Psychological Intervention For Improving Prenatal Attachment Of Pregnant Women With A History Of Previous Miscarriage

Abstract

Given that pregnant women who went through the miscarriage experience during one or moreprevious pregnancies have difficulties in forming emotional attachments to the fetus during the current pregnancy, development of psychological interventions for improving their maternal-fetal attachment is needed. The aim of this study is to present a psychological intervention centered on the Unifying-Experiential Psychotherapy for improving the prenatal attachment in pregnant women with a history of miscarriage and to investigate its effectiveness. Hence, 32 pregnant women at 10-30 weeks of gestation, who reported miscarriage in previous pregnancies, were divided in two groups: experimental and control group. All participants had completed Romanian version of Maternal-Fetal Attachment Scale MFAS) ( Cranley, 1981 )in the pre-experiment and post-experiment stages. The experimental group members participated in a psychological intervention program, while the control group did not undergo any psychological intervention. The results obtained highlight significant differences in MFAS overall scores, Roletaking and Attributing Characteristics and Intentions to the Fetus subscales scores. Our findings indicate that psychological intervention for pregnant women with a history of miscarriage could be an important factor in improving their maternal-fetal attachment. Even if is is known that MFA increases during pregnancy, one-to-one or group therapy sessions support a stronger and healthier attachment between mother and fetus.

Keywords: Maternal-fetal attachmentmiscarriagepregnancyprenatal psychology

Introduction

Out of all the pregnancy specific complications, miscarriage has the highest incidence. Because

most miscarriages occur during the first trimester, the trend among Romanian obstetricians is to ignore

this experience, especially when it is a singular one, be it at that respective moment in time or during a

following pregnancy arguing with reasons such as: It’s a common occurrence, It was just an accident,

Your loss was not an actual baby etc.

However, for women that went through a miscarriage, including the post-miscarriage period, this

experience is quite a complex one and mainly influenced by many variables: physical pain during the

moment of miscarriage, social support, age, whether the pregnancy was a natural one or obtained via IVF

procedure, if it was a desired one or unwanted, or on the information received from the medical staff.

Given that approximately 50% of women who experience a miscarriage get pregnant again,

increasingly more studies have focused on investigating the impact of prenatal losses during the

following pregnancies. Out of these, the most frequently mentioned are the pregnancy specific anxiety

(Franche & Mikail, 1999; Geller, Kerns and Klier, 2004; Bergner, Beyer, Klapp & Rauchfuss, 2008) and

its effects on prenatal maternal-fetal attachment (Armstrong &Hutti, 1998 Armstrong 2004, O'Leary,

2004; Tsartsara & Johnson, 2006). It is important here to mention that most of these studies are

considering the entire prenatal losses registry, and not just the miscarriages.

An interesting fact regarding prenatal attachment on women with a history of miscarriage is that

the qualitative studies, the conclusions and the recommendations given in the course of some quantitative

studies, highlight the strong mechanisms for avoiding emotional attachment towards the fetuses in

pregnant women during the current pregnancy. As a need to protect themselves from a new suffering after

a possible abortion, pregnant women tend to emotionally distance themselves from the pregnancy, to

retain their feelings towards the fetus, focusing exclusively on a healthy intrauterine development in order

to avoid a new miscarriage (M. Andersson, S. Nilsson, A. Adolfsson, 2011; Green & Solnit, 1964 Carey

Smith, 198; Cote-Arsenault & Mahlangu, 1998; Cote-Arsenault & B. Morrison, 2001).

Because prenatal maternal attachment was associated with the adoption of healthy behaviors in

pregnancy – e.g. nutrition, sports, giving up smoking, alcohol and drugs (Lindgren, 2001; Ustunsoz,

Guvenc, Akyus, Oflaz, 2010; Ross, 2012), with the postnatal mother - newborn attachment (Fonaggy,

Steele & Steele, 1991; Benoit Parker & Zeanah, 1997; Siddiqui & Hagglof, 2000), clinicians are more

and more concerned to develop psychological interventions focused on prenatal attachment. The existent

psychological interventions focus on different techniques as mindfulness meditation (Duncan &

Bardacke, 2009), listening to music (Chang, Yu, Chen, Chen, 2015), abdominal palpation using Leopold's

maneuvers (Nishkawa & Sakakibara, 2013), reflective functioning (Jenkins & Williams, 2008), relaxation

training (Toosi, Akbarzadeh, Farkhondeh & Zare, 2014).

