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I had to see a baby and hold a baby so that it would not affect me so much later. I would get over itfaster; it seemed to help. Disorganization. Disorganization was.
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Women's Expellence of Miscamnage A qualitative study Physicians lack knowledge on how to help women who have miscarried deal with their emotional distress. We interviewed 16 women 4 and 12 weeks after a miscarriage. The women described their experience of miscarriage and perceptions of what helped or hindered their emotional recovery, particularly physicians' actions. A grief reaction that can be divided into five stages and that was modified through the support of family and friends was identified. The intensity of the grief was related to the personal meaning of the pregnancy.

Les medecins manquent de connaissances pour aider les femmes a surmonter leur detresse emotive suite a une fausse couche. Nous avons interviewe 16 femmes quatre et douze semaines apres leur fausse couche. Les femmes ont decrit leur experience de fausse couche et leurs perceptions de ce qui a aide ou contribue a leur retablissement sur le plan emotif, surtout les interventions des medecins. On a pu identifier cinq etapes dans cette reaction de deuil, lesquelles ont ete modifiees grace au soutien et a l'appui de la famille et des amis. L'intensite du deuil est fonction du sens que chacune accorde a la grossesse. Coan m Physian 1991;37:1871-1877.

DONNA P. NANCA, MD, CCFP \IARTIN J. BASS, MD, CCFP

HYSICIANS GIV'E WOMEN WHO

miscarry little guidance

on

how to manage the emotional aftermath. Most descriptive and case studies on the emotional impact of miscarriage are incomplete, retrospective, or focus only on limited aspects of the experience.'-' Miscarriage often goes unnoticed, without any support from society or the family. Our society is not notified of such a loss through an obituary, and the fetus is frequently disposed of without the usual rituals that give comfort.4 Support can play a significant role at this time, although it is often not offered.i'3 This study was designed to describe the emotional experience of miscarriage, determine related factors, and assess the impact of support from family, friends, and physician. Qualitative methods were used to describe the emotional reactions following miscarriage and to identify factors perceived as relieving or aggravating the distress.

METHODS WVomen from southwestern Ontario, 16 Dr Manca practisesfamiy medicine and is Associate Staff Member Rqyal Alexandra Hospital, Edmonton, Alta. She was an Alberta Hnitage Trust Fellow at the time of this study. Dr Bass, a Fellow of the College, is a Pfessor of Family Medicine and is Director, Centre for Studies in Famiy Medicine, at The University of JVestern Ontario, London.

years or older, who experienced the involuntary loss of a pregnancy after less than 20 weeks' gestation were interviewed 4 and 12 weeks after their miscarriage. WVomen with gestations longer than or equal to 20 weeks, ectopic pregnancies, or elective terminations were excluded. Family physicians with admitting privileges to hospitals in the London and WVoodstock area were contacted in November 1986. To increasc the number of potential candidates, obstetricians practising in the same area were contacted in February 1987. Participating physicians (104) gave a letter explaining the study to women who miscarried between October 1986 and March 1987. During the enrolment period the physicians and their staff were contacted regularly to ascertain problems and remind them that the study was under way. The physicians were also asked to record the age, marital status, and gestation length of any women who received a letter of explanation in an attempt to assess the nonresponders. During this time 24 women received a letter from their physician, and 16 responded by mailing their telephone number to one of the investigators (D.P.M.); two interviews were arranged with each woman. Each interview was made up of a structured (quantitative) and a semistructured (qualitative) segment. The structured segment contained questions to determine age, socio-economic status of the houseCanadian Family Physician VOL 37: September 1991 1871

Table 1. DEMOGRAPHIC FEATURES OF PARTICIPANTS AND NONPARTICIPANTS

PARTICIPANTS PATIENT CHARAaERISTICS

QUANTITATIVE DATA (N 12)

Age range (years) Range of gestation at time of miscarriage (weeks) a

KINOWN NONPARTICIPANTS

QUALITATIVE DATA (N = 16)

