Support Following Miscarriage Alice Elfer D.Clin.Psy Thesis

153 Pages·2017·1.38 MB·English

by  Alice Elfer

Support Following Miscarriage

Alice Elfer
D.Clin.Psy Thesis (Volume 1), 2017
University College London
UCL Doctorate in Clinical Psychology

Thesis declaration form

I confirm that the work presented in this thesis is my own. Where information has been
derived from other sources, I confirm that this has been indicated in the thesis.

Signature:

Name: Alice Elfer

Date: 20 September 2017

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Overview
One in four pregnancies ends in miscarriage; it is the most common type of
pregnancy loss. It can be a devastating and traumatic experience, yet often it goes
unrecognised and unspoken about. This thesis, presented in three parts, looks at formal
and informal sources of support for women in the aftermath of miscarriage.
Part I is a literature review of the effectiveness of psychological interventions for
women following miscarriage. Thirteen studies met inclusion criteria. Interventions
evaluated included CBT, IPT, nurse/midwife led sessions, and psychological debriefing.
Nine of the studies found improvement in symptoms following intervention. There was
no evidence of differential effectiveness for interventions of different theoretical
underpinnings.
Part II presents the findings of a qualitative study of women’s experiences of
social support following miscarriage. Thirteen women took part in semi-structured
interviews which were analysed using Braun and Clark’s (2006) method of thematic
analysis, yielding 10 themes. Women encountered a number of barriers to talking about
miscarriage e.g. its physical nature and being surrounded by other pregnant women.
They experienced both unsupportive interactions (e.g. dismissive remarks,
encouragement to move on) and supportive interactions (e.g. validation and permission
to talk). The findings are discussed with reference to the literature on grief, trauma and
social support.
Part III is a critical appraisal of the process of conducting the research presented
in Part II. It focuses on three main areas: personal reflexivity; epistemological
reflexivity; and broader reflections on miscarriage as a taboo subject.
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Table of Contents
Overview .......................................................................................................................... 3
List of Tables and Figures .............................................................................................. 7
Acknowledgements .......................................................................................................... 8
Part I: Literature Review ............................................................................................... 9
Abstract ....................................................................................................................... 10
Introduction ................................................................................................................. 11
Previous Reviews ..................................................................................................... 13
Aims of the Current Review .................................................................................... 16
Method ......................................................................................................................... 16
Inclusion and Exclusion Criteria.............................................................................. 16
Search Strategy ........................................................................................................ 17
Study Selection ........................................................................................................ 18
Data Extraction ........................................................................................................ 19
Assessment of Methodological Quality ................................................................... 21
Synthesis .................................................................................................................. 22
Results ......................................................................................................................... 22
Overview of Results................................................................................................. 22
Quality Appraisal of Included Studies ..................................................................... 30
Study Design ............................................................................................................ 32
Sample Characteristics ............................................................................................. 33
Nature of the Intervention ........................................................................................ 34
Therapist Characteristics.......................................................................................... 38
Target of Intervention .............................................................................................. 39
Outcome Measures .................................................................................................. 39
Outcomes ................................................................................................................. 41
Discussion ................................................................................................................... 45
Study Quality and Methodological Considerations ................................................. 48
Clinical Implications and Future Research .............................................................. 49
Conclusions .............................................................................................................. 51
References ................................................................................................................... 52
Part II: Empirical Paper .............................................................................................. 59
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Abstract ....................................................................................................................... 60
Introduction ................................................................................................................. 61
Social Support .......................................................................................................... 62
Social-Cognitive Processing Model......................................................................... 63
Social Support as an Interactional Process .............................................................. 65
Social Support following Miscarriage ..................................................................... 66
Current Study ........................................................................................................... 67
Method ......................................................................................................................... 68
Ethics ....................................................................................................................... 68
Setting ...................................................................................................................... 68
Participants............................................................................................................... 69
Semi-Structured Interview ....................................................................................... 71
Qualitative Data Analysis ........................................................................................ 73
Researcher Perspective ............................................................................................ 75
Results ......................................................................................................................... 75
Overview and Context ............................................................................................. 75
Domain 1: Barriers to talking about miscarriage ..................................................... 77
Theme 1.1: ‘It’s only a miscarriage’ ........................................................................ 78
Theme 1.2: ‘It’s really hard reliving it’ ................................................................... 80
Theme 1.3: ‘It’s about women’s bits’ ...................................................................... 81
Theme 1.4: ‘I didn’t want to burden them’ .............................................................. 83
Theme 1.5: ‘All my friends are pregnant’ ............................................................... 85
Domain 2: Supportive and Unsupportive Interactions ............................................ 87
Theme 2.1: ‘Navigating the awkwardness’ ............................................................. 88
Theme 2.2: ‘Glossing over it’ ................................................................................. 90
Theme 2.3: ‘Talk, but not too much’ ...................................................................... 92
Theme 2.4: ‘Be what you need to be’ ...................................................................... 95
Theme 2.5: ‘Kindred spirits’ .................................................................................... 97
Discussion ................................................................................................................... 99
Limitations ............................................................................................................. 103
Research and Clinical Implications ....................................................................... 104
References ................................................................................................................. 107
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Part III: Critical Appraisal ........................................................................................ 115
Personal Reflexivity .................................................................................................. 116
Epistemological reflexivity ....................................................................................... 120
Assumptions........................................................................................................... 121
Setting up the interview ......................................................................................... 121
Interview style........................................................................................................ 123
Broader Reflections ................................................................................................... 124
The role of anxiety ................................................................................................. 124
A feminist perspective ........................................................................................... 125
Lack of Ritual ........................................................................................................ 126
Concluding Thoughts ................................................................................................ 126
References ................................................................................................................. 128
Appendix A: Ethical Approval from the UCL Ethics Committee .......................... 131
Appendix B: Participant Information Sheet ............................................................ 133
Appendix C: Consent Form ....................................................................................... 136
Appendix D: Study Advertisement ............................................................................ 138
Appendix E: Semi-Structured Interview Schedule .................................................. 140
Appendix F: Process of thematic analysis: example of an individual summary sheet
....................................................................................................................................... 144
Appendix G: Process of thematic analysis: illustration of initial notes, codes and
themes ........................................................................................................................... 147
Appendix H: Respondent Validation: letter of invitation ....................................... 151

