CALIFORNIA STATE UNIVERSITY SAN MARCOS

THESIS SIGNATURE PAGE

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

MASTER OF ARTS

IN

PSYCHOLOGY

THESIS TITLE Optimism, Social Support and Coping with Miscarriage

AUTHOR: Carolyn J. Parker

DATE OF SUCCESSFUL DEFENSE: May 6, 2003

THE THESIS HAS BEEN ACCEPTED BY THE THESIS COMMITTEE IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN PSYCHOLOGY

Dr. Heike I.M. Mahler 4~ J. mqv.)J4. _d~s THESIS COMMITTEE CHAIR (TYPED) SIGNATURE DATE

Dr. Joanne Pedersen J'"'-C:- OJ THESIS COMMITTEE MEMBER (TYPED) DATE

Dr. Gerardo M. Gonzalez .cJ,It,~_ THESIS COMMITTEE MEMBER (TYPED) ~

Coping with Miscarriage 1

ABSTRACT

This project was designed to examine whether individual differences in perceived social support and dispositional optimism predict coping with miscarriage. In Study

1, approximately 20 couples who had recently experienced a miscarriage were interviewed and administered measures of social support, dispositional optimism, grief (coping), helpful and unhelpful support received, and perceived severity of miscarriage relative to other types of losses. The interviews and questionnaire administration took place at three time points (between 1 and 20 days after miscarriage, 6 weeks, and 12 weeks following miscarriage). Females who more frequently mentioned their spouse as a support person were coping better at intake than females who less frequently mentioned their spouse as a support person.

Additionally, spouses who scored higher in optimism were coping better at intake than spouses who scored lower in optimism. Furthermore, there were significant differences in coping between women and their partners at intake and 12-weeks.

Finally, grief at intake was significantly associated with grief at 6-weeks and 12- weeks for both males and females. In Study 2, a comparison group of 42 people who had never experienced a miscarriage were interviewed to determine their perceived severity of miscarriage relative to other types of losses and the frequency that they would perform specific behaviors in an effort to provide support to someone who had experienced miscarriage. These specific support behaviors were categorized using the comparison groups' frequency rating and then compared to the miscarriage groups' perceptions of helpfulness. As expected, those behaviors that the comparison group

stated they would do with high frequency, moderate frequency, and low frequency were found to be very helpful, moderately helpful, and not too helpful (respectively) by miscarriage participants. Coping with Miscarriage 2

Social Support, Dispostional Optimism

and Coping With Miscarriage

It has been estimated that miscarriage (the unplanned spontaneous termination of a pregnancy prior to twenty weeks of gestation) occurs in 15-20% of known pregnancies (Layne, 1990; Pizer, & Palinski, 1980). Experiencing a miscarriage can be a very stressful event. In addition to the physical effects of miscarriage (e.g., pain, bleeding, hospitalization for evacuation of the uterus [D&C]) (Friedman, & Gath,

1989; Laferla, 1986), many women and their partners experience significant emotional effects, such as anxiety, uncontrollable crying, depression, and fears that they will never have a child (Laferla, 1986; Beutel, Deckardt, Von Rad, & Weiner,

1984; Kirkley-Best & VanDevere, 1986; Lasker & Toedter, 1994; Madden, 1988;

Moscarello, 1989; Neugebauer, Kline, O'Connor, Shrout, Johnson, Skodol, Wicks, &

Susser, 1992; Neugebauer, Kline, Shrout, Skodol, O'Connor, Geller, Stein, & Susser,

1997; Prettyman, Cordlel, & Cook, 1992;, Thapar & Thapar, 1992). Indeed, it has been documented that up to 33% of women develop severe psychological disturbances following miscarriage (Neugebauer, et al., 1992; Katz & Kuller, 1994;

Neugebauer, et al., 1997) and that the emotional effects of miscarriage can last for months or even years (Kirkley-Best & VanDevere, 1986; Rajan, & Oakley, 1993).

Such disturbances may lead to diminished work activity or absence, along with a generalized lower quality of life for each individual.

Although most women who suffer a miscarriage and their partners experience some negative psychological effects, there are individual differences in the degree and time course of the effects (Black, 1991). That is, some individuals cope more effectively than others (James & Kristiansen, 1995) .. Two individual difference factors that have been linked with adjustment to or coping with various major Coping with Miscarriage 3

stressers are perceived social support and dispositional optimism (Collins, Dunkel­

Schetter, Lovel & Scrimshaw, 1993; Scheier, Weintraub, & Carver, 1986;

VanderPlate, Aral, & Magder, 1988).'

Positive and Negative Social Support

Although consensual definitions remain elusive, social support is generally

conceptualized as a multidimensional construct consisting of emotional support

(feedback that one is valued, loved, and/or respected by others), information support

(provision of information or advice), and instrumental or tangible support (provision

of material aid or direct help) (House, 1981; Wills, 1991). Social support can be

further discriminated into positive and negative support (also referred to as social

conflict, social hindrance, or social undermining). Most previous research has

examined the effects of positive social support. Some of the benefits of positive

social support include lower rates of psychological distress (Billings & Moos, 1982;

Kaplan, Robbins, & Martin, 1983; Jones, 1991; Felston, 1998), reduced risk of

mortality (Berkman, 1985; House, Umberson, & Landis, 1988), higher compliance

with doctors recommendations (Christensen, Smith, Turner, Holman, Gregory &

Rich, 1992; Kulik & Mahler, 1993), and faster recovery following surgery (Mahler &

Kulik, 1989). Additionally, positive social support is related to bereavement outcome

after the loss of a child (Littlewood, Cramer, Hoekstra, & Humphrey, 1991; Brabant,

Forsyth, & McFarlain, 1995; Hazzard, Westin & Gutierres, 1992). Specifically,

higher levels of social support have been shown to be related to greater well being for

both mothers and fathers (Hazzard, et al., 1992; Mcintosh, Silver, & Wortman, 1993).

Not only are there physical and psychological benefits to having social support during

stressful periods (Heitzman & Kaplan, 1984; Leana & Feldman, 1991; Kissane &

MacKenzie, 1997), there are also physical and psychological costs when social Coping with Miscarriage 4 support is absent (Black, 1991; James & Kristianson, 1996), especially in individuals where the need for social support is high (Kaplan, et al., 1983). Thus, in general, the literature is consistent; positive social support is related to more effective coping with a wide variety of stressers.

Negative social support has been conceptualized as behaviors directed toward an individual that convey negative affect (e. g. anger, irritation) or negative evaluation

(e.g. criticism) and which hinder the attainment of instrumental goals (Vinokur & Van

Ryn 1993). It is becoming increasingly apparent that positive and negative social support are not necessarily opposite poles of the same construct (Abbey, Abrarnis, &

Caplan, 1985). In fact, recent work suggests that positive and negative social support may independently and uniquely contribute to well being. Among students, the more social conflict they received from any one person in their life, the greater was students' anxiety, depression, interpersonal sensitivity, and the less pleasant quality of life they experienced (Abbey, Abramis, & Caplan, 1985). Furthermore, Stephen,

Kinney, Norris, and Ritchie (1987) investigated positive and negative aspects of social support between geriatric stroke victims and their family members after the patients' returned horne from a rehabilitation facility. Even though negative interactions (e.g. receiving unwanted advice) were reported less often than were positive ones, only negative ones were related to the patients' psychological adjustment. Due to the apparent importance of negative social support to an individual, it is necessary to better understand how this type of support affects coping with stressful events.

Gender Differences and Received Social Support

Although social support has generally been demonstrated to be beneficial for both genders, there is some evidence that men and women cope with stress Coping with Miscarriage 5 differently. An experimental study by Kirschbaum, Klaueer, Filipp, and Hellhammer

(1995) found that males facing a threatening situation exhibited a reduced stress response if their female partners were present as compared to absent. In the same vein, a laboratory study by Glynn, Christenfeld, and Gerin (1999) indicated that

support from females lowered physiological reactivity in males and females during impromptu speeches. They concluded that support from women may be more effective than support from a man, when it comes to dampening physical reactivity.

In two separate studies, in a sample of college students (Felston, 1998) and the

unemployed (Malen & Stroh, 1998) women more often sought social support than men. When coping with job loss, both men and women fared better when more as opposed to less social support was utilized, however, the effect may be stronger for women (Leana & Feldman, 1991). Furthermore, in diabetic patients, males who expressed more satisfaction with their social support had poorer metabolic control than did males with lower social support. Conversely, females exhibited the opposite pattern. Females who reportedly had higher levels of satisfaction with their social

support had better metabolic control than did females who reported lower levels of

satisfaction with their social support (Heitzman & Kaplan, 1984). Following their infant's death, mothers used more available social support than did fathers (Feeley &

Gottlieb, 1989). These results suggest that men and women may use and benefit from

social support differently, also, these effects may depend on the specific stresser.

Additionally, it may be that women use social support for emotional expression, whereas men may use it more for identification or a sense of belonging (Heller, Price,

& Hogg, 1990). Coping with Miscarriage 6

Social Support After Miscarriage

Only a small body of literature exists on the topic of social support after miscarriage. Some studies have been descriptive, chronicling to whom people tum after miscarriage or whether those couples who have close relationships have more support (Cecil, 1994; Conway, 1995; Helstrom & Victor, 1987; Moscarello, 1989;

Rowe, Clyman, Green, Mikkelsen, Haight, & Ataide, 1978; Smart, 1992; Toedter,

Lasker, & Alhadeff, 1988). For example, Conway (1995) reported that women talked more to their girlfriends than their partners and that 67% found support from relatives other than their partners. Smart ( 1992) found that more than half of their sample of couples provided mutual support for each other. These mutual support couples had stronger outside support systems than did couples who were not mutually supportive of one another. Particularly, women who reported a mutual helping relationship with their husband also reported higher levels of instrumental and emotional support. This study was conducted with a sample size of only 27 couples. Only 3 of these couples miscarried (lost their baby prior to 21 weeks of gestation), the remainder of the couples experienced either perinatal death or death of a born child. Additionally, couples had experienced their loss anywhere from 6 months to 7 years prior to their enrollment into the study. Another study found that, both at 1-2 months and 6 months after their loss, women reported that they were satisfied with the support received from their partner, however, this satisfaction was significantly less at 6 months. Further, women thought their partners recovered more quickly, and men expected women to recover more quickly than they did in actuality (Black, 1991 ).

Those few studies which have explored the relationship between social support and coping following miscarriage have generally found a positive association (James

& Kristiansen, 1995; Mekosh-Rosenbaum & Lasker, 1995). For example, one study Coping with Miscarriage 7 found that individuals who withdraw socially have more adverse reactions after miscarriage than individuals who do not (James & Kristiansen, 1995). Furthermore, doctor's support, and support from significant others were negatively correlated with women's composite reactions, as measured by the Coping Strategies inventory, post miscarriage. Specifically, the more support women reported receiving from significant others and doctors, the more cognitive restructuring and engagement women used as coping strategies. These women adjusted better than women who were less supported and who used emotion-focused coping strategies (James &

Kristianson, 1995). However, at least one study found no relationship between social support and coping after miscarriage (Lasker & Toedter, 1991 ).

Although suggestive, one must use caution when interpreting the previous work examining the relationship between social support and coping following miscarriage because it is fraught with methodological limitations. Most significantly, all of the studies have been purely retrospective, making it difficult to determine the directional nature of the relationship between social support and coping with miscarriage. In addition, most of the studies have been conducted with individuals who experienced their miscarriage several months or even years prior to participation. Lasker, Jansen, and Toedter (1999) state that grief diminishes over time and that subjects who had experienced a miscarriage more than 1 year earlier than their participation in the study had significantly lower scores on the PGS than participants whose loss occurred within 1 year prior to participation. Finally, there are many reasons why those women who are coping better might be expected to receive more social support. The present study examined social support and coping with miscarriage in a prospective manner, and recruited individuals within three weeks of their miscarriage. Coping with Miscarriage 8

In addition, the present study examined gender differences in social support after miscarriage. Only two studies have examined gender differences in coping after miscarriage. McGreal, Evans, and Burrows ( 1997) interviewed 52 participants, 17 of whom were males and 3 7 of whom had miscarriages (it was not stated how many of the 17 men had experienced miscarriage). In this retrospective study, individuals had experienced their loss anywhere from 12 months to 5 years before enrollment into the

study. Men reportedly used social support, worried, and or ignored the situation, whereas women, sought support from others who had experienced the same type of loss. Furthermore, three studies have specifically addressed how men adjusted after miscarriage (Cumings, 1984; Chapman, 1994; McGreal, et al., 1997). Two were

strictly qualitative descriptions of mens' reactions and consisted ofvery small sample

sizes (Cumings, 1984; Chapman, 1994). The third discussed only the coping

strategies men used after miscarriage, however it was not clear specifically how long

after miscarriage these men were interviewed (McGreal, et al., 1997). Clearly, there

is a need for more research to examine how men cope after miscarriage. Only with a

better understanding of mens' post-miscarriage coping can effective interventions be

developed.

