Journal of Reproductive and Infant Psychology

Vol. 28, No. 3, August 2010, 287–296

The utility of a psychological intervention for coping with

spontaneous abortion
Natalène Séjourné*a, Stacey Callahanb and Henri Chabrolb
a
Université Toulouse II, Université Toulouse II CERPP, Toulouse, France;
b
Université Toulouse II, Octogone CERPP, Toulouse, France
(Received 1 April 2009; final version received 21 October 2009)
Taylor and Francis
CJRI_A_449143.sgm

Journal
10.1080/02646830903487334
0264-6838
Original
Taylor
02009
00
natalene.sejourne@laposte.net
NatalèneSéjourné
000002010
&ofArticle
Francis
Reproductive
(print)/1469-672X
and Infant
(online)
Psychology

Background: The object of this study is to implement and to examine the

effectiveness a psychological support intervention drawing from three clinical
techniques (support, psychoeducation, Cognitive-Behavioural Therapy) for
women who have suffered a spontaneous abortion. Method: 134 women
participated in the study: 66 composed the Immediate Intervention group (II) and
68 the Deferred Intervention (DI) group. All participants completed the Hospital
Anxiety and Depression Scale (HADS) and the Impact of Events Scale – Revised
(IES-R) at 3 and 10 weeks as well as 6 months following study enrollment.
Results: Results at three weeks show significant differences between the groups
for anxiety, depression and event impact. Multiple regression analyses showed
that intervention group and depression antecedents were significant predictors of
overall adaptation after a miscarriage. Conclusions: In terms of prevention, a brief
early single-session psychological intervention appears to be a particularly
pertinent, efficacious and cost-effective method for addressing psychological
distress following miscarriage.
Keywords: miscarriage; support; anxiety; depression

Introduction
Spontaneous abortion or miscarriage is a relatively common event, occurring in
between 12 and 24% of confirmed pregnancies (Carter, Misri, & Tomfohr, 2007). It
is the early and unanticipated termination of a pregnancy which occurs before 24
weeks of gestation, and for many women it is the loss of a child (Regan, 2001). Para-
doxically, while the experience of miscarriage may be relatively common from an
epidemiological standpoint, the feelings of isolation and blame felt by women who
have experienced miscarriage are often poorly confronted by not only their immediate
support system, but by health professionals as well (Regan, 2001).
The experience and psychological consequences of a miscarriage have been widely
studied, focusing on sadness, depressive symptoms, anxiety, and even post-traumatic
stress disorder (PTSD). Studies show that 40% of women suffer intense sadness, and
20–40% suffer symptoms of anxiety (Lok & Neugebauer, 2007). Many studies have
evaluated the magnitude of depressive symptoms reported by 20–55% of women (Lok
& Neugebauer, 2007). At two weeks following a miscarriage, the proportion of women

*Corresponding author. Email: natalene.sejourne@laposte.net

ISSN 0264-6838 print/ISSN 1469-672X online

© 2010 Society for Reproductive and Infant Psychology
DOI: 10.1080/02646830903487334
http://www.informaworld.com
288 N. Séjourné et al.

