WOMEN’S HEALTH

Dr. Tamazur Karim

 MISCARRIAGE

Miscarriage is a relatively common phenomenon occurring in 15–20 per cent of known

pregnancies, with 80 per cent of these occurring within the first trimester (Broquet 1999).
 DEFINITION

• Miscarriage or ‘spontaneous abortion’ has been defined as the unintended end of a

pregnancy before a foetus can survive outside the mother, which is recognized as being
before the twentieth week of gestation (Borg and Lasker 1982).
• Despite the frequency with which miscarriage occurs, it has only been in the last 10 to 15
years that research has begun to identify and explore the consequences of early pregnancy
loss.
 SYMOTOMS AFTER MISCARRIAGE

Grief
• One main area of research has conceptualized miscarriage as a loss event, assuming that after
miscarriage women experience stages of grief parallel to that of the death of a loved one (Herz
1984).
• The main symptoms identified are sadness, yearning for the lost child, a desire to talk to
others about the loss and a search for meaningful explanations (Herz 1984; Beutel et al. 1995;
Athey and Spielvogel 2000).
• Women often perceive themselves as failures for not being able to have a healthy pregnancy
• This loss is often not acknowledged by the community because there are no rituals that can be
performed (Herz 1984).
 DEPRESSION AND ANXIETY

• Friedman and Gath (1989) used the present state examination (PSE) to assess psychiatric ‘caseness’ in
women four weeks post-miscarriage.
• They found that 48 per cent of the sample had sufficiently high scores on the scale to qualify as
‘cases’ patients, which is over four times higher than that in women in the general population. When
analysed, these women were all classified as having depressive disorders.
• Klier et al. (2000) similarly found that women who had miscarried had a significantly increased risk
of developing a minor depressive disorder in the six months following their loss, compared to a
cohort drawn from the community.
• Thapar and Thapar (1992) also found that women who had miscarried experienced a significant
degree of anxiety and depression at both the initial interview and at the six weeks’ follow-up
compared to that of the control group.
 • Pretty- man et al. (1993) used the hospital anxiety and
depression scale (HADS) and found that anxiety rather
than depression was the predominant response at 1, 6 and
12 weeks after miscarriage.
• Further, Beutel et al. (1995) reported that immediately
after the miscarriage the majority of the sample
experienced elevated levels of psychological morbidity
compared to a community cohort and a pregnant control
DEPRESSION AND group, much of which persisted up until the 12-month
follow-up.
ANCIETY
• The authors concluded that depression and grief should
be considered as two distinct reactions to pregnancy loss,
with grief being the normal reaction and depression only
developing when certain circumstances are met.
• This study also showed that a large minority reported no
negative emotional reaction post-miscarriage, suggesting
that a focus on anxiety, depression and grief may only tap
into a part of the miscarriage experience.
 Miscarriage was a ‘silent event’ which was not
discussed within the wider community.

The women were described as being unable to share

their experiences and felt isolated as a result. When they
did get the opportunity to talk about their loss, they
COPING. realized how common miscarriage is and that was a
source of comfort to them.

The authors concluded that miscarriage constituted a

major life event that changed the way in which women
viewed their lives in the present and affected the way in
which they planned for the future (Bansen and Stevens
1992).
 The women described their experiences using a range of themes
which were conceptualized into three stages: turmoil, adjustment
and resolution. For the majority, the turmoil stage was
characterized by feelings of being unprepared and negative
emotions.

The women then described a period of adjustment involving social

COPING comparisons, sharing and a search for meaning.

This resolution seemed more positive for those with children and
more negative if the miscarriage was not their first. The authors
argued that, rather than being a trigger to psychological morbidity,
a miscarriage should be conceptualized as a process involv- ing the
stages of turmoil, adjustment and resolution
 MODE OF TREATMENT

• The evacuation of the retained products of conception (ERPC), also sometimes known as a
D&C (dilatation and curettage). This uses either a general or local anaesthetic and
surgically removes the lining of the womb and the foetus if it is still there.
• This occasionally causes infection, uterine perforation and bowel damage and brings with
it all the associated risks of an anaesthetic.
• Expectant management is a possible alternative and has been adopted by several clinics
across the UK. This involves letting the miscarriage take its natural course and enables the
woman to be at home as the miscarriage occurs.
 IMPACT OF MODE OF TREATMENT

• Research indicates that a woman’s experience is clearly influenced by how it is managed, and
that, although the medical management of miscarriage brings with it the risks associated with
surgery, a more ‘natural’ approach can leave women feeling misin- formed and unprepared.

• Up until recently all abortions involved the surgical removal of the foetus using a D&C and a
general anaesthetic.
• Chose
• A suction technique which can involve general or local anaesthetic or no anaesthetic,
• or the abortion pill which induces a miscarriage (later mis- carriages may be managed through
inducing labour).
 ABORTIONS

• In the UK an abortion is legal up until the 24th week of gestation (5.5 months) although
abortions occur within the first trimester.
• Illegal in Brazil, Chile, Mexico, Venezuela, Angola, Congo, Mali, Niger, Nigeria, Uganda,
Afghanistan, Iran, Egypt, Libya, Syria Bangladesh, Ireland and Malta.
• In addition, many countries only allow abortion to protect a woman’s health.
• These include Argentina, Peru, Cameroon, Ethiopia, Malawi, Zimbabwe, Kuwait, Saudi
Arabia, Pakistan, Thailand, Poland and Portugal.
 • Abortion is also legal in the USA and most European countries.
• In England and Wales one in three women is likely to have an
abortion in their lifetime (calculated from The Abortion Statistics
STATISTICS OF England and Wales 2001);
ABORTION • However, debate continues over the moral status of a human
foetus and consequently also over that of abortions (Gillon 2001).
 DECIDING TO HAVE AN ABORTION

