Research roundup: pregnancy loss

This issue looks at some of the current research on pregnancy loss and methods of giving solace to those who have experienced it.

October is Pregnancy and Infant Loss Awareness Month — an opportunity to acknowledge how frequently this occurs and to provide a space and solace to those who grieve. Pregnancy loss can include miscarriage, stillbirth and early infant death. Most psychologists will encounter patients who have experienced pregnancy loss — perhaps during treatment, perhaps precipitating treatment or perhaps as one aspect of the patient’s history. Increased understanding of the experience and how to help is important.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Bardos, J., Hercz, D., Friedenthal, J., Missmer, S. A., & Williams, Z. (2015). A national survey on public perceptions of miscarriage. Obstetrics & Gynecology, 125(6), 1313-1320. 
Summary

According to a survey published in Obstetrics & Gynecology, most of the 1,000 respondents (members of the U.S. public) believed miscarriage occurs in 5 percent or less of all pregnancies, while in reality, that statistic is closer to 20 percent. Additionally, many participants had little understanding about the causes of pregnancy loss and experienced feelings of guilt and isolation if they had experienced a miscarriage themselves.

The authors used Amazon’s Mechanical Turk to collect data on demographic characteristics of respondents to quantify that their distribution was representative of the general U.S. population and if evidence of selection bias was observed.

About 60 percent of miscarriages are due to aneuploidy, which is the presence of an abnormal number of chromosomes in a cell. Other causes can be attributed to structural abnormalities of the uterus, thrombophilia, endocrine disorders and autoimmune disorders.

Fifteen percent of participants reported a history of miscarriage, with no difference in prevalence by demographic. The majority of participants correctly believed that pregnancy loss is commonly due to a genetic condition, and this belief was mostly held by those with a higher level of education. Hispanics were twice as likely to disagree as non-Hispanics that there is a connection between genetic and/or medical problems and pregnancy loss.

Twenty-two percent wrongly believed that drug, alcohol and/or tobacco use was the leading cause of pregnancy loss, with men 2.6 times more likely than women reporting this belief. Once again, level of education was significantly associated with this assumption, with those with less than a college education more than twice as likely as their more educated counterparts to hold this belief.

Genetic abnormalities of the fetus (95 percent) was correctly identified as a cause of pregnancy loss. However, 76 percent and 74 percent believed that a single stressful event or enduring stress could cause pregnancy loss, respectively, which is not true. Other false beliefs regarding causes of pregnancy loss included having a sexually transmitted disease (64 percent), having had an intrauterine device (28 percent), having used oral contraception (22 percent) or getting into an argument (21 percent).

Thirty-eight percent of participants who had experienced pregnancy loss thought they could have stopped it from happening. Those with religious affiliations were twice as likely to compare the emotional pain of their pregnancy loss to that of losing a child. A quarter of participants who lost a pregnancy felt they did not receive sufficient emotional support.

The authors concluded that feelings such as guilt and isolation that parents experienced after pregnancy loss were often due to misperceptions about what caused the loss.

Krosch, D.J. & Shakespeare-Finch, J. (2016). Grief, traumatic stress, and posttraumatic growth in women who have experienced pregnancy loss. Psychological Trauma: Theory, Research, Practice, and Policy. http://dx.doi.org/10.1037/tra0000183.
Summary

The authors of this study sought to determine the extent to which women experience grief, Posttraumatic Stress (PTS), and/or Posttraumatic Growth (PTG) after the loss of a pregnancy either through miscarriage or stillbirth. A total of 328 women over the age of 18 who experienced a miscarriage or stillbirth were recruited through pregnancy loss support groups.

Participants were asked to take an online survey. Multiple factors to assess loss context included how much time had passed since the loss of pregnancy, gestational age of the fetus or baby at the time of the loss, how many previous losses the participant may have experienced, and whether or not the participant had living children. Participants were asked to rank the degree to which they considered their pregnancy or stillborn baby a person in order to determine personhood and event severity. The Core Belief Inventory was used to assess core belief disruption, the Perinatal Grief Scale measured behavioral and affective symptoms of grief, the Impact of Events Scale-Revised (IES-R) assessed symptoms of PTS, and the PostTraumatic Growth Inventory was utilized to measure PTG by determining positive changes experienced after the trauma.

Hierarchical multiple regression resulted in support for the following a priori research hypotheses: 1) moderate levels of PTG would be reported; 2) disruptions to core beliefs could predict perinatal grief, symptoms of PTS and PTG; and 3) perinatal grief could predict symptoms of Posttraumatic Stress Disorder (PTSD) and PTG.

Findings suggest that disruptions in core beliefs contribute significantly to post-trauma outcomes. Almost 85 percent of participants ranked personhood at least 8 out of 9, indicating that the majority of people viewed their pregnancy loss as the death of their unborn child, even when the pregnancy was still in the early stages. Most participants reported moderate to high levels of grief and PTS.

Meaney, S., Everard, C.M., Gallagher, S., & O’Donoghue, K. (2016). Parents’ concerns about future pregnancy after a stillbirth: A qualitative study. Health Expectations, 1-8. Doi: 10.1111/hex.12480.
Summary

Giving birth to a stillborn can be emotionally devastating to parents. The authors used a qualitative semi-structured interview and interpretive phenomenological analysis in order to understand and address parents’ concerns about pregnancy after experiencing a stillbirth.