suffering significant depressive symptoms was 3.4-times higher than pregnant women,
and 4.3-times higher than women in the general population (Neugebauer et al., 1992).
A French study found 3 months after a miscarriage that 51% of women fulfilled DSM-
III criteria for depression (Garel et al., 1992). Miscarriage is an unexpected event that
can imply sudden and intense pain, bleeding, hospitalisation, and surgical intervention;
it thus constitutes a physically traumatising event. In one study, the prevalence of
PTSD was observed to be 25% one month after the loss and at 7% four months post-
loss (Engelhard, van den Hout, & Arntz, 2001).
Many authors have noted the importance of support following miscarriage. Two
Anglophone studies evaluated the efficacy of a specialised clinical approach
(Nikcevic, 2003; Roswell, Jongman, Kilby, Kirchmeier, Orford, 2001) yet few
randomised controlled studies have aimed at reducing psychological distress in
women facing miscarriage. Swanson (1999) tested the effect of a specific and brief
therapeutic approach of three sessions providing women with the opportunity to
discuss their experience and the difficulties they encountered. Women who received
this support showed early in evaluations that they had lower scores of depression and
anger. One study, however, observed no significant effect for a structured therapeutic
approach using a midwife (Adolfsson, Berterö, & Larsson, 2006). Another studied the
efficacy of a one-session psychological debriefing; there were no significant results
four months following this study on measures of anxiety, depression, or event impact
(Lee, Slade, & Lygo, 1996). Yet another study showed limited but promising results
using data from previous studies to develop a brief telephone support intervention
(Neugebauer et al., 2007).
Cognitive-behaviour therapy (CBT) is a well-defined, precise, and comprehensive
psychological intervention that aims to influence dysfonctional emotions, behaviours
and cognitions through a goal-oriented procedure. Many techniques used in CBT can
be successfully transposed into different situations that cannot be strictly defined as
psychotherapeutic. For example, promising results have been shown in CBT-based
prevention interventions on post-traumatic stress (Foa, Hearst-Ikeda, & Perry, 1995).
Many authors underline the interest in using CBT techniques in situations necessitat-
ing emotional adaptation, such as grief and loss (Malkinson, 2001; Matthews &
Marwit, 2004). CBT techniques and principles have already been successfully applied
to the perinatal period, notable in the prevention of post-partum depression (Chabrol
et al., 2001) and breastfeeding intervention (Callahan et al., 2003). Carter et al. (2007)
evoked the possibility of using CBT for helping women deal with miscarriages
emphasising that these methods were particularly suitable for dealing with the feelings
of guilt, incapacity, fear, and depression often noted in miscarriage experiences. To
our knowledge, no study has yet been undertaken to explore the suggestions of Carter
et al. (2007).
As noted above many non-therapeutic approaches evaluated by different studies
(Lee et al., 1996 and Neugebauer et al., 2007) showed no marked effects. Thus, simply
discussing the experience does not seem to have any notable positive impact on well-
being, and it seems logical to provide more effective support and supplement therapy
with a more active therapeutic approach. The reality of the terrain suggests that
providing long-term psychological therapy or, at the very least, several sessions, can
be wieldy and expensive, and is not usually accepted by women (Séjourné, Callahan,
& Chabrol, 2009) and that providing a single session intervention has shown to be
effective in previous research (Chabrol et al., 2001 for post-partum depression and
Callahan et al., 2003 for breastfeeding).
 Journal of Reproductive and Infant Psychology 289

Given the success and cost-effectiveness of CBT approaches, it was hypothesised

that a single-session intervention based on CBT techniques including psychoeduca-
tion along with empathetic emotional support would be beneficial for women dealing
with miscarriage. If CBT can be applied to preventing the psychological distress
associated with a miscarriage, it appears opportune to examine its effectiveness using
a quasi-experimental approach. The current study seeks to develop and evaluate a
CBT-based intervention for women dealing with miscarriage.

Method
Participants
The study was conducted between October 2005 and March 2007 in the maternity
service of two semi-private clinics in Toulouse, France. All participants were adult
French-speaking women who had undergone dilation and curettage (DC) or vacuum
aspiration (VA) for the uncomplicated and unanticipated loss of a pregnancy (inclu-
sion criteria). The principal investigator (psychologist/researcher) and co-author of the
current study (NS) carried out the study detailed below and all women were invited to
participate by this individual.
Thus, 170 women were met on the day of their surgical intervention and were
randomly assigned based on the date to either an Immediate Intervention group on
odd-numbered days (II) or to a Deferred Intervention group on even-numbered days
(DI). Twenty-two women (13%) refused to participate and 14 (8.2%) did not meet
inclusion criteria (poor mastery of the French language, no stable postal address).
The remaining sample of 134 women was studied (mean overall age = 31.82 years;
SD = 4.99; range 22–44): 66 were assigned to the II group (mean age = 31.01 years,
SD = 4.45; range 24–43) and 68 were assigned to the DI group (mean age = 31.87,
SD = 5.32; range 22–42). The mean duration of pregnancy at the time of miscar-
riage was 9.05 weeks amenorrhoea (SD = 2.46; range 4–13) for the II group and
9.31 weeks (SD = 2.13; range 4–14) for the DI group.
The general characteristics of the two groups of participants are represented on
Table 1. None of these group differences were statistically significant.

