After Recurrent Miscarriage
More than one in 10 pregnancies will end in a miscarriage and this risk increases with age. Further, between 1% and 3% of women will suffer recurrent miscarriages, with an underlying cause found in fewer than 50% of such couples. Miscarriage is a cause of psychosocial distress, as for many women it means more than the loss of a pregnancy. It represents the feeling of a lost baby, a lost future child and a lost motherhood. Miscarriages also cause physical trauma, sudden pain, blood loss and unexpected admission to hospital. From their practice, health care workers know that women who have suffered miscarriages potentially experience two subsequent waiting periods: the period between renewed attempts to conceive and conception (waiting for conception), and the period between conception and confirmation that the pregnancy is ongoing (waiting for ongoing pregnancy). Waiting is associated with a build-up of anxiety and stress, which starts because of the uncertainty in timing of the conception and the ongoing pregnancy, but eventually also includes anticipatory anxiety about the outcome, either pregnancy loss or live birth.
Women who have experienced miscarriages may benefit from psychosocial support and counselling during these waiting periods. Several studies have investigated the influence of psychosocial interventions in women who have experienced miscarriage. Most have focused on the period immediately following miscarriage. There is less information relating to support during the first trimester of a subsequent pregnancy. Interventions such as counselling sessions with nurses, psychological counselling or a weekly ultrasound scan have been shown to reduce anxiety and depressive symptoms. Not all patients use or have access to these interventions and many request adjunct interventions that could be used in addition to such interventions, or as alternatives if they are not readily available.
Lancastle and Boivin recently developed a short self-help Positive Reappraisal Coping Intervention (PRCI) for use during medical waiting periods. It consists of daily reading of 10 positive statements encouraging the use of 'positive reappraisal coping'. This is a cognitive strategy to change the meaning of a situation, in particular, reinterpreting the situation as it stands in a more positive way. The PRCI is based on the stress theory of Lazarus and Folkman. According to this theory, emotional processes are dependent on actual expectations about the significance and outcome of a specific situation and how people cope following these appraisals. People use a variety of coping strategies to manage stressful events. Problem-focused coping strategies are aimed at confronting and seeking solutions to a situation, while emotion-focused coping strategies focus on ameliorating the associated level of emotional distress. Meaning-based strategies as used in the PRCI (e.g. deriving benefit from adversity or focusing on the positive) are future-orientated strategies that have been shown to be effective where sustained coping efforts are required when a stressor situation is uncontrollable and its outcome unpredictable. This is the case in medical waiting periods such as those after experiencing miscarriages. Another future-orientated coping strategy is 'bracing'. Bracing occurs as an attempt to anticipate unpleasant surprises, presumably to avoid disappointment.
The PRCI was originally developed for the waiting period after embryo transfer in infertility treatment. It consists of a small card (Figure 1) that contains 10 positive reappraisal statements, together with a leaflet with detailed information about the coping techniques. Women are asked to read the PRCI at least twice a day, in the morning and evening, and at any other time that they feel the need to do so. Women have to read the statements and think about how each statement applies to them personally. As conception or confirmation of ongoing pregnancy after a miscarriage often involve a sustained period of waiting, we felt that the PRCI could potentially also be a useful adjunct intervention for women in this patient group. To adapt and further develop the PRCI for women with miscarriages, the UK Medical Research Council medical framework for developing complex interventions was used.
(Enlarge Image)
Figure 1.
Positive Reappraisal Coping Intervention.9 © 2008 Cardiff University. Figure reproduced with the kind permission of the authors and Cardiff University.
This article presents the results of the first phase of the study, which was to describe the coping strategies of women after miscarriage to determine whether the PRCI intervention could also be applied to this population. To model the intervention, we used a qualitative study design involving two focus groups as recommended for implementation of interventions in novel contexts. In the focus groups we aimed to explore the experience, coping styles and strategies of women during the waiting period for ongoing pregnancy.