RECORDED DATA

(N = 5)a

26-36

25-36

21-40

5-18

5-18

10-13

Information was recordedfor five of the eight nonparticipants. hold, 14 level ofeducation, children at home, time to conceive, pain with the miscarriage,l length of warning symptoms, gestation period at the time of miscarriage, sex of the physician, years under the physician's care, prior miscarriage, planned pregnancy, awareness

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theoretical description of the miscarriage experience. An understanding of the emotional reaction to miscarriage, including relieving and aggravating factors, was sought. a

RESULTS

miscarriage possi-

bility, and the difficulty becoming pregnant. During the semistructured segment descriptions of the miscarriage experience and what helped or aggravated the patient's problems were obtained. After a pilot study on four volunteers, a suitable statement was refined to introduce the semistructured interview: "I will now turn to the miscarriage itself. I would like to hear your story to better understand what helped you or made things more difficult. Could you tell me your story from just before the pregnancy to now?" This question elicited detailed descriptions of the

Stages of recovery From the descriptions of the miscarriage experience, five distinct stages were identified: uncertainty, shock and denial, searching and yearning, disorganization, and

miscarriage experience.

reorientation.

The semistructured interviews were recorded on tape and transcribed. Interpretations of the transcripts were assessed by another family physician. Immediately after the interview, field notes were made and consisted of descriptions of what was observed, theoretical notes or interpretations derived from the observations, and methodological notes, to remind the researcher of the information required to complete the second interview. The taped interviews were reviewed at least three times. The descriptive information was assessed using qualitative methods.'6-20 The qualitative data were continuously analyzed for similarities and differences. Evolving patterns were constantly in the process of becoming better integrated into

Uncertainty. The women described a time of uncertainty when they did not know whether they were miscarrying or not. Many had fears that were not addressed. Some of these fears focused on damage to the baby, damage to the uterus, a possible tumor, the possibility of the baby's drowning in the toilet, concern that the husband would be upset, and fear that if the pregnancy continued it would be abnormal, resulting in a defective or retarded child. To more than half of the women, the most disturbing period was the time of uncertainty. The women described what waiting was like. So tired sitting around waiting. I said, "I know I'm going to lose this baby. I wish it would hurry up

September 1991

Data were complete for both interxiews on 12 women. Two women entered the study too late to be used for the 4-week assessment, and two failed to complete the second interview. The women interxiewed had an axerage age of 31 years and tended to have upper middle socio-economic status

(Table 1).

because I can't stand sitting here waitingfor the axe to drop." Then, cold clammy fear when they [the physicians] confirmyour worst suspicion. Yes, its really happening. Shock and denial. All the women described periods of denial. Many sought to verify that their pregnancy was "okay," often to be faced with avoidance, false reassurance, or the painful reality of the miscarriage. More than half reacted in anger at what was happening; many were also relieved to know where they stood. They did not want to be told they were miscarrying and often became angry at the person confronting them with the bad news. In the long run, however, they appreciated the honesty and resented people who provided false reassurance. I was so scared. I knew there was something wrong. Ijust didn't want to accept this was a miscamage. You hear women bleed thmugh their pregnancy. I kept asking my doctor, 'Am I going to lose my baby?" I just wanted to know that I wasn't going to lose my baby. I don't think I would have gone to the hospital on my own. I needed someone to tell me. More than half of the women described shock when they realized they were miscarrying. Two made serious driving errors while driving themselves to the hospital from the physician's office. They had just been told that they were miscarrying. During this period the women described feeling numb and not remembering what was told to them, "They're [the physicians] telling you all this stuff. It's going in but it's not really clicking in, and then finally after, when all that other stuff is over with, I think about what he was telling me. What did he say?"

Searching andyearning. Searching and yearning were described during time of hospitalization and after discharge. Many women described searching for evidence that the miscarriage did happen to them. Some would fall back into their pregnant routine to be painfully reminded that they were no longer pregnant. They would yearn for the lost pregnancy. With each reminder came feelings of anger or sadness. They often felt anger, which was projected outward; for example, some of the women described feeling angry at other pregnant women. Some projected the anger inward as guilt.