Therefore, in terms of the examination of perceived social support, the current

studies dramatically improve on previous methodology by being the first to examine

perceived social support quantitatively and prospectively after miscarriage and by

examining the coping process for men.

Dispositional Optimism

A second goal of Study 1 was to examine how dispositional optimism is related

to coping.following miscarriage. Dispositional optimism has been defined as the

generalized expectancy that outcomes will be good (Scheier & Carver, 1985). A Coping with Miscarriage 9 number of studies have found a relationship between optimism and coping. For example, Scheier and Carver (1985) found that students who reported themselves as highly optimistic were less bothered by physical symptoms that developed during the study period than students who reported themselves as less optimistic. Additionally, among undergraduate students, optimists reported greater engagement in health­ promoting behavior and more specific attempts at flu prevention (Hamid, 1990). In another study, breast cancer patients reported their level of optimism at diagnosis and subsequently reported their recent coping responses and distress levels at, 1 day presurgery, 10 days postsurgery, and at 3-, 6-, and 12-month follow-ups. Optimism was negatively related to distress at each time-point, even when prior distress was controlled for (Carver, Pozo, Harris, & Noriega, 1993). Finally, Scheier, Matthews,

Owens, and Magovem (1989) found that dispositional optimism, as assessed prior to coronary bypass surgery, was associated with a faster physical recovery rate in the hospital, a faster rate of return to normal life activities, and a better quality of life at 6 mos. after coronary bypass surgery. In sum, dispositional optimism has been found to be predictive of coping with a wide variety of stressful and health-related events.

Therefore, it is possible that individuals recovering from miscarriage may also cope better if they are higher in dispositional optimism. However, dispostional optimism has not been studied in the context of miscarriage.

Study 1

In order to examine the foregoing issues, couples who had recently experienced a miscarriage completed standardized measures of perceived social support, dispositional optimism, and coping at three time points (1 -20 days after miscarriage,

6, and 12 weeks after miscarriage.) . Coping with Miscarriage 10

It was predicted that: 1) Higher levels of social support at intake would predict better adjustment at 6 and 12 weeks after miscarriage for both males and females, 2)

Higher levels of optimism at intake would predict better adjustment at 6 and 12 weeks after miscarriage for both males and females.

Method

Participants

The miscarriage group contained 24 women and 18 of their partners between the ages of 18 and 42 years (M = 25.56, SD = 6.89 for women, M = 28.53, SD = 8.17 for men) who recently experienced a miscarriage (within past 20 days). All participants were active duty (n = 18), dependents (n = 18), retirees (n= 1), or declined to say (n = 6) of the U.S. Marines or the U.S. Navy and were recruited in

Oceanside, CA at Camp Pendleton Hospital. Most women were married (92% ), had

graduated from high school (M = 13.7, SD = 2.35), and were 62% Caucasion, 31 %

Hispanic, and 4% Asian. Some women went through a D/C procedure (58.8%), had previous elective abortions (12%), had other living children (41.6%), and sought professional help to help them cope with miscarriage (32%). Men ( 94% were married) were more educated than their partners (M = 14. 70, SD = 2.46), and were

57.7% Caucasian, 11.5% Hispanic, and 3.8% African American. Five partners were

deployed and therefore unreachable and two partners declined to participate.

Measures

Perinatal GriefScale (PGS). The actual degree and time-course of grief

following miscarriage was assessed by the PGS (Toedter, Lasker, & Alhadeff, 1988).

The PGS has been shown to have good reliability and validity for this purpose. The

short 33-item version has been divided into 3 sections, each containing eleven 5- point Likert-type questions. The first sub scale determines "normal" grief, called Coping with Miscarriage 11

"Active Grief' and is defined as feelings of sadness, anger, fear, and loneliness

accompanied by crying, missing the baby, and a need to talk about the baby. Sub

scale II: "Difficulty Coping" is defined by feelings of isolation, indecisiveness,

lethargy, losing the desire to live, having let people down, needing professional help,

and by withdrawal from usual activities. Sub scale III: ''Despair" is defined by

feelings of guilt, worthlessness, worry, unprotectedness, physical illness accompanied

by taking medicine for nerves, lack of sense of humor, self-blame, and a desire to withhold love (See Appendix A). In this study, Cronbach's alpha for the entire PGS

for both men and women was acceptable, .91(intake), .93 (6wk.), and .93 (12 wk.)

for women, and .88 (intake), .92 (6wk), .86 (12wk) for the men.

GriefExpectation Scale (GES). In order to assess participants' expectations

regarding the degree and time course of grief experienced following miscarriage the

Grief Expectation Scale (GES) was developed for this study. The GES consisted of the same items as the Perinatal Grief Scale. The items were simply slightly reworded to reflect participants' expectations regarding the sadness, anger, worry, etc. that they

would experience during the coming weeks (See Appendix B). Cronbach's alpha for

the entire GES was acceptable for both women (.91 -intake and .97- 6 wk.) and men

(.96- intake and .95- 6 wk).

Life Orientation Test (LOT}. Dispositional optimism was measured by the LOT

(Scheier & Carver, 1985). The LOT has been used in a variety of medical and non­

medical situations to assess dispositional optimism (See Appendix C). The original

LOT had an acceptable reliability in this sample (a= .86 for women and .70 for men).

There were validity concerns about the original LOT and therefore Sheier, Carver,

and Bridges (1994) introduced a revised version, LOT-R. Since the present study Coping with Miscarriage 12 was conceived shortly after the LOT-R was introduced and before any publications using it were available, both the LOT and LOT-R were measured. The overall

LOT-R had acceptable reliability for women (a= .71). However, while the pessimism subscale of the LOT-R had acceptable reliability for women (a= .74), the optimism subscale had poor reliability (a= .47). Neither the overall LOT-R nor its' subscales were reliable for male spouses. Consequently, the original LOT was used as the measure of optimism in this study.

Social Support Questionnaire (SSQ). The SSQ (Sarason , Levine, Basham, &

Sarason, 1983) has been used in a variety of situations to assess overall quantity and quality of social support (See Appendix D). It is a 27-item scale that yields a number

score (N: quantity) and a satisfaction score (S: quality). In this sample, the alpha coefficient for men and women on N scores was .92 and .94 respectively and the alpha for men and women on S scores was .98 and .93 respectively. The correlation between the two scores for women was .28 and for men was .14, suggesting that

quantity and quality of social support are related, but, different components of social

support

Background Information Sheet (BIS). Demographics were also collected, including: ethnicity, age, gender, years of formal education, and, occupation. Other

background questions included prior knowledge of miscarriage, prior elective

abortions, whether the couple had chosen a name, whether the nursery had been

decorated, whether baby clothes had been bought, if the pregnancy was planned, how

long the couple knew they were pregnant, and who knew about the pregnancy (See

Appendix E). Finally, how many days of work were missed due to the miscarriage

and how many visits to medical professionals ensued related to the miscarriage and why were asked (See Appendix F). Coping with Miscarriage 13

Procedure

Three methods were used to gain access to couples who had recently experienced a miscarriage. First, an emergency room (ER) nurse or co reman (on duty), briefly described the study to couples presenting to Naval Hospital, Camp

Pendleton emergency room with evidence of aborted fetal tissue. If the couple was interested in the study, the ER nurse or coreman asked them to sign a consent form authorizing the investigator to contact them. Signed forms were picked up in the ER by the investigator on Mondays, Wednesdays, and Fridays.

The second method used to recruit couples who had recently experienced a miscarriage, involved the investigator working closely with Lt. Meggan McGraw, at

RTS (Resolve Through Sharing) Bereavement, Naval Hospital, Camp Pendleton,

Oceanside, CA. As part of her job, Lt. McGraw routinely contacted individuals who had recently experienced a miscarriage, and who were receiving prenatal care at

Camp Pendleton, to offer condolences and bereavement services. At the time of her initial contact, Lt. McGraw informed potential participants that a research study examining coping with miscarriage was being conducted, and asked permission to have the investigator contact the couple. The investigator contacted Lt. McGraw in the late afternoon of each working day (M - F) to obtain the names and telephone numbers of couples who had agreed to be contacted.

Third, some women who had miscarried were routinely examined at the OB­

GYN clinic or the Family Practice clinic, Naval Hospital, Camp Pendleton by either a physician or a nurse. During this routine appointment, the examining nurse or physician briefly described the study to potential participants. Names and phone numbers of couples who expressed an interest were provided to the investigator. Coping with Miscarriage 14

After obtaining names and phone numbers of potential participants, the investigator telephoned each couple, described the study purpose and procedures, and determined whether the couple was interested in participating. Couples who agreed to participate were interviewed, either in person or over the telephone, within 1 to 5 days and no later than 20 days after the date of miscarriage.

At the first interview, the investigator reiterated the purpose of the study and detailed the nature of the couples' participation. Participants read and signed the consent form. Any participant questions were then answered and concerns were addressed prior to the interview. The Perinatal Grief Scale (PGS), Life Orientation

Test (LOT), Social Support Questionnaire (SSQ), Grief Expectation Scale (GES), and the Background Information Sheet (BIS) were then administered.

To schedule the 6-week and 12-week post miscarriage interviews, the investigator contacted each couple one week before each time point to schedule the interview as close as possible to 6 or 12 weeks post miscarriage. Again the purpose of the study was reiterated and any questions were answered. At the 6-week interview, participants completed the Perinatal Grief Scale (PGS), and the Grief

Expectation Scale (GES). At the 12-week follow-up interview, participants completed the PGS, and some additional background questions (i.e. how many days of work missed due to the miscarriage; how many phone calls to medical professionals were made in the last 3 months; how many doctor visits they had in the past 3 mos, and for what reason; and how emotionally recovered they felt at that time point). All questionnaires for males and females were identical. However, the wording of several questions on the background information sheet varied appropriately, according to the gender of the participant. Coping with Miscarriage 15

During each interview, participants were instructed to interrupt the experimenter at any time if they had a question. They were also told that they could stop the interview at any time without penalty. At the end of the interview, participants had the opportunity to have their questions answered. After participants completed their final follow-up(- 12 weeks after miscarriage), they were informed that the purpose of the study was to determine how dispositional optimism and social support may be related to coping and adjustment following miscarriage. Participants were offered the opportunity to have a written summary of the findings mailed to them when available. Results

Preliminary Analyses

Tables 1 - 6 present the intercorrelations of the predictors and outcome variables for patients and their spouses separately at each time point. For females, the

SSQ Number total (r = .40,p = .05) and the number of times the spouse was listed as a support person (r = .66,p = .01) were significantly correlated with the LOT.

Therefore, to avoid the problem of multicolinearity, all outcomes for females were analyzed using two separate regressions 1) using SSQ number total and number of times their spouse was listed as a support person as predictors, and 2) using the LOT and SSQ satisfaction as the predictors (Cohen & Cohen, 1975). Additionally, for females at intake, "patient occupation" (r = - .46, p = .05) and "chose baby name"

(r = -.58, p = .05) were significantly inversely related to the PGS total score at intake.

Having planned their pregnancy was related to PGS total score both at 6 weeks Coping with Miscarriage 16

(r = -.47,p = .05) and at 12 weeks (r =-.50,p = .03). Consequently, these variables were statistically controlled for in the respective regressions (intake, 6-wk, 12-wk) for females.

For male spouses, number of times patient was mentioned as a support person was significantly correlated with the LOT (r = .48, p = .05). Due to the problem of multicolinearity, all outcomes for males spouses were analyzed using two separate regressions, 1) using the number of times the patient was mentioned as a support person as the predictor, and 2) using the LOT, SSQ number total, and SSQ satisfied total as the predictors (Cohen & Cohen, 1975). For males, at intake, pt. rank was inversely related to PGS total score (r =-.59, p = .05). At 6 weeks, years of education

(r = .60, p = .05), patient rank (r = -.55, p = .05), patient ethnicity (r = -.52, p = .05), age (r = .63,p = .01), number of prior elected abortions fathered (r = -.58,p = .05), and number of spouses' friends who knew the couple was pregnant (r = .53, p = .05) were related to PGS total score for males. Therefore, these variables were statistically controlled for in the respective regressions (intake and 6-wk) for males spouses. At

12 weeks there were no background factors significantly related to PGS total score for males.

Paired samples t-tests were done between males and females on all three social support variables (SSQN, SSQS, number oftimes patient or spouse mentioned as support person). There were no significant differences between males and females in number of support persons reported (p = .26), social support satisfaction (p = .39), or number of times patient (or spouse) were mentioned as a support person (p = .69). Coping with Miscarriage 17

Paired samples t-tests were also done between males and females on the LOT total score. Males (M= 25.19, SD = 5.05) were more optimistic than females (M=

22.19, SD = 7 .19), however this difference only approached significance t( 1) = -1.97, p=.07.