Background
More than one in 10 pregnancies will end in a miscarriage and this risk increases with age. Further, between 1% and 3% of women will suffer recurrent miscarriages, with an underlying cause found in fewer than 50% of such couples. Miscarriage is a cause of psychosocial distress, as for many women it means more than the loss of a pregnancy. It represents the feeling of a lost baby, a lost future child and a lost motherhood. Miscarriages also cause physical trauma, sudden pain, blood loss and unexpected admission to hospital. From their practice, health care workers know that women who have suffered miscarriages potentially experience two subsequent waiting periods: the period between renewed attempts to conceive and conception (waiting for conception), and the period between conception and confirmation that the pregnancy is ongoing (waiting for ongoing pregnancy). Waiting is associated with a build-up of anxiety and stress, which starts because of the uncertainty in timing of the conception and the ongoing pregnancy, but eventually also includes anticipatory anxiety about the outcome, either pregnancy loss or live birth.
Women who have experienced miscarriages may benefit from psychosocial support and counselling during these waiting periods. Several studies have investigated the influence of psychosocial interventions in women who have experienced miscarriage. Most have focused on the period immediately following miscarriage. There is less information relating to support during the first trimester of a subsequent pregnancy. Interventions such as counselling sessions with nurses, psychological counselling or a weekly ultrasound scan have been shown to reduce anxiety and depressive symptoms. Not all patients use or have access to these interventions and many request adjunct interventions that could be used in addition to such interventions, or as alternatives if they are not readily available.
Lancastle and Boivin recently developed a short self-help Positive Reappraisal Coping Intervention (PRCI) for use during medical waiting periods. It consists of daily reading of 10 positive statements encouraging the use of 'positive reappraisal coping'. This is a cognitive strategy to change the meaning of a situation, in particular, reinterpreting the situation as it stands in a more positive way. The PRCI is based on the stress theory of Lazarus and Folkman. According to this theory, emotional processes are dependent on actual expectations about the significance and outcome of a specific situation and how people cope following these appraisals. People use a variety of coping strategies to manage stressful events. Problem-focused coping strategies are aimed at confronting and seeking solutions to a situation, while emotion-focused coping strategies focus on ameliorating the associated level of emotional distress. Meaning-based strategies as used in the PRCI (e.g. deriving benefit from adversity or focusing on the positive) are future-orientated strategies that have been shown to be effective where sustained coping efforts are required when a stressor situation is uncontrollable and its outcome unpredictable. This is the case in medical waiting periods such as those after experiencing miscarriages. Another future-orientated coping strategy is 'bracing'. Bracing occurs as an attempt to anticipate unpleasant surprises, presumably to avoid disappointment.
The PRCI was originally developed for the waiting period after embryo transfer in infertility treatment. It consists of a small card (Figure 1) that contains 10 positive reappraisal statements, together with a leaflet with detailed information about the coping techniques. Women are asked to read the PRCI at least twice a day, in the morning and evening, and at any other time that they feel the need to do so. Women have to read the statements and think about how each statement applies to them personally. As conception or confirmation of ongoing pregnancy after a miscarriage often involve a sustained period of waiting, we felt that the PRCI could potentially also be a useful adjunct intervention for women in this patient group. To adapt and further develop the PRCI for women with miscarriages, the UK Medical Research Council medical framework for developing complex interventions was used.
(Enlarge Image)
Figure 1.
Positive Reappraisal Coping Intervention.9 © 2008 Cardiff University. Figure reproduced with the kind permission of the authors and Cardiff University.
This article presents the results of the first phase of the study, which was to describe the coping strategies of women after miscarriage to determine whether the PRCI intervention could also be applied to this population. To model the intervention, we used a qualitative study design involving two focus groups as recommended for implementation of interventions in novel contexts. In the focus groups we aimed to explore the experience, coping styles and strategies of women during the waiting period for ongoing pregnancy.