If anything I've been more angry. I've had more pent-up anger, sort offrustration. It'l like they [feelings]flash. To me it wasn't so much order, like outrage. [Thefeelings she experienced did not occur in a specific order.] Depending on how Ifelt at the time, I'd get really sad and quiet, introverted, mad and angry, and then it started settling down to the point where it's really personal grief, sadness, and that goes away too. Ifelt guily that I had let that baby down. I did something wrong. And I thought, if it was caused by work, then myjob means nothing in comparison to having a baby. There wasn't anything I wouldn't have done to bring back that baby. Painful reminders of the miscarriage consisted of a nephew who looked like the dream child, baptisms, funerals, birth notices, pregnant women, baby showers, babies, diaper commercials, telling others about the miscarriage, the first menstrual period, sexual intercourse, the husband's touch, seeing the physician's office or the hospital, letters or people asking about the pregnancy, flowers ("for the funeral"), the nursery, maternity clothes, and the baby's due date. Initially the reminders were a painful intrusion of reality. With time they became less painful. All the women described periods of avoiding reminders that alternated with seeking out the reminders at times when they wanted to face the reality of the loss. One woman described walking by the nursery to view the babies. Another described seeking out her girlfriend's baby. These periods ofconfrontation would alternate with periods of avoidance. After it happened that weekend, I was more upset almost about how to tellpeople. Everybody in my neghborhood knew that I was pregnant. Ijust couldn'tface anyone. I stayed in the house for 3 to 4 days. I wouldn't go out, and I said to /her husband], "Oh honey, please, you go out and tell them. " I had to see a baby and hold a baby so that it would not affect me so much later. I would get over it faster; it seemed to help.

Disorganization. Disorganization was observed at the time of the first interview (4 weeks after the miscarriage) in many of the women. When they were pregnant their lives were organized around the pregnancy. What was done or eaten was perceived as possibly affecting the future ofthe pregnancy. After the miscarriage they no longer had Canadian Family Physician VOL 37: September 1991 1873

a pregnancy around which to organize their lives. They felt sadness and began to accept that the loss had occurred. One woman described the experience as like being on an emotional rofler coaster. Many described nervous energy and wanting to keep busy. When something like this happens to you, you feel out of control, likeyou have no control over it, you know. Andyoufeel weak and vulnerable. And everything becomes a bit disorganized inyour daily routine. And I like to feel organized. I like to feel on top of things, that I am capable ofgoing through the day and can do my normal routine without constanty having to sit down andfeel miserable. One day Pd feel not bad, as though I'm getting better, and the next day I'dfeel crummy again. It was dis-

baby with a name, sex, and role in the family. To them a miscarriage could mean the loss of, for example, a baby boy. Others felt the pregnancy was just a piece of tissue, "a blob," in which the miscarriage could represent a delayed period that never had the chance to form a baby. Women with children were more likely to describe a specific baby than women who had not experienced childbirth. Factors that influenced the perceived value of the pregnancy were technology, perceived maternal age, ease of becoming pregnant, planned pregnancy, previous successful pregnancies, gestation length, and time of anticipation of miscarriage.

couraging, depressing.

Technology. Ultrasound examination was perceived to add to the certainty of the pregnancy in the one woman who had an ultrasound examination before the miscarriage. The remaining women, however, did not have normal or Doppler ultrasonography before developing the warning signs that the miscarriage was occurring.