Due to recent evidence that the LOT may consist of two distinct factors

(optimism and pessimism; Scheier, Carver, & Bridges, 1994), principal components factor analyses using a V arimax rotation technique were performed for the miscarriage patient sample and their spouses separately on the LOT. However, because these analyses did not indicate two distinct factors for either patients or spouses, the original LOT, was used for all ofthe primary analyses reported below. 1

Primary Analyses

Since the goal was to examine the relationship of Optimism (total original

LOT score) and Social Support with adjustment to miscarriage, independent of background factors and one another; a series of hierarchical multiple regression analyses were employed. For each analysis, those background variables that were

significantly associated with PGS scores at each time point were entered into the equation first followed by the predictors on the second step.

1 Since the 3rd factor was correlated to factor 2 (r = .66) and not to factor 1 (r = -.05) , regressions for optimism and pessimism were also done separately for females. The only result to change was at intake, where Optimism was not a significant predictor of coping. For spouses, factor 2 was moderately correlated to factor 3 (r = .68), and factor 4 ( r = .59). Further, factor 3 was moderately inversely correlated to factor 4 (r = -.75) and factor 4·moderately associated with factor 1 (r = .62). Coping with Miscarriage 18

Female Coping at Intake. The overall hierarchical multiple regression involving the LOT and SSQ-satisfaction was significant [R = .74, F (4,20) = 5.98,

p = .002]. However, among the individual effects, only the occupation effect approached significance (See Table 7). Additionally, the multiple regression involving SSQ number total and the number of times the spouse was listed as the

support person was also significant [R = .74, F (4,20) = 5.88,p =.003]. Females who had chosen a name for the baby were exhibiting poorer coping as indexed by the PGS than those who had not yet chosen a name at the time of the miscarriage. Also, those who had a higher status occupation were exhibiting better coping. Independent of these effects, females who more frequently mentioned their spouse as a support

person were coping better at intake (See Table 7).

Male Coping at Intake. The overall hierarchical multiple regression involving the LOT, SSQ-number, and SSQ-satisfaction was significant [R = .79, F (4,12) =

5.12,p =.01]. However, of the individual effects, only the LOT score was

significantly associated with PGS. Spouses who scored higher in optimism were

coping better at intake than those with lower optimism (See Table 8). The overall

hierarchical multiple regression involving the number of times the patient was

mentioned as the support person was also significant [R =.59, F (2,14) = 3.82,p =.05;

see Table 8]. However, none of the individual effects were significant.

Female Coping at 6 Weeks. The overall hierarchical multiple regression

involving the LOT and SSQ-satisfaction was significant [R = .67, F(4,19) = 3.92,p =

.02]. However, the only effect to reach significance was PGS total at intake. Those Coping with Miscarriage 19 who had better coping scores at intake were also coping better at 6 weeks as indexed by the PGS than patients who scored higher on the PGS at intake (See Table 9). The multiple regression involving SSQ-number and the number of times the spouse was listed as a support person was also significant [R = .68, F(4,19) = 4.00,p = .02], with patients who planned their pregnancy exhibiting significantly poorer coping as indexed by the PGS than patients who did not plan their pregnancy. However, neither of the social support measures predicted coping (See Table 9).

Male Coping at 6 Weeks. The overall hierarchical multiple regression involving the LOT, SSQ-number and SSQ-satisfaction was nonsignificant [R = .95,

F(10,4) = 3.35,p = .13]. None ofthe variables entered contributed significantly to the model ( See Table 10). Although, the multiple regression involving the number of times the patient was mentioned as the support person was significant [R = .92, F(8,6)

= 4.11, p = .05], the only effect to reach significance was PGS total at intake. Again, as would be expected, those spouses were who coping better at intake were also coping better at 6 weeks (See Table 10).

Female Coping at 12 Weeks. The overall hierarchical multiple regression involving the LOT and SSQ-satisfaction was significant [R = .87, F(4,14) = 10.78, p < .001]. However, neither the LOT nor the SSQ-satisfaction predicted coping at 12 weeks. Only coping at intake and whether the pregnancy had been planned were predictive of coping. Patients who were coping better at intake and those who had not planned their pregnancy were coping better at 12 weeks than patients with poorer coping scores at intake or who had planned their pregnancy (See Table 11 ). Coping with Miscarriage 20

Furthermore, the multiple regression involving the SSQ-number and the number of times the spouse was listed as a support person was also significant [R = .87, F(4,14)

= 11.32,p < .001]. Again, however, the only significant effects were for PGS total at intake and whether patients planned their pregnancy, with the same pattern as described in the previous equation (See Table 11 ).

Male Coping at 12 Weeks. The hierarchical regression involving the LOT,

SSQ-number, and SSQ-satisfaction was nonsignificant [R =.54, F(4,10) = 1.02, p = .44], with only the PGS total at intake effect approaching significance (See Table

12). Further, the multiple regression involving the number of times the patient was listed as a support person was also nonsignificant [R = .43, F(2,12) = 1.33, p = .30].

None of the individual effects were significant (See Table 12).

Utilization ofHealthcare Services and Sick Days!. Additional ways to determine how well individuals are coping with a health stressor is to measure their utilization of health care services and how much time they missed from work.

Therefore, hierarchical regressions were also calculated to determine if optimism and/or social support independently predicted these indicators of coping for both patients and spouses. Neither optimism nor social support significantly predicted number of phone calls to or visits with health professionals, concerns or problems reported, or days of work missed for either patients or their spouses at intake, 6 weeks, or 12 weeks after experiencing a miscarriage (Tables 13-20). However, for women, number of visits with health professionals was significantly negatively correlated with PGS total score at the 12-week follow-up only (r = -.49,p = .05). Coping with Miscarriage 21

Days of work missed and number of concerns or problems were not significantly correlated with coping , at any of the three time points.

Relationship Between Patient's and Spouse's GriefLevels. At intake, it appears that there was a significant difference with respect to grieving (coping) with miscarriage between males (M= 134.67, SD = 16.02) and females (M= 108.75, SD =

21.31), such that males reported more grief, t (17) =- 5.14,p < .001. Furthermore, males (M= 138.61, SD = 22.75) and females (M= 118.94, SD = 18.88) significantly differed on how well they expected to be coping at 6 weeks, with males expecting to have a harder time than females, t(17) = -4.52, p < .001. At 6 weeks, there was only a marginal difference between patients and their spouses in this sample with respect to current coping (p = .09), and no difference in expectations for how well they would be coping at 12 weeks (p = .34). It is noteworthy to mention that the trend was that females were coping and expected to cope better. Again, at 12 weeks, there was a significant difference between females (M= 137.63, SD = 20.08) and males (M=

149.37, SD = 12.62) in coping with miscarriage, with males reporting greater coping difficulties (t (14) = -2.30,p = .04). Recent studies have suggested the Despair sub­ scale of the PGS as an indicator of folks most at risk for affective reactions (Puddifoot

& Johnson, 1999), therefore paired sample t-tests were also done using this subscale.

At intake, men had higher despair scores (t(17) = -2.85,p = .01) than did women.

Although, the men still had higher despair scale scores, at both the 6 week and 12 week interviews, the difference between men and women was no longer significant (p

= .34 and p= .28 respectively). Coping with Miscarriage 22

Relationship Between Expectations and Actual Grief In female patients, expected grief at intake was related to actual grief at six weeks (r = .54, p = .007).

Additionally, expected grief at six weeks was significantly correlated with actual grief at 12 weeks (r = .85,p < .001). Similarly, in male spouses, expected grief at intake was also related to actual grief at 6 weeks (r = .81, p = .001 ), and expected grief at six weeks was significantly associated with actual grief at 12 weeks (r = .85, p = .001).

Discussion

This study examined coping with miscarriage prospectively and quantitatively, thereby improving on previous methodology used in this area of research. It was hypothesized that social support at intake would predict better adjustment to miscarriage at 6 and 12 weeks post-miscarriage for both female patients and their male partners. Female patients who mentioned their spouse as a support person more often were coping better at intake. However, other social support variables were not associated with coping at intake and did not significantly predict coping at 6 or 12 weeks after miscarriage. For their male partners, none of the 3 social support variables at intake, 6 weeks and 12 weeks were significant predictors of coping after miscarriage. Therefore, the hypotheses that social support would predict coping with miscarriage for both patients and their partners was generally not supported in this study.

Although these results are consistent with those of one previous study (Lasker

& Toedter, 1991), they are inconsistent with most of the work that has examined Coping with Miscarriage 23 coping after miscarriage (James & Kristiansen, 1995; Mekosh-Rosenbaum & Lasker,

1995, Smart, 1992). That is, most previous studies have found a positive association between social support and coping following miscarriage (James & Kristiansen, 1995;

Smart, 1992). It should be noted that due to the small sample size (Females n = 26, and males n = 19), the failure to find significant effects of social support in this study may well be due to insufficient power. It is also possible that the failure to find results consistent with the existing literature is due to the differences in methodology employed. As mentioned previously, much of the existing work, which has demonstrated a positive association between social support and coping with miscarriage, has been retrospective and qualitative. Retrospective reports may be tainted by current coping status, and qualitative measures may yield very different findings than quantitative assessments. The lack of association between social support and coping in this study may also be due to the type of quantitative assessment used. That is the SSQ is a measure of general social support. It is possible that due to the nature of miscarriage (a permanent personal loss), the patient may need to deal with the loss with her partner more than her general support system, particularly in the early stages following the loss. The finding that females who mentioned their spouse more often as their support person were coping better at intake is consistent with this possibility. Finally, rather than satisfaction with general social support or numbers of persons in an individual's support system, it may be that the types ofbehaviors an individual experiences, regardless of who they come from, Coping with Miscarriage 24 are more influential after this type of loss. These issues warrant attention in future work.

It should also be noted that the findings that females who mentioned their male partner as a support person were coping better with their miscarriage at intake, whereas mentioning female patients as support persons was not significantly predictive of coping for male partners, may be viewed as inconsistent with the recent work of Glynn, Christenfeld, and Gerin (1999). These authors found that support from females lowered physiological reactivity in both males and females, suggesting that support from females may be more beneficial than support from males. The pattern of findings from the present study might suggest that it is actually support from males that is more beneficial. Again, however, there are several methodological differences between the Glynn et al. (1999) experiment and the present study that might account for the different pattern. The Glynn et al. (1999) experiment was conducted in a lab with college students whereas this study was done in the field after a particularly stressful health related event. Males in this study were coping more poorly than females overall after miscarriage, whereas men and women were otherwise equal in

Glynn et al. (1999). Additionally, this study relied on self-report measures

(perceptions of support) whereas Glynn et al. (1999) used measures of physical reaction (cardiovascular changes). Finally, unlike female participants in Glynn et al.

(1999), the females in this study were grieving for their own loss. Therefore, it may not have been possible for them to provide effective support to their partners. Coping with Miscarriage 25

The present study also failed to find much support for the hypothesis that higher optimism would be associated with better coping at intake, 6 weeks and 12 weeks after miscarriage. Although higher optimism was associated with better coping for male partners at intake, optimism did not significantly predict coping for males at

6 weeks and 12 weeks or for females at any of the 3 time points.

Optimism has not previously been studied in the context of miscarriage, therefore this is the first glimpse at how this construct may play out after this type of loss. Intuitively, it makes sense that individuals who are optimistic about their future might cope better with any stressful event, but that may not be the case. It may be that since miscarriage is a loss in addition to a health stressor, that coping with the permanence of this event is unaffected by optimism for patients. On the other hand, since the event did not happen inside the partner's body, optimism is allowed to play a role at intake. As time goes on, the permanence of the event becomes more realistic to men and, later on in the coping process, being optimistic no longer makes a difference in coping. In terms of other stressful health related events, recent work using the original LOT has found associations with bodily pain and perception of mental health. Achat, Kawachi, Spiro III, DeMolles, and Sparrow (2000) found that

Optimism (original LOT) did not predict social functioning or role functioning due to physical or emotional problems in a large sample of 1329 men as part of the

Normative Aging Study. However, Achat et al. (2000) did find that optimism predicted higher vitality, freedom from bodily pain, general perception and mental health. Furthermore, Mahler and Kulik (2000) found that optimism was also Coping with Miscarriage 26 associated with bodily pain. Although there is some bodily pain associated with miscarriage for patients and not spouses, this study did not measure pain. This study focused on overall coping, which is more of an emotional and physical adjustment for couples to face. In that vein, neither optimism nor social support had any impact on psychosocial adjustment in women coping with coronary artery disease, which is a chronic condition (Tokumine, 2002). These results are consistent with the results found in this study. It may be that the permanence (or lack thereof) of the health stressor is a factor in how optimism relates to coping with that stressor. More research is needed in this area to clarity these gender differences and physical vs. bodily pain variables and how optimism may play a role in coping.

