PRIMARY CARE CONSIDERATIONS OF MISCARRIAGE MANAGEMENT
By

Shandalin Marks
B.S.N., University of the Fraser Valley, 2003

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR
THE DEGREE OF MASTERS OF SCIENCE IN NURSING FAMILY NURSE
PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
JULY 2016
©SHANDALIN MARKS, 2016

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Abstract
Nearly 1 in 4 women experiencing a miscarriage during their child bearing years. This,
coupled with the fact that many health care providers are communicating to these women
that this is an insignificant event, has left many women feeling empty and even traumatized.
As a result, the research is shows that these women are presenting with clinically high levels
of anxiety and depression post miscarriage. Focusing on this, an investigation was
undertaken to look at what the existing primary care approaches are to care are for women in
their 20s and 30s who are experiencing depression and anxiety after a miscarriage. Using the
Cochrane Collaboration method of reviewing, a systematic approach was taken to examine
the literature pertaining to the investigation. The search included various provincial, national
and international practice guidelines, as well as the electronic databases: Medline, Academic
Search Complete, Psych INFO and CINAHL. The results indicated that this group of women
have unique needs for support, require early interventions, and need to be screened for
anxiety and depression. Recommendations were made to help guide the practice of nurse
practitioners founded on Swanson’s theoretical framework for caring.

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TABLE OF CONTENTS
Abstract ……………………………………………………………………………………... ii
Table of Contents ………………………………………………….……………………...... iii
List of Tables ………………………………………………….……………………………. v
List of Figures ……………………………………………………………………………… vi
Acknowledgements ………………………………………………………………………... vii
Dedication ………………………………………………………………………………… viii
Chapter One

Introduction …………...……………….……………………………. 1

Chapter Two

Background and Context ...………….………………………….….... 9

Chapter Three

Theoretical Framework ………….….……………………………… 13
Knowing .………………………………………...………... 14
Being With …………………………………………………. 14
Doing For …...……………………………………………… 14
Enabling ……………………………………………………. 15
Maintaining Belief ....………………………………………. 15

Chapter Four

Methodology ………………………………………………………. 17
Integrative Review Process ………………………………… 17
Preliminary Search ………………………………… 17
Focused Search …………………………………...... 20
Inclusion criteria …………………………… 21
Exclusion criteria …………………………... 21
Analysis ……………………………………………. 22

Chapter Five

Findings ….………………...………………………………………. 23
Needs for Support Are Unique …………………………...... 23
Screening for Depression and Anxiety is Necessary ………. 30
Early Interventions Are Desired and Effective ……………. 35

Chapter Six

Discussion ….………………………………………………………. 42
Knowing …………………………………………………… 45

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Being With ………………….…………………………........ 47
Doing For ............................................................................... 48
Enabling ……………………………………………………. 49
Maintaining Belief …………………………………………. 51
Chapter Seven

Summary and Conclusion …...……………………………………... 53

References ……………………………………….………………………………….……….57
Appendix A ………………………………………………………………………………… 62
Appendix B ………………………………………………………………………………… 63

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List of Tables
Table 1

Clinical Practice Guidelines Search ...……………………...……………. 19

Table 2

Search Strategy Methodology and Detailed Database Search Results ……. 20

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List of Figures
Figure 1

Nursing as Informed Caring for the Well-being of Others ………………... 16

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Acknowledgements
I would like to acknowledge the ongoing support and guidance of my supervisory
committee Lela Zimmer, RN, BScN, PhD and Connie Lapadat BSN, MSN-FNP-C, FNP-BC.
Thank you.

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Dedication
This project is dedicated entirely to my husband Duncan O’Mahony. Without you,
this story of sadness and hope would never have been written. Thank you for helping me to
see the beauty that can come from suffering.

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Chapter One: Introduction
For most women the experience of pregnancy is profoundly emotional. Pregnancy
represents the realization of a dream and a central stage in a woman’s life. “In my mind, the
essence of a woman is to be a mother. It’s part of the aspiration of every woman to reach
perfection. It’s a kind of inner need, to fulfill yourself.” (Gerber-Epstein, Leichtentritt, &
Benyamini, 2009, p. 16). Sometimes, however the dream turns into a nightmare when the
pregnancy stops progressing, and the life that has been growing in the woman’s womb dies.
Murphy and Merrell (2009) describe miscarriage as a global health issue.
Approximately 1 in 4 women will have a miscarriage during their lifetime (Adolfsson, 2011).
For many women, miscarriage constitutes an often sudden, unexpected physically as well as
psychologically traumatic event. It is estimated that 15-25% of all clinically recognized
pregnancies end in miscarriage; most of these occur within the first three months (Geller,
Psaros, & Kornfield, 2010). Miscarriages are more frequent in older women, but even in
those younger than 35 years of age it is estimated that 10-12% will miscarry. Miscarriage is
defined as the spontaneous death of a fetus before 20 weeks’ gestation (Geller, Psaros, &
Kornfield, 2010). This can also be referred to as a fetal demise or spontaneous abortion.
Therapeutic abortion is used to describe the surgical or medical termination of pregnancy at
any time during gestation by the request of a patient (Gaudet, 2010). Stillbirth is the death of
the baby after 20 weeks’ gestation. For the woman experiencing the involuntary loss, the
term “abortion” can be distressing and using the term “miscarriage” is preferable
(Thorstensen, 2000). For the duration of this paper, the term miscarriage will be used to
describe the involuntary loss of a pregnancy before 20 weeks.

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Many health professionals and the lay community perpetuate the belief that
miscarriage is an insignificant event (McCreight, 2008). It is thought that a woman will
recover with no lasting psychological effect on herself, her partner, or her family. Pregnancy
has different meanings to each woman, much of this meaning is dependent on the woman’s
circumstance, however for many women pregnancy and subsequent miscarriage is a highly
emotional occurrence (Adolfsson, 2011).
As if I’d been naive and everything was going well and everything was fine, and then
you lose it, because suddenly bad things are happening, that’s what makes it so very
traumatic. Tragic . . . It [the miscarriage] changed my understanding, I mean, it
brought me down to earth. Suddenly I saw that bad things happen in the world.
(Gerber-Epstein, Leichtentritt, & Benyamini, 2009, p. 14).
Women express common emotions and feelings associated with miscarriage that include
shame, uncertainty, dread, guilt, emptiness, and lack of control. Many women consider the
miscarriage as the loss of a child and for many the experience will be similar to that of losing
a close relative (Bardos, Hercz, Friefenthal, Missmer, & Williams, 2015). In addition to
physical complications, miscarriage can be an unforeseen emotional devastation for women
and their partners. Although some women are relieved after miscarrying, many women find
the experience quite traumatic, and this can trigger psychological problems.
The thought of carrying a dead embryo inside me drove me crazy . . . There was a
sort of transition, where earlier I said I didn’t want them to touch me, then I said, OK,
come on, take it out already! I was terribly confused— on the one hand, take it out
because it’s dead, and on the other: don’t touch, it’s my child . . . I had very
ambivalent feelings, I literally didn’t know my left from my right . . . But then I tell
you it was a long nightmare, I tell you that time [four days] was an eternity, it simply
didn’t pass. (Gerber-Epstein, Leichtentritt, & Benyamini, 2009, p. 12)
Research consistently documents clinically high levels of depression, anxiety, guilt and
shame among women who have recently miscarried (Bennett, Litz, Maguen, Ehrenreich,

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2008; Nikčević & Nicolaides, 2013; Woods-Giscombe, Lobel, Crandell, 2010). More
specifically Major Depressive Disorder (MDD), which is a medical illness, can affect how
you feel, think and behave causing persistent feelings of sadness and loss of interest in
previously enjoyed activities (American Psychiatric Association, 2013). Using DSM-IV
criteria, clinicians were advised against diagnosing major depression in individuals within
the first two months following the death of a loved one in what has been talked about as
bereavement exclusion. In the current 5th edition of the DSM, the bereavement exclusion has
been removed. This change now helps prevent major depression from being overlooked and
facilitates the possibility of appropriate treatment being recommended in a timely manner for
the individual.
Like depression, an anxiety disorder affects how we think, feel, and act. It is
completely natural to feel nervous or worried at times, as this type of anxiety can be helpful
when it motivates us to do something when faced with a threat. An anxiety disorder, however
causes unexpected or counterproductive worry and fear that can seriously impact our lives,
including how we feel, think, and act. According to the American Psychiatric Association
(2013) an anxiety disorder is excessive anxiety and worry that occurs more days than not
during a six-month period in which a person finds it difficult to control the worry. As well
the anxiety, worry, or associated physical symptoms may cause clinically significant distress
or impairment in social, occupational, or other important areas of life.
Without specifying miscarriages, Statistics Canada (2008) reports that fetal loss is
one in 1000 pregnancies. Despite the frequency of miscarriage, there remains an invisibility
associated with this loss. Public perception is that miscarriage occurs only in 5% of
pregnancies when the actual rates can be up to 25% (Bardos, Hercz, Friefenthal, Missmer, &

4

Williams, 2015). Clearly, many people erroneously believe that miscarriage is a rare
complication of pregnancy and as a result this misconception may encourage the alienation
that patients feel as they experience a miscarriage. Despite the frequency of miscarriage, it is
often shrouded in silence and shame, even within a close social circle of family and friends.
Lack of awareness, of miscarriage impact, can leave the woman feeling isolated, alone, and
vulnerable to mental illness.
In Canadian culture, women often wait at least 12 weeks before publicly announcing
their news of being pregnant. This results in family and friends often being unaware of the
pregnancy until they hear of the loss. A consequence of this is that many of those just hearing
the news for the first time can have a difficult time in relating to and understanding the
impact of the loss on the woman. To compound this unseen grief, is the lack of universal
response or formal mourning process that is associated with this loss.
[Friends and family] ignored it; after a week I was supposed to be alright, back to
normal, happy and bouncing around and obviously I wasn’t, but because it hadn’t
happened to them it was something to talk about for a couple of days and then after
that . . . I don’t think people really understand unless they actually go through it
themselves, to be honest. (Brady, Brown, Letherby, Bayley, & Wallace, 2008, p.
188).
The woman may be left feeling bereft of any memory or token of the child that she never
met. The feelings of guilt and shame compound the isolation of losing the “invisible” or not
yet seen child, and may have negative consequences on marital relationships, social
relationships, future pregnancies and surviving children (Lamb, 2002). This emotional
burden appears to be under appreciated by health care professionals and the general
community.