Reorientation. All except one of the 14 women interviewed described going through this stage at the second interview (12 weeks after the miscarriage). Even though it had been early in the pregnancy, plans had been made. A room was often set aside and prepared to become the future nursery: "We had the spare bedroom painted; we were out shopping for carpeting for the nursery." Reorientation occurred as the women accepted the loss and made plans for the future. The nursery was dismantled, maternity clothes were put away, and plans were made about future pregnancies. The other day Ijust moved stuffaround in my closet; the maternity clothes are downstairs now. Itl like what happened, happened a long time ago. rou think about it. Andyou think time has passed now, and my bodyIflne, and Ifeel good, and what's past is past, and letl get on with lfe. Letl carry on. 7herel things that are going to go unanswered, anyway. I was asking, "Why did I lose my baby?" Itl just an unanswered question. Maybe not just accepting it, but what am Igoing to do with it? Like, am I going to try again, going to have children, or am I going to be miserable the rest of my Ife? It would be wasted, and thatl terrible. Its two lives instead of one. What the pregnancy means The miscarriage experience can be influenced by what the pregnancy meant. The more meaningful the pregnancy, the deeper the sense of loss. Some women described the pregnancy as meaning a specific 1874 Canadian Family PhySicia WVL 37:

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Perceived maternal age. Approximately a quarter of the women commented on the pressure to become pregnant soon because of their age. These women appeared to view the pregnancy as more at risk, and a few even sought to be cared for by a specialist as an extra measure of safety. Ease of becoming pregnant. Four women had difficulty becoming pregnant and wanted the pregnancy very much, which added to their sense of loss. For one woman with endometriosis, the pregnancy meant more than a pregnancy; it meant mastering a disease.

Planned pregnancy. The few women who did not plan the pregnancy were often unaware that they were pregnant until later in the pregnancy or at the beginning of the miscarriage. The pregnancy had not come to mean a baby to them. Previous successful pregnancies. Many of the women with children described how they more quickly came to view the pregnancy as a potential child because they had experienced the outcome of a previous pregnancy.

Gestation. The length of gestation itself was not described as important as other periods identified by the woman. One important hurdle was perceived to occur around 3 months' gestation when the pregnancy became more certain, as miscarriage was thought unlikely to occur.

Anticipatory time. The length of warning symptoms and signs, such as bleeding and cramping, before the miscarriage appeared to be related to the meaning of the pregnancy. The women who had a shorter period of warning had thought they were safely pregnant and therefore began to attach more deeply to the pregnancy. What factors affected the experience? Support from family and friends had a significant role in modifying the grief reaction. Helpful factors consisted of telling others for her, offers of tangible support (car rides, babysitting), acknowledgment of loss, sympathy, acceptance, attentive listening, someone to be with, and positive regard. Hurtful factors consisted of avoidance, lack of recognition by society, and hurtful comments. Hurtful comments were often made by other significant women. One woman's mother commented, "I don't know about these kids today. I had three children and I didn't have any problem." The presence of other children had an impact on the distress. Those women with children found relief in knowing that they could have a positive pregnancy outcome. However, the demands of returning home to care for a young child added to the women's stress. One child, who had been toilet trained, regressed to requiring diapers after the miscarriage. Unfortunately, the difficulties encountered in tending to their children's needs often reduced the woman's self-esteem. Four of these mothers spontaneously commented that they perceived themselves to be a "bad mother," and that maybe it was good that the miscarriage occurred, as they probably would be unable to cope with a baby. Many of the women required dilation and curettage. The dilation and curettage was viewed differently by different women. Many wondered whether the procedure

was taking their baby. Some viewed it as a life-threatening operation. A few women viewed the dilation and curettage as removing dirty or unclean tissue from the womb. This perception could be intensified by some of the language physicians use, as illustrated by this quote, "He said, 'You've got to get cleaned out."' The women's partners also grieved but expressed their grief in a different way than the women. One woman described her partner's reaction, "I felt he was mad at me because I lost his baby. He was very withdrawn about the whole thing. It was his way of grieving but I didn't know that. You see, nobody tells you how fathers grieve." One husband had a "nervous breakdown" within 2 weeks of the miscarriage, and two women described lack of support at work for their husbands. The miscarriage was not perceived by one husband's employer to be a legitimate reason to take time off work. The women described many things the physician did that helped or aggravated their situation: treating the patient instead of the case, offering specific reassurances, and providing detailed explanations.

