Coping After Recurrent Miscarriage
Coping After Recurrent Miscarriage
This qualitative study was aimed at exploring the coping strategies in women with single and recurrent miscarriage. We also examined whether a PRCI was perceived as useful for this population. The results show that two core categories, 'uncertainty' and 'bracing', differed between women with RM or SM. The more miscarriages women had experienced, the more likely that bracing was adopted as the core coping strategy to deal with increasing uncertainty about a current or eventual pregnancy. Women thought that coping interventions during the waiting period could be useful and that these could include positive reappraisal tools such as PRCI or other cognitive or psycho-educational interventions.
All women thought that the PRCI could be practical and applicable but most women with SM did not want to use this or any other intervention, in contrast with women with RM who did. This asymmetry may be due to differences between groups in appraisal of the situation. Women with SM felt that the first miscarriage was bad luck, and expected the present pregnancy to continue, lessening the need for additional support. In contrast, women with RM clearly lacked confidence about future outcomes, with perceptions and coping orientated toward potential failure (i.e. bracing for the worst). Another explanation for the difference can be found in the Common Sense Model. This model proposes that people make mental representations of their illness using different sources of information, for instance from memory, social environment and somatic information. Mental representations may change with the increasing number of miscarriages. In this cognitive context, women with RM may benefit from coping strategies targeting reappraisal, such as PRCI. These findings support conclusions from a recent survey on the modes of support likely to be valued by women with RM.
The use of the coping strategy 'brace for the worst', by which women try to control their emotions and future emotions as much as possible, has not previously been described among women with RM. However, in qualitative studies, similar behaviour has been reported such as "holding back emotions" and "emotional cushioning". In a longitudinal, qualitative study among 82 pregnant women who had experienced loss, a number of comparable coping styles were reported. For example, some women were hesitant to express their growing self-assurance because they were afraid to "jinx" their pregnancy and they delayed the announcement of pregnancy. The women in that study actively pursued many avenues to gain control and cope with the difficulties of their pregnancies. Kiwi argued that patients with recurrent miscarriages might develop a protective emotional shield during pregnancy in an attempt to reduce the pain of impending loss. Norem and Cantor described emotional cushioning as a process by which individuals protect themselves against threats to self-esteem in risky situations. The reason why women with SM did not use bracing is not clear. The differences could be caused by the fact that all women in the SM group were pregnant while most women in the RM group were not. Carroll et al. proposed that bracing was an attempt to avoid disappointment and reflected the cognitive strategy of defensive pessimism. Women with SM still had hope for the future, seeing the first miscarriage as "bad luck", and therefore experienced the new pregnancy as benign or a challenge.
In risky situations, two strategies can be used: defensive pessimism and an optimistic strategy. Defensive pessimism is discounting of past successes and the lowering of expectations prior to entering a situation. In the optimistic strategy, the expectations are high at the outset with post hoc restructuring of the situation when the outcome is known. It may be that women with SM were already using the coping style of positive reappraisal to deal with the current pregnancy. This optimism may explain the lack of bracing. Clearly all these future-oriented approaches theoretically overlap with bracing (and cushioning). However, our results and those from other studies concur that the particular characteristics of waiting for an ongoing pregnancy provoke specific cognitions and emotions that women may find difficult to manage because they refer to a future unknown, unpredictable and uncontrollable outcome. As such, more research attention should be devoted to this topic in relation to miscarriage and to whether bracing (and other future-oriented coping strategies) leads to positive or negative emotions in women with SM or RM.
The uncertainty for women in the RM group increased with every new miscarriage. The relationship between the number of miscarriages and the level of anxiety in a subsequent pregnancy is unclear. Some studies find a positive relationship and others no relationship.
In the present study, women used mainly emotion-focused coping styles to handle anxiety, which is consistent with the context. Terry and Hynes argue that in low-control situations the use of emotion-focused coping is more effective than problem-focused coping. In contrast to our findings, in a longitudinal study of 82 women pregnant after previous miscarriage, the dominant form of coping was problem-focused and women appraised their pregnancies as a moderate threat. These differences may be explained by the timing of the assessments. Women entered that study during their 10th to 17th week of pregnancy. Lazarus and Folkman reported that the longer the waiting period, the more the period was likely to be appraised as a threat. While the pregnancy is progressing, the waiting period becomes shorter. Time can be a variable that changes the coping styles.
The main weakness of the present study was the difference between the number of miscarriages and current pregnancy status, since all women in the SM group were currently pregnant compared with just one in the RM group. All women in the RM group had had a miscarriage 3 months or longer ago and they were all waiting for conception. All women in the SM group were at more than 12 weeks of gestation. A further weakness was the non-attendance and consequent reduced sample size. It is likely that non-attendance resulted in a less varied representation of miscarriage experience. The minimum acceptable number of focus groups and the sample size for each group in the literature is ambiguous. Halcomb et al. advise at least two focus groups of each participant type and a group size between four and 12 participants. In our study, we used two focus groups and the final sample size (four and five) was still within an acceptable range.
In conclusion, similarities and differences were found in the experiences of women with SM or RM. Despite the limitations of this study, the two core categories, bracing and uncertainty, were found to be important for women with RM in the waiting period for ongoing pregnancy. More research is required to understand whether modulating these coping strategies might reduce stress in women who have suffered RM. However, the presented findings indicate that the coping strategies adopted by women with recurrent miscarriage as they wait for confirmation of ongoing pregnancy are likely to be amenable to a specifically designed PRCI. A randomised study to assess whether this intervention can improve coping during this stressful waiting period is currently in progress.