Fifteen parents, 10 women and five men, were recruited from a patient list of people who had a stillbirth at a maternity hospital. Participants were interviewed on their experiences in relation to the stillbirth, four to 16 months after it occurred. Two main themes emerged from the authors’ findings: 1) aspirations for future pregnancies; and 2) expectations of future care.

In terms of aspirations for future pregnancies, the study showed that just days after a stillbirth parents start contemplating the prospect of another pregnancy, but feared negative outcomes. Participants felt they were not well informed about the risk of stillbirth during the course of the unsuccessful pregnancy, and had “adopted a fatalistic approach to pregnancy.” Participants also discussed unhelpful, even hurtful, societal responses they received after their stillbirth that would make them wary of talking about fears and concerns in regards to future pregnancy. Women and men had conflicting parental aspirations. While mothers felt a sense of failure, they wanted to continue planning future pregnancies. However, fathers were uncertain about trying again. Women whose male partners were averse to planning future pregnancy reported negative emotional effects in response to their partner’s reluctance and disengagement.

All participants expressed concern regarding what to expect when considering future pregnancy. They expressed appreciation of clear guidance from healthcare staff in regards to appointments and potential preventative measures. For some participants, this guidance, while desired, was not enough and they felt the need for consistent specialized care for future pregnancies. 

Kersting, A., Dolemeyer, R., Steinig, J., Walter, F., Kroker, K., Baust, K., & Wagner, B. (2013). Brief Internet-based intervention reduces Posttraumatic Stress and Prolonged Grief in parents after the loss of a child during pregnancy: A randomized controlled trial. Psychotherapy and Psychosomatics, 82, 372-381.
Summary

As many as 20 percent of recognized pregnancies end in loss, which can cause PTS and prolonged grief in women and their partners. The authors of this study created an internet-based intervention, utilizing exposure and cognitive restructuring techniques that have been effective in the treatment of PTSD and prolonged grief. The 228 participants who met inclusion criteria were randomized to either the treatment group (TG; n = 115), or the waiting list control group (WLC; n = 113).

The TG received five weeks of cognitive behavioral intervention and were given 45-minute writing assignments twice a week, totaling 10 essays over three treatment phases: self-confrontation, cognitive restructuring and social sharing components. During the self-confrontation phase, participants wrote about the pregnancy loss, describing in the present tense and from a first-person perspective their sensory perceptions of the experience. In the cognitive appraisal treatment phase, participants wrote a supportive letter to an imaginary friend who, hypothetically, had also suffered a pregnancy loss. The objective of the letter was to adopt a new mindset about the pregnancy loss by discussing feelings of guilt, change dysfunctional thinking and behaviors, and challenge unrealistic expectations. For the social sharing phase, participants wrote a letter about their most painful memories of the pregnancy loss, their experience of the therapeutic process and how they will deal with future losses. The letter was to be written to a meaningful person in the participant’s life, someone who was present during the loss of pregnancy or to the participant themselves.

Compared to the WLC group, the TG showed reduced symptoms of PTS, prolonged grief, depression and anxiety. Post-treatment symptom reductions were maintained at both three-month and 12-month follow-ups. Treatment effects between d = 0.84 and d = 1.02 for PTS and prolonged grief from pretreatment to post-treatment were reported during intention-to-treat analysis. The authors conclude that technology can be used effectively for assisting women with pregnancy loss, thereby providing a low-cost intervention.

Clinical Implications

Given the frequency of occurrence of pregnancy loss — through miscarriage, stillbirth or early infant death — psychologists will likely encounter patients touched by this experience. It is therefore critical that they recognize the importance of clinical and emotional support to deal with, not only the aftermath of a pregnancy loss, but the impact it has on successive pregnancies.

To begin, many individuals are unaware of the high number of pregnancies that end in loss, which only serves to increase the feelings of isolation who have experienced such loss. Added to that, individuals often have erroneous beliefs about the causes of miscarriage (and potentially other pregnancy loss) and report guilt and shame when a loss does occur. Misperceptions such as these can contribute to depression, anxiety and stress that can be addressed with accurate information and psychotherapy. Psychologists are in an important position to intervene, not only in regards to the loss but also in terms of what the loss means to the family and future decisions to have children.

While psychotherapy can be an important mode to address these concerns, delivering evidence-based practices through the internet and other means shows promise as well. Psychologists may wish to identify evidence-based, web-based interventions to use in adjunct to ongoing psychotherapy. Alternatively, the practices described in the Kersting et al (2013) article are typical of some treatments for PTSD and could readily be applied in individual, group or couples therapy. Providing a safe and supportive space to talk about the loss and its emotions, developing new ways of understanding the loss, and identifying strategies to cope with reminders and possible future losses could all be beneficial. Not all individuals with a history of pregnancy loss may need or want psychotherapy, but for others, addressing the loss in therapy may allow them to cope with powerful and sometimes overwhelming feelings and incorporate the loss into their overall experience. For those in therapy for other reasons, addressing the pregnancy loss may have a beneficial impact on their treatment for other challenges. Psychologists’ openness to hearing and supporting their patients’ unique experiences with clear, factual understanding and allowing them to express powerful emotions can be one of the benefits of psychotherapy.