Treating the patient. Treating the person and not the case was important, as illustrated by this quote: Family doctors have a tendency to treat their patients as people because they see them, andyou actually talk to them as people. I ask him how his wife and kids are. He asks me how my husband and kids are. In the hospital we are not a body bleeding. We are a person hurting. Other factors described as helpful were physicians' accepting feelings and giving permission to feel, using the self as medi-

cine (eg, being confident when she lacked confidence), checking understanding and providing information (including providing test results as soon as possible), being available, offering tangible support (eg, admitting to hospital), giving specific direction about what to do (eg, telling her to go to hospital when necessary), providing vigorous pain control, caring (as communicated by a telephone call from the office checking on how she was doing), and scheduling follow-up appointments (preferred 1 to 2 weeks after the miscarriage). Canadian Family Physician VOL 37: September 1991 1875

Offering specific reassurances. Specific information that many of the women found helpful consisted of reassurance that bleeding is common and does not necessarily mean the pregnancy is abnormal, that miscarriages are relatively common, that "if it is going to happen, it is going to happen," and that "there is nothing you could do to stop it." Providing detailed explanations. Specific questions asked by the women were: "What caused the miscarriage?" "When can I resume intercourse?" "Can I use tampons?" "Can I ever get pregnant again?" "When can I become pregnant again?" "What will I feel like emotionally and physically after the dilation and curettage?" "What should I watch for (bleeding, pain, clots, and fever)?" "Should I notify the physician of abnormal symptoms?" "When can I return to work?" "Can I manage my children?" and "When will my next period occur?" The following quote indicates what was perceived helpful when one woman was spotting. He was realy honest. He said, "It doesn't seem too good. Asyou probably know itl really quite common," and there really wasn't anything they could offer me. It was just hope for the best, and go home and rest, and he assured me there isn't anything that I could have done at this stage that would have done it, and if it& going to happen it' going to happen. I wanted the truth, and it was something to expect. Increasing distress. Unfortunately physicians also do things that add to the woman's distress: not addressing her questions or fears, avoiding her, providing false reassurance, and removing needed support. Only one out ofthe 10 women who had significant pain described receiving adequate pain control. Medical terminology added to this woman's distress, "He's long forgotten the layman's term for it. He used the medical terminology. He said, 'a missed abortion.' I had a miscarriage. We don't like the term abortion. Missed abortion sounds like you wanted it to happen!" Four women commented that their physician did not do a pelvic examination during follow up, and they were not reassured that their uterus had returned to normal. 1876 Canadian Family Physician VOL 37: September 1991

DISCUSSION The findings of this study were 1) there were five stages of grief; 2) support from family and friends was important; 3) women with children at home had greater distress; 4) the physician's actions influence women's distress; and 5) it is important to assess the partner's role. Most of the women described five stages of grief: uncertainty, denial, searching, disorganization, and reorientation. Understanding the stages of grief can help the physician to recognize denial or disorganization and realize that sad or angry feelings are part of the process. There is a danger, however, in interpreting the stages of grief too literally. Each woman's experience was unique. To understand the experience of miscarriage requires an understanding of the personal meaning of the miscarriage to that woman. This understanding can be acquired by listening to the woman's story and hearing the meaning behind her words. The sense ofloss was described as related to the personal meaning of the pregnancy. Support from family and friends was described as important. The physician could encourage the woman to mobilize and seek out necessary support. Women with children at home described increased distress. These women seemed to bond more deeply to the lost pregnancy. After the miscarriage these busy women also had small children to care for. It was difficult to tend to their children's needs when they were grieving. This difficulty contributed to feelings of failure in the role

of mother. The women described specific instances when the physician helped or aggravated their distress. The most important thing a physician can do appears to be helping patients mobilize their own supports. Preparation for the emotional effects can be helpful. It might help the patient to know that painful reminders can occur and that other women who described feeling as if they were going crazy or that they wouldn't get over it improved markedly with time. The language physicians use must be chosen carefully. Terms such as "clean out" and "abortion" have negative connotations. It is important to assess the partner's role. Many of the women described their

