EMPIRICAL STUDIES doi: 10.1111/j.1471-6712.2011.00927.

How women who have experienced one or more miscarriages

manage their feelings and emotions when they become
pregnant again – a qualitative interview study

Ida-Maria Andersson RN (Candidate for Master’s Degree in Midwifery)1, Sandra Nilsson RN (Candidate for
Master’s Degree in Midwifery)1 and Annsofie Adolfsson PhD, RNM (Senior Lecturer)1,2
1
School of Life Sciences, University of Skövde, Skövde, Sweden and 2Department of Obstetrics and Gynecology, Skaraborg Hospital, Skövde,
Sweden

Scand J Caring Sci; 2012; 26; 262–270 another pregnancy terminate in disappointment. There-
fore, the women manage their feelings by distancing
How women who have experienced one or more mis-
themselves from their pregnancies. Simultaneously, they
carriages manage their feelings and emotions when
are managing their emotions by seeking affirmation that
they become pregnant again – a qualitative interview
their current pregnancy is normal.
study
Conclusion: Generally speaking, women manage their
Aim: The aim of this study was to investigate how women emotions by themselves. They feel isolated with their
who have experienced one or more miscarriages manage worries and concerns, and they are in need of the support
their feelings when they become pregnant again. provided from their intimate circle of friends and family as
Method: Individual qualitative interviews were conducted well as from the staff of the maternity health care ward.
with 16 women who were pregnant again after experi- Unfortunately, the women do not feel that they get the
encing one or more miscarriages. The interviews were support they need from the staff, instead they have to rely
analysed using qualitative content analysis with an on their friends, family and partners to help them manage
inductive approach. their emotions.
Results: The analysis of the material ended up in five cat-
egories: distancing herself from her pregnancy, focusing on Keywords: manage, pregnancy, qualitative content
her pregnancy symptoms, searching for confirming infor- analysis, miscarriage, support, ultrasound.
mation, asking for ultrasound examination and asking for
professional and social support. Because of their past Submitted 25 February 2011, Accepted 1 September 2011
experience with miscarriage, it could be painful to have

Miscarriage by definition is when a foetus terminates

Introduction
and is expelled from the uterus before the 22nd week in a
As approximately 15–25% of all known pregnancies ter- pregnancy. This definition is to include a stillborn foetus
minate in miscarriage, many women will have this that is <35 cm in length independent of the length of the
unfortunate experience sometime during their reproduc- pregnancy. Furthermore, the difference between an early
tive lives (1, 2). Most women that have suffered a mis- and a late miscarriage is that pregnancies that terminate
carriage have either carried a baby to term or will do so before the thirteenth week are termed to be an early
after their miscarriage experience, which is important for miscarriage. After the thirteenth week, the risk of miscar-
the women that have experienced a miscarriage to riage decreases significantly (3).
understand, because there is definitely hope for a suc- Missed abortion is the term used when the deceased
cessful pregnancy in the future (1). foetus remains in the uterus for a period of time before it
is expelled. The most common signs of a missed abortion
are the disappearance of pregnancy symptoms such as
morning sickness and swollen breasts that are typically
accompanied with soreness (4). The term stillbirth or
Correspondence to:
stillborn babies applies when the pregnancy exceeds
Annsofie Adolfsson, School of Life Sciences, University of Skövde,
P.O. Box 408, SE-541 28 Skövde, Sweden.
22 weeks or if the stillborn foetus weighs in excess of
E-mail: [email protected] 500 g (3).

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 Master feelings during pregnancy after miscarriage 263