It should be noted that social support, optimism, and coping were each assessed with self report scales and therefore, it is possible that it is only participants' reports of coping that are not associated with social support and not actual coping. In order to address this limitation, other measures of coping, which might be less subject to concerns of common method variance were also taken. However, neither social support nor optimism predicted number of visits to health professionals, number of times talked with a health professional, number of concerns or problems reported, or number of days of work missed.

When it comes to grieving, surprisingly the male spouses in this study reported having a harder time coping with the miscarriage than did the female patients at intake and again at 12 weeks post miscarriage. This finding is consistent with o~e study of similar methodology looking at gender differences after miscarriage (Conway Coping with Miscarriage 27

& Russell, 2000), but inconsistent with previous, retrospective studies (Lin & Lasker,

1996; Puddifoot & Johnson, 1999; Stinson, Lasker, Lohmann, & Toedter, 1992).

Specifically, the only other study to prospectively examine grief in males and females after miscarriage found similar results. At intake (3 to 6 weeks post miscarriage)

Australian men had higher scores on the PGS than females, suggesting that men had more difficulty coping than did the female patients. At 8-16 weeks post miscarriage, men still had higher scores, but the difference was not significant (Conway & Russell,

2000). Conway and Russell (2000) also analyzed men's scores on the Despair scale and the pattern of results remained the same, suggesting that this scale might be used in place of the entire PGS. In the present study, the significant difference between men and women with respect to coping with miscarriage disappeared at the 12 week time point when using the PGS despair scale in place of the PGS total score. Here, the despair scale and the PGS total score related differently to coping. One other study examined grief in men at one time point only, up to 8 weeks after miscarriage finding different results. Puddifoot and Johnson (1999) found that, in their sample of

323 English males, scores on the PGS were diverse with a generally raised level of grief and that they did not differ from PGS total scores of females reported in other literature. Other retrospective studies with larger sample sizes found that women had a harder time coping (Lin, & Lasker, 1996; Stinson, Lasker, Lohmann, & Toedter,

1992).

There are many possibilities for the pattern of gender differences in coping obtained in this study. For example, it is possible that females were seeking out and Coping with Miscarriage 28 receiving more social support than were their male partners. However, the findings that men and women did not differ with respect to reported number of supporters, satisfaction with received social support, or number of times the respective spouse was mention as the support person are inconsistent with this interpretation. It is also possible that females who had a more difficult time coping declined to be in this study thereby skewing the results. There is no way to determine how women who declined to participate were coping or how they compared to those who did participate because data was not collected on non participators. Another possibility is that the older studies (Lin & Lasker, 1996; Stinson et al., 1992) were retrospective. When women are asked about their miscarriage experience 1 year or more after miscarriage they may recall the experience as more difficult than they would if they were asked just after miscarriage during the recovery process.

Additionally, men may have been having a harder time coping due to fewer opportunities for cathartically expressing themselves and were therefore holding back, during the timeframe of this study. Men may also be conflicted between appearing strong for others and their own need to grieve. A third possibility is that men chose to drink alcohol as a way of coping with the miscarriage thereby, actually thwarting their attempts to cope. There is some evidence to suggest that men are more likely than women to use alcohol when coping with work stress (Gianakos, 2002). Additionally, when coping in general, men were more likely to use alcohol and increase their sports activity, whereas women tended to cope by using emotional release and religion

(Angst, Gamma, Gastpar, Lepine, Mendlewicz, & Tylee, 2002). In fact, it has been Coping with Miscarriage 29 suggested that grieving fathers may try to avoid the pain of reproductive loss by using drugs, alcohol, or other forms of acting out (Gray, 2001). In this study, the participants stated whether or not they agreed with the statement, "I took medicine for my nerves", however, alcohol consumption may not have been perceived as

"medicine". Since the quantity of alcohol consumption was not specifically addressed, it was impossible to explore this issue. Clearly, other prospective research examining coping after miscarriage using the PGS is necessary to clarify the grieving process for men in comparison to women. It would be useful to do a longer term prospective study (through 1 year) with a much larger sample size including a variable addressing alcohol consumption directly.

This was the first study to use the PGS as an expectancy questionnaire. Not only was the PGS reliable and valid for this purpose, in this study, but this form of utilization produced some interesting results. Both for men and women, grief expectancies at intake were related to actual grief at 6 weeks. Additionally, grief expectancies measured at 6 weeks for female patients and their male partners were also related to actual grief at 12 weeks. In other words both men and women were coping as they expected to be coping. Of course, it must be acknowledged that it is possible that these significant results are due to common method variance. Although this sample was small, the results of this study suggest that the expectancy version of the PGS may be used as the grieving process begins after miscarriage to identify people who may have a hard time coping as the recovery period progresses. Coping with Miscarriage 30

Study 2

Couples who miscarry have reported they do not feel supported even though there are supporters in their environment (Cecil, 1994). One reason for this may be that the types of behaviors others are engaging in, in an effort to support them, may not actually be supportive after a miscarriage. The purpose of Study 2 was to more carefully examine issues of helpful and unhelpful types of social support in the context of miscarriage.

Helpful vs. Unhelpful Support

It has been suggested that the specific dimensions of social support that may impact coping with a particular stressful event are not yet identified (Thoits, 1982).

To date, studies have concentrated on who has or how many have provided support to individuals experiencing a stressful event. However, it is also important to know what kinds of support (emotional, informational, and instrumental) are provided and received. Additionally, it would be important to identify support attempts that might be considered helpful or unhelpful, in an effort to identify the dimensions of social support that could be associated with coping and adjustment after miscarriage.

However, no studies have examined actual support behaviors nor have any studies examined which behaviors are helpful or unhelpful after miscarriage. The purpose of

Study 2 was to examine the kinds of support considered helpful or unhelpful after m1scarnage.

The only previous study that examined reported helpful or unhelpful support behaviors by the bereaved did so with individuals who lost a spouse or child in an automobile accident (Lehman, Ellard, & Wortman , 1985). Bereaved individuals were interviewed and asked what kinds ofbehaviors from their support group (friends and family) were considered helpful or unhelpful after their loss. Lehman et al. Coping with Miscarriage 31

(1985) found that there was some agreement across individuals as to what constituted helpful support attempts and unhelpful support attempts. Specifically, behaviors found to be unhelpful by individuals who experienced the death of a spouse or a child were giving advice (e.g. "The person who came in and told me to go fishing with them to get me out of the house''), encouragement of recovery (e.g. "Your husband has been dead a few years, now you should get married again ... ''), minimization/forced cheerfulness (e.g. ''You can have another child. It can't be that bad.''), and identification with feelings (e.g. "People often say, I know how you feel or

I know exactly what you're going through, and they don't-not unless you've been there''). Examples of support attempts considered helpful by the bereaved were contact with a similar other, expressions of concern (e.g. "The comfort that knowing that people cared and showing their love and support has helped."), the opportunity to ventilate feelings (e.g. ''Friends have listened to me when I needed to talk about it.''), involvement in social activities (e.g."Some of my friends wanted me to go fishing with them to get me out of the house.''), and the mere presence of another person.

When control respondents were asked what they would do if attempting to provide support to a bereaved person, they most often reported that they would "be there" for them, express concern for them, and provide opportunities for discussion of feelings.

These behaviors were the same as the behaviors reported by the bereaved as being most helpful. Although controls said they would not engage (hypothetically) in the unhelpful support behaviors of minimizing the loss, encouraging recovery, or giving advice, it is interesting that the bereaved reported that they had experienced just such behaviors. It may be that what is considered helpful or unhelpful just after the loss may change over time. Walker, MacBridge, and Vachon ( 1977) suggested that emotional support is most important immediately following the loss of spouse, Coping with Miscarriage 32 whereas, instrumental support is most important in the later phases of grief. Another possibility for what Lehman et al (1985) found is that what the comparison group reported they would do hypothetically is not what they would do in the "heat of the moment" when offering actual support.

Lehman et al. (1985) also compared a group of yoked controls to bereaved individuals with respect to beliefs about recovery, and found no significant differences between how recovered bereaved respondents actually felt and how recovered controls expected them to feel 4 to 7 years after the death. The primary weakness of this study is that participants reported support behaviors from memory 4-

7 years after the loss of the child or spouse (i.e., not during the initial stages of coping).

The current study was the first to examine reported support attempts after miscarriage that may be helpful or unhelpful during the initial stages of coping and in a quantitative fashion.

Overview of Study 2

In order to more fully understand helpful and unhelpful support attempts, a group of individuals who had never experienced miscarriage were interviewed one time only to assess their perceptions of recovery time, perceived severity, and types of support behaviors considered helpful and unhelpful after miscarriage. Their responses were then compared to the responses of the sample from Study 1 on the same items.

This study created the HS from the classifications of the specific support behaviors found in Lehman et al (1985). Therefore, consistent with their findings it was predicted that: 1) Those behaviors that the comparison group said they would do with high frequency would be rated as more helpful by the miscarriage group than Coping with Miscarriage 33 those behaviors the comparison group said they would do with moderate or low frequency. Another reason those who miscarry do not feel supported could be that supporters who have never experienced miscarriage may consider miscarriage to be a minor loss whereas those who miscarry may consider it more devastating. Therefore, it was also predicted that: 2) Individuals who had not experienced miscarriage would rate miscarriage as a more minor loss than couples who had experienced miscarriage; and 3) Individuals who had not experienced miscarriage would underestimate the time it takes to recover from miscarriage.

Method

Participants

The comparison group (N = 42) contained women (n = 22) and men (n= 22) who were predominately married (n = 39) and unrelated to one another. They were between the ages of 19-48 years (M= 26.29, SD = 7.14), had between 10 and 18 years of education (M = 13.08, SD = 1.57), and were 50% Caucasion, 32% Hispanic,

9.1% African American, 5% Asian American, and 5% Native American. Participants in this group were either active duty personnel in the U.S. Navy or U.S. Marine

Corps ( 44% ), family members ( 45%) of active duty personnel, or civilians (11% ). All were recruited at Camp Pendleton Hospital, Oceanside, CA. None of the participants in the comparison group had ever experienced miscarriage themselves or as a spouse.

The miscarriage group consisted of the same individuals who participated in Study 1.

Measures

Helpful Support (HS). In order to assess perceptions of helpful and unhelpful support attempts, the HS was developed for this study based on qualitative findings from parents who lost a child in an automobile accident (Lehman, et al. 1986).

Miscarriage participants were asked to rate how helpful 19 different types of social Coping with Miscarriage 34 support specific to loss had been during this miscarriage, from 1 (very unhelpful) to 7

(Very helpful) or 8 (not applicable, coded as missing data, See Appendix G). The HS for comparison participants listed the same support behaviors as those listed on the

HS for the miscarriage group. However, comparison group participants were asked to estimate how often (from 1 =never to 7 =as often as possible) they would engage in a particular support behavior while trying to support a friend or family member who had recently miscarried. This scale was found to be reliable for this sample

(Miscarriage group a= .71, Comparison group a= .75).

Comparison ofLoss (COL). All participants were asked to independently rate the severity of 6 different types of loss (death of a spouse, miscarriage, death of a parent, paralysis, job loss, and death of a child) on a scale of 1 (minor loss) to 6

(completely devastating loss) .. In addition, the comparison group participants were asked to imagine that someone similar to them in terms of age, race, and social class had experienced each of the 6 types oflosses independently. They were then asked to rate how recovered they think this hypothetical person would be at 3 months after the loss, from 1 (not at all recovered) to 6 (entirely recovered) (See Appendix H) .

Background Information Sheet (BJS). Participants were also asked to provide demographic information, including: relationship status, ethnicity, age, gender, years of formal education, degree, and occupation, rank, knowledge of miscarriage, # of children, and number people they know who have experienced miscarriage (See

Appendix I).

Procedure

Miscarriage Group. The procedures followed for recruiting and interviewing the miscarriage group were detailed in Study 1. In addition to the measures described Coping with Miscarriage 35 in study 1, the Helpful Support (HS) and the Comparison of Loss Scale (COL) were given to both males and females at each time point.

Comparison Group. Potential comparison group participants were approached by the investigator in one of two Family Practice waiting areas at Naval Hospital,

Camp Pendleton, Oceanside, CA. A number of potential participants could be approached at any given time in each waiting room. Therefore, in order to avoid sampling bias, each waiting room was split into 6 sections. The first potential participant in section 1 was approached first, then the first potential participant in section 2, etc. through section 6, until the first potential participant from each section was asked to participate. This was repeated until the desired number of comparison participants was obtained. Each section was approached with equal frequency provided there were potential participants sitting in that section. Both males and females were approached. The investigator introduced herself and said that the primary goal of the study was to examine attitudes regarding various types of losses, in an effort to help people who experience a loss in the future. Potential participants were then asked if they had experienced the loss of a spouse, loss of a child, loss of a job, miscarriage, loss of a parent, or paralysis in an effort to identify those who had not experienced miscarriage. Individuals who qualified for the study (those who said they had never experienced miscarriage) were told that their participation would involve completing a brief questionnaire about loss, that would take approximately 20 minutes. They were then asked to participate.