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The past few decades have shown an increase in research and discussion about the
psychological impact of miscarriage. The psychological morbidity can be quite high for
women experiencing miscarriage, yet, unlike stillbirth, a miscarriage is less frequently
associated with support services and has not been the object of specific service delivery.
Once the miscarriage has begun, the outcome is inevitable and the practitioner has few
preventative measures to offer. For many years the health care system viewed these loses as
minor physical occurrences not requiring close follow up (Lamb, 2002). Due to the
frequency of miscarriage, for a practitioner, this can be viewed as a common clinical
problem. The woman and her partner may view the miscarriage very differently from the
practitioner, and this loss may be as distressing as that of late miscarriage or a stillbirth
(Evans, 2012). In a study by Rowlands and Lee (2010), the majority of women described
experiencing poor care from their medical professional particularly due to the lack of
information and insensitive comments. “Generally I found the attitude there [GP office] was
unsympathetic to what I was going through. I was treated as though I just had a medical
condition, rather than any recognition of the loss I had suffered” (Simmons, Singh,
Maconochie, Doyle, & Green, 2006, p. 1943). The implications were that health care
professionals were failing to meet the needs of women and their families during and after
miscarriage.
In contrast, women who receive sensitive aftercare from various disciplines are
described as having greater satisfaction after miscarriage and those who receive appropriate
and timely follow-up have decreased psychological distress compared to those who do not
(Rowlands & Lee, 2010a).
During the whole weekend that I was here at home the obstetrician’s office called and
made me feel like I should never hesitate to call, 1:00 o’clock in the morning,

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whenever. It didn’t matter. When I went back for the check up, he talked for a while
to make sure I was doing OK. I never felt like I had just been processed through.
(Wojnar, Swanson, & Adolfsson, 2011, p. 548).
Research has identified that there is a desire from women for a formal follow up process that
would include providing them with more information and that also addresses the many false
assumptions they have surrounding the miscarriage (Nikcevic, Tunkel & Nicolaides, 1998;
Rowlands, & Lee, 2010; Swanson, 1999b; Wong, Crawford, Gask, & Grinyer, 2003).
Despite this obvious need, there are currently few evidence based practice guidelines that can
be utilized by primary care practitioners. As a result of this it would seem that women who
miscarry are experiencing higher levels of depression and anxiety than women without a
recent reproductive loss (Geller, Psaros, & Kornfield, 2010).
The nurse practitioner, as a primary care provider, is well trained to offer health
services throughout the various stages of life span development (College of Registered
Nurses of British Columbia, 2011). A major developmental milestone in a women’s life is
during the prenatal period of pregnancy. The nurse practitioner, in primary care, is well
positioned to come face to face with many women in the different stages of prenatal
development. Statistics have clearly shown the reality that miscarriages will be part of the
pregnancy for some of these women. Due to the specific care needs of this demographic, it
would be best practice for the nurse practitioner to create an environment for these women so
that they can receive the necessary information, support and intervention to meet their unique
needs. In order to meet the individual needs of the woman, the nurse practitioner must gather
information from each woman pertaining to what type support is needed or wanted after a
miscarriage and then this must be applied to primary care practice.
The most acceptable definition of epidemiology, for the use in this paper, is the study
of the distribution and determinants of health related status or events in specified populations

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(Morris, 2007). There is a wealth of epidemiological research about women in their
childbearing years who have miscarriages and this research speaks to things like incidence
rate, distribution and other homogenous factors associated with miscarriage. In contrast to
the current epidemiological research, the purpose of this paper will be to review the recent
research literature, discuss the delivery of care, and to bring to light the gaps in service in a
primary care setting for women in their twenties and thirties who have experienced a
miscarriage. This paper will look specifically at anxiety and depression in women who have
miscarried during their prime child-bearing years. This comes with the understanding that the
experience of miscarriage is not defined by socioeconomic status and is not age dependent.
Women in their twenties and thirties, although not completely representative of all
childbearing women, do represent a large part of this population.
A potential gap in service with miscarriage management is the grief associated with
it. Not only is miscarriage grief often unrecognized and unsupported, but the psychological
impact can be underestimated by the health care provider. The nurse practitioner, in primary
care, has a unique opportunity to assist the woman in the grieving process. This opportunity
will be explored using evidenced-based approaches to care that are guided by Swanson’s
informed caring framework. Swanson’s (1993) five processes of informed caring are as
follows: knowing, being with, doing for, enabling, and maintaining hope. According to
Swanson, the primary care provider must engage in these processes in order to preserve the
dignity of the woman and enhance her well-being. This informed caring framework can be
used within many patient transactions, but is particularly well developed to provide care for a
woman who has had a miscarriage.

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As of now, there is no standard of care for women who are experiencing anxiety and
depression after miscarriage. This is due to the limited research that exists for this population
of women, however, this paper will draw upon what pre-existing research is available by
means of a literature review. Furthermore, this paper will attempt to create practice
recommendations based on this literature review. By doing this there is a possibility that the
recommendations and lessons learned will provide a basis for improving care and guiding
further research that is applied to this unique population.

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Chapter Two: Background and Context
Do not judge the bereaved mother. She comes in many forms. She is breathing, but
she is dying. She may look young, but inside she has become ancient. She smiles, but her
heart sobs. She walks, she talks, she cooks, she cleans, she works, she is, but she is not, all at
once. She is here, but part of her is elsewhere for eternity.
-Author unknown
Miscarriage is a profound event that is best understood in the context of the woman’s
beliefs. How miscarriage is experienced and the meaning attributed to the event will
determine how the woman navigates these emotions and moves forward with healing
(Gerber-Epstein, Leichtentritt, & Benyamini, 2009; Huffman, Swanson, & Lynn, 2014). The
intensity of these emotions varies from woman to woman being influenced by personal
circumstances and the reactions of others. This heterogeneous group of women will each live
their miscarriage through their own experiential lens, however they will share certain
common themes throughout their individual experiences. One study showed that 37% of
women felt that they had lost a child, 47% felt guilty, 41% were left feeling that they had
done something wrong, 41% felt alone, and 28% felt ashamed (Bardos, Hercz, Friefenthal,
Missmer, & Williams, 2015). Swanson (1999b) found that 39% of women grieved for six
months or longer after the loss. Elevated levels of anxiety were found in 32% of women 12
weeks after miscarriage (Geller, Psaros, & Kornfield, 2010) and these rates can be as high as
45% of women, persisting for up to a year (Nikcevic & Nicolaides, 2013; Sejourne,
Callahan, Chabrol, 2010b). Compared to their male counterparts, women appear quite
vulnerable to developing a depressive episode following a stressful life event (Groh & Hoes,
2003) and as many as 15% of women will experience depression for up to a year after a
miscarriage (Nikcevic & Nicolaides, 2013).

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Psychological issues such as depression and anxiety can be diagnosed and managed
by the nurse practitioner in primary care. According to the College of Registered Nurses of
British Columbia (2016) Scope of Practice for Nurse Practitioners, as primary care providers
nurse practitioners have advanced training (e.g. cognitive assessments) in interventions (e.g.
cognitive behaviour therapy) necessary to diagnose and manage those who are at risk for
depression and anxiety. This combined with the ability of the nurse practitioner to establish
strong relationships with patients, equip them to provide holistic care regarding miscarriage
management.
Research shows that nurse practitioners provide treatment for women with depression
that is consistent with national standards (Groh & Hoes, 2003). Nurse practitioners
consistently use a variety of assessment tools including the Beck Depression Inventory, Zung
Depression Rating, and the State and Trait Anxiety Inventory (Groh & Hoes, 2003). As the
primary care provider for this population, the nurse practitioner can also prescribe antidepressants, sleep aids, and is able to manage the patient on these medications for as long as
necessary. Should the need arise, the nurse practitioner can refer to a psychiatric specialist for
further support.
Women often find that their spiritual, maternal, feminine, and sexual personhood is
challenged and needs to be re-evaluated after miscarriage (Bennett, Litz, Maguen, &
Ehrenreich, 2008). An attempt must be made to update a personal narrative, which now
includes the experience of having had a miscarriage. Many women express a desire to have
more education and knowledge following a miscarriage (Adolfsson, 2011). A study by
Nikcevic (2007) showed that 92% of women felt that they would benefit from a consultation
with a psychologist to discuss aspects of their miscarriage. Studies using medical counselling

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(Nikcevic, Kuczmierczyk, & Nicolaides, 2007), early single session cognitive behavioral
therapy (Nakano, Akech, Furukawa, & Sugiura-Ogasawara, 2013) and a brief, miscarriage
specific therapeutic approach (Swanson, 1999a) showed short and long term benefits to
women. These interventions showed the necessary care and understanding that woman
require and influenced their long term well-being (Sejourne, Callahan, & Chabrol, 2010a).
The nurse practitioner has a commitment to the patient to facilitate a personal
connection and this commitment relays an acknowledgement to the woman that she is
worthwhile, deserving of respect, attention, commitment, and care (Dunphy, Porter, WinlanBrown, & Thomas, 2015). Utilizing the nurse-patient relationship and the nurse practitioner’s
intimate knowledge of a patient’s response patterns can help the nurse practitioner to make
sound clinical judgments about patient care (Blair & Jansen, 2015). Understanding the
meaning of this loss, acknowledging questions asked, and giving anticipatory guidance
would be congruent with a high level of patient care within the context of miscarriage
management. Providing follow-up, education, and reassurance can positively impact the
perception of the experienced loss and overall psychological well-being of both the woman
and her partner. More specifically, the nurse practitioner can provide medical counselling,
and psychological interventions like Cognitive Behavioural Therapy (CBT) early on
following the loss and continue to provide interventions for as long as they are needed to
help stabilize the patient.
Given the dearth of evidence, current research has been scrutinized in the writing of
this paper to better understand the experiences of women who have miscarried and what
these women need from their health care providers. In the literature review, similar themes
surfaced and after reading numerous peer-reviewed journal articles, it became evident that

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early follow-up care is desirable, women who have miscarried have unique needs, and
screening for depression and anxiety after miscarriage should be a standard of care.
However, despite the research supporting a change in practice, less than optimal care is often
given (Geller, Psaros, & Kornfield, 2010; Lok & Neugebauer, 2007; Rowlands, & Lee,
2010). This is likely due to the lack of practice guidelines addressing the holistic supports
needed during and after miscarriage. Given the profound impact of a miscarriage on a
woman, this author was motivated to research and bring about for discussion, what the best
practice recommendations for care are, based on the available evidence.
By providing a critical review of the literature, including relevant guidelines and
policy it is the intended purpose of this author to bring forward practice recommendations for
primary care providers caring for women who have had a miscarriage. By doing this, a
practical clinical application to meeting the psychosocial needs of women who have
experienced miscarriage within a primary care context will be initiated. The organization of
this project will be directed by the research question: What are the Primary Care
considerations for women in their twenties or thirties who are experiencing depression and
anxiety after a miscarriage?

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Chapter Three: Theoretical Framework
If you have built castles in the air, your work need not be lost: that is where they
should be. Now put foundations under them.
Henry David Thoreau, Walden
Dr. Kristen Swanson (1991) developed a middle-range theory of caring which she
validated through phenomenological investigations of women’s and caregivers’ experiences
in the perinatal period including women’s experiences of miscarriage. A major feature of
phenomenological research is the recognition that an individual’s experience provides the
essential meaning of knowledge (Harvey, Moyle, & Creedy, 2001). With this in mind the
woman who has miscarried has a wealth of important knowledge and insights to contribute.
Swanson contextualized the five caring processes through a number of different interpretive,
descriptive, and experimental research studies (Swanson,1999a; Swanson, 1999b ; Swanson,
Chen, Graham, Wojnar, & Petras, 2009). This theory is applicable to a wide range of practice
settings, utilizes a psychosocial approach, and is appropriate to use with women of various
ages. Therefore, Kristen Swanson’s middle-range theory of caring will form the theoretical
framework of this paper.
Nursing practice is to care for the patient experiencing actual or potential health
deviations until such time as the client is independently able to care for herself (Swanson,
1991). Swanson also defines caring as a “nurturing way of relating to a valued other as
toward whom one feels a personal sense of commitment and responsibility” (p. 62). The five
caring processes of knowing, being with, doing for, enabling, and maintaining belief were
developed by Kristen Swanson to reflect the nursing profession. With this being said it is the
intended purpose of this paper to propose that these processes can be used as therapeutic
interventions in the primary care setting by the nurse practitioner in the context of care for