The majority of miscarriages are because of a chromo- feelings exhibited more anxiety and showed more signs of
somal defect in the embryo and not to the mother’s genetic depression than the women that had the opportunity to
codes. Other reasons can be a structural abnormality in the fully discuss and express their feelings about the experi-
uterus, the presence of genital infections, hormone or ence. Conversations with their partners, their families and
immunological imbalances. Excessive alcohol use and friends were found to have a significant positive impact on
smoking can also be a contributing factor (5). In most the resolution process. Other women who have shared the
miscarriages, the ultimate reason is difficult to diagnose same experience can confirm to the women suffering a
and therefore many times the reason remains unknown miscarriage that they are not alone and the feelings they
(6). When the reason for a miscarriage is unknown, the are experiencing are similar to those of other women with
women will many times assume responsibility for it and the same experience (7).
consequently experience the guilt that goes it. They feel It is not unusual to have mixed feelings at the beginning
that because it was their body that did not successfully of a new pregnancy (7). The wonderful emotions and
complete the pregnancy to term it was their fault (7). feelings associated with the prospect of a new pregnancy
When a reason for the miscarriage can be successfully may be confusing in contrast to the misgivings of the
diagnosed and verified, the mother is less likely to hold potential disappointment associated with miscarriage (15).
herself accountable for the unfortunate event (8). In some cases, the apprehension can outweigh the happi-
Anticipation and planning for the future is an important ness (7). Women tend to protect themselves by holding
dynamic for the woman in the early stages of pregnancy. back their feelings and emotions with regard to their new
When a woman’s pregnancy is verified, she instinctively is pregnancy and the prospective child, as they do not feel
preparing to be a mother in her mind and in her body. As a confident that they can predict the outcome of their
consequence, when a miscarriage occurs, it is accompanied pregnancy based on their previous experience of a mis-
with a sensation of a vast emptiness and a tremendous carriage. Some women delay telling their family and
amount of sadness (7). After a miscarriage, many women friends about their pregnant condition, and other women
are concerned that they will not be able to become pregnant tell their intimate circle of acquaintances that they need
again, and if they do, they may be apprehensive because of their support during this apprehensive period (16). Many
their concern for another miscarriage (9). Women who women do not receive the support and understanding that
have children before the experience of miscarriage are more they need related to their concerns about their pregnant
likely to be positive about their prospects for future preg- condition after suffering a miscarriage (10).
nancies because of their successful delivery in the past (10). When women who have experienced a miscarriage
Many women described the sensation of suspecting that become overly concerned about the outcome of their cur-
something was not normal with their pregnancy as if they rent pregnancy, they contact the maternity health care
were anticipating problems associated with their pregnancy. ward (MVC) to ask questions about how they can avoid
Perhaps, it is the decreasing pregnancy indicators such as the having another miscarriage. In some cases, the women’s
associated morning sickness and the tension in her breasts concerns are not taken seriously and they are asked to
that are signalling to her that everything is not normal in her return later after the 3-month point in their pregnancy for
pregnancy. In spite of these signs, women tend to cling to registration with the MVC. If the women call with concerns
their hopes that nothing is wrong until the miscarriage is of bleeding, they were told not to worry about it because it is
confirmed by an ultrasound examination (7, 11). normal to have some bleeding when they are pregnant. This
After a miscarriage, women may feel themselves to be in advice does not necessarily make a woman who has expe-
a very vulnerable position and sometimes they feel that rienced a miscarriage feel any more secure (7).
the health care personnel are unsympathetic or unsup- After a woman suffers a miscarriage, it is natural and
portive of their needs (9). This also may be the case with normal for her to be anxious about the prospects for
other forms of perinatal loss such as stillbirth, which may becoming pregnant again. Therefore, it is important for her
make it even more difficult for the women to cope with to have her emotional needs validated in order for her to
their loss (12). These women have a strong desire that their manage the anxiety and concerns about being pregnant
grief and their sense of loss be taken seriously. It is again (15, 17). A literature study performed in 1999
important to them that they have a competent staff to examined the importance of increased support for those
provide them with adequate support, who can answer any women that were evaluated to be at higher risk for
questions they may have (7). Follow-up care after a mis- premature birth or miscarriage. The study found that the
carriage is not a high priority in the health care system most effective emotional support included some form of
(12). Stratton and Lloyd (13) state that a follow-up visit counselling, reassurance, sympathetic listening, informa-
after a miscarriage should include treatment for both the tion and guidance. This study demonstrates that extra
psychological and medical aspects. This is based on a study support during pregnancy helps to decrease the predelivery
by Nikcevic et al. (14), which concluded that the women anxiety for women who have experienced a miscarriage in
who did not have an adequate opportunity to discuss their the past. These pregnant women need support from their

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264 I.-M. Andersson et al.