Discussion
This qualitative study was aimed at exploring the coping strategies in women with single and recurrent miscarriage. We also examined whether a PRCI was perceived as useful for this population. The results show that two core categories, 'uncertainty' and 'bracing', differed between women with RM or SM. The more miscarriages women had experienced, the more likely that bracing was adopted as the core coping strategy to deal with increasing uncertainty about a current or eventual pregnancy. Women thought that coping interventions during the waiting period could be useful and that these could include positive reappraisal tools such as PRCI or other cognitive or psycho-educational interventions.
All women thought that the PRCI could be practical and applicable but most women with SM did not want to use this or any other intervention, in contrast with women with RM who did. This asymmetry may be due to differences between groups in appraisal of the situation. Women with SM felt that the first miscarriage was bad luck, and expected the present pregnancy to continue, lessening the need for additional support. In contrast, women with RM clearly lacked confidence about future outcomes, with perceptions and coping orientated toward potential failure (i.e. bracing for the worst). Another explanation for the difference can be found in the Common Sense Model. This model proposes that people make mental representations of their illness using different sources of information, for instance from memory, social environment and somatic information. Mental representations may change with the increasing number of miscarriages. In this cognitive context, women with RM may benefit from coping strategies targeting reappraisal, such as PRCI. These findings support conclusions from a recent survey on the modes of support likely to be valued by women with RM.
The use of the coping strategy 'brace for the worst', by which women try to control their emotions and future emotions as much as possible, has not previously been described among women with RM. However, in qualitative studies, similar behaviour has been reported such as "holding back emotions" and "emotional cushioning". In a longitudinal, qualitative study among 82 pregnant women who had experienced loss, a number of comparable coping styles were reported. For example, some women were hesitant to express their growing self-assurance because they were afraid to "jinx" their pregnancy and they delayed the announcement of pregnancy. The women in that study actively pursued many avenues to gain control and cope with the difficulties of their pregnancies. Kiwi argued that patients with recurrent miscarriages might develop a protective emotional shield during pregnancy in an attempt to reduce the pain of impending loss. Norem and Cantor described emotional cushioning as a process by which individuals protect themselves against threats to self-esteem in risky situations. The reason why women with SM did not use bracing is not clear. The differences could be caused by the fact that all women in the SM group were pregnant while most women in the RM group were not. Carroll et al. proposed that bracing was an attempt to avoid disappointment and reflected the cognitive strategy of defensive pessimism. Women with SM still had hope for the future, seeing the first miscarriage as "bad luck", and therefore experienced the new pregnancy as benign or a challenge.
In risky situations, two strategies can be used: defensive pessimism and an optimistic strategy. Defensive pessimism is discounting of past successes and the lowering of expectations prior to entering a situation. In the optimistic strategy, the expectations are high at the outset with post hoc restructuring of the situation when the outcome is known. It may be that women with SM were already using the coping style of positive reappraisal to deal with the current pregnancy. This optimism may explain the lack of bracing. Clearly all these future-oriented approaches theoretically overlap with bracing (and cushioning). However, our results and those from other studies concur that the particular characteristics of waiting for an ongoing pregnancy provoke specific cognitions and emotions that women may find difficult to manage because they refer to a future unknown, unpredictable and uncontrollable outcome. As such, more research attention should be devoted to this topic in relation to miscarriage and to whether bracing (and other future-oriented coping strategies) leads to positive or negative emotions in women with SM or RM.
The uncertainty for women in the RM group increased with every new miscarriage. The relationship between the number of miscarriages and the level of anxiety in a subsequent pregnancy is unclear. Some studies find a positive relationship and others no relationship.
In the present study, women used mainly emotion-focused coping styles to handle anxiety, which is consistent with the context. Terry and Hynes argue that in low-control situations the use of emotion-focused coping is more effective than problem-focused coping. In contrast to our findings, in a longitudinal study of 82 women pregnant after previous miscarriage, the dominant form of coping was problem-focused and women appraised their pregnancies as a moderate threat. These differences may be explained by the timing of the assessments. Women entered that study during their 10th to 17th week of pregnancy. Lazarus and Folkman reported that the longer the waiting period, the more the period was likely to be appraised as a threat. While the pregnancy is progressing, the waiting period becomes shorter. Time can be a variable that changes the coping styles.
The main weakness of the present study was the difference between the number of miscarriages and current pregnancy status, since all women in the SM group were currently pregnant compared with just one in the RM group. All women in the RM group had had a miscarriage 3 months or longer ago and they were all waiting for conception. All women in the SM group were at more than 12 weeks of gestation. A further weakness was the non-attendance and consequent reduced sample size. It is likely that non-attendance resulted in a less varied representation of miscarriage experience. The minimum acceptable number of focus groups and the sample size for each group in the literature is ambiguous. Halcomb et al. advise at least two focus groups of each participant type and a group size between four and 12 participants. In our study, we used two focus groups and the final sample size (four and five) was still within an acceptable range.
In conclusion, similarities and differences were found in the experiences of women with SM or RM. Despite the limitations of this study, the two core categories, bracing and uncertainty, were found to be important for women with RM in the waiting period for ongoing pregnancy. More research is required to understand whether modulating these coping strategies might reduce stress in women who have suffered RM. However, the presented findings indicate that the coping strategies adopted by women with recurrent miscarriage as they wait for confirmation of ongoing pregnancy are likely to be amenable to a specifically designed PRCI. A randomised study to assess whether this intervention can improve coping during this stressful waiting period is currently in progress.
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