Those who agreed were escorted to a private room at in the Family Practice

Clinic and asked to read and sign the consent form. This group was interviewed one time only using the Comparison of Loss (COL), Helpful Support (HS), and the

Background Information Sheet (BIS). These questionnaires were also the same for Coping with Miscarriage 36 females and males, however, the wording varied slightly in order to be appropriately relevant to the participant's gender.

After completing their interview, comparison group participants were informed that their data would be part of a larger study examining coping with miscarriage.

They were further informed that their responses would be used to compare the expectations regarding degree and time-course of grief following miscarriage of individuals who have versus those who have never experienced a miscarriage.

Results

Preliminary Analyses

Independent sample t-tests were done to determine if the miscarriage group differed from the comparison group with respect to any background factors. The miscarriage group was significantly different from the comparison group in terms of years of education (t (74.08) = 2.51,p = .01), degree obtained (t (81.71) = 2.23,p =

.03), ethnicity (t (70.38) = -2.06,p = .04) and number of children (t (83) = -2.70,p =

.008). The miscarriage group had more education, higher degrees, more caucasion participants, and less children than the comparison group. Additionally, three of these variables were moderately correlated to a few Helpful Support items. Years of education and degree obtained were negatively associated with "having someone provide a philosophical explanation for the miscarriage" (r = -.29,p = .008 and

r = -.33, p = .002 respectively). Degree obtained was also negatively associated with

"others saying you (your partner) can get pregnant again" (r = -.24,p = .03). Number of children was negatively associated with "talking with someone else who experienced a miscarriage" (r = -.27,p = .02) and "discussing the miscarriage with others even when I did not feel like it" (r = -.25,p .03). Coping with Miscarriage 37

The Helpful Support (HS) measure was subjected to a principal components

Factor Analysis using a Varimax rotation technique for the miscarriage and comparison groups separately to determine whether items loaded together into a 3 factor structure, consisting of emotional, instrumental, and informational types of support. For the miscarriage group, 5 factors with eigenvalues greater than one explained 93.28% ofthe variance (See Table 21). The first 3 factors explained

76.12% of the variance, the last 2 factors adding the additional17.16%. Factor 4 was moderately correlated to factor 1 (r = .51) and factor 5 was modestly negatively correlated to factor 3 (r = -.42). Factor 1 contained items that were, for the most part, instrumental support, factor 2 contained informational types of support, and factor 3 contained items that would qualify as emotional support. For the comparison group,

6 factors had eigenvalues greater than or equal to 1, explaining 70.87% of the variance. The first 2 factors explained most of the variance (42.10% ), the following four factors together adding the remaining 28.77%. The first 2 factors seem to be more reflective of positive and negative types of support, rather than instrumental, informational, and emotional types of support as was found in the miscarriage group

(See Table 21 ).

Primary Analyses

Comparison ofLoss. A 2(Group: miscarriage vs. comparison) X 6 (Loss: spouse, miscarriage, parent, paralysis, job, child) analysis of variance (ANOVA) was performed on subjects' severity ratings (See Table 22). There was a main effect for loss (F (1,79) = 13.11,p = .001). Specifically, all losses were rated as significantly different from one another in terms of severity except two pairs. "Death of a spouse" and "death of a child" and "miscarriage" and "paralysis of legs" were not rated as significantly different from one another (see Table 23). The main effect for group Coping with Miscarriage 38

(p = .61) and the loss X group interaction (p = .25) were nonsignificant (See Table

22). Additionally, at-test between groups on the severity of miscarriage was done.

No significant differences were found between those who miscarried and those who did not (t (86) = -.37,p = .71).

Helpful support. Independent sample t-tests with Bonferroni corrections were performed between males and females in the comparison group and the miscarriage group separately to determine if there were gender differences in support efforts and how helpful support attempts were perceived respectively. There were significant differences between males and females in the comparison group on only one support behavior. Females (M= 6.67, SD = .66) would more often say "how much they cared" to hypothetically support a friend or family member who miscarried than would males (M = 5.36, SD = 1.37). Additionally, among couples who had recently experienced miscarriage, males (M = 6.08, SD = 2.18) rated "when others avoided talking about the miscarriage" as more helpful than did females (M= 3.61, SD =

2.81 ). Given that only 1 out of 19 HS items for each group demonstrated a significant gender difference, all HS analyses reported below were collapsed across gender.

Next the means of each of the HS items were calculated for the comparison group (See Table 24), and these means were then ranked from lowest to highest and divided into 3 groups: low frequency support behaviors, moderate frequency support behaviors, and high frequency support behaviors (See Table 25). Then, three new variables were created for each member of the miscarriage group at each time point.

The new variables consisted of the mean of each person's responses to those HS items that the comparison group had indicated that they would perform with low frequency, moderate frequency, and high frequency, respectively. One-way repeated measures Coping with Miscarriage 3 9

ANOV AS were then calculated on these 3 new variables at each time-point separately, to assess the helpfulness of these behaviors for the miscarriage group.

The within subjects repeated measures ANOVAs at intake, 6 weeks, and 12 weeks were significant (F (1,25) = 98.72,p < .001, F (1,13) = 39.71,p < .001,

F( 1,14) = 61.36,p < .001, respectively). Specifically, at intake, those behaviors found to be most helpful by miscarriage participants were the same behaviors comparison group participants would do most frequently. Additionally, miscarriage participants rated support behaviors they experienced in the moderate frequency category (M= 5.94, SD = 1.21) as more helpful than support behaviors in the low frequency category (M = 3.29, SD =1.30). Although there was a difference in terms of mean helpfulness between the high frequency (M = 6.23, SD = . 71) and moderate frequency categories, it was nonsignificant (p = .56). At 6 weeks, miscarriage participants rated those support behaviors they experienced in the high frequency

(M = 5.98, SD = 1.25) category as significantly more helpful than support behaviors in the moderate (M= 4.79, SD =.95) and low frequency categories (M= 3.58,

SD = 1.43). Additionally, support behaviors in the moderate frequency category were more helpful than support behaviors in the low frequency category, however this difference only approached significance (p = .07). The ANOV A with repeated measures at 12 weeks was nonsignificant (p = .14).

Recovery Time for Women. For comparison group participants, 18.2 % said females would never recover from a miscarriage and only 6.8% said females would be fully recovered at 3 months. The remaining comparison participants thought it would take between 4 and 42 months for females to recover. However, 63.2% of women who miscarried agreed and 31.6% disagreed with the statement "I am fully recovered from this loss" at 12 weeks (3 mo.) after miscarriage. Furthermore, in response to the Coping with Miscarriage 40 statement" I will never recover from this loss", 78.9% disagreed and only 15.8% of women agreed. Thus, contrary to expectations, females who had experienced a miscarriage actually recovered more quickly from their loss than most comparison participants thought they would.

Recovery Time for Men. For the comparison group, 6.8% thought males would never recover and 38.6% thought spouses would be fully recovered at 3 months. The remaining percentage of comparison participants thought it would take anywhere from 3.5 to 18 months for male to recover from miscarriage. However, 60% of males in the miscarriage group agreed with and 33.4% disagreed with the statement" I am fully recovered from this loss" at 12 weeks (3mo.) after miscarriage. Further, only

6.7% agreed with and 93.3% disagreed with the statement" I will never recover from this loss" 12 weeks after the miscarriage. Again, contrary to expectations, males who had experienced a miscarriage actually recovered more quickly from their loss than most comparison participants thought they would.

Discussion

This was the first study to examine support behaviors that would be helpful quantitatively to determine what specific types of social support would be helpful or unhelpful for men and women after experiencing a miscarriage. This study created a scale, the Helpful Support Scale, based on the categories Lehman et al. (1985) developed from their interviews of people who lost a spouse or child four to seven years earlier. Their methodology was improved upon because miscarriage participants were interviewed shortly after their loss, during the coping process. This study replicated and extended the results of Lehman et al. (1985).

One explanation Lehman et al., (1985).offered for their obtained discrepancy between what a support person would say or do after their friend or relative Coping with Miscarriage 41 experienced a loss was that the loss was somehow less significant in the mind of the supporter than in the mind of the one who experienced the loss. To examine this possibility, in this study, all participants rated how severe they thought miscarriage was, in addition to other losses. It was hypothesized that the miscarriage group would differ from the comparison group in their severity rating for miscarriage. This hypothesis was not supported. There were no differences between the would be support group (comparison group) and the group of couples who miscarried on their ratings of severity for miscarriage. Both groups rated the miscarriage as significantly more devastating than the loss of a job, not significantly different than sudden paralysis in their legs, and not as devastating as the loss of a parent, spouse, or child.

When the Helpful Support Scale was examined in both groups using factor analyses, the results were very different. The factors that emerged for the miscarriage group seemed to suggest that most of the data from 19 support behaviors could be reduced to 3 factors labeled instrumental, informational, and emotional types of support as predicted. However, the factors explaining the most variance in the analyses for the comparison group seemed to suggest labels of positive and negative types of support. This is an interesting finding in terms of support because it seems that, in this sample, support recipients view most of these behaviors differently than do potential supporters. Certainly, and most probably, the wording on the questionnaire could explain these differences (comparison group -"how often would you engage in these behaviors", miscarriage group - " how helpful did you find these behaviors"). However there is no way to be sure in this study. It may be that a supporter is trying to be helpful and trying to stay away from unhelpful behaviors and categorizing them this way in their head drives their answers on the questionnaire. Coping with Miscarriage 42

Whereas support recipients may be more aware of what is supportive to them and are being driven to answer the questionnaire by this specificity.

However, when the miscarriage group's perceived helpfulness of each of the

HS behaviors was examined as a function of the frequency with which the comparison group would perform the behaviors greater consistency was found.

Specifically, the support behaviors that comparison individuals stated that they would perform with high frequency at intake were perceived as significantly more helpful by the miscarriage group than the support behaviors these individuals would perform with low frequency. Additionally at 6 and 12 weeks, support behaviors the comparison group said they would perform with high frequency were perceived as significantly more helpful than behaviors in the moderate and low frequency categories. This suggests that couples who miscarry are experiencing the most helpful support behaviors most frequently in the first 12 weeks after miscarriage. It is unclear if time affects this pattern due to the fact that in this sample only 5 out of 53 participants actually experienced support behaviors in each category across the three time points. This is an interesting finding on it's own. It appears that in this sample, the majority of the support behaviors were not experienced by either patients or spouses at 12 weeks after miscarriage. This may be due to the fact that the majority of the sample reported being completely recovered from this loss at that time and therefore let their supporters know that their support was no longer necessary.

Additionally, since the low, moderate, and high frequency categories were created from the comparison group's hypothetical attempts of support, it is possible that what was offered in terms of support by the actual supporters was different and not reflected on the Helpful support measure. Coping with Miscarriage 43

These results makes sense given that Lehman et al. (1985) found that there were no differences between their groups of couples who lost a child or spouse and hypothetical supporters on their qualitative analysis of support behaviors. These results have been replicated using a more quantitative approach based on the qualitative information Lehman et al. (1985) identified from couples who experienced loss. This study provides evidence that those types of behaviors combined into the

Helpful Support measure provide a valid and reliable scale to measure how helpful these behaviors are or how frequently these behaviors occur after miscarriage. It is necessary to use this scale after other losses to determine how helpful and unhelpful support attempts affect coping with these other losses.

There was no support for the hypothesis that supporters would underestimate the amount of time it takes to recover from miscarriage. Although there were differences in terms of the percentage of miscarriage participants who were fully recovered at 3 months and the percentage of comparison group participants that thought those who miscarried would be recovered in 3 months, it was not in the direction expected. On the whole, the comparison group thought that it would take longer for men and women to recover from miscarriage than it actually took for most of the miscarriage group in this study. It is possible that this group of individuals recovered quicker than other groups, however, this question has never been directly addressed in this context as a basis for comparison until now.

Finally, the helpfulness of the support behaviors that miscarriage participants received or the lack thereof, remained consistent over the course of this study. Since this is the first study to quantitatively and prospectively measure support behaviors after miscarriage it may be that the qualitative results that suggested miscarriage participants needed more and better quality support (Cecil, 1994) were anecdotal and Coping with Miscarriage 44 a function of the way in which the research was conducted. It is also possible that the dissatisfaction with support occurs later than 3 months in the recovery process as was suggested by Black (1991). Finally, it is possible that since a woman's body is physically recovered from miscarriage at 3 months after the event, they "feel" fully recovered at that time. Then, at some point after 12 weeks they realize they are not recovered emotionally and that this is how and when perceptions of support change.