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the woman who has miscarried. The model harmonizes well with the health management and
holistic care that nurse practitioners provide. Kristen Swanson’s framework for caring will
now be discussed in the context of the nurse practitioner as the primary care provider for the
woman who has had a miscarriage.
Knowing
The first concept of this theory is knowing (Swanson, 1991), this is what allows the
nurse practitioner to know the woman’s reality during her miscarriage. In knowing, the nurse
practitioner strives to understand the event as it has meaning in the life of the woman. It
causes the nurse practitioner to avoid assumptions, instead focusing on the woman and
thorough assessment of the woman’s experience. This knowing sets the stage for the
therapeutic interventions of being with, doing for, and enabling to be perceived as relevant to
the woman. As stated previously, women who experience miscarriage are a heterogeneous
group and to each, the experience has a different meaning and impact.
Being With
Being with conveys to the woman that their experiences matter, it is the availability
of the nurse practitioner and willingness to give their time, authentic presence, and attentive
listening (Swanson, 1991). This willingness to endure with the woman and witness her
experience is the responsibility of the nurse practitioner as a primary care provider. Swanson
(1993) describes practical application of being with as ensuring the woman has access to
supports including sharing clinic phone numbers, giving email contacts, and allowing the
woman to feel that it is safe to contact the nurse practitioner if she so wishes.
Doing For

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Doing for is the care of the woman to do for them what they would do for themselves
if they could (Swanson, 1991). This speaks more to the actions of the nurse practitioner, but
can also include therapeutic communication skills. This includes referrals, the setting up of
opportunities, and programs or systems that provide safe arenas, within which the woman
can bring about her own healing. The doing for also includes comforting, performing skills
competently, protecting the woman from harm, and preserving her dignity. The ability of the
nurse practitioner to provide cognitive behavioral therapy would be an aspect of doing for.
Enabling
The penultimate process to this theoretical framework is enabling. Which is defined
by Swanson as the validation and supportive guidance of the woman’s passage through life
transitions and unfamiliar events (Swanson, 1991). This is the coaching, informing, and
explaining component of care. The nurse practitioner allows the woman to have this
experience, while helping her to maintain a focus on important issues, generating
alternatives, and guiding her to think through the issues at hand. This is done with the goal of
ensuring the woman’s long-term well-being.
Maintaining Belief
The final process in this model of caring is maintaining belief, and this has been
described as “sustaining faith in the other’s capacity to get through an event or transition and
face a future with meaning” (Swanson, 1991, p. 165). It also means believing in others and
holding them in high esteem, all the while maintaining a hope-filled attitude, and standing by
them no matter how the situation may unfold. The concept of maintaining belief is
foundational and underpins this entire model of caring.

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The five components of this theoretical orientation are overlapping, they are not
mutually exclusive, and the central theme throughout is caring. Caring is anchored by
knowing, conveyed through being with and enacted through doing for and enabling
(Swanson, 1993). The theoretical underpinning of this paper is that only in the context of
caring can the treatment be established (Watson, 1988). This is the belief that there is
personal meaning to be found in the challenge of miscarriage. It is the sustaining faith of the
nurse practitioner in the woman to get through this event and face the future with meaning.
The nurse practitioner who embraces this perspective will bring a commitment to the
physical and emotional health of the women in the present moment, while looking to ensure
her long term wellbeing.
Figure 1: Nursing as Informed Caring for the Well-being of Others (Swanson, 1993, pg.
355).

Swanson’s structure of caring will help guide my discussion of the forthcoming
literature review. This framework is not bound by a linear approach to clinical practice,
rather, a fluid and dynamic one will emerge. Through this process a focus on the woman’s
well-being is always maintained.

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Chapter Four: Methodology
For where thou art, there is the world itself, And where thou art not, desolation.
-William Shakespeare, King Henry VI, Part 2
A literature review was completed in order to answer the research question: What are
the primary care approaches to women in their 20s and 30s who are experiencing depression
and anxiety after a miscarriage? Using the Cochrane Collaboration method of reviewing, a
systematic approach was taken to examine the literature pertaining to the research question
(Aveyard, 2010). Integrative reviews assimilate results of research studies by comparing and
contrasting them in order to describe the state of knowledge, and incorporate both
quantitative and qualitative research studies (Davis & Logan, 2008). By examining the
current evidence, recommendations for practice, research, and education will be made. The
following section will provide an overview of the literature selection and review process.
Integrative Review Process
The review was undertaken through a series of stages, including the development of a
research question, a preliminary search of the literature, a focused search through the use of
specific inclusion and exclusion criteria, and finally through analysis and reporting.
Preliminary search. A preliminary search of the literature was undertaken in order
to ensure a robust search strategy and to assess the landscape of the current evidence.
Starting broadly, a search was conducted for clinical guidelines and protocols in BC, Canada

18

and in North America. Next, was a search for evidenced-based guidelines, clinical practice
guidelines and/or protocols for practice. These documents are referred to as ‘preprocessed’,
that is, someone has reviewed the literature and has chosen only the methodologically best
studies for inclusion in document development (DiCenso, Guyatt, & Ciliska, 2005). Such
guidelines and protocols are updated regularly and are made available through the different
websites that act as portals to online databases. The justification for this sampling approach
is that evidence-based clinical guidelines are the cornerstone of nursing practice and when
these are not available, other preprocessed sources must be explored (DiCenso, Guyatt, &
Ciliska, 2005).
The BCguidelines.ca website was searched using the keyword ‘miscarriage’ and
returned no results. The Canadian Nurses Association (CNA) best practice site was also
explored, but also returned no results regarding miscarriages. The College of Registered
Nurses of British Columbia (CRNBC) website also was searched and returned one result
which was not deemed appropriate for this review. The Canadian Medical Association
Clinical Practice Guidelines (CMACPG) were searched using the keyword ‘miscarriage’ and
returned two results, which appeared to be the same article, based on the year and authors,
with one in French and the other in English. The articles discussed indicators for various
diagnostic imaging studies in relation to obstetrics and gynecological patients which was not
useful for this project.
The National Guidelines Clearinghouse (NGC) was searched using only
‘miscarriage’ and 35 results were found, upon cursory inspection, none were relevant to this
review. The articles were directed towards women experiencing recurrent miscarriages,
ectopic pregnancy, and the medical components of miscarriage management. A high

19

percentage of the articles did not pertain to miscarriage. The Society of Obstetricians and
Gynecologists of Canada (SOGC) guidelines were searched using the word ‘miscarriage’.
One result was found and it pertained to the medical cause of miscarriage. The American
Congress of Obstetricians and Gynecologists Guidelines (ACOG) were searched, also using
the word ‘miscarriage’ and 22 results were found. Only one of the articles specifically
addressed management of early pregnancy loss and this was with a surgical, medical, or an
expectant management focus. The World Health Organization (WHO) guidelines were also
searched, specifically under the heading ‘Maternal, reproductive and women’s health’. None
of the guidelines found were pertaining to miscarriage care but were more about women and
children’s physical health during and after pregnancy. The National Institute for Health and
Care Excellence (NICE) guidelines were searched using ‘miscarriage’ and one result was
found which pertained to the diagnosis and initial management of miscarriage; however, the
psychosocial implications of miscarriage were not addressed. These searches are
summarized in Table 1 below.
Table 1: Clinical Practice Guidelines Search
Institute’s
Guidelines

Initial
Results

Relevant
Guidelines

NGS
SOGC
ACOG
WHO
NICE
BC Guidelines
CAN
CRNBC
CMA

35
1
22
10
1
0
0
0
2

0
0
0
0
0
0
0
0
0

20

An electronic search of Medline with Full Text, Academic Search Complete, Psych
INFO and CINAHL Complete databases was conducted in February 2016, using the key
words “miscarriage (abstract),” OR pregnancy loss (abstract)” AND “anxiety (abstract)” OR
“depression (abstract)” AND “primary care (all text)”. Figure 1 is a schematic of the search
strategy and also indicates the number of articles per search term. Search terms were used
separately or in combination using AND/OR in Boolean search mode.
Table 2. Search Strategy Methodology and Detailed Database Search Results

Key Words
Library Data Bases- UNBC
Academic Search Complete, CINAHL
Complete, Medline with Full Text, Psych
INFO

Search
Results
Depression OR Anxiety
610,618

Anxiety
(Abstract)
Pregnancy loss OR miscarriage
20,648
Miscarriage
(Abstract)
Primary Care
440,755
(All Text)
Combined with ‘AND’
46

Relevant articles identified and
selected for review: n= 6
Articles gleaned from reference
list of original 6: n=3
Total articles for review: 9

21

Focused search. The initial search led to the necessity of a more focused search with
inclusion and exclusion criteria to narrow the scope. To achieve this, specific inclusion and
exclusion criteria were developed. Stage two of the search strategy involved the use of
Mendeley Desktop (reference manager software) as a citation manager for collecting the
articles.
Inclusion criteria. Titles and abstracts that were relevant to the topic of miscarriage
and the principles of primary care were analyzed. In order to examine the most current
information and research, only full text articles that were peer-reviewed containing original
research, written in English and published between the dates of 2005 and 2016 were
included. The dates were selected as they enabled the most recent and relevant literature to
be identified. Hand searches of relevant articles that met inclusion criteria from each of the
sources’ reference lists were also included to ensure that the search was comprehensive and
no important additional sources were overlooked.
Exclusion criteria. Articles that were not accessible through the University of
Northern British Columbia library database were excluded, as were articles that were not in
English. Articles related to in-vitro fertilization, recurrent miscarriages, still births, and
therapeutic abortions were excluded.
When deciding to include annotations of reviews or systematic reviews, strengths and
limitations of these analyses had to be considered. Although there may be many strengths,
like the pooling of quantitative data, and large sample sizes, it was determined that the
limitations outweighed the strengths in this situation. One critique, albeit an anecdotal one, is
that a systematic review is an exercise in mega-silliness, and inappropriately mixing apples

22

and oranges (Biondi-Zoccai, Lotrionte, Landone, & Modena, 2011). Another is that
considering the research question proposed by this author it was only possible to retrieve a
few studies which focused on the given primary care question. A few annotations of reviews
and one systematic review were found, but these were of low quality and were not
contributory to the research question. As a result of this, it seemed unhelpful to include
articles of low quality in the analysis. In doing so, the intended audience could be misled.
With so many inconsistencies to consider the decision to not include annotations of reviews,
and systematic reviews was made. With regards to ‘grey literature’ which includes opinion
pieces, theses, and internal institutional reports a decision was made to exclude them. These
works would not be considered as ‘best evidence’ when addressing my research question.
Although grey literature sources often provide a more complete presentation of data than is
possible in peer-reviewed commercial publications, they fall outside the bibliographic
control mechanisms of commercial publishing (i.e., database indexing). This makes them
very difficult to 'discover', if you are not already aware of their existence (Mahood, Van Erd,
& Irvin, 2014). Newspaper articles and women’s magazine articles related to depression and
anxiety after miscarriage had come to my attention through social networks but were
anecdotal pieces of literature and so not part of my final literature review. If including
literature from various forms of media, it would be quite difficult to duplicate this search.
Analysis. Following the search, a final cohort of 9 articles was selected for inclusion.
Each article was reviewed in detail according to the research extraction guide outlined in
DiCenso, Guyatt and Ciliska (2005). The articles were appraised according to their
methodological rigor, the strength of the evidence, and relevance for intervention with a
woman experiencing anxiety or depression after a miscarriage in the context of primary care.