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List of Tables and Figures

Part I: Literature Review ............................................................................................... 9
Table 1. Search Terms ................................................................................................. 19
Figure 1. Study Selection Flow Chart ......................................................................... 20
Table 2. Characteristics of included studies ................................................................ 23
Table 3. Quality Assessment of Reviewed Studies ..................................................... 31
Table 4. Outcome Measures ........................................................................................ 40
Table 5. Effect Sizes .................................................................................................... 43
Part II: Empirical Paper .............................................................................................. 59
Figure 1. Outline of Recruitment Process ................................................................... 70
Table 1. Participant Characteristics ............................................................................. 72
Table 2: Themes and sub-themes ................................................................................ 76

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Acknowledgements

Firstly, I would like to thank my supervisors, Nancy and Chris, for their
incredible support throughout the process of this research. Their unwavering
encouragement, attention and empathy has made this challenging journey so
worthwhile. I would also like to thank the Miscarriage Association, particularly Ruth
Bender-Atik, for being so supportive of this project and Lorna, for giving her thoughts
and experiences when this project was just beginning.
The completion of this project and my clinical training would not have been
possible without the love and care of my family, particularly my husband, Luke. You
have lived through each high and low with me and always believed I could do it.
Most importantly, I would like to thank the women who participated in this
study. This thesis is dedicated to you: your courage, openness and determination to help
others has been truly inspiring.

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Part I: Literature Review

Psychological Interventions for Women Following Miscarriage

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Abstract
Aims: Miscarriage can be a devastating and traumatic experience for women, one which
increases the risk of psychological morbidity in the months that follow. This review
aimed to evaluate the effectiveness of psychological interventions designed to reduce
these psychological sequelae.
Methods: A systematic search for relevant studies was conducted via the electronic
databases PsychInfo, MedLine, CINAHL and the Cochrane Library, citation searching
and manual searches of bibliographies. The methodological quality of studies was
assessed using the Effective Public Health Practice Project Quality Assessment Tool.
Results: 13 papers met the inclusion criteria. They comprised four CBT interventions,
five nursing/midwife interventions, three IPT interventions and one psychological
debriefing intervention. Ten studies used a randomized controlled trial design and three
were uncontrolled. Overall, study quality was mixed; while study design was an area of
strength, areas of weakness included selection bias, blinding and drop-out. Nine of the
studies found improvement in symptoms following intervention. There was no evidence
of differential effectiveness for interventions of different theoretical underpinnings. For
the RCTs there was a median Cohen’s d of 0.18; for the uncontrolled studies the median
d was 0.69.
Conclusions: The findings provide preliminary evidence that intervention following
miscarriage can benefit women. While symptoms improve naturally over time
intervention can hasten and improve resolution of symptoms. However, further research
is needed to replicate and expand on these findings.

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