General Discussion

The correlation of optimism and social support with copin~ with miscarriage was examined in a sample of couples who had recently experienced miscarriage.

Additionally, gender differences with respect to coping with miscarriage were evaluated. Finally, in a second study, types of support behaviors considered to be helpful or unhelpful were explored.

Overview ofMajor Findings From Study # 1

It was found that even after controlling for background factors, optimism predicted coping for males at intake, but not at the 6 or 12 week time points.

Additionally, after controlling for background factors, optimism did not predict coping at any time point for female patients. Also, the number of times females mentioned their spouse as a support person was the only social support predictor of coping at intake (3 - 20 days after miscarriage), but this variable did not predict coping at 6 or 12 weeks after miscarriage. None of the 3 social support variables predicted coping with miscarriage for male spouses at any time point.

Gender differences in grief after miscarriage were also found. Men had a harder time coping with miscarriage than women at intake and again at 12 weeks after the miscarriage occurred. Using the PGS as an expectancy questionnaire produced some interesting results. For both men and women, grief expectations at intake and 6 Coping with Miscarriage 45 weeks were related to actual grief experienced at 6 and 12 weeks respectively. That is, the way individuals in this study expected to be coping with their loss was significantly related to how well they really were coping.

Overview ofMajor Findings From Study #2

Potential supporters were compared to individuals who miscarried with respect to 19 types of support behaviors specific to miscarriage and loss. Those behaviors the comparison group stated they would do with high frequency, moderate frequency and low frequency were stated as most helpful, moderately helpful, and not too helpful, respectively, by the miscarriage group at intake, 6 weeks, and 12 weeks after miscarriage. Furthermore, individuals who had just experienced miscarriage stated the following behaviors as being very helpful: "having friends and family say how much they cared", "having someone to just be there", "having others do things for them", talking to others who experienced miscarriage", and discussing the miscarriage with others even when not feeling like it". Finally, there was some support for utilizing the Helpful Support Scale (HSS) inspired by Lehman et al (1985) as a measure of helpful and unhelpful support attempts after miscarriage and/or loss ..

It is important to further explore this issue of helpful vs. unhelpful support attempts to more fully understand the mechanisms of social support that operate just after miscarriage. Since very little attention has focused on specific types of behavior, this study is a solid step in the exploration of these specific types ofhelpful and unhelpful social support behaviors.

Strengths and Limitations

Study #1 was the first study after miscarriage to, prospectively and quantitatively, examine the relationship between optimism, social support, and Coping with Miscarriage 46 copmg. Further, this was one of the first studies to examine gender differences qualitatively after miscarriage.

Study # 2 was the first study to examine support behaviors that would be helpful quantitatively to determine what specific types of social support would be helpful or unhelpful for men and women after experiencing a miscarriage. Previous methodology was improved upon because miscarriage participants were interviewed shortly after their loss, during the coping process.

Caution must be used in interpreting the results of study # 1 because the small sample size was crippling in terms of power. However, sample size was not a problem in study# 2.

These studies are both limited in terms of generalizability. The population of these studies was comprised of active duty, family members, and retirees of the U.S.

Marines and U.S. Navy stationed in Southern California. While a military population may provide more generalizability geographically, due to the fact that participants stationed in the San Diego, CA area grew up and have lived all over the United

States; it is limiting due to the fact that being associated with the military sets one apart from the general population. Additionally, the context of this study took place after miscarriage and may not generalize to other types of loss, especially since this sample rated loss of a spouse, child and parent as being significantly more devastating than miscarriage.

Conclusions

Healthcare professionals could easily and economically give the 32 item PGS to couples at the time of their miscarriage. At that time, professionals would be able to identify individuals who expected to have a hard time grieving and keep a closer watch and/or offer those individuals the appropriate additional coping tools/resources. Coping with Miscarriage 4 7

Additionally, the HS could be especially useful in studies where those who experienced a specific loss are compared to the actual people who supported them during their loss. However, since this is logistically almost impossible to accomplish, the HS (used as it was in this study) provides a way to use a group of hypothetical supporters to accomplish this task. If it is found that supporters are not providing the desired support, or not providing it long enough, this information could then be used to educate society about support attempts that are helpful and unhelpful after various types of losses. Behavior of a support person after a stressor is a relatively easy issue to educate the public on, once the appropriate information has been obtained.

Pamphlets, videos, and/or websites could be prepared, specific to miscarriage and other stressors detailing what types of support behavior are most helpful or unhelpful after the particular stressors. This is a low-cost way to possibly affect the coping with or the feeling of support after an individual experiences a miscarriage or other specific stressor. Coping with Miscarriage 48

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Table 1 Intercorrelations Among Predictors and Outcomes for Patients at Intake

PGS Patient Patient Total SSQ SSQ #times total Occupa Chose LOT Satified Number spouse tion BB total Total mentioned Name PGS total 1.00 -.46* -.37* .65** .18 .13 .50*

Patient 1.00 .08 -.44* .48* -.11 -.20 occupation Patient 1.00 -.34* -.11 -.18 -.01 chose BB name LOT total 1.00 .21 .40* .65**

SSQ 1.00 .28 .43* Satisfied total SSQ 1.00 .49* Number Total #times 1.00 spouse mentioned *p::; .05 **p::; .001 Coping with Miscarriage 58

Table 2 Intercorrelations Among Predictors and Outcomes for Patients at 6 Weeks

PGS6 PGS Patient Total SSQ SSQ #times week total Planned LOT Satified Number spouse total pregnancy total Total mentioned

PGS 6week 1.00 .52* -.47* .15 .27 .15 .33 total PGS total 1.00 -.10 .58** .18 .14 .50*

Patient planned 1.00 20 -.31 -.20 .01 pregnancy LOT total 1.00 .16 .40* .66**

SSQ 1.00 .16 .43* Satisfied total SSQ 1.00 .50* Number Total #times 1.00 spouse mentioned *p::; .05 **p::; .001 Coping with Miscarriage 59

Table 3 Intercorrelations Among Predictors and Outcomes for Patients at 12 weeks

PGS12 PGS Patient LOT SSQ SSQ #times week total planned total Satisfied Number spouse total pregnancy Total Total mentioned

PGS12 1.00 .74** -.50* .32 .32 .22 .43* week total PGS 1.00 -.09 .57* .10 .17 .46* total Patient 1.00 .15 -.36 -.22 .01 planned pregnancy LOT 1.00 .07 .40* .66** total SSQ 1.00 .28 .43* Satisfied Totall SSQ 1.00 .54* Number Total #times 1.00 spouse mentioned *p::;; .05 **p::;; .001 Coping with Miscarriage 60

Table 4 Intercorrelations Among Predictors and Outcomes for Spouses at Intake

PGS Patient Total SSQ SSQ #times total Rank LOT Satified Number spouse total Total mentioned PGS total 1.00 -.59* .61 * .57* .22 .46*

Patient 1.00 -.17 .56* -.29 -.65* Rank LOT total 1.00 .37 -.04 .48*

SSQ Satisfied 1.00 .14 .39 total SSQ 1.00 .38 Number Total #times 1.00 spouse mentioned *p ~ .05 **p ~ .001 Table 5 Intercorrelations Among Predictors and Outcomes for Spouses at 6 weeks

PGS 6 PGS Pt. Sp. Sp. Sp. Sp prior Sp.# LOT SSQ SSQ #times week total Rank ethnic Years age elected friends total Satisfi # patient total ity educat. abortions knew Total Total ment. pg PGS 6 week total 1.00 .74** -.50* .03 -60* -.63* -.60* -.54* .36 .49* .51* .38

PGS total 1.00 -.09 .01 -.49* -.33 -.38 -.50* .57* -.55* .30 .50*

Patient Rank 1.00 -.13 .48* .36 .57* .48* -.15 -.56* -.34 .-.65*

Spouse ethnicity 1.00 -.33 -.30 -.22 .50* .08 .24 .03 .24 Sp. Years 1.00 .58* .63* .13 -.23 -.20 -.34 -.40 education Spouse age 1.00 .49* .17 .06 -.07 -.38 -.32 Sp prior elected 1.00 .42 .07 -.32 -.25 -.26 abortions ('j 0 Sp. # friends knew 1.00 -.07 -.14 -.41 -.12 'e pg 1:1 (1Q-· LOT total 1.00 .39 .04 .54* ~ ...... SSQ Satisfied 1.00 .30 .14 1:1"'-· Total $:; rJl SSQNumber 1.00 .38 -·(') i:l) Total ::i i:l) # times patient 1.00 (1Q-· mentioned ('!)

*p::::; .05 0'\ **p::::; .001 - Coping with Miscarriage 61

Table 6 Intercorrelations Among Predictors and Outcomes for Spouses at 12 Weeks

PGS PGS Total SSQ SSQ #times 12wk intake LOT Satified Number spouse total total total Total mentioned PGS 12 wk 1.00 .41 * .09* -.01 .15 .11 total

PGS intake 1.00 .75** .31 .03 .50* total LOT total 1.00 .49* -.03 .48*

SSQ Satisfied 1.00 .01 .39 total SSQ 1.00 .38 Number Total #times 1.00 spouse mentioned *p ~ .05 **p ~ .001 Coping with Miscarriage 62

Table 7 Results ofHierarchical Regression Predicting Coping After Miscarriage (Intake) in Females

Optimism and Social Support Satisfaction Social Support Quantity ~ t df p ~ t df p occupation -.44 -2.49 24 .02 occupation -.43 -2.49 20 .02 ChoseBB ChoseBB name -.33 -1.88 24 .07 name -.33 -1.88 20 .07 SSQ LOT(total) .34 1.62 24 .12 Number -.24 -1.33 20 .20 total SSQ Total# satisfied .30 1.48 24 .15 spouse .54 3.06 20 .01 total mentioned 2 2 R = .55 R =.54 Coping with Miscarriage 63

Table 8 Results ofHierarchical Regression Predicting Coping After Miscarriage at Intake in Males

Optimism and Social Support Number of times patient Quantitiy and Satisfaction mentioned as support person 13 t df p 13 t df p Pt. Rank -.59 -2.80 16 .01 Pt. Rank -.59 -2.80 16 .01 LOT Total .50 2.55 16 .03 Total# pt .13 .46 16 .66 mentioned 2 SSQ .10 .53 16 .60 R = .35 Number Total SSQ .10 .43 16 .68 Satisfied Total

2 R = .63 Coping with Miscarriage 64

Table 9 Results ofHierarchical Regression Predicting Coping After Miscarriage (6 week) in Females

Optimism and Social Social Support Quantity Support Satifaction ~ t df p ~ t df p PGS tot PGS total (intake) .48 2.92 .19 .008 (intake) .48 2.92 19 .008 Pt. Planned Pt. Planned Pregnancy -.42 -2.57 .19 .02 Pregnancy -.42 -2.57 19 .02 SSQ LOT(total) -.09 -.41 .19 .67 Number -.07 -.35 19 .73 total SSQ Total# satisfied -.08 .44 .19 .67 Spouse .15 .69 19 .50 total mentioned R 2 = .45 R 2 = .46 Coping with Miscarriage 65

Table 10 Results ofHierarchical Regression Predicting Coping After Miscarriage at 6 Weeks in Males

Optimism and Social Support Number of times patient Quantitiy and Satisfaction mentioned as sup£Ort £erson ~ t df p ~ t df p Pt. Rank .12 .55 14 .60 Pt. Rank .12 .55 14 .60 PGS total .62 2.86 14 .02 PGS total .62 2.86 14 .02 (intake) (intake) Ethnicity -.07 -.32 14 .76 Ethnicity -.07 -.32 14 .76 SP years of -.02 -.07 14 .95 SP years of -.02 -.07 14 .95 education education SP age -.36 -1.88 14 .10 SP age -.36 -1.88 14 .10 SP Prior SP Prior elected -.22 -.90 14 .40 elected -.22 -.90 14 .40 abortions abortions SP #friends SP# knew -.10 -.36 14 .73 friends -.10 -.36 14 .73 pregnant knew pregnant LOT total .09 .35 14 .75 Total# pt -.05 -.21 14 .84 mentioned SSQNumber .14 .63 14 .56 total 2 SSQ .20 .70 14 .52 R = .85 Satisfied Total 2 R = .89 Coping with Miscarriage 66

Table 11 Results ofHierarchical Regression Predicting Coping After Miscarriage (12-week) in Females

Optimism and Social Social Support Satisfaction Support Satisfaction ~ t df p ~ t df p PGS tot PGS total .71 5.59 14 .000 (intake) .71 5.59 14 .000 (intake) Pt. Planned Pt. Planned Pregnancy -.43 -3.41 14 .004 pregnancy -.43 -3.41 14 .004 SSQ LOT(total) -.05 -.28 14 .78 Number -.09 -.54 14 .60 total SSQ Total# satisfied .11 .75 14 .46 spouse .19 1.07 14 .30 total mentioned 2 2 R = .76 R = .76 Coping with Miscarriage 67

Table 12 Results ofHierarchical Regression Predicting Coping After Miscarriage at 12 Weeks in Males

Optimism and Social Support Number of times patient Quantity and Satisfaction mentioned as surrort person ~ t df p ~ t df p PGS Total .41 1.62 14 .13 PGS Total .41 1.62 14 .13 LOT -.47 -1.08 14 .31 Total# pt Total mentioned -.13 -.44 14 .67 SSQ# .12 .44 14 .67 R 2 = .18 Total SSQ -.01 -.03 14 .98 Satisfied Total R 2 = .29 Coping with Miscarriage 68

Table 13 Results ofHierarchical Regression Predicting Number of Times Patients Talked with Professionals After Miscarriage Optimism and Social Social Support Quantity Support Satisfaction and Number ~ t df p t df p SSQNumber LOT(total) .28 1.36 24 .19 total -.20 -.82 24 .42 SSQ Total# spouse satisfied .07 .36 24 .73 mentioned .19 .77 24 .45 total R2 = .09 R 2 = .18 Coping with Miscarriage 69

Table 14 Results ofHierarchical Regression Predicting Patients' Number of Visits with Professionals After Miscarriage.