husbands as grieving. Some women also described, in retrospect, misunderstanding their husbands' behavior. This misunderstanding could result in a perception of reduced support. Husbands or partners also grieve, and they often express their grief differently than the woman. Although the number of women studied in this sample was small and biassed toward mature, middle-class women, a thorough understanding of the described experiences should help physicians to better understand the experience of their own patients. Other review articles and studies describe similar observations.2"-23 The conclusions of this study are not generalizable to women from a younger age group, such as teenagers; to single women; or to women of lower socio-economic status. As Parkes said so succinctly, "We can make better use of limited time if we have a greater understanding ofloss and develop those special skills which enable us to focus support where and when needed."244 Acknowledgment We thank Dr Moira Stewart, Dr Carole Farber, and Dr George Deagle. Requests for reprints to: Dr Donna P Manca, Family Practice, 6304-129 Ave, Edmonton, AB T5A OG1

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2. Leppert PC, Pahlka BS. Grieving characteristics after spontaneous abortion: a management approach. Obstet Gynecol 1984;64: 119-22. 3. Swanson-Kauffman K. The unborn one: a profile of the human experience of miscarriage [thesis]. Boulder, Colo: The University of Colorado, 1983. 4. Herz E. Psychological repercussions of pregnancy loss. Psychiatr Ann 1984;14:454-7. 5. StackJM. The psychodynamics of spontaneous abortion. Am 7 Orthopgychiat?y 1984;54: 162-7.

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health-related functions of social support. J Behav Med 1981;4:381-406. 9. Turner RJ, Frankel BG, Levin D. Social support: conceptualization measurement and implications for mental health. In: Greenley JR, editor. Research in community and mental health. Vol III. Greenwich, Conn: Jai Press, 1983:67-111. 10. Turner RJ, Noh S. Social support, Ife events and psychological distress: a three wave panel analysis. London, Ont: The University of Western Ontario, 1982. 11. Broadhead WE, Kaplan BH, James SA, Wagner EH, Schoenbach VJ, Grimson R. The epidemiologic evidence for a relationship between social support and health. Am J Epidemiol 1983;1 17:521-37. 12. Kaplan HB. Psychological distress in sociological context: toward a general theory of psychosocial stress. In: Kaplan HB, editor. Psychological stress. New York, NY: Academic Press, 1983:195-264.

13. Turner RJ. Direct, indirect and moderating effects of social support upon psychological distress and associated conditions. In: Kaplan HB, editor. Psychosocial stress. New York, NY: Academic Press, 1983:105-55. 14. Blishen BR, McRoberts HA. A revised socioeconomic index for occupations in Canada. Can Rev Soc Anthropol 1976; 13:71-3. 15. Melzack R, Torgerson WB. On the language of pain. Anesthesiology 197 1;34:50-9. 16. Glaser BG, Strauss Al. The discovegy ofgrounded theo?y: strategies for qualitative research. New York, NY: Aldine Publishing Company, 1967. 17. Gorden RL. Interviewing: strategy, techniques, and tactics. Homewood, Ill: The Dorsey Press, 1980.

18. Chenitz WC, Swanson JM. From practice to grounded theo?y: qualitative research in nursing. Menlo Park, Calif: Addison-Wesley Publishing Company, 1986. 19. Schatzman L, Strauss AL. Field research: strategies for a natural sociology. Englewood Cliffs, NJ: Prentice-Hall, 1973.

20. Strauss A. Qualitative analysis for social scientists. New York, NY: Cambridge University Press, 1987. 21. Bryant HE. Miscarriage: how to help in the crisis. Can Fam Physician 1985;31:1 109-16. 22. Stirtzinger R, Robinson GE. The psychologic effects of spontaneous abortion. Can Med Assoc i 1989; 140:799-801. 23. Friedman T. Women's experiences of general practitioner management of miscarriage. J R Coll Gen Pract 1989;39:456-8. 24. Parkes CM. Bereavement: studies ofgrief in adult Ife. Harmondsworth, Middlesex, Engl: Penguin Books, 1986: 18.

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