Instruments
Socio-demographic information and details regarding the miscarriage were gathered
using an experimenter-designed questionnaire specific to the current study.
The Hospital Anxiety Depression Scale (HADS) is a 14-item scale detailing
anxious and depressive symptomology (Zigmond & Snaith, 1983; French translation
Lépine, Godchau, Brun, & Lempérière, 1985). The 14 items are divided into 2 scales
and items evaluating depression are alternately presented with those evaluating anxi-
ety. Intensity of each symptom for the previous week is evaluated on a Likert-type
scale going from 0 to 3. The scores for each subscale can total between 0 and 21,
higher scores indicative of higher levels of each symptom. A cut-off score of 8 for
each subscale was used to determine the presence of either depression or anxiety
(Bjelland, Dahl, Haug, & Neckelmann, 2002). In this study, Cronbach’s alphas were
.82 for the whole scale, .66 for anxiety and .78 for depression subscales.
The Impact of Events Scale, Revised (IES-R) provides a measurement of PTSD
symptoms (Horowitz, Wilner, & Alvarez, 1979; Weiss & Marmar, 1997). For this
study, the translated and validated French version was used (Brunet, St-Hilaire, Jehel,
290 N. Séjourné et al.

Table 1. General characteristics of the two groups of participants.

Group II Group ID
N = 56 N = 52
n % n %
Women with a stable couple relationship 52 92.8 49 94.2
Women who had children 24 42.8 31 59.6
Hoped pregnancy 47 83.9 43 82.7
History of depression (women had take antidepressants) 10 17.8 12 23
Women without any past gynecological difficulties 31 55.3 29 55.7
Women with history of:
Miscarriage 11 19.6 14 26.9
Elective abortion 11 19.6 8 15.4
Medically assisted conception 4 7.1 4 7.7
Ectopic pregnancy 1 1.8 1 2
Therapeutic abortion 1 1.8 – –
Importance attributed to the loss:
– ‘No big deal’ 5 10 1 1.91
– Plans for the future, Hope 4 8 6 11.54
– Pregnancy, embryo 15 30 14 26.91
– Baby, child 26 52 29 55.77

& King, 2003). The IES-R has 22 items over three subscales corresponding to symp-
toms of PTSD indicated in the DSM-IV: intrusion, avoidance, and hyper vigilance.
Each item is evaluated on a 5-point scale (0 = not at all and 4 = extremely) arriving at
a total score of between 0 and 88. In this study, Cronbach’s alphas were .92 for the
whole scale, and, respectively, .88, .78, .80 for the three subscales.

Procedure
The study was presented to the ethics boards of the participating institutions and
received full permission to proceed. All women were initially met at the clinic on the
day of surgical intervention. Once the study was presented and fully informed consent
provided, the women agreeing to participate signed informed consent forms. All
participants were able to contact the principal investigator at any time.
All women in the II group were asked to participate in a support intervention
consisting of one psychological session on the day of the surgical intervention. The
support intervention was composed of three elements. First, an empathic listening
approach was used in order to encourage therapeutic alliance and emotional
expression. Second, a psychoeducational approach was aimed at helping the women
understand the context of miscarriage, their incidence, and as well understanding
normal psychological reactions and their repercussions. This involved, for example,
systematically asking women if they were aware of the actual frequency of miscar-
riage; in the event that they did not know or were mistaken about their estimates, the
correct knowledge was provided to them. Information for the construction of this
component was gleaned from specific and detailed sources on miscarriage (Regan,
2001). Finally, techniques from cognitive behaviour therapy like cognitive reframing
 Journal of Reproductive and Infant Psychology 291