Optimism and Social Social Support Quantity Support Satisfaction ~ t df p ~ t df p SSQNumber LOT( total) .27 1.30 24 .21 total -.18 -.76 24 .45 SSQ Total# satisfied .08 .38 24 .71 spouse .16 .68 24 .51 total mentioned 2 2 R = .08 R = .03 Coping with Miscarriage 70

Table 15 Results ofHierarchical Regression Predicting Patients' Reported Problems or Concerns After Miscarriage.

Optimism and Social Social Support Quantity Support Satisfaction ~ t df p t df p Sp Sp planned planned .40 1.72 17 .10 pregnancy .40 1. 72 17 .1 0 pregnancy SSQ LOT total .07 .28 17 .78 Number .18 .63 17 .54 total SSQ Total# satisfied .33 1.33 17 .21 spouse -.42 -06 17 .96 total mentioned 2 R = .27 Coping with Miscarriage 71

Table 16 Results ofHierarchical Regression Predicting Patients' Days of Work Missed After Miscarriage.

Optimism and Social Social Support Quantity Support Satisfaction p t df p p t df p Sp Sp planned .48 2.16 17 .05 planned .48 2.16 17 .05 pregnancy pregnancy SSQ LOT total .02 .11 17 .92 Number .15 .54 17 .54 total SSQ Total# satisfied .35 1.47 17 .16 spouse -.01 -.04 17 .97 total mentioned R2 = .34 R 2 =.50 Coping with Miscarriage 72

Table 17 Results ofHierarchical Regression Predicting Number oftimes Spouses Talked to Professionals After Miscarriage Optimism and Social Support Total Number Times Patient Quality and Quantity Mentioned as Supporter ~ t df p ~ t df p Prank .49 .84 10 .08 Prank .49 .84 10 .08 Dr cause -.43 -2.00 10 .12 Dr cause -.43 -2.00 10 .12 MC MC external external LOT total -.34 -1.73 10 .32 SSQ Total# satisfied .26 .37 10 .73 patient .19 -.33 10 .75 total mentioned SSQ Number -.24 -.88 10 .42 total 2 2 R = .72 R = .74 Coping with Miscarriage 73

Table 18 Results ofHierarchical Regression Predicting Spouses' Number of Visits with Health Professionals After Miscarriage.

Optimism Social Support Total Number Times Patient Quality and Quantity Mentioned as Supporter ~ t df p ~ t df p Prank .37 1.53 10 .17 Prank .37 1.53 10 .17 Dr cause -.01 -.03 10 .98 Dr cause -.01 -.03 10 .98 MC MC external external Pt planned .58 .1.54 10 .17 Pt planned .58 .1.54 10 .17 pregnancy pregnancy LOTtotal -.23 -.61 10 .58 SSQ Total# satisfied -.004 .62 10 .57 patient .16 -.23 10 .83 total mentioned SSQ Number -.23 -.01 10 .99 total R2 =.74 R 2 = .70 Coping with Miscarriage 74

Table 19 Results ofHierarchical Regression Predicting Spouses' Number of Concerns or Problems after Miscarriage.

Optimism Social Support Total Number Times Patient Quality and Quantity Mentioned as Supporter ~ t df p ~ t df p Prank .37 1.53 10 .17 Prank .37 1.53 10 .17

Dr cause .002 .005 10 .99 Dr cause .00 .005 10 .99 MC external MC external 2 Sp planned Sp planned pregnancy .58 1.56 10 .16 pregnancy .58 1.56 10 .16

LOT(total) -.22 -.59 10 .59 SSQ Total# satisfied .48 .57 10 .60 patient -.11 -.24 10 .82 total mentioned SSQ Number -.02 -.03 10 .98 total 2 2 R = .74 R = .70 Coping with Miscarriage 75

Table 20 Results ofHierarchical Regression Predicting Spouses' Number ofDays of Work Missed after Miscarriage.

Optimism Social Total Number Times Patient Support Quality and Quantity Mentioned as Supporter ~ t df p ~ t df p Prank .37 1.52 10 .17 Prank .37 1.52 10 .17 Dr cause -.06 -.15 10 .88 Dr cause -.06 -.15 10 .88 MC MC external external Sp Sp planned planned .53 1.41 10 .20 pregnancy .53 1.41 10 .20 pregnancy

LOTtotal -.24 -.62 10 .57 SSQ Total# satisfied .44 .52 10 .63 patient -.09 -.21 10 .84 total mentioned SSQ Number -.02 -.05 10 .96 total 2 2 R = .73 R = .70 Coping with Miscarriage 76

Table 21 Factor Loadings for Helpful Support Items as a Function ofGroup

Group Miscarriage Comparison Helpful Support Factor 1 2 3 4 5 1 2 3 4 5 6 Item Opportunity to vent .88 .85 feelings Friends and Family .96 .68 say how much cared Someone to be there .97 .57 Philosophical .65 .74 explanation Religious suggestion .91 .80 Encrgmnt for social .75 .55 activities Advise to cope .94 .46 Encouragement for .82 .82 recovery Blaming loss .71 .95 GetPG again .95 .74 Know how you feel .53 .62 A void talking about MC .91 .62 Others did things .87 .88 needed Talk to others who .66 .45 MC BarelyPG .82 .79 Have other children .80 .58 Others did things .76 -.81 not needed Discuss MC, not .86 .85 want to Discuss memories of .79 .68 PG Coping with Miscarriage 77

Table 22 Analysis ofVariancefor Type ofLoss

Source df F p

Between subjects

Group 1 .25 .99 .62

Error 84 (1.25)

Within Subjects

Loss 1 108.64* .56 <.01

Loss X Group 1 1.32 .02 .25

Error 84 (.53) Note. Values enclosed in parentheses represent mean square errors. Coping with Miscarriage 78

Table 23 Means (and Standard Deviations) for Severity ofLoss as a Function ofCondition

Group Loss Miscarriage Comparison (n= 44) (n= 44) Death of spouse 5.98(.15) 5.83(.37)*

Miscarriage 4.53(1.37) 4.64(1.19)

Death of parent 5.84(.43) 5.50(.74)*

Paralysis of legs 4.45(1.43) 4.89(1.19)

Job loss 2.49(1.35) 2.89(1.48)

Death of child 5.95(.21) 5.8(.40) p < .05* Coping with Miscarriage 79

Table 24 Means (and Standard Deviations) for Helpful Support Items

Group Helpful Support Item Miscarriage Comparison (n = 44) (n= 44) Opportunity to vent 6.11(1.09) 6.61(.81)* feelings Friends and family 6.24(1.03) 6.01(1.25) Someone to be there 6.58(1.01) 6.63(.77) Philosophical 3.80(2.36) 4.05(2.05) explanation Religious suggestion 4.62(2.04) 4.75(1.96) Encrgmnt for social 4.43(1.77) 5.54(1.57)* activities Advise to cope 4.44(1.99) 4.54(2.22)

Encouragement for 5.58(1.31) 6.38(1.28)* recovery Blaming loss 1.60(.23) 1.49(.2) Get PG again 3.26(2.39) 4.01(1.79) Know how you feel 3.72(2.17) 3.02(2.28) Avoid talking about MC 3.66(2.22) 4.62(2.24) Others did things needed 6.52(1.06) 5.95(1.75)* Talk to others who MC 6.00(1.60) 5.17(1.75)* Barely PG 2.04(1.65) 1.82(1.7) Have other children 3.51(2.22) 3.30(2.06) Others did things not 4.89(2.24) 5.22(1.59) needed Discuss MC, not want to 4.18(2.07) 1.82(1.4)** Discuss memories of PG 3.85(2.03) 2.25(1.58)** p::;; .05* p::;; .001 ** Coping with Miscarriage 80

Table 25 Rankings ofComparison Group Means and Helpful Support Categories

Helpful Support Item Means (and standard Deviations)

Low Frequency

Blaming loss 1.49(.2) Discuss MC, not want to 1.82(1.4) Barely PG 1.82(1.7) Discuss memories of PG 2.25(1.58) Know how you feel 3.02(2.28) Have other children 3.30(2.06) Get PG again 4.01(1.79) Philosophical explanation 4.05(2.05)

Moderate Frequency

Advise to cope 4.54(2.22) A void talking about MC 4.62(2.24) Religious suggestion 4.75(1.96) Talk to others who MC 5.17(1.75) Others did things not needed 5.22(1.59) Encrgmnt for social activities 5.54(1.57)

High Frequency Others did things needed 5.95(1.75) Friends and family 6.01(1.25) Encouragement for recovery 6.38(1.28) Opportunity to vent feelings 6.61(.81) Someone to be there 6.63(.77) Coping with Miscarriage 81

Appendix A Perinatal GriefScale. Each of the items below is a statement of thoughts and feelings which some people have concerning a loss such as yours. There are no right or wrong responses to these statements. For each item, circle the number which best indicates the extent to which you agree or disagree with it at the present time. If you are not certain, use the "neither" category. Please try to use this category only when you truly have no opinion.

Remember, there are no right or wrong responses to these statements.

Neither Agree Strongly Nor Strongly Agree Agree Disagree Disagree Disagree

I. I feel depressed. 2 3 4 5

2. I find it hard to get along with 2 3 4 5 certain .eeo_ele.

3. I feel empty inside. 1 2 3 4 5

4. I can't keep up with my normal 2 3 4 5 ctivities.

5. I feel a need to talk 2 3 4 5 about the baby.

6. I am grieving for the baby. 2 3 4 5

7. I am frightened. 2 3 4 5

8. I have considered suicide 2 3 4 5 since the loss.

9. I take medicine for my nerves. 1 2 3 4 5

10. I very much miss the baby. 2 3 4 5

11. I feel I have adjusted well 2 3 4 5 to the loss.

12. It is painful to recall memories 2 3 4 5 of the loss. Coping with Miscarriage 82

Neither Agree Strongly Nor Strongly Agree Agree Disagree Disagree Disagree

13. I get upset when I think 1 2 3 4 5 about the baby.

14. I cry when I think about 1 2 3 4 5 him/her

15 I feel guilty when I think about 2 3 4 5 the baby.

16. I feel physically ill when I 2 3 4 5 think of him/her.

17. I feel unprotected in a 2 3 4 5 dangerous world since. he/she died

18. I try to laugh, but nothing 2 3 4 5 seems funny.

19. Time passes so slowly since 2 3 4 5 the bab died.

20. The best part of me died 2 3 4 5 with the baby.

21. I have let people down since 2 3 4 5 the baby died.

22. I feel worthless since he/she 1 2 3 4 5 died.

23. I blame myself for the baby's 2 3 4 5 death.

24. I get cross at my friends and 2 3 4 5 relatives more than I should.

25. Sometimes I feel like I need a 2 3 4 5 me get my life back together again.

26. I feel as though I'm just 2 3 4 5 existing and not really living since he/she died. Coping with Miscarriage 83

Neither Agree Strongly Nor Strongly Agree Agree Disagree Disagree Disagree

27. I feel so lonely since he/she 2 3 4 5 died.

28. I feel somewhat apart and 2 3 4 5 remote, even among friends.

29. It's safer not to love. 2 3 4 5

30. I find it difficult to make 2 3 4 5 decisions since the baby died.

31. I worry about what my future 2 3 4 5 will be like.

32. Being a bereaved parent means 2 3 4 5 means being a "Second-Class Citizen".

33. It feels great to be alive. 2 3 4 5

34. I feel that I will never recover 2 3 4 5 from loosing the baby.

35. I feel fully recovered from the 2 3 4 5 loss of the baby. Coping with Miscarriage 84

Appendix B GriefExpectaion Scale (GES). Each of the items, below, is a statement of thoughts and/or feelings which some people have concerning a loss such as yours. We are interested in finding out whether you expect to have some of these thoughts and feelings during the next several weeks. For each item, circle the number which best indicates the extent to which you agree or disagree with the statement. If you are not certain, use the "neither" category. Please try to use this category only when you truly have no opinion.