23

Chapter Five: Findings
No one ever told me that grief felt so like fear.
C.S. Lewis, A Grief Observed
The overarching goal of the literature analysis was to explore an approach to primary
care for a women experiencing anxiety or depression after a miscarriage. An integrative
literature review was undertaken and 9 articles were selected and analyzed. The following
section will provide a critical analysis of the research findings, organized by the key themes.
The themes identified include: the need for support after miscarriage are unique; there is a
need to screen for depression and anxiety after miscarriage; and early interventions are most
desirable and most effective in alleviating anxiety and depression after miscarriage.
Needs for Support Are Unique
Following a comprehensive review of the research literature, women’s needs for
support as unique after miscarriage emerged as a key theme. As a result, individualized
assessment for and management of all women after miscarriage is imperative. Four of the
nine articles used in this review addressed needs of the woman who had miscarried as being
unique. Cumming et al. (2007) stated that health care providers need to be able to assess
women after miscarriage using a brief but valid and reliable method to identify those most at
risk for psychological morbidity, namely depression and anxiety. Cumming et al. (2007)
used a semi-structured interview and standardised self-report questionnaire to screen women.
Rowlands and Lee (2010a) used the 5-item Mental Health subscale (MHI-5) of the
Australian standard version Short Form Health Survey (SF-36). This 5-item mental health

24

subscale was used to conceptualise mental health and responses that scored higher were
indicative of better mental health and conversely, those with lower scores had more mental
health concerns. Rowlands and Lee (2010a) expounded that women with a greater number of
life events, in addition to miscarriage, had lower mental health scores than others. Examples
of such life events were hospitalisation for a major illness, break-up with a partner and
serious financial difficulty. Women’s long term adjustment was affected by a prior diagnosis
of anxiety or depression; in contrast, women with higher education and higher satisfaction
with their primary care practitioners had higher mental health scores (Rowlands & Lee,
2010b). In the study done by Sejourne, Callahan, and Chabrol (2010b) it was identified that
not all women needed psychological help but there was a need to identify women who are at
higher risk for psychological distress or who have specific and unique circumstances
predisposing them to greater difficulties in facing the miscarriage.
Two of these four articles were chosen for detailed examination as they discussed
miscarriage management within the context of depression and anxiety. The first of these
articles was a study by Adolfsson, Bertero, and Larsson (2006). This study captured the
uniqueness of the women who had miscarried using the Perinatal Grief Scale Swedish short
version to measure whether follow-up was helpful to reduce grief (Adolfsson, Bertero, &
Larsson, 2006).
Adolfsson, Bertero, and Larsson (2006) sought to identify women’s need of a followup visit to the midwife after miscarriage and, in such cases, what the focus of the visit should
include. The open randomized study took place in Sweden in a medium-sized town at a
gynecologic clinic. In order to be included in the study, the women had to be over 18 years
old, Swedish speaking, and have had a miscarriage before 13 weeks’ gestation. Eighty-eight

25

women made up the sample population. Both the control and intervention groups were seen
21-28 days after their miscarriage. The control group had their medical concerns addressed
but there was no discussion about the woman’s feelings or emotions regarding the
miscarriage. If the woman took initiative to ask further questions then additional time would
be allotted to the visit, otherwise the appointment lasted only 30 minutes. With the
intervention group, Swanson’s Framework for Caring informed the midwife’s attitude by
allowing her to be emotionally present and an hour was given for the appointment. The
woman would be treated as influenced by Swanson’s theory of caring which allowed the
midwife to be emotionally invested in the woman, to treat the woman with dignity, and be
competent in skillfully meeting the woman’s needs. During the visit, the midwife aided the
woman in understanding her experience by giving clear information which helped facilitate
the grieving process. The midwife also helped with the woman’s self-esteem, and
encouraged her to retain hope, and be optimistic, as well as giving her the needed space to
mourn what had been lost.
The women in both groups responded to the perinatal grief scale Swedish short
version at the first follow-up visit to a midwife and at a subsequent follow-up visit four
months after the miscarriage. The Perinatal Grief Scale has three subscales each of which
measures various aspects of one’s reaction to a loss. The subscales include active grief,
difficulty in coping, and despair, which had a longer lasting effect on loss. The perinatal grief
scale includes guilt and anxiety and has been validated in depression and marital
relationships. The authors chose the Perinatal Grief Scale because it measures depression and
normal grief rather than just depression (Adolfsson, Bertero, & Larsson, 2006).

26

The results of this research emphasized that women who experience a miscarriage are
not a homogenous group. Coping after a miscarriage is largely influenced by a number of
variables including whether they have had a complete miscarriage, incomplete miscarriage
with heavy hemorrhage, incomplete miscarriage with little hemorrhage, or a missed
miscarriage. The measures using the Perinatal Grief Scale at four months’ post miscarriage
showed that women with missed miscarriages had significantly higher perinatal grief scores
for active grief and more difficulty in coping than the women with other diagnoses. The
reason for this was postulated by the authors as follows: when these women suspected
something was wrong with their pregnancy, they were told by their health care providers that
changes during pregnancy were normal, and to not worry. The resulting invalidating
environment created a credibility gap between the patient and their caregivers. The clinicians
involved with this research later changed their practice to allow for earlier appointments for
those women who suspected that something is amiss with their pregnancies (Adolfsson,
Bertero, & Larsson, 2006).
Not surprisingly, this study showed that women with no other children had
significantly higher perinatal grief scores regardless of whether they were in the control or
intervention group. They had more active grief four months after their miscarriages and these
women expressed their grief in unique ways. Interestingly, this study revealed that the effect
of the structured follow-up visits for the intervention group did not show a statistically
significant difference from the intervention group. Having said this, there was a 30%
reduction in the grief of the intervention group from the first follow-up to the 4-month
follow-up but this could not be deemed statistically significant as there were not enough
participants to demonstrate this.

27

The limitation of this study was the small sample size. Although the study started out
with 146 participants, only 88 women remained in the study after the inclusion criteria were
applied. Although the control and intervention groups were well matched, the authors stated
that they could not demonstrate statistical significance in the reduction of perinatal grief
scores as the sample size was too small to demonstrate statistical significance and in order to
do so, the study would need 169 women in each group (Adolfsson, Bertero, & Larsson,
2006).
Adolfsson, Bertero, and Larsson (2006) demonstrated that a woman’s physical,
emotional and psychological needs after miscarriage vary greatly, but those with a missed
abortion and no other living children may need increased follow-up care. Evidence from this
research is insufficient to demonstrate the need for a psychological intervention as a first line
of treatment versus medical care in the management of a woman post-miscarriage. Having
said this, given the evidence this research provides, a woman’s preference for treatment and
follow up should play the greatest role in the decision-making around psychological care of a
woman after miscarriage.
The second article to be examined in detail was an Australian study undertaken by
Rowlands and Lee (2010b). The aim of this research was to identify the characteristics of
women who coped well, or poorly, after a miscarriage in order to help guide interventions to
assist women dealing with this significant event. The authors here administered and
statistically analyzed a government funded survey about women’s health to a total of 40,000
randomly selected female Australian citizens and permanent residents at three different
times, 1996, 2000, and 2003. Nine hundred and ninety-eight women aged 18-23 who
reported a miscarriage were identified from the sample.

28

Adjustment after miscarriage was measured using the 5-item mental health subscale
of the Australian standard version of the SF-36. The SF-36 is reliable and valid for use with
adults throughout their lifespan. The internal consistency of the scales has shown a
Cronbach’s alpha of 0.8 or higher. Rowlands and Lee (2010b) stated that higher scores
indicate an overall better mental health functioning and include domains of functioning like
vitality, amount of bodily pain, and an understanding of one’s physical, emotional, and social
roles. Predictors of lower mental health scores included multiple miscarriages, being
unmarried, and/or separated, and divorced or widowed. Women with a greater number of life
events and higher stress levels had lower mental health scores. Long term adjustment to
miscarriage was related to a diagnosis of anxiety or depression prior to the miscarriage.
Higher mental health scores were shown within populations that had greater satisfaction with
their primary care provider and patients who have higher levels of education. Overall, this
research supports recognition of a number of variables associated with adjustment after a
miscarriage. These variables include education level, satisfaction with primary care provider,
other life stressors, prior diagnosis of depression or anxiety, internal and external coping
resources, marital status, other living children, and number of previous miscarriages
(Rowlands & Lee, 2010a).
Rowlands and Lee (2010b) suggested that women who are pregnant would benefit
from cognitive-behavioural therapy if they were identified as having high levels of stress.
They also recommended screening for high levels of stress and provision of information on
stress management as a routine aspect of antenatal healthcare visits with the primary care
(Rowlands & Lee, 2010a). Poor communication by health care professions along with
inadequate emotional care and inadequate information about miscarriage are identified as

29

commonly missed aspects of care. The authors asserted that adequate care after miscarriage
should include acknowledgement of the loss and provision of reliable resources. Some
women may also benefit from discussion about their overall well-being including the impact
of miscarriage on self-esteem and how to cope with inappropriate guilt and anxiety. Primary
care providers should be aware of those women who have had a history of mental health
problems and/or high levels of stress in order to more closely follow them in the primary care
setting (Rowlands & Lee, 2010a).
The strength of this study is that the researchers used a measure of general mental
health rather than specifically focusing on presence or absence of clinical levels of
depression and anxiety. The research used a target population of 40,000 potential participants
selected randomly and the database was for all Australian citizens and residents regardless of
age or income. The data used for this study came from a younger cohort, ages 18-23 years,
which was thought to be broadly representative of the Australian population of women in this
age group. There were 7790 women from the younger cohort who responded to all three
surveys [1996, 2000, 2003], which is a large sample population from which conclusions can
be drawn for future research and current practice. A limitation may be that the younger
cohort may be slightly over representative of those women with more education and who are
non-smokers (Rowlands & Lee, 2010b). This may limit the applicability of results to those
women with less education and with life style choices different from the study population.
Screening for Depression and Anxiety is Necessary
The need for early identification of women who are at risk and/or suffering from
anxiety and depression is a key theme that has emerged from this review of the literature.
There are certain populations identified as being at higher risk and these are discussed in

30

detail within the research. Six of the nine articles discuss the need for health care providers to
detect those at risk for psychopathology, specifically anxiety and depression.
Mann, Mckeown, Bacon, Vesselinov, and Bush (2008) suggested that clinicians be
alert to the signs of depression, particularly in younger women, which are defined as less
than 28.9 years and women with a prior history of mental illness. Rowlands and Lee (2010b)
suggested that a routine aspect of antenatal health care visits could be screening for high
stress levels. Kong, Lok, Lam, Yip, and Chung (2010) found that the majority of health care
providers believed that routine psychological support should be provided after a miscarriage
and only a small percentage of these health care providers felt that the existing health care
structure was adequate.
In a study by Lok, Yip, Lee, Sahota, and Chung (2010), women who exhibited signs
of depression and anxiety immediately after miscarriage, with time, had their symptoms
typically diminish. In this research, inclusion of non-pregnant women unexposed to recent
miscarriage or pregnancy was used as the comparison group. This helped to demonstrate that
the psychological morbidity experienced by women who had miscarried was a specific
consequence strongly related to miscarriage. Also identified by this research was the need for
a brief yet reliable screening tool as many clinicians are not familiar with comprehensive
psychiatric assessments. Lok et al. (2010) suggested using the General Health Questionnaire
(GHQ-12) or Beck Depression Inventory (BDI) for screening. Similarly, Cumming et al.
(2007) suggested that clinicians use a brief but reliable method of identifying those at risk.
The following is a detailed discussion of two of the articles that addressed the need
for screening as evidenced by the research. The first of these articles was a study carried out
by Cumming et al. (2007) in which the findings of anxiety and depression in women and in

31

men 13 months after miscarriage were presented. As well, this research discussed the clinical
implication of early identification and management. The second study to be discussed is by
Lok et al. (2010) in which a one-year longitudinal study was done to measure the
psychological outcome after miscarriage. The practice recommendations of this study are
particularly useful and will be discussed in detail.
The study done by Cumming et al. (2007) sought to identify the trajectories of
anxiety and depression in women and their partners over 13 months after miscarriage. The
setting for this study was three early pregnancy assessment units in Scotland. The
assessments occurred at 1, 6, and 13 months after miscarriage. Both qualitative and
quantitative data were gathered in order to identify predictive factors for depression and
anxiety associated with variations in the methods of measurements. The researchers used
semi-structured interviews to gain qualitative data, and the Hospital Anxiety Depression
scale (HADS) as a screening tool to measure self-reported general psychopathology.
The selection criteria for the sample population included women and their partners
over the age of 16 years, who were able to give written consent, had experienced a
miscarriage before 24 weeks’ gestation, and had completed the medical management portion
of the miscarriage. Excluded were those women who had management involving the use of
invasive diagnostic procedures, women presenting with threatened abortion, those presenting
with more than one fetus on scan with subsequent demise of at least one fetus and the
continuation of at least another fetus. Final exclusion criteria included those with cognitive
impairment. The final sample population included 275 women and 135 men for a total of 410
participants.