friends, their families and from the medical staff (18). become pregnant again. These participants had been
Women who have experienced a perinatal loss require selected to participate in the previous studies regarding
more frequent visits to the MVC to give them reassurance follow-up visits with a midwife after experiencing a
that all are normal with their current pregnancy (19). In a miscarriage that were conducted during the years 2002–
study that was conducted in two large cities in Sweden, it 2003 (21) and 2004–2005 (9, 22). The women were
was demonstrated that women that are pregnant again after asked to contact the interviewer if they got pregnant
experiencing a miscarriage are offered an increased access to again. The participants received verbal and written
the MVC in the form of visits, consultations with doctors information that clarified the aim of this study and
and an earlier than routine ultrasound examination. This regarding the selection process. They signed a consent
additional attentiveness from the health care system is form and a confidentiality agreement. They confirmed
designed to have a reassuring effect on the women by that they were participating of their own free will, and
allowing them to hear the baby’s heartbeat and to let them they were assured that any personal data or information
see the image from the ultrasound on a monitor in order for that identified the participants would be excluded (23).
them to feel that the foetus inside their body is healthy and Participants included women who volunteered after
alive (11). According to Adolfsson et al. (7), in spite of this hearing about the study and also participants that
additional attention, it is not possible to entirely eradicate included women who were referred to the study by
the mother’s worries and concerns even after the ultra- women who were already participating in the
sound examination. A study by Coté-Arsenault and Mar- study (24). The inclusion criteria for the study included
shall (19) concludes that the results from an ultrasound that the women should be Swedish speaking, over
examination will only give the women a brief respite from 18 years of age, between 9 and 12 weeks pregnant and
their worries and concerns. had also experienced at least one previous miscarriage.
The aim of this study was to investigate how these women A total of 16 women chose to participate in the
in Sweden, who experienced one or more miscarriages, study. There were two interviews that were terminated
managed their feelings when they became pregnant again. because of circumstances regarding the women’s health.
Of the 14 interviews that were conducted, only 13 are in
the results because one interview did not answer
Materials and methods
to the aim of the study. The interviewee did not talk
about how she mastered her feelings, only about how
Design
she felt.
This qualitative interview study used the content analysis The Committee on Research Ethics at the University of
method with an inductive approach to describe how Gothenburg judged that the advantages of participating in
women manage their feelings when they become pregnant the study outweighed any potential risk for the partici-
again after experiencing one or more miscarriages. When pants before they approved it.
using the inductive approach, text materials are analysed
without any preconceived theory. Inductive approach is
Data collection
used on texts that describe an individual’s experience. The
aim of qualitative content analysis is to find knowledge The unit of analysis for this study was created from the
and understanding within the specific research objective. interviews of 13 women during the years from 2002 to
The purpose of the method is to find similarities and dif- 2006. The interviewer initiated the interview with some
ferences in the text of the interview transcripts, which can light conversation to create a relaxed atmosphere and
be sorted into categories and themes based on different presented the interviewee with a short description about
levels of logic (20). the purpose of the study (23). The interview consisted of
only one question. The interviewee was asked, ‘You have
become pregnant again. Can you tell me how you man-
Settings
aged your feelings regarding your pregnancy?’ If the
All of the women participating in the study were receiving interviewer felt that she needed to further develop the
treatment and care at a Swedish hospital in a medium- interviewee’s response she would repeat the woman’s
sized city of approximately 50 000 inhabitants. The response to her, which would motivate the woman to
interviews were performed in a consultation room of the elucidate further (23). Before the interview was termi-
hospital’s outpatient gynaecology clinic. nated, the women were asked whether they had anything
more to add to their story (23). The interviews were taped
so that the interviewer could concentrate on the woman’s
Selection of participants
response and on the dynamics of the interview itself (23).
The participants in this study were women who expe- The interviews lasted in length between 12 and 60
rienced at least one miscarriage and had subsequently minutes.

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interviews were condensed and coded independently.

Data analysis
The midwife students continued to read and discuss each
The interviews were transcribed verbatim to not lose any other’s analysis of the interviews to further strengthen
of the content with regard to how the women managed the trustworthiness of the study (24). The codes were
their feelings (25). The interviewer in the study was the compared and analysed, and 12 subcategories were sub-
supervisor of the two midwife students, and the super- sequently evolved (Table 2). These subcategories evolved
visor also had the responsibility for the data collection. into five categories from the similarities and differences
The transcripts of the tapes were closely listened to a in the contents of the interviews, which are the most
number of times by the midwife students to accurately important features of the qualitative content analysis
extract the data from the interviews and to properly method (Table 1). During the analysis period, the pen-
present the entire scope of the interview in the study dulum of perspective swung between focusing on the
(20). The main content in the interviews was discussed parts and on integrating them into the whole in order to
by the authors of the study, and meaning bearing units not lose the meaning of the text. Finally, a theme was
were assigned to words or phrases that addressed the aim identified when the underlying meaning of the categories
of the study (Table 1). The meaning bearing units were wove like a red thread going from category to category
further condensed to minimize the text further, and (20).
then, the units were assigned word codes to reveal the
essence of the interviews. The codes were used to elevate
Results
the contents of the interviews to a higher level of logic.
A code can be described as a label for the meaning The five categories that materialized from the results were
bearing unit and should be used to understand the entire as follows: distancing herself from her pregnancy; focusing
context of the interview (20). The midwife students on her pregnancy symptoms; searching for confirming
began by analysing three interviews together to information; asking for an ultrasound examination; and
synchronize their analysis technique. The remaining asking for professional and social support (Table 2). The

Table 1 Examples of meaning bearing units, condensed meaning bearing units, codes, subcategories and categories from the transcripts of the
interviews

Meaning unit Condensed meaning unit Code Subcategory Category

..very sensitive to signs from the Sensitive to signs from the body. Nausea is a Notice pregnancy Focusing on her
body, so it is great to feel sick…38 Good to feel nausea positive sign symptoms pregnancy
symptoms
..it was great to have Good to have an Ultrasound Safety, confirmation Asking for
this meeting booked.. I knew ultrasound so you can examination ultrasound examination ultrasound
that I would get an ultrasound... confirm a healthy pregnancy examination
so that I would
know after this meeting.. 117