An important thing to remember is that there are no right or wrong responses to these statements.

During the next several weeks I expect... Neither Agree Strongly Nor Strongly Agree Agree Disagree Disagree Disagree

1. I will feel depressed. 2 3 4 5

2. I will find it hard to get 2 3 4 5 along with certain people.

3. I will feel empty inside. 2 3 4 5

4. I will be unable to keep up 2 3 4 5 with m~ normal activities.

5. I will feel a need to talk 2 3 4 5 about the baby.

6. I will grieve for the baby. 2 3 4 5

7. I will be frightened. 2 3 4 5

8. I will consider suicide. 2 3 4 5

9. I will take medicine for 2 3 4 5 my nerves.

10. I will very much miss the . 2 3 4 5 bab .

11. I will feel that I have 1 2 3 4 5 adjusted well to the loss. Coping with Miscarriage 85

During the next several weeks, I expect... Neither Agree Strongly Nor Strongly Agree Agree Disagree Disagree Disagree

12. It will be painful to recall 2 3 4 5 memories of the loss.

13. I will get upset when I think 2 3 4 5 about the baby.

14. I will cry when I think. 2 3 4 5 about him/her

15. I will feel guilty when I 2 3 4 5 think about the baby.

16. I will feel physically ill 2 3 4 5 when I think about the baby

17. I will feel unprotected in a 2 3 4 5 dangerous world.

18. I will try to laugh, but nothing 1 2 3 4 5 will seem funny.

19. that time will pass so slowly. 2 3 4 5

20. I will feel that the best part 2 3 4 5 of me died with the baby.

21. 1 will let people down. 2 3 4 5

22. I will feel worthless. 1 2 3 4 5

23. I will blame myself 2 3 4 5 for the babts death.

24. I will get cross at my 2 3 4 5 friends and relatives more than I should. Coping with Miscarriage 86

During the next several weeks, I expect...

Neither Agree Strongly Nor Strongly Agree Agree Disagree Disagree Disagree

25. I will sometimes feel like professional counselor 2 3 4 5 to help me get my life back together again

26. I will feel as though I'm 2 3 4 5 just existing and not really livin .

27. I will feel so lonely. 2 3 4 5

28. I will feel somewhat apart and remote, even 2 3 4 5 among friends.

29. I will feel that it is safer 2 3 4 5 not to love.

30. I will find it difficult to 1 2 3 4 5 make decisions.

31. I will worry about what my 2 3 4 5 future will be like.

32. I will feel that being a 2 3 4 5 bereaved parent means being a "Second-Class Citizen".

33. It will feel great to be alive. 2 3 4 5

34. I will feel that I will never 2 3 4 5 recover from loosinB the bab~.

35. I will feel fully recovered 2 3 4 5 from the loss of the baby. Coping with Miscarriage 87

Appendix C Life Orientation Test (LOT). Please indicate the extent to which you agree with each of the statements below. There are no correct or incorrect answers. Please answer each question as openly and honestly as possible, and try not to let your answers to one question influence your answers to other questions.

Strongly Disagree Neutral Agree Strongly disagree agree

1. In uncertain times, I 2 3 4 5 usually expect the best.

2. It's easy for me to relax. 2 3 4 5

3. If something can go. 2 3 4 5 wrong for me, it will

4. I always look on the 2 3 4 5 bright side of things.

5. I'm always optimistic 2 3 4 5 about my future.

6. I enjoy my friends a lot. 2 3 4 5

7. It's important for 2 3 4 5 me to kee.e bus~

8. I hardly ever expect 2 3 4 5 things to go my wa~.

9. Things never work out 2 3 4 5 the way I want them to.

10. I don't get upset too easily. 1 2 3 4 5

11. I'm a believer in the idea that 2 3 4 5 "every cloud has a silver lining"

12. I rarely count on good 2 3 4 5 things happening to me. 13. Overall, I expect more good things to happen to me 2 3 4 5 than bad. Coping with Miscarriage 88

Appendix D Social Support Questionnaire (SSQ).

IThere are no right or wrong answers to these questions-we just want to know what is true for you

The following questions ask about people in your environment who generally provide you with help and support. Each question has two parts. For the first part, list all the people you know, excluding yourself, whom you can count on for help or support in the manner described. Give the person's initials and their relationship to you. Do not list more than one person next to each of the numbers beneath the questions.

For the second part, circle how satisfied you are with the overall support you have of the type described.

You will probably not receive all of the kinds of support listed, therefore, if you do not generally receive the support in a particular question, circle "No One" , it is important to rate your level of satisfaction, even when you circle "No One".

1. Whom can you really count on to listen to you when you need to talk?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

2. Whom could you really count on to help you if a person whom you thought was a good friend insulted you and told you that he/she didn't want to see you again?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

3. Whose lives do you feel that you are an important part of?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9) Coping with Miscarriage 89

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

4. Whom do you feel would help you if you had just separated from your spouse?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

5. Whom could you really count on to help you out in a crisis situation, even though they would have to go out of their way to do so?

No one I) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

6. Whom can you talk with frankly, without having to watch what you say?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied Coping with Miscarriage 90

7. Who helps you feel that you truly have something positive to contribute to others?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

8. Whom can you really count on to distract you from your worries when you feel under stress?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

9. Whom can you really count on to be dependable when you need help?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

10. Whom could you really count on to help you out if you had just been fired from your job or expelled from school?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied Coping with Miscarriage 91

II. With whom can you totally be yourself?

No one I) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

12. Whom do you feel really appreciates you as a person?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

I3. Whom can you really count on to give you useful suggestions that help you to avoid making mistakes?

Noone I) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

I4. Whom can you count on to listen openly and uncritically to your innermost feelings?

No one I) 4) 7) 2) 5) 8) 3) 6) 9) How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly I - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied Coping with Miscarriage 92

15. Who will comfort you when you need it by holding you in their arms?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

16. Whom do you feel would help if a good friend of yours had been in a car accident and was hospitalized in serious condition?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

17. Whom can you really count on to help you feel more relaxed when you are under pressure or tense?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

18. Whom do you feel would help if a family member very close to you died?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9) Coping with Miscarriage 93

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

19. Who accepts you totally, including both your worst and your best points?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

20. Whom can you really count on to care about you, regardless of what is happening to you?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

21. Whom can you really count on to listen to you when your are very angry at someone else?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

22. Whom can you really count on to tell you, in a thoughtful manner, when you need to improve in some way?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9) Coping with Miscarriage 94

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

23. Whom can you really count on to help you feel better when you are feeling generally down­ in-the-dumps?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

24. Whom do you feel truly loves you deeply?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

25. Whom can you count on to console you when you are very upset?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied Coping with Miscarriage 95

26. Whom can you really count on to support you in major decisions you make?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied

27. Whom can you really count on to help you feel better when you are very irritable, ready to get angry at almost anything?

No one 1) 4) 7) 2) 5) 8) 3) 6) 9)

How satisfied are you with this support?

6 - very 5 - fairly 4 - a little 3 -a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied Coping with Miscarriage 96

Appendix E Backround Information Sheet (BJS).

BACKROUND INFORMATION SHEET

1. Marital Status 1 married 2 single, living with partner 3 single 4 divorced 5 widowed

2. Yrs of formal education (12 =high school grad.)

3. Degree earned

4. Occupation

5. Ethnicity 1-Caucasion 2-Hispanic 3-African-American 4-Asian-American 5-Native-American 6-0ther 5. Date tlfBirth

Age______

6. Date of miscarriage Date of 1st interview______

Date of the first day of your last period______DIC? ______

7. Prior elective abortions (include those that occurred prior to your current relationship)

8. What was your knowledge of miscarriage, BEFORE you suffered this loss? Coping with Miscarriage 97

9. What do you think caused this miscarriage?

10. Did you pick a name for the baby? Yes___ _ No____ _

11. Had you purchased any baby clothes or furniture? Yes___ _ No____ _

12. Had you decorated the nursery? Yes___ _ No____ _

13. List the initials of your friends and family and their relationship to you who knew that you were pregnant.

1. 3. 5. 7.

2. 4. 6. 8.

14. Was your pregnancy planned? Yes___ _ No____ _

15. How many other children do you have?

16. Have you participated in any support groups related to miscarriage? Yes No

17. Have you talked with a psychologist, psychiatrist, social worker, or counselor since your miscarriage? Yes No__ _

If you are interested in obtaining a copy of the results of this study, please give us your address: Coping with Miscarriage 98

Appendix F Background Information Sheet 12 Weeks.

I just have a couple of background questions to ask before we get started with the questionnaire ...

1. How many times did you talk with a health professional re: this loss?

2. How many times did you visit with a health professional for the above concerns?

3. What concerns, problems, and/or complications did you discuss?

4. How many days of work did you miss due to the miscarriage? Coping with Miscarriage 99

Appendix G Helpful Support Scale (HS) Below are listed some activities/behaviors that someone who has experienced a miscarriage might find helpful or unhelpful. For each item, please indicate how helpful or unhelpful you found that particular activity/behavior to be. If you never experienced a particular activity/behavior since the time of your miscarriage, please circle "N/A" for not applicable.

I found that... Very Very Unhelpful Helpful

1. having an opportunity 2 3 4 5 6 7 N/A to vent my feelings was ...

2. having friends and 2 3 4 5 6 7 N/A much they cared for me was ...

3. having someone to 2 3 4 5 6 7 N/A "just be there" when I needed them was ...

4. having someone provide 2 3 4 5 6 7 N/A a philosophical explanation for the miscarriage was ... (e.g. it was God's will )

5. suggestions to turn to 2 3 4 5 6 7 N/A God or religion were ....

6. receiving encouragement 2 3 4 5 6 7 N/A to participate in social activities was ..

7. receiving advice about 2 3 4 5 6 7 N/A how to cope with my miscarriage was ...

8. receiving encouragement 2 3 4 5 6 7 N/A for m~ recovery was ...

9. when someone blamed 2 3 4 5 6 7 N/A the loss on someone or something, it was ...

10. when others said "you) 2 3 4 5 6 7 N/A (your partner )can . get pregnant again", it was ... Coping with Miscarriage 100

I found that ... Very Very Unhelpful Helpful

11. when others said "I know 2 3 4 5 6 7 NIA exactll: how you feel", it was ...

12. when people intentionally 2 3 4 5 6 7 N/A avoided mentioning the miscarriage around me, it was ...

13. when others did things 1 2 3 4 5 6 7 N/A I needed such as make dinner for me or take me places I needed to ~o, it was ...

14. talking to someone 2 3 4 5 6 7 NIA else who had experienced a miscarriage was ...

15. when others said, "you 2 3 4 5 6 7 N/A (your partner)were barely pregnant", it was ....

16. when others said, 1 2 3 4 5 6 7 N/A " you can have other children", it was ...

17. when others did things for me or gave me things 2 3 4 5 6 7 N/A that I did not need, it was ...

18. discussing the miscarriage with others even when I 2 3 4 5 6 7 N/A did not feel like talking about it was ...

19. discussing memories 2 3 4 5 6 7 N/A of the 12regnancy was ... Coping with Miscarriage 101

Appendix H Comparison ofLoss (COL) Please rate your perception of the severity of each of the following events. There are no correct or incorrect answers. We are simply interested in your honest opinions. Please consider each event independently.

Minor Completely Loss Devastating Loss

I. Death of a spouse 2 3 4 5 6

2. Miscarriage 2 3 4 5 6

3. Death of a parent 1 2 3 4 5 6

4. Paralysis, loss of feeling in legs 2 3 4 5 6

5. Loss of job 2 3 4 5 6

6. Death of a child 2 3 4 5 6 Coping with Miscarriage 102

Appendix I Background Information Sheet-Comparison Group.

BACKROUND INFORMATION SHEET

1. Marital Status 1 married 2 single, living with partner 3 single 4 divorced 5 widowed

2. Yrs of formal education (12 =high school grad.)

Degree earned

3. Occupation

4. Ethnicity 1-Caucasion 2-Hispanic 3-African-American 4-Asian-American 5-Native-American 6-0ther 5. Date of Birth Age______

6. How many children do you have?___ _

7. How many miscarriages have you or a partner of yours experienced?______

8. How many people close to you have experienced at least one miscarriage?___ _

9. What do you know about miscarriage?

10. How long do you think it would take most women to feel fully recovered emotionally following a miscarriage?

11. How long do you think it would take most men to feel fully recovered emotionally following a miscarriage?