and problem resolution were employed. Cognitive reframing was used to help women
dealing with feelings of guilt or responsibility. For example, this involved helping
women imagine other possible causes for miscarriage when they initially provided a
cause that suggested personal responsibility, like a period of excessive fatigue at work.
Reminding women that the majority of miscarriages were due to chromosomal anom-
alies and that all women who have exhausting work schedules do not necessarily have
miscarriages provided a means for them to reduce their feelings of personal responsi-
bility and any guilt associated with it. Problem resolution was used to help women
finding concrete solutions to problems anticipated and encountered (dealing with
social relationships and insensitive comments, dealing with significant other relation-
ships, anticipated pregnancies, etc.) and facilitating the use of adaptive coping strate-
gies. This could, for example, consist in helping women to elaborate responses to
unpleasant comments from their family and friends by stating their point of view and
affirming themselves in a non-threatening manner. The interviews lasted on average
37 min (SD = 14.38 min; range of 20–90 min). Two weeks after the interview, they
received a telephone follow-up.
The women in the DI group were informed that they were participating in a study
on the psychological experience of miscarriage. They were provided with the
opportunity for a support intervention at 3 months post-miscarriage and contacted
immediately following the second set of questionnaires at 10 weeks through telephone
calls or e-mail. Those women desiring to participate confirmed their participation
following this contact.
All women received the two follow-up questionnaires at 3 and 10 weeks, as well
as at 6 months post-miscarriage based on the original date of intervention at the clinic.

Data analysis
All statistical analyses were carried out using Statistica 7.0. One-tailed Student’s t-
tests were used to estimate means difference between groups. Post-hoc power analysis
for Student’s t-test showed that observed power was between 0.48 and 0.84 at 3
weeks, between 0.17 and 0.28 at 10 weeks, and between 0.07 and 0.39 at 6 months.
Chi-square tests allowed for examining group differences with regards to qualitative
nominal data. Multiple regression analyses provided insight on the factors likely to
influence negative symptoms following miscarriage. The subjects-to-predictors ratio
was adequate for multiple regression analysis following the traditional guideline of at
least ten subjects per predictors (Howell, 1997). The minimum level of p < 0.05 was
adopted for determining significant differences.

Results
Access to psychological support
Among the women who participated in the II group, 43 (86%) felt that it was helpful
while still 9 (20%) felt it was insufficient, some women feeling the need for more
support. Not all of the women in the DI group responded when contacted at 10 weeks
post-miscarriage. Thus, the deferred interview was offered to a total of 48 women: 24
refused the interview, 10 accepted, and the others did not follow-up on the offer.
While participation was high initially, it dropped steadily over the period of the
entire study. For the II group, of the 66 participants 50 (75%) responded at 3 weeks,
292 N. Séjourné et al.

45 (68%) at 10 weeks and 33 (50%) at 6 months. Respondants and non-respondants

showed no significant scores on measures gathered at 3 weeks. This rate was similar
for the DI group of 68 participants with 52 (76%) responding at 3 weeks, 37 (54%) at
10 weeks, and 34 (50%) at 6 months. However, women who did not answer at 6
months had significantly higher scores on anxiety (t(40) = 2.05; p = 0.04) and IES-R
(t(40) = 2.53; p = 0.01) at 3 weeks than those who answered.

Comparisons between groups

Student t-tests revealed that at 3 weeks post-miscarriage, the women in the DI group
had higher scores on anxiety (t(100) = −2.62; p = 0.00), depression (t(100) = −1.64;
p = 0.04) the total IES-R (t(100) = −2.22; p = 0.02) as well as the IES-R ‘Intrusion’
subscale (t(95) = −2.01; p = 0.04) and the ‘Hyperactivity’ subscale (t(95) = −1.61;
p = 0.04) (Table 2).
There were no significant differences at either 10 weeks or 6 months post-miscar-
riage with regards to symptom intensity. However, at 10 weeks, more women in the
DI group showed elevated scores on depression (score HADS > 8); one women (2.2%)
in the II group compared to 8 women (21.6%) in the DI group (χ2 = 7.82; p < 0.01).

Multiple regression analyses

Several regression analyses were performed in order to examine the different scores
on psychopathology indicators for the entire sample of women who responded at 3
weeks post-miscarriage (n =102). Predictive variables were: intervention group (II vs.

