THE UNBORN ONE: A PROFILE OF THE HUMAN EXPERIENCE OF MISCARRIAGE by Kristen M. Swanson-Kauffman B.S., University of Rhode Island, 1975 M.S.N., University of Pennsylvania, 1978 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillm ent of the requirements for the degree of Doctor of Philosophy School of Nursing 1983 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. KRISTEN M. SWANSON-KAUFFMAN ALL RIGHTS RESERVED Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This thesis for the Doctor of Philosophy degree by Kristen M. Swanson-Kauffman has been approved for the School of Nursing / Ebert ibert J. Harmon Laura D. Goodwin Glenn Webs Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Swanson-Kauffman, Kristen M. The Unborn One: A Profile of the Human Experience of Miscarriage Thesis directed by Professor M. Jean Watson The purpose of this dissertation was to describe the human experience of miscarriage and the caring needs of the women who miscarried. A qualitative (modified grounded theory) research design was chosen for its compatibility with the research purpose and its methodological f i t with the valuing of nursing as a human science. A convenience sample of 20 women who had miscarried within 15 weeks prior to study entry were interviewed twice about their experience with early pregnancy loss and the associated caring needs. The taped interviews were open-ended and transcripts were analyzed qualitatively for recurrent themes/categories that would aid the description of the phenomena. The categories were evolved using a constant comparative method in which each informant was compared to all other informants; all informants were compared to each emerging category; and fin a lly , all categories were compared to the study's underlying assumptions as well as the literature reviewed. The six experience categories developed were: 1) Coming to Know: describes the confusing painful process of balancing the mounting evidence of impending loss against hopes for a healthy pregnancy outcome; 2) Losing and Gaining: depicts the m ultiplicity of perceived losses and gains amongst the informants; 3) Sharing the Loss: summarizes the amount of recognition and support the women received throughout their loss; 4) Going Public: describes the process of letting others know about the loss and the price paid at Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. miscarriage for having (or not having) gone public with the pregnancy; 5) Getting Through It : compares the grieving patterns of the informants; and 6) Trying Again: discusses the decisions made related to plans for future pregnancies and identifies the related ongoing fears of future loss. The five caring categories developed were: 1) Knowing: identifies the woman's desire to be understood for her personal experience; 2) Being With: illustrates the woman's need to have others feel with her; 3) Enabling: depicts the need to have her grieving facilitated; 4) Doing For: describes the need to have others do for her ( i.e ., physical care); and 5) Maintaining Belief: focuses on the need to have others maintain belief in her capacity to get through the loss and to eventually give birth. The significance of this study for nursing is that it: 1) enables nurses and other health care providers to more clearly understand miscarriage in particular and perhaps human loss in general; 2) provides information which is of potential use to the diagnosis and treatment of human responses to the actual and potential health problem of miscarriage; 3) lends support to Watson's Theory of Caring; and 4) offers a methodology that is compatible with the valuing of nursing as the science of human care. The form and content of the a b s tractV e approved. I recommend its publication. s i FacultyTfiember in charge of thesis ■ - Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. DEDICATION I dedicate this dissertation to Chuck and J.C., the two most important people in my lif e . I love you both very much and thank you for being with me every step of the way. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGEMENTS Grateful acknowledgement is extended to a number of very special people whose support and assistance were integral to the completion of this research. First and foremost I extend a warm thank you to the 20 women who so openly shared their miscarriage experience with me. Their patient teaching brought me closer to an understanding of the human experience of miscarriage and the caring needs of a woman who miscarried- In addition, I thank their care providers whose assistance in obtaining informants was crucial. Grateful acknowledgement is also extended to those individuals who assisted me with my attempts at re lia b ility and valid ity. The critical comments of JoAnn Glittenberg, JoAnne Middleton, Donna Arthur, Susan Stroble and Nancy Nickel were all deeply appreciated. Valuable research assistance was realized in the efforts of Linda Campbell and Kristine Stemper. Their efficient, rapid transcription of tapes onto the computer was deeply appreciated. Nora Arbogast is also gratefully acknowledged for her assistance with proofreading, filin g , and most of a ll, mothering my son in my absence. I thank John Seidel for his invaluable assistance with the use of The Ethnoqraph. In addition, Cheryl Hershey is thanked for her excellent efforts in typing this dissertation. Acknowledgement is also gratefully extended to both the Sigma Theta Tau Alpha Kappa Chapter-At-Large and to Dr. Joseph Butterfield and the Denver Children's Hospital Regional Program Planning Committee for their financial support of this study. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. v ii To each of my committee members: Jean Watson, Marilyn Ebert, Colleen Conway, Robert Harmon, and Laura Goodwin, I thank you for your support, guidance and trust in my capacity to carry out this project. I also thank Glenn Webster for agreeing to serve as an external expert reviewer to this dissertation. The comments and suggestions provided by all of you were insightful and contributed greatly to the quality of my dissertaion experience. I especially wish to thank my chairperson, Jean Watson, whose caring is expressed in all that she does. I am deeply grateful to Jean for her ongoing mandates for excellence tempered by patient guidance and warm encouragement. To my husband Charles and my son John Charles, I thank you for your patience and loving support. Your belief in me and willingness to be there for me made i t all possible. Finally, I thank God, in Whose loving hands it has always worked out to the good. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CONTENTS CHAPTER I. THE QUEST............................................................................ 1 Significance of the Study .......................................... 2 Statement of the Questions ...................................... 5 Theoretical Background .............................................. 7 Assumption O n e ......................................................... 8 Assumption T w o ......................................................... 15 Assumption Three ..................................................... 18 Assumption Four ..................................................... 22 Assumption Five ..................................................... 26 Summary and Restatement of the Questions .... 30 I I . PROFILES OF PERINATAL LO SS.......................................... 32 Grief in G e n e ra l ......................................................... 32 The Needs of "Grievers in G e n e ra l" ....................... 38 Perinatal Loss ............................................................. 44 Review of Perinatal Loss Research Articles . 47 Summary of Clinical Articles .................................. 83 Spontaneous Abortion .................................................. 101 Recent Books Which Address Miscarriage ............... 110 Pilot Study: Preliminary Investigation of the Emotional Impact of Miscarriage .... 114 Data Collection ..........................................................115 Data Analysis ......................................................... 115 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ix CHAPTER Results .........................................................................116 Summary of the Pilot Study .................................... 124 Summary of the Review of the L ite ra tu re ....................124 I I I . THE PROCESS.............................................................................125 The Multiplicity of Realities .................................. 125 The Nature of R e a lity ......................................................127 Description of the Methodology .............................. 132 Research Strategy ..................................................... 136 Info rm an ts ..................................................................... 136 Data Collection and A n a ly s is ...................................138 Interview Schedule ....................................................