Support Following Miscarriage Alice Elfer D.Clin.Psy Thesis (Volume 1), 2017 University College London UCL Doctorate in Clinical Psychology Thesis declaration form I confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signature: Name: Alice Elfer Date: 20 September 2017 2 Overview One in four pregnancies ends in miscarriage; it is the most common type of pregnancy loss. It can be a devastating and traumatic experience, yet often it goes unrecognised and unspoken about. This thesis, presented in three parts, looks at formal and informal sources of support for women in the aftermath of miscarriage. Part I is a literature review of the effectiveness of psychological interventions for women following miscarriage. Thirteen studies met inclusion criteria. Interventions evaluated included CBT, IPT, nurse/midwife led sessions, and psychological debriefing. Nine of the studies found improvement in symptoms following intervention. There was no evidence of differential effectiveness for interventions of different theoretical underpinnings. Part II presents the findings of a qualitative study of women’s experiences of social support following miscarriage. Thirteen women took part in semi-structured interviews which were analysed using Braun and Clark’s (2006) method of thematic analysis, yielding 10 themes. Women encountered a number of barriers to talking about miscarriage e.g. its physical nature and being surrounded by other pregnant women. They experienced both unsupportive interactions (e.g. dismissive remarks, encouragement to move on) and supportive interactions (e.g. validation and permission to talk). The findings are discussed with reference to the literature on grief, trauma and social support. Part III is a critical appraisal of the process of conducting the research presented in Part II. It focuses on three main areas: personal reflexivity; epistemological reflexivity; and broader reflections on miscarriage as a taboo subject. 3 Table of Contents Overview .......................................................................................................................... 3 List of Tables and Figures .............................................................................................. 7 Acknowledgements .......................................................................................................... 8 Part I: Literature Review ............................................................................................... 9 Abstract ....................................................................................................................... 10 Introduction ................................................................................................................. 11 Previous Reviews ..................................................................................................... 13 Aims of the Current Review .................................................................................... 16 Method ......................................................................................................................... 16 Inclusion and Exclusion Criteria.............................................................................. 16 Search Strategy ........................................................................................................ 17 Study Selection ........................................................................................................ 18 Data Extraction ........................................................................................................ 19 Assessment of Methodological Quality ................................................................... 21 Synthesis .................................................................................................................. 22 Results ......................................................................................................................... 22 Overview of Results................................................................................................. 22 Quality Appraisal of Included Studies ..................................................................... 30 Study Design ............................................................................................................ 32 Sample Characteristics ............................................................................................. 33 Nature of the Intervention ........................................................................................ 34 Therapist Characteristics.......................................................................................... 38 Target of Intervention .............................................................................................. 39 Outcome Measures .................................................................................................. 39 Outcomes ................................................................................................................. 41 Discussion ................................................................................................................... 45 Study Quality and Methodological Considerations ................................................. 48 Clinical Implications and Future Research .............................................................. 49 Conclusions .............................................................................................................. 51 References ................................................................................................................... 52 Part II: Empirical Paper .............................................................................................. 59 4 Abstract ....................................................................................................................... 60 Introduction ................................................................................................................. 61 Social Support .......................................................................................................... 62 Social-Cognitive Processing Model......................................................................... 63 Social Support as an Interactional Process .............................................................. 65 Social Support following Miscarriage ..................................................................... 66 Current Study ........................................................................................................... 67 Method ......................................................................................................................... 68 Ethics ....................................................................................................................... 68 Setting ...................................................................................................................... 68 Participants............................................................................................................... 69 Semi-Structured Interview ....................................................................................... 71 Qualitative Data Analysis ........................................................................................ 73 Researcher Perspective ............................................................................................ 75 Results ......................................................................................................................... 75 Overview and Context ............................................................................................. 75 Domain 1: Barriers to talking about miscarriage ..................................................... 77 Theme 1.1: ‘It’s only a miscarriage’ ........................................................................ 