Table 2. Questionnaire data for the two intervention groups (II et DI) gathered at three different
times post-miscarriage.
3 weeks 10 weeks 6 months
II n = 50 II n = 45 II n = 33
DI n = 52 DI n = 37 DI n = 34
Anxiety: II 7.21 (3.02)* 6.22 (3.52) 5.33 (3.42)
DI 9.06 (3.95)* 7.16 (4.25) 6.50 (3.49)
Depression: II 3.93 (3.38)* 3 (2.46) 2.24 (2.79)
DI 5.08 (3.60)* 3.48 (3.20) 2.44 (2.50)
IES-R: II 26.15 (16.87)* 20.37 (17.23) 16.68 (15.43)
DI 33.77 (17.65)* 23.67 (15.62) 16.02 (14.65)
Intrusion:
II 11.72 (7.60)* 9.37 (7.70) 7.43 (7.53)
DI 15 (8.33)* 8.97 (5.99) 7.05 (5.95)
Avoidance:
II 9.55 (6.95) 7.06 (6.38) 5.76 (5.25)
DI 11.13 (6.78) 9.05 (6.67) 6.38 (6.58)
Hyperactivity:
II 5.57 (5.23)* 3.79 (5.09) 3.03 (3.94)
DI 7.41 (5.83)* 4.91 (4.84) 2.33 (3.87)
*Starred results are significant at p < .05.
 Journal of Reproductive and Infant Psychology 293

DI), age, marital status, number of children, previous depression, number of gyneco-
logical antecedents, desired pregnancy, pregnancy duration, and importance attributed
to the loss (obtained through an ordinal score between 1 and 4 to estimate the impact
of the women’s loss, Table 1).
The resulting model explained 16% of the variance for anxiety. Two significant
predictive factors were revealed for anxiety: intervention group (β = 0.24; p < 0.05)
and previous depression (β = 0.24; p < 0.05).
The model explained 12% of the variance for depression. Only previous depres-
sion predicted the scores on depression following miscarriage (β = 0.34; p < 0.01).
The model explained 31% of the variance for scores on the IES-R. Three signifi-
cant predictive factors were revealed: intervention group (β = 0.23; p < 0.01), previous
depression (β = 0.39; p < 0.001) and the importance attributed to the loss (β = 0.22;
p < 0.05).

Discussion
The overall number of participants and the response level were acceptable in the
current study. While the sample is specific and the results cannot be generalised to all
the women who have had a miscarraige, the two groups considered were comparable
on most of the demographic characteristics studied. All measures of psychological
adaptation at 3 weeks following miscarriage reveal the difficulties confronted by the
women. The depression and anxiety scores were similar to those seen in previous stud-
ies (Nikcevic, Tunkel, & Nicolaides, 1998; Roswell et al., 2001) while measures of
PTSD were slightly higher than those seen in previous studies (Engelhard et al., 2001).
An important first result of the current study confirms the psychological distress
experienced by most of women facing miscarriage.
At three weeks post-miscarriage a comparison of the scores between the two
groups shows that women having benefited from an interview and telephone follow-
up showed lower scores and less intense symptoms of anxiety, depression and PTSD
than those who were offered deferred follow-up. Scores on all measures, however,
decreased over time and there were no significant differences seen at either 10 weeks
or 6 months post-miscarriage. This result is in keeping with previous studies in
miscarriage interventions and some authors have suggested that feelings of sadness
and grief are absent at 3 or 4 months post-miscarriage and thus it is difficult to
measure the impact of a support intervention (Adolfsson et al., 2006; Lee et al., 1996).
That being said, it was noted in the current study that significantly more women in the
DI group showed clinically significant depressive symptoms 10 weeks after the inter-
vention. Moreover, it is unclear whether women who receive no intervention or
support following miscarriage are truly ‘cured’ of their feelings anxiety; or rather
simply fall into a pattern of denial. It was the impression of the current principal inves-
tigator that women who refused the intervention in the DI group at 3 months did not
want to ‘revisit’ their experience and that perhaps many suffered feelings of unre-
solved grief. Significant differences on anxiety and PTSD at 3 weeks between women
who sent back questionnaires at 6 months and women who did not may confirm this
hypothesis. This would be an important element for future studies as it would provide
additional insight and support for providing immediate intervention.
The regression analyses are in keeping with these results since the intervention
group was shown to be a significant predictive factor for anxiety and post-traumatic
stress. Aside from the intervention group, and also in keeping with results of previous
294 N. Séjourné et al.