32

Findings of the Cumming et al. (2007) study give an overview of the emotional
burden of miscarriage on both men and women. Although this research is focussed on
women, the significance of acknowledging the partners within the miscarriage context is of
utmost importance. This particular study revealed that miscarriage represents an emotional
burden, particularly for women, up to 13 months after the loss. This emotional burden,
although demonstrated by the data, may in fact be greater than the data revealed as the
individuals who did not complete the subsequent assessments had higher scores for
depression and anxiety at the initial assessment than those participants who completed all
three assessments (Cumming, et al., 2007). Anxiety symptoms or more specifically those
diagnostic norms that meet the DSM5 criteria for General Anxiety Disorder (GAD), were
found to be a greater clinical burden than a Major Depressive Disorder (MDD) diagnosis,
and were more likely to be experienced after miscarriage by both men and women. The
effects of miscarriage can be long lasting, even beyond 13 months and are often complex in
resolution. This research showed that women’s anxiety remained elevated during all three
assessments, but that there was a gradual decrease in symptoms over time (Cumming, et al.,
2007).
Cumming et al. (2007) discussed clinical implications of this research highlighting
that the increase in GAD symptoms after miscarriage provides an opportunity for health care
providers to detect psychological morbidity and treat it accordingly. The authors suggest that
the health care provider should understand that these symptoms can be long lasting, even
beyond 13 months and significant. If left untreated, there is an increased risk that
psychosocial functioning may be impaired and other psychological issues may develop. One
such possibility is the diagnosis of posttraumatic stress disorder. In a study by Hamama,

33

Rauch, Sperlich, Defever, and Seng (2010) the authors found a prevalence of prenatal PTSD
after complications in a prior pregnancy of between 8.9 and 12.5%, suggesting that
miscarriage may be an important risk factor for PTSD. A limitation to this study is that “the
investigators did not control for the effect of other lifetime trauma exposures in estimating
risk for PTSD in the subsequent pregnancy” (p.700, 2010). Screening should be done using a
brief but reliable method in order to accurately identify those at risk. Consideration should
also be given for the woman who goes on to become pregnant again as there is a possibility
that a miscarriage could affect the woman’s emotional well-being during subsequent
pregnancies. Cumming et al. (2006) brought forward the claim from previous research
showing that an increase in stress [anxiety] during the first trimester of pregnancy can lead to
an increased risk of miscarriage. Cumming et al. (2006) did not bring forward the idea that
this anxiety and depression could lead to post-traumatic stress disorder. However, this idea
does emerge from the research by Sejourne, Callahan, and Chabrol (2010a). Post-traumatic
stress disorder was not a theme found consistently throughout the literature, rather aspects of
this disorder such as anxiety and depression emerged.
One of the strengths of the research by Cumming et al. (2006) was the large sample
population as well as the longitudinal research period of 13 months as compared to many
other studies that are less than six months. The weakness of the research is that no
comparison group was used. Without the comparison group it is difficult to say with absolute
certainty that the increased anxiety found in men and women is solely related to the
miscarriage and not to other factors that are common to couples in their reproductive years.
The second article for this section to be discussed in detail is by Lok et al. (2010). As
mentioned above, this longitudinal observational study examined the course of psychological

34

outcomes for a year after miscarriage. The setting was a university affiliated teaching
hospital in Hong Kong. The sample included a case group of 190 women who had miscarried
and a control group of 150 non-pregnant women who were seeking contraception advice.
Exclusion criteria were unwillingness to participate, problematic study observation due to
immigration regulation or other factors, or history of a psychiatric illness. The 190 women
comprising the cases completed the psychometric scales at four time points after miscarriage,
as did the control group. The time points were immediately, 3, 6, and 12 months after
miscarriage. Most of these women had miscarried in the first trimester.
Results of the analysis showed a statistically significant reduction in the GHQ-12
scores, particularly in the first three months. More than half of the women scored high on the
GHQ-12 immediately after miscarriage, this was reduced to 25.1% at three months and
17.9% remained distressed 1-year post miscarriage. Beck Depression Inventory scores across
time also showed a statistically significant change from immediately after the miscarriage to
three months after; 26.8 % of women scored high on the Beck depression inventory
immediately after miscarriage and this decreased significantly at three months (18.9%) and a
year later (9.3%). Both the GHQ-12 and the BDI scores were statistically significantly higher
in the miscarriage group immediately and three months after miscarriage in comparison to
the control group.
Strengths of this research were in the 12-month longitudinal time span as well as in
the use of a control group. This enabled a more accurate picture of the effect of time on
psychological morbidity. The research used a large sample, which supported the statistical
significance. This along with the use of universally recognized tools lends itself to solid
conclusions and practice implications. The limitations of this research were that the

35

measurements used were not necessarily able to diagnose depression and anxiety. The
psychological outcomes assessed by this study were purely the result of psychometric testing
and not equivalent to a diagnosis by a qualified diagnostician. Another limitation was that the
psychometric testing itself could have had an unintended therapeutic effect on the
participants. Finally, this study was done in Hong Kong with a different a sample population
whose culture and ethnicity is different than Canada. The study results and implications may
not be completely transferable to Canadian culture and health care. This was not mentioned
by the authors as a limitation.
The practice implications of this particular research suggest that women that are more
distressed immediately after miscarriage continue to be at higher risk for psychological
morbidity for the following year. However, this does not exclude women who are initially
less distressed from developing psychological morbidity. Screening and care for these
women is necessary and prudent.
Early Interventions Are Desired and Effective
Sejourne et al. (2010a) found that 86% of women felt that the medical appointment
they had after their miscarriage was insufficient for dealing with the issues surrounding the
miscarriage and that these women indicated that they would appreciate continuing
psychological, social, and emotional support after their miscarriage. The women felt that
they were not given sufficient information concerning the causes of miscarriage, the process
of miscarriage, what was to be expected after a miscarriage, future pregnancies, and the
psychological experience of miscarriage (Sejourne et al., 2010a). Cumming et al. (2007)
suggest that lack of routine follow-up may increase anxiety in women who have miscarried,
while Rowlands and Lee (2010a) posit that such women will benefit from follow-up care.

36

Neugebauer et al. (2007) found that there was a marked decrease in depressive symptoms
among women, who received telephone-administered interpersonal counselling, which was a
scaled down version of psychotherapy administered by an interpersonal psychotherapist
(IPT) or registered clinical psychologist. The counselling sessions were scheduled within 14
days of initial contact and then weekly for 6 weeks. The length of each session was not
stated.
Rowlands and Lee (2010a) found that important aspects of early interventions include
provision of information and acknowledgement of loss. Information in the form of patient
education may require specific training in order to achieve a constant level of adequate
support (Rowlands & Lee, 2010a). Rowlands and Lee (2010a) also identified that poor
communication between women who are miscarrying and their health care providers had a
negative impact on women’s lived experience of miscarriage. Women repeatedly expressed a
desire for more information about the many aspects of miscarriage. They also expressed a
desire to have resources from which they could receive emotional support (Rowlands & Lee
2010a; Sejourne et al. 2010a).
Acknowledgement of the loss was found to be an important aspect in postmiscarriage support (Adolfsson, Bertero, and Larsson, 2006; Rowlands & Lee, 2010b).
Women need to have their feelings of loss and emptiness acknowledged. When the loss is
ignored or passed over to discuss medical concerns, the woman may feel that her loss is
inconsequential to others.
The articles chosen for detailed examination reflect the larger body of literature
indicating that interventions early after a miscarriage are most desired by women and appear
to be most effective in light of long term well-being. The first article to be discussed in

37

detail is written by Neugebauer et al. (2007). This study evaluated the potential of telephone
administered counselling for women after miscarriage. The second article to be examined in
detail describes a study by Sejourne, Callahan, and Chabrol (2010b) that examined the
effectiveness of psychological support interventions, psychoeducation, and cognitivebehavioural therapy.
The research by Neugebauer et al. (2007) took place in two New York City Medical
centers in low-income neighborhoods with women who were seeking medical care for
miscarriage. Inclusion criteria for the project were that the woman was over 17 years of age,
spoke English or Spanish, could be reached via telephone, had a medically documented
miscarriage within 18 weeks of the first interview, and reported at least mildly elevated
symptoms. This was quantified by having a score greater than 13 on the Centre for
Epidemiologic Studies-Depression (CES-D) scale, evaluated by a trained rater. Excluded
were women who had life-threatening physical illness, mental retardation, suicidal ideation, a
current major mood disorder, current depressive symptoms that started prior to the
miscarriage, a substance use disorder, a history of psychotic illness, or refused to have the
sessions audiotaped. The final sample included nine women as many of the originally
selected women were lost to follow-up for a number of reasons.
Participants were given an initial counselling session within 14 days of the first
telephone interview and then weekly thereafter for a total of six sessions. Sessions were done
using interpersonal counselling, which is a modification of interpersonal psychotherapy and
works from the premise that life events, such as loss and bereavement influence mood. A
counselling script was designed by the researchers and administered one-on-one by a
psychotherapist. Results of the study show that participants experienced significant

38

improvement of depressive symptoms that decreased by 52% using the CES-D scale
(Neugebauer, et al., 2007). This study suggests that telephone administered mental health
care would be a feasible option for this patient population.
Limitations of this research are that the article describing the study was not clearly
written or easy to understand. Also, in order to make a generalization about this intervention
a randomized controlled trial would be needed. In addition, the sample size was quite small
and so statistical significance was impossible to determine. In conclusion, this research
shows limited but promising results using data from previous studies to develop a brief
telephone supportive intervention.
The second article to be thoroughly examined is by Sejourne, Callahan, and Chabrol
(2010b) who hypothesized that a single-session intervention based on cognitive behavioral
therapy techniques including psychoeducation and empathetic emotional support and
cognitive reframing would be beneficial for women dealing with miscarriage. Empathetic
emotional support was defined by the researchers as an empathetic listening approach that
was used in order to encourage therapeutic alliance and emotional expression. Cognitive
behavioural therapy including cognitive reframing was used to help women deal with
feelings of guilt or responsibility. The researchers used a quasi-experimental approach and
the study was conducted in two semi-private clinics in Toulouse, France. The sample
population was comprised of 134 adult women who spoke French and who had undergone
dilation and curettage or vacuum aspiration for the uncomplicated and unanticipated loss of a
pregnancy. The sample was divided into an immediate intervention group and a deferred
intervention group. The measurement tools used were the Hospital Anxiety Depression Scale
and the Impact of Events Scale Revised, which provided a measurement of post-traumatic

39

stress disorder (PTSD) symptoms. At the time of the study DSM-IV diagnostic criteria of
PTSD was used and therefore the IES-R only had three subscales: intrusion, avoidance, and
hypervigilance to measure PTSD. Today the DSM-5 has outlined four distinct diagnostic
symptom clusters instead of three, with the new symptom being negative cognition and
mood. What has remained constant between the two versions is that the duration of
disturbances is more than one month. The measurements were taken at three and 10 weeks
and then again at six months’ post-miscarriage. The women in the deferred intervention
group were provide with an opportunity for support intervention at three months after
miscarriage. The women in the immediate intervention group received a single psychological
session on the day of their surgical intervention, this session lasted an average of 37 minutes.
Two weeks after this session they received a telephone follow-up.
The results of this study showed that women in the deferred intervention group had
higher depression scores than the immediate intervention group at 10 weeks post
miscarriage. There were significant predictive factors for anxiety found in the deferred
intervention group and in those with previous depression despite having intervention or being
part of the deferred intervention group.
This study showed that at three weeks’ post-miscarriage, women benefitted from
having an interview and telephone follow-up. This was demonstrated by less intense
symptoms of anxiety and depression in those with immediate follow-up when compared with
those who were offered deferred follow-up (Sejourne, Callahan, & Chabrol, 2010b). Those in
the deferred intervention group showed clinically significant depressive symptoms 10 weeks
after the miscarriage. Many of the participants in the immediate intervention group found
that the interventions were useful and 20% expressed a desire for even more support,