Teenage mother’s
• Mother’s support
• Family support
• Financial reasons
• Ambitions
• Societal norms
• Privileged
• Health care
 • These ranged from specific issues such as the
importance of accessibility of information and
recommendations that abortion be treated as an
urgent rather than elective procedure, to the wider
social context of abortion regarding women’s
ownership and respect for their decisions and the
removal of the stigma that surrounds abortion.
• They reported that, overall, having an unwanted
W O ME N’ S pregnancy was experienced as a rare event which was
E X P E R IE N C E S O F accompanied by feelings of lack of control and loss of
S E RV IC E S status.
• Further, the process of arranging and having an
abortion led to a reinstatement of status, control and
normality.
• However, this process was sometimes hindered by
inaccessible information, judgemental health
professionals and the wider social context of abortion
in which abortion is seen as a generally negative
experience.
 • Zolese and Blacker (1992) argue that approximately 10 per cent of
women experience depression or anxiety that is severe or persistent
after an abortion.
• Adler et al. (1990) reviewed the most methodologically sound US
studies and concluded that incidence of severe negative responses
is low.
• that distress is greatest before an abortion and reactions are often
P S Y C H O L O G I C A L I M PA C T O F positive.
A N A B O RT I O N
• They argue that abortion can be considered within a stress and
coping framework and that the small numbers of women who
experience distress are insignificant from a public health
perspective.
• Söderberg et al. (1998) conducted interviews with a large sample of
Swedish women (n = 845) a year after their abortion and found that
55 per cent experienced some form of emotional distress.
 PSYCHOLOGICAL IMPACT OF AN
ABORTION

• In contrast, however, Kero et al. (2004) interviewed 58 women in Sweden a year after their
abortion and concluded that most reported no distress following their abortion and that
more than half reported only positive experiences.
• Other researchers have found that relief is commonly expressed after an abortion
(Rosenfeld 1992)
• Major et al. (2000) found that 72 per cent of their sample was satisfied with their decision
two years after.
• Russo and Zierk (1992) followed up women eight years after
their abortion and compared them to those who had kept the
child.
• They found that having an abortion was related to higher
global self-esteem than having an unwanted birth,
suggesting that any initial negative reactions decay over
time.
THE LONGER-TERM
IMPACT OF HAVING
• In a similar vein, Major et al. (2000) explored the variation in AN ABORTION
emotional reactions over time and reported that negative
emotions increased between the time of the abortion and two
years, and satisfaction with the decision decreased.
• These results also suggest a linear pattern of change but one
towards worse rather than better adaptation.
 • In contrast, however, some researchers have argued that emotional
responses do not always alter in a linear way.
• Kumar and Robson (1987) found that neurotic disturbances during
pregnancy were significantly higher in those who had had a
THE LONGER-TERM previous termination than those who had not and suggest that this
IMPACT OF HAVING is due to unresolved feelings about the abortion that had been
AN ABORTION reawakened by the pregnancy.
• Adler et al. (1990) argued that research from other life stressors
has found that if no severe negative responses are present from a
few months to a year after the event, it is unlikely that they will
develop later.
• Belief system affected the emotional response.
 THE IMPACT OF MODE OF INTERVENTION

• Slade et al. (1998) examined the impact of having either a medical or surgical abortion.
• The results showed that those opting for surgical procedure had to wait longer and were more
advanced by the time of the abortion but that the two groups showed similar emotional
responses prior to having the abortion.
• After the abortion, however, the medical procedure was seen as more stressful and was
associated with more post-termination problems and was seen as more disruptive to their life.
• Further, seeing the foetus was associated with more intrusive events such as nightmares,
flashbacks and unwanted thoughts. Fifty-three per cent of the medical group said they would
have the same procedure again whereas 77 per cent of the surgical group felt this.
 • Similarly, Goodwin and Ogden (2006) suggest from their study
that the abortion pill technique may result in a more negative
experience for several women than other methods as some
women described seeing the foetus as it was expelled from their
bodies.
TH E IMPA CT O F MO D E • Lowenstein et al. (2006) compared surgical and medical
O F IN T ERVEN TI O N management of abortion and reported no differences in anxiety
by two weeks following the abortion.
• In line with this, Howie et al. (1997) reported no differences in
emotional change two years after having either a medical
abortion or vacuum aspiration.
• Perhaps the mode of intervention does result in short-term
differences in the women’s experiences but after a while the
differences begin to disappear.
 • People have extremely strong views about terminations which are
reflected in alliances such as ‘pro-choice’ and ‘pro-life’.
• researchers are not immune to their own political or moral
positions.
P R O B L E M S W IT H
T E R M I NAT IO N • Research exploring the impact of termination is problem-atic
RESEARCH • For example, an ideological position either for or against
termination could affect the choice of research design, the selection
of participants, the ways the data are analysed or the ways the data
are interpreted and the results presented
• https://www.youtube.com/watch?v=wrQYHeodRio