Table 2 Presentation of subcategories, categories and theme

Subcategories Categories Theme

Unable to be happy Distancing herself from her pregnancy ‘Pregnant woman need support and
about being pregnant confirmation when they distance
Avoids thinking about being pregnant themselves from their pregnancy’
Frequent checking for bleeding Focusing on pregnancy symptom
Noticing pregnancy symptoms
Comfort with ultrasound examination Asking for an ultrasound examination
Relief experienced after ultrasound exam
The need for information Searching for confirming information
Relieved by information
The need to talk about their miscarriage Asking for professional and social support
Lack of support
The need for support from medical staff
Calmed by support from friends and family

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266 I.-M. Andersson et al.

theme of the five categories evolved into: Pregnant woman differently from when they were experiencing the
needs support and confirmation when they distance miscarriage. Women who have delivered a child know the
themselves from their pregnancy. difference in how they feel about their bodies when they
Women who become pregnant after experiencing a compare their experiences of successful and unsuccessful
miscarriage tend to have some ambiguous feelings about pregnancies. The symptoms have a calming effect on these
their pregnancies. On the one hand, they tend to distance women that know the difference in how their bodies felt
themselves from their pregnant condition as a defence under the different circumstances. These women find it
mechanism based upon their disappointment of their easier to manage their anxious feelings and worrying. The
earlier miscarriage but on the other hand, they actively symptoms were like a security blanket.
pursue confirmation that their current pregnancy is ‘The worse the nausea became and the sorer my
normal and healthy. breasts got… the calmer I was’.
In the same respect that the morning sickness and the sore
breasts give the women a sense of assurance, the absence of
Distancing herself from her pregnancy
bleeding is also a source of comfort. The women talked
This category describes how women that became pregnant about managing their worries of miscarrying by regularly
after having suffered a miscarriage tended to distance going to the bathroom to check for signs of bleeding. While
themselves from their pregnancy as a defence mechanism it is fatiguing for the women to constantly have this sense of
to protect their self from feeling the deep sense of disap- worry hanging over them, it gives them a sense of comfort
pointment that they felt when they suffered a miscarriage. and a temporary respite from their anxiety when they check
They felt that they had lost a baby and it was not just an for possible bleeding and they do not find any. This can give
embryo or a just a foetus. It was the child of their dreams, it them renewed and strengthened hope for their pregnancy.
was the child that they longed for and it was the child that At least for the moment, they have a confirmation that the
they carried in their wombs. Losing this child became an pregnancy is still going in the right direction.
integral part of their daily existence. ‘There has not been any bleeding…not even a little...
The uncertainty of a successful outcome in pregnancy so this time it feels like … I am a little surprised…you
has filled them with doubts as to whether they should know, this feels really good’.
become pregnant again. Even though they are pregnant Some bleeding would be a source of anxiety for the
again, the fear of having another miscarriage prevents women, as they are well aware that bleeding is a possible
them from feeling happy and confident about their indicator of miscarriage. The women who have
pregnant condition. The women distance themselves from experienced bleeding during their current pregnancy may
their current pregnancy by not allowing themselves to become very upset. These women try to manage their
think that they are carrying a child the way they did in worrying, and they hope for a different outcome from
their previous unsuccessful pregnancy. They try to take it the miscarriage they suffered previously. If they still feel
1 day at a time and try to not dare to get their hopes too the presence of morning sickness, they interpret this as a
high. They may avoid making purchases for the future positive sign regarding their pregnancy and this gives them
child such as the baby carriage and the baby clothes. They hope for a positive outcome. Perhaps, the presence of the
may avoid telling their friends and family that they are bleeding made them suspect the worst, but the presence of
pregnant again to make the disappointment more man- other pregnancy symptoms helps to give them the feeling
ageable in the event of another miscarriage. The women that the pregnancy could be successful. They can also find
may even hesitate to book an appointment at the MVC, some degree of comfort in the fact that there have been
which is traditionally performed at the 12-week point in women who have had bleeding and have still successfully
the pregnancy, because they are worried that they may given birth to a healthy child.
have to cancel if they have another miscarriage. They feel ‘The last time I was bleeding I felt something was
more comfortable booking their appointment once they wrong, but this time I was still feeling nauseous, so I
have passed a point in their pregnancy that exceeds the felt that it could still be possible that this bleeding was
point when they suffered the earlier miscarriage. normal’.
‘I don’t feel right about thinking of a child in my
stomach as I may have felt before...therefore it is dif-
Asking for an ultrasound examination
ficult to prepare in the same way...I put some distance
between myself and my pregnancy...’ When the women experienced a miscarriage, it was con-
firmed by an ultrasound examination performed by a
doctor. Even though the women may have had their sus-
Focusing on her pregnancy symptoms
picions that something was wrong with their pregnancy,
The pregnancy symptoms console the women that every- they described feeling shocked and in despair when it was
thing is normal in their pregnancy because their bodies feel confirmed that they had miscarried. It is very important for