40

although the researchers did not clarify the type of support, it can be surmised that it would
be in the way of further therapy sessions. The researchers suggest that intervention by way of
systematic counselling such as cognitive behavioural therapy should be provided to women
immediately following a miscarriage (Sejourne, Callahan, & Chabrol, 2010b).
A weakness in this study was that there was no allowance for a global evolution of
symptoms over time. Therefore, the study did not measure potential intervention efficacy
starting at the initial period after miscarriage. Also to be considered is the unintended
therapeutic effect that the questionnaires and measures may have had on the deferred
intervention group.
Summary
This literature review brought forward nine research articles that were analyzed in
order to identify themes that would inform an approach to primary care delivery for a woman
experiencing anxiety and depression after a miscarriage. The key themes derived from the
literature include; women’s needs for support after a miscarriage are unique; there is a need
for primary care providers to screen for depression and anxiety; and early interventions are
most effective when managing anxiety and depression after miscarriage. These findings will
be used in a discussion that will encompass Swanson’s Framework and provide implications
for clinical practice.
Limitations of this review of the literature include the lack of research about the
primary care needs of women in their 20s and 30s who have experienced a miscarriage.
There was a limited amount of studies from which to draw conclusions and many of the
studies included small samples sizes which reduced the generalizability of their conclusions.

41

All research studies reviewed were conducted outside of Canada. Conclusions from these
studies may differ according to varying cultural values and perspectives within Canada. This
study may not be applicable to populations such as teen mothers, women in their 40’s, those
receiving fertility treatments, and other sub-groups. Another limitation of these studies, when
comparing, is that the instrumentation used to measure depression and anxiety after
miscarriage was not standardized. Each of the studies that address depression and anxiety
after miscarriage used a variety of different instruments. This makes comparison of studies
that are addressing similar issues challenging.

42

Chapter Six: Discussion
There’s nothing more calming in difficult moments than knowing there’s someone fighting
with you.
-Mother Teresa
Miscarriage occurs frequently and is thought to be as high as 25% of all pregnancies.
Unfortunately, amongst health care providers, a tone is being set that communicates to these
women that their experience of having a miscarriage is viewed as being an insignificant
event. This oversight is leaving many women feeling unsupported and even traumatized.
Research has shown that, as a result of these experiences, there are clinically high levels of
depression and anxiety among women who have recently miscarried. The literature clearly
states that psychological care after miscarriage is not a standardized service across primary
care settings (Geller, Psaros, & Kornfield, 2010; Maker & Ogden, 2003; Kong, Lok, Lam,
Yip, & Chung, 2010) and the women who are accessing these services express that they are
not given sufficient information or support from their providers (Sejourne, Callahan, and
Chabrol, 2010a).
Nurse practitioners, upon licensure, have the knowledge, skills, and abilities that are
essential to independent clinical practice. The MScN-FNP degree is built upon a sound
undergraduate degree where theoretical concepts are taught, and clinical experience is gained
with extensive hours in clinical practice. This foundation is then applied to the Master’s
degree by building upon these core concepts while incorporating advanced knowledge and
skills acquired by clinical and classroom learning which adds a greater depth and breadth of
knowledge. Nurse practitioner competencies have an emphasis on independent, interdisciplinary practice, that use analytical skills for evaluation as well as providing evidence-

43

based, patient centered approaches across a multitude of settings while maintaining advanced
knowledge of the health care delivery system (The National Organization of Nurse
Practitioner Faculties, 2011). The role of the family nurse practitioner is one that is grounded
in a holistic and collaborative approach to patient care (Canadian Nurses Association, 2009;
CRNBC, 2011). Along with these attributes is the fact that the family nurse practitioner
functions as a primary care provider, patient educator, and patient advocate (Canadian
Nurses Association, 2009). As nurse practitioners gain more of a role in primary care, there
is no doubt, that the topic of miscarriage will be a pervasive part of their scope of practice.
Within the culture of nursing, loss is not viewed as a failure but as an opportunity to
respond to the complex and varied needs of the patient, in this case the woman. For women
that have experienced a miscarriage, the family nurse practitioner is in a privileged position
to come alongside them, and help shape the miscarriage experience. Nurse practitioners have
demonstrated that they are effective, safe practitioners who positively influence patient
outcomes (Donald, et al., 2010). Nurse practitioners, who have established a meaningful
relationship with a patient who has miscarried, should not be focused on “curing” the
woman, but rather on introducing the process of healing through caring. This direct focus of
caring that is foundational to nursing will also incorporate medical knowledge (Dunphy,
Porter, Winlan-Brown, & Thomas, 2015). Caring is central to nursing, and although the
concept of caring is not unique to nursing knowledge or practice, Swanson (1991) reminds us
that caring is “a nurturing way of relating to a valued other toward whom one feels a
personal sense of commitment and responsibility” (p 165). As nurse practitioners incorporate
more medical knowledge into their practice, it is imperative to not forget to draw upon the
foundational core concept of caring that guides their practice.

44

Fortunately, the nurse practitioner, as a primary care provider, has acquired the
necessary training combined with clinical experience to be a proficient provider of care for
these women that is both timely and meets women’s physical and psychological needs. The
nurse practitioner can achieve this level of care for the woman who has miscarried by
drawing on the five principles of Swanson’s framework for caring. This holistic model can
help guide the nurse practitioner’s choice of therapeutic intervention so that it meets the
unique needs of the woman who has miscarried. This proposed model of care not only
attends to the woman in the present moment, but also looks to ensure her long term well
being.
The evidence presented in this paper supports the position that there is a gap in the
delivery of miscarriage care, for those woman who present as having unique needs for
support, the need to be screened for anxiety and depression, and require early interventions.
The biopsychosocial responses to pregnancy after miscarriage appear to be consistent among
women in their 20s and 30s, and as a result the emergent themes from the literature review
can help shape and guide future nurse practitioner practice. The literature review revealed
that both anxiety and depression are common responses that are consistently found. The
nurse practitioner needs to identify the women that are at risk and can do this by providing
ongoing assessments and early interventions. Fortunately, Swanson (1991) has provided a
theoretical framework for caring that can inform nurse practitioner practice for the care of
these women. The following discussion will provide a critical analysis of the research
findings organized within Swanson’s framework. “In the theory’s most recent form, caring
consists of five categories or processes. They are knowing, being with, doing for, enabling,

45

maintaining belief” (Swanson, 1991, p.161). These five processes provide the structure for
the following discussion.
Knowing
The literature review identified that women who miscarry present with unique needs.
Striving to understand the event as it has meaning to the woman is a crucial first step that
should be done as part of the assessment of the woman. Recognizing the woman as a
significant being and striving to understand her experience while creating a climate for
establishing a commitment to healing and avoiding assumptions is what Swanson (1991),
describes as knowing. This knowing portrays the centering on the one cared for by assessing
thoroughly and identifying the woman’s desire to be understood for her experience. By
asking the woman questions about her miscarriage we can avoid assumptions and move
toward fully understanding the event. Exploring the meaning of the loss with the woman will
allow the practitioner to gain insight into what the loss means to that woman. As the
literature so clearly portrays, the woman’s needs for support are unique, and these needs
must be identified by the nurse practitioner. The knowing will allow the nurse practitioner to
address the needs of the women, then choose the appropriate intervention, whether it might
be for education, reassurance, medical management, or counselling.
Rowlands and Lee (2010b) found that women with more education, higher
satisfaction with their primary care provider, and having other living children seem to
manage better in the long term. The higher the level of education a woman has obtained, the
more able a woman seems to be to draw upon more options and resources to help deal with
the loss and move forward with the grieving process. Having a better understanding that they
are not responsible for the miscarriage could also be attributed to such women, however

46

intellectual knowing does not necessarily mitigate guilt and self-blame. In contrast, women
who had been hospitalized for a major illness, had a break-up with their partner, had serious
financial difficulty, or lack of perceived support had more difficulty managing life after a
miscarriage (Rowlands & Lee, 2010b). Further identifiers of women who could be at risk
discussed in the literature include being younger than 28 years, having a history of mental
health problems and having higher stress levels (Mann et al., 2008; Rowlands and Lee,
2010b). When the nurse practitioner operates from a basis of knowing in the context of
individualized care after a miscarriage, this results in both the woman and the care provider
being engaged with one another and this then brings about the appropriate course of support
(Swanson, 1991). Since nurse practitioners are typically employed as salaried practitioners,
time constraints, which often exist with fee-for-service providers, and can result in a barrier
to patient care, are not as prevalent with nurse practitioners. As a result, nurse practitioners
are free to spend a full 15-20 minutes and in some cases even longer with a patient in order
to allow the psychological aspects of care to be incorporated.
The second theme that emerged from the literature is that women who have
miscarried need to be screened for depression and anxiety. Sejourne, Callahan and Chabrol
(2010b) identified that women who are at higher risk for psychological distress need to be
identified early in the miscarriage process. The nurse practitioner can use a brief but reliable
screening tool to identify these women. The screening for those at risk builds upon the
concept of understanding the unique needs of this patient population. Women need to be
screened for early identification and management, but not all women will need treatment. In
knowing, the nurse practitioner assesses thoroughly, remains curious, and seeks clues from
the woman’s verbal communications and non-verbal presentation in order to identify those

47

who might be at risk. By remaining curious about the woman who has miscarried the nurse
practitioner will be attuned to her current presentation and should be able to recognize a
depressed mood or general state of anxiety. Both of these diagnoses consist of overlapping
symptoms with things like a lack of interest in daily activities or irritability, fatigue, appetite
and sleeping fluctuations, as well as concentration problems.
Five of the nine articles examined underline the need for the health care provider to
know their patient in order to understand her needs. Cumming et al. (2007) suggest using a
brief but reliable screening tool to assess those at risk for psychological morbidity, although
no specific tool was recommended. Rowlands and Lee (2010b) utilized the 5-item Mental
Health subscale of the Australian standard version Short Form Health survey to screen.
Adolfsson (2006) utilized the Perinatal Grief Scale. Sejourne et al. (2010b) utilized the
Hospital Anxiety and Depression Scale and the Impact of Events Scale. Lok et al. (2010)
suggested using the General Health Questionnaire (GHQ-12) or Beck Depression Inventory
(BDI) for screening. Regardless of which screening tool is utilized, the nurse practitioner will
need to assess her patient in order to truly know her.
Being With
The concept of being with is described by Swanson (1991) as one step beyond
knowing; it is conveying ability, being emotionally present even in physical absence. It is
where the nurse practitioner provides comfort measures and preserves personhood in the face
of pain and extreme breakdown. The woman is far more likely to respond positively when
approached by a nurse practitioner who is emotionally available. The screening tools
discussed previously can have some therapeutic benefits and the woman will often feel heard
through their use, which results in having her grief validated. Being with also allows the

