Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1497 Experiences of Miscarriage CAROLINE JANSSON ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-513-0454-0 UPPSALA urn:nbn:se:uu:diva-362136 2018 Dissertation presented at Uppsala University to be publicly examined in Auditorium Minus, Museum Gustavianum, Akademigatan 3, Uppsala, Tuesday, 27 November 2018 at 09:15 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will be conducted in Swedish. Faculty examiner: Professor Ingela Rådestad (Sophaihemmets Högskola). Abstract Jansson, C. 2018. Experiences of Miscarriage. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 1497. 76 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-513-0454-0. Experiences are unique and both men and women experience grief, anxiety, depressive symptoms after a miscarriage. The overall aim was to describe and measure experiences among women and men after a miscarriage. Study one was a qualitative study with interviews with Swedish midwives' and nurses' experiences of women's reactions after routine ultrasonographic diagnosis of a missed miscarriage. Study two concerned validation of "The revised impact of miscarriage scale" for Swedish conditions and a comparison of Swedish and American women's and men's experiences of miscarriage. Study three was a longitudinal study of Swedish women's and men's emotions. Study four was a longitudinal study, on women's feelings in relation to diagnosis and treatment. Scales about experiences, grief, and depressive symptom were used. The results showed that midwives perceived that the women had had a premonition of symptoms of a missed miscarriage and a follow-up was performed. The degree of consistency showed that the questionnaire can be used in a Swedish setting. The Swedish and American women and men scored similarly in two factors, and the women's experiences were more pronounced than the men's. Grief and depressive symptoms became reduced over time, while experiences persisted. No previous children, miscarriage or infertility treatment prior to miscarriage made the experience worse especially grief reaction. There was no difference between the two diagnosis groups in experiences one week after the miscarriage and their experience improved after four months. Women treated with misoprostol had more depressive symptoms than women treated with misoprostol and subsequent vacuum aspiration. In conclusion, care providers can confirm women's premonition of a missed miscarriage so a diagnosis can be set early in the pregnancy and they can do an individual follow-up. The high consistency between the countries in two factors show that RIMS is reliable for both women and men. Grief and depressive symptoms become reduced, while experiences persist. Previous miscarriage, lack of previous children and an infertility diagnosis can lead to negative feelings as grief. A diagnosis of miscarriage has a limited influence on experiences, and a shorter duration of treatment and treatment with misoprostol and subsequent vacuum aspiration led to a fewer depressive symptom. Keywords: Miscarriage, spontaneous abortion, missed abortion, pregnancy loss, gender, measurement, emotion, care, stress Caroline Jansson, Department of Women's and Children's Health, Akademiska sjukhuset, Uppsala University, SE-75185 Uppsala, Sweden. © Caroline Jansson 2018 ISSN 1651-6206 ISBN 978-91-513-0454-0 urn:nbn:se:uu:diva-362136 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-362136) To anyone who has experienced a miscarriage List of Papers This thesis is based on the following papers, which are referred to in the text by the Roman numerals I-IV. I Jansson C., Adolfsson A. A Swedish study of midwives' and nurses' experiences when women are diagnosed with a missed miscarriage during a routine ultrasound scan. Sexual and Reproductive Healthcare Journal; 2010: 2:67-72. II Jansson C., Volgsten H., Pounder-Huffman C., Skoog-Svanberg A., Swanson M. K., Stavreus-Evers A. Validation of the Revised Impact of Miscarriage Scale for Swedish conditions and comparison between Swedish and American couples experiences after miscarriage. The European journal of contraception & reproductive health care: the official journal of the European Society of Contraception. 2017: 6:412-417. III Volgsten H., Jansson C., Skoog-Svanberg A., Darj E., Stavreus-Evers A. Longitudinal study of emotional experiences, grief and depressive symptoms in women and men after miscarriage. Midwifery. 2018: 64:23-28. IV Volgsten H., Jansson C, Darj E., Stavreus-Evers A. Women's experi- ences of miscarriage related to diagnosis, duration, and type of treat- ment. Acta Obstetricia et Gynecologica Scandinavica. 2018. In press. Reprints were made with permission from the respective publisher. Contents Introduction ................................................................................................... 11 Background ................................................................................................... 12 Definition of miscarriage ......................................................................... 12 Symptoms of miscarriage ......................................................................... 13 Prevalence of miscarriage ........................................................................ 13 Menstrual cycle and early pregnancy period ............................................ 13 Causes of miscarriage ............................................................................... 14 Risk factors of miscarriage ....................................................................... 14 Diagnosis of miscarriage .......................................................................... 15 Treatment ................................................................................................. 16 Expectant treatment ............................................................................. 16 Medical treatment ................................................................................ 16 Surgical treatment ................................................................................ 17 Antenatal care in Sweden and the USA ................................................... 18 Antenatal care in Sweden .................................................................... 18 Antenatal care in the USA ................................................................... 19 Caring and emotions ..................................................................................... 20 Caring and well-being .............................................................................. 20 Feelings after a miscarriage ...................................................................... 20 Experiences of miscarriage ...................................................................... 21 Mental health ............................................................................................ 21 Grief ......................................................................................................... 21 Theoretical framework .................................................................................. 22 Rationale ....................................................................................................... 23 Aims .............................................................................................................. 24 Overall Aim .............................................................................................. 24 Specific Aims ........................................................................................... 24 Methods ........................................................................................................ 25 Design of the included studies.................................................................. 25 Qualitative study ...................................................................................... 26 Design of the qualitative study ............................................................ 26 Study participants ................................................................................ 26 Data collection ..................................................................................... 26 Data analysis ........................................................................................ 27 Quantitative studies .................................................................................. 28 Design of the quantitative studies ........................................................ 28 Data collection ..................................................................................... 29 Study participants (Studies II-IV) ........................................................ 29 Meaning of Miscarriage Model ........................................................... 30 Impact of Miscarriage Scale ................................................................ 31 Revised Impact of Miscarriage Scale .................................................. 31 Translation of the Revised Impact of Miscarriage Scale ..................... 32 Montgomery-Åsberg Depression Rating Scale ................................... 33 Center for Epidemiologic Studies-Depression Scale ........................... 33 Perinatal Grief Scale ............................................................................ 33 Statistical analysis ................................................................................ 34 Ethical considerations