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 Master feelings during pregnancy after miscarriage 267

these women to get confirmation of a viable pregnancy that they had performed something before their pregnancy
through an ultrasound examination because it is the only was confirmed, which could have damaged the embryo or
reliable way to confirm a healthy pregnancy in the early foetus, and therefore, they were responsible for the mis-
stages. At the time of the interview, there was an oppor- carriage. Perhaps, they had eaten something that was ill
tunity for the women to get their pregnancy confirmed advised or perhaps, some jarring movement or excessive
with an ultrasound examination and this was very signif- physical activity may have prompted the miscarriage. The
icant for them. It helped them to manage their feelings of women that had suffered a miscarriage worried about
anxiety and worry that the present pregnancy could result other things in addition to the things that they may have
in another miscarriage. It gave them a real sense of security originally worried about in their earlier pregnancy. With
to see the image of the foetus on the monitor and to see the the new pregnancy, the women want to do everything
beating of the tiny heart. To get an appointment for the possible to prevent another miscarriage and they have a
ultrasound with the interview was viewed as an additional desire to confirm that the present pregnancy is proceeding
opportunity for the women to confirm their pregnancy normally and they have not performed anything to nega-
and to help them feel positive. tively influence it. Therefore, they seek information from
‘I have known since my pregnancy test came back reading books and magazines and search the internet to
positive that I would have the opportunity to get an find information that confirms to them that their preg-
early ultrasound examination along with the nancy is healthy and viable. When in the course of their
interview…early in the pregnancy...I would have research they find resolution to the things that concern or
been much more concerned if I had not had this worry them, it helps them to manage their negative feel-
meeting and this ultrasound exam planned’. ings. When they find that there is no reason to believe that
The women feel that the ultrasound examination is a dif- they have performed anything to harm the foetus inside
ficult moment for them because it was at this point in their them, it helps them to feel calmer and more assured.
previous pregnancy that they were confirmed to have ‘I tried to find information about the things that
suffered a miscarriage. They had seen the image of a foetus concerned me…to convince myself that it was not a
that did not have a heartbeat. There was no sign of life. miscarriage, so I read everything I could find about
They were afraid of what they might see this time. When it...to find logical explanations about the things that
they see the image of a foetus with a normal beating heart worried me certainly made me feel calmer’.
during this subsequent pregnancy, they are reassured that
everything is alright this time and it gives them a sense of
Asking for professional and social support
confidence and inner peace. The ultrasound examination
is important for the women because it confirms that there Many times, the anxiety that the women experience during
is a healthy foetus that is living and growing in their the early stages of their pregnancy after experiencing a
uterus. It is the potential healthy child of their dreams. former miscarriage is too much to manage on their own.
Now, they can dare to speak about their pregnancy more These women have experienced a significant disappoint-
freely, sharing their happiness, hopes and dreams for their ment in their lives, and many times, this loss is not com-
baby with their family, friends and intimate circle. Before pletely resolved. The women have a strong desire to talk to
the confirmation of the ultrasound, this had been difficult someone who is a qualified professional about their earlier
for the women because of their residual misgivings that miscarriage and regarding their concerns for their present
were based on the previous miscarriage. pregnancy, but they are not sure who to turn to. They tend
‘It was really calming to have the ultrasound test to feel that waiting until the registration time with the
confirm that everything was alright early in my midwife at the MVC during the twelfth week is too late for
pregnancy in order to leave some needless worries and them. Their concerns for a new miscarriage tend to start
doubts behind’. with the positive pregnancy test, which typically is taken a
The women who have already had an ultrasound exami- number of weeks prior to the twelfth week, and this is a
nation during this pregnancy experience feelings of elation long time for them to manage their fears on their own.
when they learn that everything is normal. In spite of Their need of support and their need of someone to talk
already having the good news, they want another ultra- with about their anxiety were confirmed in the results of
sound examination because they are again afraid that the interviews. Apprehension of another miscarriage and
something would not be right with the pregnancy. worries regarding the health and viability of their present
pregnancy was a common topic among the women.
‘I think it has been very helpful to have these con-
Searching for confirming information
versations in the interview process in association with
The anxiety and fear associated with a new pregnancy after this study. It has been a good source of extra support’.
experiencing a miscarriage can be a source for questions as When the women experience a symptom such as bleeding
well as a catalyst of doubt for the women. They may feel when they are pregnant again, they seek help at the MVC

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268 I.-M. Andersson et al.