48

woman’s preference for follow up and treatment to drive decision making around care.
Adolfsson et al. (2006) reiterated the varied physical, emotional, and psychological needs of
a woman after a miscarriage. Knowing and being with will allow the nurse practitioner to
make appropriate decisions in partnership with the woman.
Doing For
The third sub-dimension of Swanson’s (1991) theory of caring, doing for, can take
place only after a thorough screening process for depression and anxiety has been completed.
This builds on the concept of women who have miscarried and have unique needs. As with
most mental illnesses, depression and anxiety rob the individual of the ability to function in
many domains of their daily life. As a result of this the nurse practitioner takes on the role of
doing for others as they would have done for themselves if they were capable. If a mental
illness occurs for the woman who has miscarried, then an intervention is needed to help her
regain dignity and control in her life. The nurse practitioner can facilitate treatment through
CBT, brief psychotherapy, or by using a referral process to a mental health practitioner.
Prescriptions of anti-depressants or anti-anxiety drugs may also be needed. Although this
paper does not address pharmacological treatment for this population, it may be an option for
some patients depending on their needs.
The earlier a therapeutic intervention is initiated by the nurse practitioner, the better
the outcome can be for the woman. Neugebauer et al. (2007) found that a telephone
administered counselling session with women within several days of entering into the study
was effective to reduce depressive symptoms. Although the nurse practitioner may not be
doing counselling per se, the patient could be brought into the office within a week after the
miscarriage for an assessment and a decision about an early intervention could be made. The

49

intervention itself could actually be the appointment, thereby creating the space the woman
needs to discuss the meaning of the loss for her. The nurse practitioner could provide other
forms of counselling and if needed, medication therapy.
Enabling
Enabling depicts the need to have the woman’s grieving facilitated. The nurse
practitioner enables the woman by validating and giving supportive guidance that helps the
woman find ways to care for herself and seek support from others. It is a form of
empowerment. Assessing the women’s current support systems and coping strategies will
allow the primary care provider to use a strength based approaches in care. Questions such
as, “when you have gone through difficulties before, who did you talk to?” or “what
strategies have helped you deal with hardships in the past?” Helping the woman to identify
and use her strengths will enable her to move forward through the grief.
Through the process of enabling, the nurse practitioner can be the person that will
help the grieving mother through her difficult life transition. This can be done by acting as
the person who can validate the woman’s experience in that moment, provides both medical
and psychosocial supports, as well as addressing other needs of care. The woman may
require support by the provision of information about what is to be expected physically. If
she is being managed medically as an outpatient, she will need to anticipate what the
physical nature of the miscarriage will be like and how to prepare for this.
The nurse practitioner may need to prescribe or recommend medications such as antidepressants, pain medications, or sleep aids that would be beneficial in the woman’s care. As
the woman is physically experiencing the miscarriage, the nurse practitioner can provide

50

education about anticipated blood loss, infection, how to manage the products of conception,
and when to seek emergency care. The nurse practitioner can also ensure that the woman has
adequate follow up in the clinic or via telephone and a further physical assessment could be
completed at that time. There are community resources that women could be referred to if
their own psychosocial support network is not adequate enough to meet their needs. The
nurse practitioner, in collaboration with the woman, can determine what further supports or
additional care is required. The nurse practitioner, although the primary care provider, does
not necessarily need to be the one to provide ongoing support, but can ensure that the
ongoing support is provided. By taking on this important role, the nurse practitioner frees up
much needed emotional energy for the woman who miscarried to focus on her immediate
concerns and physical needs. As the grieving process continues, the woman equipped with
the necessary support and information can move through the process of generating
alternative explanations about her miscarriage experience. Finding the meaning in her loss
will allow the woman who miscarried the opportunity to grow and hopefully, to selfactualize (Swanson, 1991).
The necessity for early intervention is the third theme that emerged from the literature
review. Many women identified that their follow-up medical appointment was insufficient to
deal with the issues (Sejourne, N., Callahan, S., & Chabrol, H., 2010a) and concerns
(Cumming, et al., 2007) that they had following a miscarriage. Enabling, would allow the
nurse practitioner to help navigate the woman’s passage through this often difficult life
transition and the complexities that come with this journey (Swanson, 1991). Enabling can
facilitate the woman’s capacity to grow, heal, and practice self-care. By offering alternatives
to and reframing their current situation, the nurse practitioner can meet the biopsychosocial

51

needs of the woman who has miscarried and help change the course of treatment. In the
context of primary care for women experiencing anxiety and depression after miscarriage,
the nurse practitioner can provide a safe and nurturing space. This creates the openness to
talk, make referrals for more in-depth counselling, recommend self-help books, allows the
woman, perhaps for the first time, to articulate the meaning of her loss, and use
psychological interventions like cognitive behavioural therapy and motivational interviewing
techniques to help move the woman in the direction of healing.
Nodding (1984) describes when the primary care provider sees the other’s reality as a
possibility for himself or herself, it triggers a response within the care provider to try and
eliminate the other’s intolerable suffering. When we act to eliminate the intolerable, reduce
the pain, and fill the need to actualize another’s dream, we are truly embodying what it
means to practice both knowing and enabling. This process in action will allow the nurse
practitioner to come beside the woman in order to meet her unique needs and assist the
woman to work through her pain and move towards healing.
Maintaining Belief
Swanson’s fifth and final sub dimension, maintaining belief, is the culmination of
striving to know, being with, doing for, and enabling the other. No matter how unique the
needs of a woman who miscarries are, what the results of screening for anxiety or depression
tell us, or even the stage at which an intervention takes place, the nurse practitioner must be
at least one person in the woman’s life who can maintain belief about their situation, and
reinforce to the woman that she has the capacity within her to get through this experience.
“In nursing, maintaining belief is a pervasive part of our profession; nurses approach human
responses as meaningful aspects of their clients’ realities.” (Swanson, 1991, p.165). In doing

52

this the nurse practitioner is going the distance for their patient while being sensitive to her
unique needs.
At the core of using a therapeutic intervention, when using Swanson’s theoretical
framework, is maintaining belief. This is the nurse practitioner sustaining a hope-filled
attitude while offering realistic optimism, and supporting the woman in her search to find
meaning. Nurse practitioners can communicate their belief in the woman’s capacity to heal
and face the future with hope. This can help the woman to decide whether, when, and how to
move on and to deal with her next pregnancy. By instilling this belief early on in the
miscarriage process, the woman can be supported into maintaining a sense of hope about her
situation.

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Chapter 7 Summary and Conclusion
“All the art of living lies in a fine mingling of letting go and holding on.”
-Havelock Ellis
The focus of this paper was limited to women in their 20s and 30s who have
experienced a miscarriage. Even though this age group makes up the majority of childbearing
women, the lessons learned here should not be generalized to all childbearing woman. The
emergent theme that these women are a heterogeneous group is only further complicated
when teens and woman over 40 are included. Building on this is the fact that there was such
a limited number of studies to draw from with regards to this age group, most of which had
small samples sizes, therefore one can only assume there might be an overrepresentation of
woman with negative experiences post miscarriage who participated in these studies.
Recommendations for Nurse Practitioner Practice
Once a miscarriage has been identified, the woman should be brought in for an office
visit to discuss management. If possible, having a support person being present would be of
great benefit as the woman may not hear all of the advice and education due to the distress
she may be experiencing. Typically, the woman is offered surgical, medical, or expectant
management. Risks and benefits of all options should be discussed and weighed out with the
woman. Teaching and education can be provided to the woman regarding what to expect
physically with a miscarriage including pain management. Emotional support and
reassurance along with education around the causes of miscarriage would be ideal. Nurse
practitioners should advise the woman to come back to the office in 1-2 weeks for a followup. At that time, screening for depression and anxiety can be initiated using a brief but
reliable screening tool in order to better identify women at risk for a psychiatric illness. Such

54

tools discussed earlier that can be used are the Beck Depression Inventory, Perinatal Grief
Scale, or the Hospital Anxiety and Depression Scale. For those women who are identified as
high risk for anxiety and depression, referral to community programs and supports should be
offered. Psychoeducation around what anxiety and depression look and feel like should be
conducted by the nurse practitioner. CBT can be offered by the nurse practitioner if qualified,
otherwise, a referral to a registered counselling clinic or private practice practitioner should
be recommended. To help bridge the time to therapy, a discussion about the use of
psychotropic medications like antidepressants and sleep aids can be offered.
Nurse practitioners may want to include screening for increased stress levels as part
of routine antenatal health visits. This would allow the practitioner to have a sense of the
woman’s pre-existing stressors and supports by establishing a baseline. The Perceived Stress
Scale (PSS) is one such quick and easy screening tool to administer and score. This would
alert the practitioner to the need for supports and early intervention should a miscarriage
occur.
Nurse Practitioner Education
Nurse practitioner programs would benefit by providing their students with
supplemental education and training to include not only the statistics around miscarriage, but
the psychosocial impacts that a miscarriage can have on a woman, her partner, and her other
children if any. Standard nurse practitioner training and education does not prepare emerging
graduates to be proficient or even fully aware about the management of this all too frequent
event. An anecdotal case in point was, when a midwife who was conducting a lecture about
pregnancy was asked about the management of miscarriages, she answered by saying how
they are very routine, and just another part of pregnancy. She went on to say that they are

55

insignificant for the woman miscarrying and life goes on (Karen Gerlach, personal
communication, January 14, 2016). If this is the perceived level of attention to care by a
specialist, then how can future nurse practitioners avoid negative outcomes with such a small
amount of attention being given to this matter?
Areas for Further Research
It would be strongly recommended that those individuals choosing to do further
investigations within this area of primary care focus on topics such as, minority groups who
have experienced miscarriage, and ways in which culture affects women’s handling of a
miscarriage. Unfortunately, none of the studies used in this paper drew upon a Canadian
sample population, therefore it would be interesting to find out if the findings reported here
are consistent within the multicultural context that is the Canadian healthcare system. With
the prevalence of mental health concerns in society today, and with the increasing destigmatizing of mental health, future research considerations could include the development
of a valid, reliable, brief screening tool developed to isolate the symptoms associated with
miscarriage. Building on this scale, primary care practitioners would be better able to
identify women at risk for anxiety and depression after miscarriage. A number of different
tools were used in the research, but there is not one specific tool that emerged as ideal for
this group of women. Developing such a scale could ensure that women who miscarry are
receiving the best possible care available to them early enough. Although not talked about in
any great depth in this paper future research regarding pharmacological management of
miscarriages would also be an area of future investigation. A possible question to be asked
would be if the pharmacological management of a miscarriage with antidepressants and anti-

56

anxiety medications is just as effective as psychotherapy by itself or is a combination of the
two more effective?
Conclusion
Nurse practitioners, as primary health care professionals, have advanced nursing
practice competencies that enable them to provide health care services from a holistic
perspective for their patients. As a family nurse practitioner, events that make up the life
span will be a significant part of what is dealt with in practice. Not to be underestimated in
these life events is the psychological morbidity and emotional impact that the various
diseases, illnesses, and life events have on a patient. The nurse practitioner’s role now not
only includes counselling families on miscarriage, but also extends to educating medical and
nursing staff on the emotional impact. Nurse practitioners must take on the challenge to care
holistically for women, and to recognize that the loss of any pregnancy is a significant life
crisis and can have far-reaching implications for the woman. In the past 20 years significant
strides have been made in recognizing these increased psychological needs. All health care
providers, not just nurse practitioners, must continue this pursuit, because they are the ones
in a position to take on this task by positively affecting the experience of the woman who has
miscarried.

57

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Appendix A Chapter 5 Findings
62

Source
Adolfsson,
Bertero, &
Larsson,
2006

Purpose/
Research Question
Posed

To measure whether
a structured followup visit to a midwife
at 21-28 days after
early miscarriage
could reduce the
women’s grief.

(Cumming,
et al., 2007)
To present the
findings of anxiety
and depression in
women and in men
of 13 months after
miscarriage and to
discuss the clinical
implications of early
identification and
management.