studies (Janssen, Cuisinier, Graauw, & Hoogduin, 1997), the principal predictive vari-
able of anxiety, depression and post-traumatic stress was previous depressive
episodes, which is an important point for predicting those who might benefit from
more intervention. In order to have the most dependable information on previous
depressive episodes, this information was combined with information on taking anti-
depressors. Give the responses provided by the women this appeared to be indeed the
best means for taking into account established previous depressive episodes. That
being said, future studies could incorporate a wider diversity of variables associated
with previous depressive episodes, including their duration and frequency as well as
any psychotherapy.
The absence of initial measures does not allow for taking into account a global
evolution of symptoms over time and presents a major limit to the current study. Thus,
the study does not fully measure potential intervention efficacy starting at the initial
period following miscarriage and suggests the need to put into place a series of time-
dependent measures as was done by Swanson (1999). It is, however, important in this
type of study to take into account the potential placebo effect linked to the use of
questionnaires and simple participation in the study, particularly for the DI group.
Neugebauer et al. (1992) noted a fortuitous therapeutic effect on depressive symptoms
through the use of research interviews carried out by telephone following pregnancy
loss. Comparison using an early measure would have allowed for analysis of predictor
variables implicated in long-term differences in symptoms as well as potentially
aggravating or protective factors. To fully confirm the utility of this type of interven-
tion, a more detailed and in-depth study will be necessary in order to take into account
desired effects over time, and as well any non-desirable effects, including those that
could be potentially deleterious as has been found for some psychological debriefing
interventions following trauma (Feldner, Monson, & Friedman, 2007; Iucci,
Marchand, & Brillon, 2003).
While this research does emphasise the benefits of the intervention under study, it
is important to note that other variables have a significant impact on the success of
psychological intervention: context, relationships with others, and expectations of the
women studied. It should also be noted that no apparent benefit was obvious after 10
weeks in the measured domains. Another limit which complicates interpretation is the
declining response rate over the period of the study. It does not appear related to inter-
vention group (since the rates are nearly identical). It can be suggested that the lack of
response to the questionnaires was related to the participant’s psychological state, but
unclear whether it can be attributed to higher distress, less distress, or a decision to
avoid completing the study.
Finally, a large majority in the II group found the intervention useful and moreover
20% would have liked more support. In order to provide women with the necessary
psychological support following a miscarriage, it seems clear that systematic counsel-
ling be provided at the time of the event, with no delay. This type of intervention
would allow to take into account from the very beginning anxious and depressive
symptoms experienced by women along with any subclinical symptoms which may
not necessarily impel women to seek help later on yet may negatively impact their
well-being in a significant and durable manner. Dollander and de Tychey (2000) noted
in this vein that, with regards to primary prevention, the grief process starts immedi-
ately following the loss. The early intervention carried out in the current study was
particularly appreciated by the women participating and many expressed feelings of
being supported and understood. Many felt that they were given a means for dealing
 Journal of Reproductive and Infant Psychology 295

with difficulties surrounding miscarriage; in particular for dealing with their entourage
and with significant others, as well as helping to confront irrational beliefs about their
miscarriages and any potential guilt they might have felt. It is also possible that by
allowing women to confront their feelings and difficulties, the intervention might have
an impact in the future, in particular with the anxiety that many women feel regarding
pregnancy following a miscarriage.

Conclusion
Although miscarriage is a relatively common event in a woman’s reproductive life, it
represents a loss and can lead to psychological distress; the current social–medical
climate provides little possibility for support following miscarriage. While not all
women who experience miscarriage need psychological help, and although sadness
and grief do usually attenuate over time, it seems useful and important to provide an
early psychological intervention in order to help women deal with miscarriage. Aside
from providing basic support in a time that is widely understood as difficult, this type
of intervention could also serve to identify women who are at higher risk for psycho-
logical distress or have specific and unique circumstances predisposing them to
greater difficulties in facing miscarriage.

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