or at the emergency ward to confirm that everything is bleeding or an ultrasound examination (7, 11). The
alright with their pregnancy. They need to hear from pregnancy symptoms are an important confirmation that
qualified professional personnel that their symptoms are the pregnancy is viable for the women that have experi-
not a cause for excessive concern. It is important to the enced a miscarriage in the past. The presence of these
women that they can separate themselves from unneces- symptoms can resolve some of the women’s concerns and
sary doubts and worries, and often, they need help in worries. According to Swanson et al. (10), women who
managing these concerns. Unfortunately, they have not have previously had successful pregnancies ending in a
always received the necessary support when they needed it. healthy birth find that pregnancy symptoms help them to
‘It was a little uneasy from the start with the midwife at manage their anxiety by associating these symptoms with
the maternity centre…she talked about the negative a healthy and successful pregnancy.
impact that alcohol can have on a foetus and this was a The ultrasound examination was found to be, perhaps,
cause for concern because I had taken some drinks the most important and the most convenient confirmation
before I knew that I was pregnant. Then she informed to the women that their pregnancy was healthy and viable
me that there was a film that I must see…that everyone (28). The presence of life that is indicated through the
was to see, in fact…about the damage that alcohol ultrasound monitor is the closest thing to an actual phys-
intake can have on healthy pregnancies…very ical confirmation that the women can have. Some of the
important movie to see. The midwife was unaware that women may have already had an earlier ultrasound
perhaps it wasn’t the explicit information about the examination but were really pleased that they would have
dangerous effects of alcohol that I was interested in…I another one performed in connection with the interview
needed help with the worrying I was doing about tak- to reaffirm the health and growth of the foetus within
ing the drinks before I knew I was pregnant. It sort of them. This is the optimistic coping strategy according to the
bothered me that the midwife did not seem to under- Jalowiec coping scale (26, 27). The ultrasound examina-
stand’. tion does not always give final resolution to the women’s
If the women did not feel that they were getting the type or worries and concerns. A study by Coté-Arsenault & Mar-
level of support that they needed from the health care shall (19) maintains that the ultrasound examination is
system, they found themselves turning to their partners, just a temporary relief and the women may return
families and friends instead. To them, it felt very consoling believing they are in need of another examination. There
to get support from them and to be able to confide in their are a couple of other studies that are in agreement with the
intimate circle. It helped them to manage their worries authors that maintain it is more important to provide the
about their previous miscarriage, and at the same time, it necessary support in the form of conversations and con-
felt good to get support and to hear warm words from their sultations with qualified health care personnel (15, 17).
intimate circle. When they became aware that they are This is the supportive coping strategy according to Jalowiec
pregnant again, it is difficult to confide in others about their coping scale (26, 27).
condition. Perhaps, there are only a couple of people that As a result of the interview process, the women dem-
they feel they can confide in who can help them to manage onstrated a definite need for support and counselling.
their concerns. Talking with other women who have had A significant amount of the conversation during the
the same experience of having a miscarriage and then interview revolved around the experience of their mis-
becoming pregnant again is really helpful. It helps the carriage, and interestingly, it was the moment that they
women to know that they are not alone and isolated in their realized that they were pregnant again that was the cata-
situation. The worries and concerns are easier to manage lyst for much of their worrying and concern. The fact that
when they can share them with someone else. the women did not know where to turn or who to talk to
about their worries is indicative that there was a lack of
built-in support within the health care system. Earlier
Discussion
studies have demonstrated that these women who have
Pregnancy symptoms were the most common way for suffered a miscarriage and have become pregnant again are
these women to confirm that their pregnancy was normal. missing the necessary support and understanding
As long as the women were experiencing symptoms such regarding their anxieties that they need under their cir-
as morning sickness and sore breasts, they were assured cumstances (10). Therefore, health care professionals need
that their pregnancy was progressing normally. This is the to be able to recognize the women’s needs to provide
palliative coping strategy according to the Jalowiec coping effective care (28). It is these women who are in definite
scale (26, 27). These signs often diminished or disappeared need of support; therefore, the authors believe that the
when they were in the process of experiencing their mis- midwives in the health care system should get the training
carriage. Earlier studies have demonstrated that women and education that will enable them to provide this type of
experiencing diminished pregnancy symptoms may have support for the women (29). There should be opportunities
suspected a miscarriage before they had it confirmed with in the MVC for the women to receive the support they

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 Master feelings during pregnancy after miscarriage 269