Setting &
Method used

Characteristics of
Sample

Results

Relevance to
Practice

Structured follow-up visits are
not imperative for all women
A gynecologic
Women who experience
with early miscarriage.
clinic in mediummiscarriage are not a
Women with suspicion of
sized town in the
homogenous group.
missed abortion receive an
southwest of
Women with missed
early appointment to attend a
Sweden
88 women who had a
abortion and who did not
clinic and should be given
Swanson’s
miscarriage before 13
have other children had
information regarding early
framework for
weeks of gestation,
higher PGS scores at both
miscarriage.
caring was used in
over 18 years of age
visits
Knowledge of women’s needs
the first group,
and Swedish speaking. Structured follow-up visits after miscarriage is important in
control group had
did not imply any
order to help facilitate the
medical concerns
significant reduction in
grieving process and prevent
addressed but no
grief as measured using the
complicated grief.
discussion about
PGS scale.
The whole chain of health care
women’s feelings.
needs to relay the same
information
Setting: Three
Anxiety was a greater
Early Pregnancy
clinical burden than
There are high levels of anxiety
Assessment Units
depression
following miscarriage.
in Scotland.
Women 273
Pregnancy loss represents a The increase in anxiety in men
Assessments
Men 133
significant emotional
and women may represent a
occurred at 1, 6
Above 16 years
burden for women, to a
lost opportunity for HCP to
and 13 months
Able to give written
lesser extent for men for at detect psychological morbidity
after miscarriage.
consent
least 13 months after loss.
after miscarriage and treat
Methods: SemiMiscarriage occurred
The effects of miscarriage
accordingly.
structured
prior to 24 weeks
can last a long time and are
HCP need training to detect
interviews
Completed
complex in resolution.
those at risk for
Used HADS as
management of index
Anxiety rather than
psychopathology.
standardize selfmiscarriage
depression was more likely
Need a brief but valid and
report measure of
to be experienced after
reliable method of identifying
general
miscarriage by men and
those at risk.
psychopathology.
women.

63

Kong, Lok,
Lam, Yip, &
Chung, 2010

Lok, Yip,
Tak-Sing,
Sahota, &
Chung, 2010

(Mann,
McKeown,
Bacon,
Vesselinov,
& Bush,
2008

To assess HCPs and
patient’s attitudes
towards the
psychological impact
of miscarriage

Setting: Antenatal
clinic at a hospital
in Hong Kong
Method:
Prospective,
cross-sectional
survey. Postal an
face-to-face
interview

To examine the 1year longitudinal
course of
psychological
outcomes after
miscarriage.

Setting:
University
affiliated teaching
hospital in Hong
Kong
Method:
Longitudinal
observational
study using GHQ12 and BDI scales

Setting: 3
obstetrics
To identify antenatal
practices 1 in
predictors of
Mississippi and 2
depressive symptoms in South Carolina.
and grief following
Method:
pregnancy loss.
Prospective
cohort study using
religiosity

1269 HCP: Family
physicians 41.5%,
obstetricians 9.3%,
other specialists
49.1% and midwives
0.1%.
1209 pregnant women
and 310 of their
spouses. 42.8% had
other children, 23.8
had a previous
miscarriage.

Study cohort: 190
miscarrying women
Control group: 150
non-pregnant women
seeking contraception
advice.

374 adult women
enrolled during
prenatal care

There may be a lack of
continuity of care as most of
the health care professionals
There is less appreciation
look after a woman during
of psychological morbidity
miscarriage, but not many after
after miscarriage compared
discharge.
with that of postnatal
Primary care providers share
depression among both
the responsibility of managing
health care professionals
psychological aspects of
and patients.
miscarrying women; it is
10% of HCPs were not
important that a good referral
aware of possible
system from a primary care
psychological morbidity
provider to specialists are
after miscarriage.
available if needed. Patients
should be aware that such care
is available.
Although psychometric
Targeting interventions aimed
scores reduced over time,
at alleviating psychological
the levels of psychological distress after miscarriage. There
distress and depressive
is a need to assess the
symptoms were
psychological symptoms of
statistically higher than
women who have miscarried
those of the control.
and counseling services are
A statistically significant
necessary. The psychological
proportion of patients
care of women who have
reported psychological
miscarried cannot entirely
morbidity shortly after
focus on those who are initially
miscarriage.
more distressed.
Clinicians should be alert to
signs of depression following
Age and religious
miscarriage in younger women
attendance at least a few
and in women with a history of
times a month were
mental illness during or before
significantly inversely
pregnancy. in religious
associated with grief
activities provides a venue for
scores.
interpersonal support and
encouragement.

64

measure: daily
spiritual
experiences and
frequency of
participation in
organized
religious
activities.
(Neugebauer,
Setting: Two New
et al., 2007)
York City
To evaluate the
medical centers in
potential utility of
low-income
telephoneneighborhoods
administered
Method: Open
interpersonal
pilot trial using
counseling for
telephonewomen after
administered
miscarriage.
interpersonal
counseling
(Rowlands & Whether trajectories
The Australian
Lee, 2010)
of Mental Health
Longitudinal
among women with a
Study on
history of
Women’s Health
miscarriage differ
using a
according to the
government
demographic factors, funded survey of
internal and external
all Australian
coping resources,
citizens and
and other measures
permanent
of psychological
residents
health and wellrandomly elects
being. The broader
40,000
aim is to identify
participants
characteristics of
Method: The 5women who cope
item Mental
well, or badly, after a Health subscale of
miscarriage to
the Australian

9 women
Mean age: 32.5 years
Hispanic: 35.3
Black: 5.9
Non-Hispanic white:
47.1
High school educated:
88.2
Married 53%
Other children: 64.7%

998 women aged 1823 years old who had
a miscarriage

Participants experienced
substantial symptomatic
improvement. Mean
decline in completer
sample from 23.6 at
baseline to 11.2 post
intervention probably
reflects clinically
significant improvement.
Need a RCT to prove.

Preliminary evidence for the
feasibility and acceptability of
telephone-administered mental
health care for this patient
population.

Significant main effects
were found for satisfaction
with PCP and for
education, both when
higher, were each
associated with higher
Mental Health Scores.
Women with greater
number of life events and
higher stress had lower
Mental health than others.
Adjustment in the long
term was also affected by
prior diagnosis of anxiety
or depression.
Shows that there are a
number of variables
associated with adjustment

Women who are pregnant or
planning pregnancy, and
experiencing high levels of
stress, may benefit from
cognitive behavioural stress
management interventions
which could potentially be
incorporated into antenatal
classes. Routine screening for
high levels of stress could be a
routine aspect of antenatal
healthcare visits. Greater
provision of information on
managing stress, through PCPs
and other community
resources, may also be
beneficial.
Adequate support after

65

inform interventions
to assist women
dealing with this
significant event.

(Sejourne,
Callahan, &
Chabrol,
2010b)

standard version
of the sF-36 was
used to assess the
women’s
adjustment after
miscarriage.

It was hypothesised
that a single-session Setting: Maternity
intervention based on
service of two
CBT techniques
semi-private
including
clinics in
psychoeducation
Toulouse, France
along with
Method: All
empathetic emotional
participants
support would be
completed the
beneficial for women Hospital Anxiety
dealing with
and Depression
miscarriage. This
Scale and Impact
study seeks to
of Events Scale at
develop and evaluate
3 and 10 weeks
a CBT-based
and then again at
intervention for
6 months.
women dealing with

after miscarriage.

134 women
French-speaking
All had undergone
dilation and curettage
or vacuum aspiration
for the uncomplicated
and unanticipated loss
of a pregnancy.

At 3 weeks postmiscarriage, a comparison
of the scores between the
two groups shows that
women who had an
interview and follow-up
showed lower scores and
less intense symptoms of
anxiety, depression and
PTSD than those who were
offered deferred follow-up.
No significant differences
seen at either 10 weeks or
6 months’ postmiscarriage. Significantly
more women in the
deferred intervention group

miscarriage generally should
include acknowledgment of the
loss, providing or directing
women to reliable sources of
information about miscarriage
and to resources for emotional
support. Some women may also
benefit from discussions about
general well-being including
the impact on self-esteem and
how to cope with inappropriate
guilt and anxiety. PCPs offer
targeted support to miscarrying
women who have a history of
mental health problems or high
levels of life stress, to ensure
their well-being in the months
after loss and in subsequent
pregnancies.

Not all women need
psychological help it seems
useful and important to provide
an early psychological
intervention in order to help
women deal with miscarriage.
Need to identify women who
are at higher risk for
psychological distress or have
specific and unique
circumstances predisposing
them to greater difficulties in
facing miscarriage.

66

miscarriage.

(Sejourne,
N., Callahan,
S., &
Chabrol, H.,
2010a)

Ask women about
their desire for
support following
miscarriage and
specifically about
aspects of content,
type and timing of
support.

showed clinically
significant depressive
symptoms 10 weeks after
the intervention.
Early intervention was
appreciated by women
participating.

Setting: Internet
site housing
research study
questionnaires for
a period of 5
weeks. Message
was sent to
several Frenchlanguage forums
dealing with
maternity of
medical issues
Method: An
experimenterdesigned
questionnaire was
presented to
internet forums
dealing with
miscarriage or
gynecological
medical
information.

350 Francophone
women participants
ages 18-43.
Majority lived in
France from all
regions of the country
with exception of the
Limousine and
Corsica regions.
Remaining sample
were from Belgium
and other foreign
countries.
Half the sample had
no other children.
Most of the women
had experienced a
single miscarriage in
the past 2 months. The
majority had not
received any medical
treatment for their
miscarriage. 48% had
natural evacuation and
45% having
undergone either
vacuum aspiration or
D&C. Half the women
had been hospitalized.

Most women indicated that
they would appreciate
support after a miscarriage.
All of the proposed
interventions appeared
useful to the women,
particularly the medical
aspects of miscarriage.
95% felt that some sort of
post-miscarriage support
was necessary in general
and 91% would have
personally wanted support
following their own
miscarriage.
Intervention that appeared
the most useful were
having and in-depth
discussion with their
doctor, the possibility of
contacting a health care
professional at any time,
improved medical followup and group therapy for
women who had
experienced miscarriage.
Information brochures,
systematic appointments
with a psychologist or

Need for providing more
comprehensive care for women
after miscarriage and provide
information about how support
could best be provided. Many
means for providing support
exist and new methods should
be implemented to provide
more systematic and widely
available support.

67

psychiatrist was also
considered to be helpful
although less so. Women
felt that the best timing for
interventions was support
immediately following the
diagnosis of their
miscarriage. Least
favorable period was
before or after any medical
intervention.
86% of women felt that
their medical appointment
was insufficient for dealing
with the issues brought up
by the miscarriage.

Appendix B Quick Reference for Post Miscarriage Follow-up

Hospital Anxiety Depression
Scale
Strengths and Supports
Miscarriage already occurred or
imminent.

Acknowledge loss
Validation
Empathy
Discuss meaning of the event to
the women

Education
• Cause of miscarriage
• Future pregnancies
• Signs and symptoms of anxiety and
depression
• Physical aspect of miscarriage

What to do with products of
conception?
Signs and symptoms of infection
Pain Management
Referral to grief counsellor
Cognitive Behaviour Therapy
(CBT)
Sleeps aids
Antidepressants and Antianxiety
medications

Follow-up 1-2 weeks

Beck Depression Inventory or

Active listening and reflection

Step 3 Doing For

Assess for Anxiety and
depression.

Step 2 Being With

Within 1-3 days
of miscarriage
news, confirmed
by ultrasound,
the women
should be
brought into the
office

Step 1 Knowing

68

Re-assess grief levels, anxiety,
depression
Discuss physical aspects of
miscarriage
Fetus passed?
Continuous bleeding?
Pain/Fever?