78 Theme 1.2: ‘It’s really hard reliving it’ ................................................................... 80 Theme 1.3: ‘It’s about women’s bits’ ...................................................................... 81 Theme 1.4: ‘I didn’t want to burden them’ .............................................................. 83 Theme 1.5: ‘All my friends are pregnant’ ............................................................... 85 Domain 2: Supportive and Unsupportive Interactions ............................................ 87 Theme 2.1: ‘Navigating the awkwardness’ ............................................................. 88 Theme 2.2: ‘Glossing over it’ ................................................................................. 90 Theme 2.3: ‘Talk, but not too much’ ...................................................................... 92 Theme 2.4: ‘Be what you need to be’ ...................................................................... 95 Theme 2.5: ‘Kindred spirits’ .................................................................................... 97 Discussion ................................................................................................................... 99 Limitations ............................................................................................................. 103 Research and Clinical Implications ....................................................................... 104 References ................................................................................................................. 107 5 Part III: Critical Appraisal ........................................................................................ 115 Personal Reflexivity .................................................................................................. 116 Epistemological reflexivity ....................................................................................... 120 Assumptions........................................................................................................... 121 Setting up the interview ......................................................................................... 121 Interview style........................................................................................................ 123 Broader Reflections ................................................................................................... 124 The role of anxiety ................................................................................................. 124 A feminist perspective ........................................................................................... 125 Lack of Ritual ........................................................................................................ 126 Concluding Thoughts ................................................................................................ 126 References ................................................................................................................. 128 Appendix A: Ethical Approval from the UCL Ethics Committee .......................... 131 Appendix B: Participant Information Sheet ............................................................ 133 Appendix C: Consent Form ....................................................................................... 136 Appendix D: Study Advertisement ............................................................................ 138 Appendix E: Semi-Structured Interview Schedule .................................................. 140 Appendix F: Process of thematic analysis: example of an individual summary sheet ....................................................................................................................................... 144 Appendix G: Process of thematic analysis: illustration of initial notes, codes and themes ........................................................................................................................... 147 Appendix H: Respondent Validation: letter of invitation ....................................... 151 6 List of Tables and Figures Part I: Literature Review ............................................................................................... 9 Table 1. Search Terms ................................................................................................. 19 Figure 1. Study Selection Flow Chart ......................................................................... 20 Table 2. Characteristics of included studies ................................................................ 23 Table 3. Quality Assessment of Reviewed Studies ..................................................... 31 Table 4. Outcome Measures ........................................................................................ 40 Table 5. Effect Sizes .................................................................................................... 43 Part II: Empirical Paper .............................................................................................. 59 Figure 1. Outline of Recruitment Process ................................................................... 70 Table 1. Participant Characteristics ............................................................................. 72 Table 2: Themes and sub-themes ................................................................................ 76 7 Acknowledgements Firstly, I would like to thank my supervisors, Nancy and Chris, for their incredible support throughout the process of this research. Their unwavering encouragement, attention and empathy has made this challenging journey so worthwhile. I would also like to thank the Miscarriage Association, particularly Ruth Bender-Atik, for being so supportive of this project and Lorna, for giving her thoughts and experiences when this project was just beginning. The completion of this project and my clinical training would not have been possible without the love and care of my family, particularly my husband, Luke. You have lived through each high and low with me and always believed I could do it. Most importantly, I would like to thank the women who participated in this study. This thesis is dedicated to you: your courage, openness and determination to help others has been truly inspiring. 8 Part I: Literature Review Psychological Interventions for Women Following Miscarriage 9 Abstract Aims: Miscarriage can be a devastating and traumatic experience for women, one which increases the risk of psychological morbidity in the months that follow. This review aimed to evaluate the effectiveness of psychological interventions designed to reduce these psychological sequelae. Methods: A systematic search for relevant studies was conducted via the electronic databases PsychInfo, MedLine, CINAHL and the Cochrane Library, citation searching and manual searches of bibliographies. The methodological quality of studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. Results: 13 papers met the inclusion criteria. They comprised four CBT interventions, five nursing/midwife interventions, three IPT interventions and one psychological debriefing intervention. Ten studies used a randomized controlled trial design and three were uncontrolled. Overall, study quality was mixed; while study design was an area of strength, areas of weakness included selection bias, blinding and drop-out. Nine of the studies found improvement in symptoms following intervention. There was no evidence of differential effectiveness for interventions of different theoretical underpinnings. For the RCTs there was a median Cohen’s d of 0.18; for the uncontrolled studies the median d was 0.69. Conclusions: The findings provide preliminary evidence that intervention following miscarriage can benefit women. While symptoms improve naturally over time intervention can hasten and improve resolution of symptoms. However, further research is needed to replicate and expand on these findings. 10