need depending upon their individual needs. This will help circumstances surrounding the recruitment of the
to minimize and manage the worries and concerns that the participants. The potential participants were asked to take
women experience during their pregnancy after having a part in this interview study after they had experienced
previous miscarriage (18). It is also important that the their miscarriage. They were asked in the event they
women get the support that they need after their miscar- became pregnant again, would they consider participating
riage to work through their loss (30, 31). This can be a in a study that was investigating the management of the
determining factor in the women having a positive expe- emotions and feelings that women experience under these
rience in a new pregnancy because it will enable them to particular circumstances. The question then becomes is
manage their feelings and emotions. In this way, they are there a certain personality type that may be more likely to
provided with the proper tools to deal with their concerns participate in a study such as this rather than other per-
during subsequent pregnancies (13). sonality types? A new data collection was performed in
Some of the women use an avoidance technique of not 2010 (M Rosebrink, M Zekaj, A Adolfsson, unpublished
talking about their new pregnancy to distance themselves data), which confirmed the results of this study and con-
from their condition because of residual fears they may have firmed that there were a sufficient number of participants
from the previous miscarriage. By avoiding feelings of hap- to generate enough transcripts and data to make the data
piness about their pregnancy, they subconsciously feel they analysis meaningful. Another study that would comple-
are suppressing a potential disappointment in the event that ment this study is one that would analyse women’s feel-
they should suffer another miscarriage. This is the evasive ings after an ultrasound examination performed during a
coping strategy according to Jalowiec coping scale (26, 27). current pregnancy after experiencing a miscarriage.
This avoidance of feelings was confirmed in a study that was
conducted by Coté-Arsenault and Mahlangu (16) that
Conclusions
reveals that women are reluctant to indulge in feelings of
happiness when they are not certain about the outcome of Women who become pregnant after experiencing a mis-
their pregnancy. The normal reaction to pregnancy in its carriage tend to manage their feelings and their emotions by
early stages is to plan for the future, but after a miscarriage, their own devices. They do this through the use of avoid-
these women protect themselves by not doing this planning ance techniques to distance themselves from their new
(7). They feel that this protects them by taking things 1 day pregnancy. The women may avoid some of the normal
at a time. In some cases, this could be a sound emotional planning for the future child to minimize their involvement
management technique by not planning too far in advance, and intimacy with their new pregnancy. They may do this
but if it is taken too far, the women may lose out on building by focusing on their pregnancy symptoms and seeking
a sound foundation of emotional attachment with their information from books, publications and the internet that
pregnancy experience and the baby itself. This is another will pacify their worries and concerns. These women often
aspect of the results of the interviews that confirms that find that they get the most therapeutic confirmation from
pregnant women who have previously experienced a mis- an ultrasound examination because it can physically pro-
carriage need extra support from the MVC and the health vide them with evidence on a monitor that everything is
care system (16). normal with their current pregnancy, even though it may
This study is the first from a Swedish context where only be a short-term relief. Feeling alone and isolated is a
women were interviewed during their pregnancy after common feeling among these women, and they need sup-
experiencing a miscarriage. To demonstrate the trustwor- port to help them manage their emotions. This support
thiness of this study, we have included representative typically comes from their intimate circle of family, friends
quotations from the transcripts of the text. The fact that and from the health care system itself. The women gener-
one of the authors is doing research on a daily basis is ally feel that they get the necessary support from their
further evidence of the trustworthiness of this study (20). family, friends and partner but they may have some mis-
A limitation of this study is the midwife students who givings about the health care system falling short in helping
analysed the interviews did not conduct the interviews them to resolve their issues regarding their previous mis-
themselves. As the authors did not conduct the interviews, carriage experience. They must be able to resolve the con-
they listened to the recordings and read the transcripts of flicts associated with the miscarriage to experience their
the interviews a number of times to understand the spe- new pregnancy with the fullest potential in terms of their
cific nature of the complications that the women were joy and happiness in connection with it.
experiencing as they attempted to manage their feelings
about their pregnancy after experiencing a previous mis-
Acknowledgements
carriage. Another possible limitation in this study is that
the women were all from a similar geographic location and The writers would like to thank all the women who have
they were all being treated under the same health participated in the study, sharing their feelings and expe-
care system. Finally, we must take into consideration the riences.

 2011 The Authors

Scandinavian Journal of Caring Sciences  2011 Nordic College of Caring Science
270 I.-M. Andersson et al.

11 Jansson C, Adolfsson A. A Swedish miscarriage: a randomized study.

References study of midwives’ and nurses’ Acta Obstet Gynecol Scand 2006; 85:
1 Hemminki E, Forssas E. Epidemiology experiences when women are diag- 330–5.
of miscarriage and its relation to nosed with a missed miscarriage 22 Adolfsson A, Tullander-Tjörnstrand
other reproductive events in Finland. during a routine ultrasound scan. Sex K, Larsson PG. Decreased need for
Am J Obstet Gynaecol 1999; 181: 396– Reprod Healthc 2010; 1: 67–72. emergency services after changing
401. 12 Corbet-Owen C, Kruger L. The health management for suspected miscar-
2 Adolfsson A, Larsson PG. Cumulative system and emotional care: validating riage. Acta Obstet Gynecol Scan 2011;
incidence of previous spontaneous the many meanings of spontaneous 90: 921–3.
abortion in Sweden 1983–2003: a pregnancy loss. Fam Syst Health 2001; 23 Kvale S, Brinkmann S. The Qualitative
register study. Acta Obstet Gynecol Scand 19: 411–27. Research Interview, 2nd edn. 2009,
2006; 85: 741–7. 13 Stratton K, Lloyd L. Hospital – based Literature for students, Lund.
3 World Health Organisation. WHO rec- interventions at and following mis- 24 Polit DF, Beck CT. Essentials of Nursing
ommended definitions, terminology carriage: literature to inform a Research: Methods, Appraisal, and Utili-
and format for statistical tables related research – practice initiative. Aust N Z zation, 6th edn. 2006, Williams &
to the perinatal period and use of a new J Obstet Gynaecol 2008; 48: 5–11. Wilkins, Philadelpia, PA, USA.
certificate for cause of perinatal deaths. 14 Nikcevic AV, Tunkel SA, Nicolaides 25 Wengraf T. Qualitative Research
Modifications recommended by FIGO KH. Psychological outcomes follow- Interviewing: Biographic Narrative and
as amended October 14, 1976. Acta ing missed abortions and provision of Semi-Structured Methods. 2001, Sage
Obstet Gynecol Scand 1977; 56: 247–53. follow-up care. Ultrasound Obstet Publications, Los Angeles, CA, USA.
4 Shankar M, Economides DL, Sabin CA, Gynaecol 1998; 11: 123–8. 26 Jalowiec A, Murphy SP, Powerss MJ.
Tan B, Kadir RA. Outpatient medical 15 Coté-Arsenault D, Bidlack D, Humm A. Psychometric assessment of the Jalo-
management of missed miscarriage Women’s emotions and concerns dur- wiec coping scale. Nurs Res 1984; 33:
using misoprostol. J Obstet Gynecol ing pregnancy following perinatal loss. 157–61.
2007; 27: 283–6. Am J Mat Child Nurs 2001; 26: 128–34. 27 Shu-Hsin L, Shu-Chuan W, Ching-
5 Cramer DW, Wise LA. The epidemiol- 16 Coté-Arsenault D, Mahlangu N. Im- Pyng K, Pi-Chao K, Maw-Sheng L,
ogy of recurrent pregnancy loss. Semin pact of perinatal loss on the sub- Meng-Chile L. Grief responses and
Reprod Med 2000; 18: 331–9. sequent pregnancy and self: women’s coping strategies among infertile
6 Regan L, Rai R. Epidemiology and the experiences. J Obstet Gynaecol Neonatal women after failed in vitro fertiliza-
medical causes of miscarriage. Bail- Nurs 1999; 28: 274–82. tion treatment. Scand J Caring Sci
lière’s Best Practice and research. Clin 17 Swanson KM. Predicting depressive 2010; 24: 507–13.
Obstet Gynaecol 2000; 14: 839–54. symptoms after miscarriage: a path 28 Skuladottir H, Halldorsdottir S.
7 Adolfsson A, Larsson PG, Wijma B, analysis based on the Lazarus para- The quest for well-being: self-iden-
Berterö C. Guilt and emptiness: digm. J Womens Health Gend Based Med tified needs of women in chronic
women’s experiences of miscarriage. 2000; 9: 191–206. pain. Scand J Caring Sci 2011; 25:
Health Care Women Int 2004; 24: 543–60. 18 Hodnett ED. Support during preg- 81–91.
8 Nikcevic AV, Tunkel Kuczmierczyk nancy for women at increased risk. 29 Wojnar DM, Swanson KM, Adolfsson
AR, Nicolaides KH. Personal coping Cochrane Database Syst Rev (online) A. Confronting the inevitable: a con-
resources, responsibility, anxiety and 2000; 2: CD000198. ceptual model of miscarriage for use
depression after early pregnancy loss. J 19 Coté-Arsenault D, Marshall R. One in clinical practice and research. Death
Psychosom Obstet Gynaecol 1998; 19: foot in – one foot out: weathering the Stud 2011; 35: 536–58.
145–54. storm of pregnancy after a perinatal 30 Adolfsson A. Women’s well-being
9 Adolfsson A. Applying Heidegger’s loss. Res Nurs Health 2000; 23: 473–85. improves after missed miscarriage
interpretive phenomenology to 20 Graneheim UH, Lundman B. Quali- with more active support and
women’s miscarriage experience. Psy- tative content analysis in nursing application of Swanson’s Caring
chol Res Beh Manag 2010; 3: 75–79. research: concepts, procedures and Theory. Psych Resh Behav Manag
10 Swanson KM, Connor S, Jolley SN, measures to achieve trustworthiness. 2011; 4: 1–9.
Pettinato M, Wang TJ. Contexts and Nurse Educ Today 2004; 24: 105–12. 31 Jansson C, Adolfsson A. Application
evolution of women’s responses to 21 Adolfsson A, Berterö C, Larsson PG. of ‘‘Swanson¢s Middle Range Caring
miscarriage during the first year after Effect of a structured follow-up visit Theory’’ in Sweden after miscarriage.
loss. Res Nurs Health 2007; 30: 2–13. to a midwife on women with early Int J Clin Med 2011; 2: 102–9.

 2011 The Authors

Scandinavian Journal of Caring Sciences  2011 Nordic College of Caring Science
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