The prenatal attachment implications are sustained both by its complexity and by the variety of its

meanings, for example, Cranley M. (1981) defines prenatal attachment based on the affiliation and the

interaction behaviors of the pregnant women to the fetus, while M. Muller (1993) takes into account the

unique and affectionate character of the relationship between the mother and the unborn child and

Condon (1993), the love towards the fetus. Doan and Zimerman (2003) define prenatal attachment as an

abstract concept, which is representative for the affiliate relationship between the parent and the child,

potentially present even before pregnancy, which depends on cognitive and emotional abilities to

conceptualize another human being and that is developed within an ecological system.

Problem Statement

Given that pregnant women who went through the miscarriage experience during one or more

previous pregnancies have difficulties in forming emotional attachments to the fetus during the current

pregnancy, it is necessary that the psychological intervention refer primarily to the emotional dimension

of these women.

So, they need to be encouraged to experiment different personal and original interactions with their

fetuses using expressive-creative means, so as to be able to build a healthy and safe attachment during

pregnancy. Concerning this, the Unifying-Experiential Psychotherapy, method developed by Mitrofan

(2004) and centered on symbol analysis, personal and self-change development through challenging

exercise, on the creative improvisation and meditation with art-therapy and expressive support, answers to

the genuine psychological needs during pregnancy.

PEU focuses on three axes of intervention – the identity roles axis, the time axis and the awareness

axis, among which, subjective experiences are being processed through a four-step methodology:

a) the identification of lived through experiences, their meanings and manifestations;

b) the connection and analysis of the level of merger of the experiences with the verbal and

nonverbal external manifestations;

c) the symbolic outsourcing or reconstitution of traumatic experiences that allow their exploration

and redefinition;

d) the creative self-transformation based on the activation of inventive resources by methods of

identification, formulation, rearrangement and integration of alternative, healthy and creative solutions,

actions and behaviors. Each of the three experiential- unifying ways aims specific milestones, and their

unifying effect is the result of the simultaneous and interrelated functioning.

Research Questions

The questions that we ask ourselves in this study are:

i. What is the specific of psychological intervention carried out in order to optimize the

maternal-fetal attachment in pregnant women with a history of miscarriage?

ii. To what extent does the therapeutic intervention program proposed lead to the

improvement of the maternal-fetal attachment in pregnant women with a history of

miscarriage?

Purpose of the Study

The purpose of this article is to present a psychological intervention centered on the Unifying-

Experiential Psychotherapy techniques (Mitrofan, 2004) formulatedin order to optimize the maternal-

fetal attachment in women with a history of miscarriage and also to examine its effectiveness on the

maternal-fetal relationship.

Research Methods

Findings

Our study focuses on presenting a psychological intervention in order to improve the prenatal

attachment in pregnant women with a history of miscarriage and also to measure its effectiveness.

According to Table.1, the results in this study show that after our psychological intervention are

significant differences in prenatal attachment, that is the MFAS overall score, in pregnant women in the

experimental group compared to the control group (t (29.66) = 2.87, p <0.05).

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On the MFAS subscale level, the results show that for the Attributing characterics to the fetus

and Roletaking subscale level, pregnant women in the experimental group compared with ones in the

control group had significantly higher scores or t (23.22) = 6.07, p <0.05 and t (25,12) = 2.90, p <0.05.

Regarding the other scales - Interaction, Differentiation of Self from Fetus, Giving of Self, we can

notice that the scores increase both for pregnant women in the experimental group and for the ones in

the control group, with no significant difference between them. We believe that this is due to specific

intrauterine fetal development, with frequent and strong movements that begin to structure in ceritain

recognizable patterns known by pregnant women, but also as a response to the ways of interaction of

pregnant women. In this regard, the results obtained are consistent with those obtained by Cranley

showing that maternal fetal attachment increases during pregnancy.

We consider that Giving of Self subscale scores of the two groups are closely related to the

history of miscarriage of the participants, whereas the adoption of healthy practices in the current

pregnancy is for the pregnant women a way to avoid another perinatal loss and so ensure the viability of

the fetus.

Significant differences between the two subgroups on the prenatal attachment overall score, but

also on the Attributing characteristics to the fetus and Role-taking scores subscales, arising from our

psychological intervention support its effectiveness in improving maternal-fetal relationship.

As result of our study, we can say that through the creative language used according the Unifying

Experiential Psychotherapy in our psychological attachment intervention, the pregnant women had a

direct access to their own “here and now” experiences with their unborn babies. In this way, the

participants of or experimental group became aware of the way they get in touch with their fetus from a

cognitive, emotional, and behavioural point of view, the difficulties preventing them from establishing a

secure and intense attachment relationship to their fetus ;

Conclusion

The results confirm that the psychological intervention is an important factor in improving the

maternal-fetal relationship for pregnant women with a history of miscarriage. Just time as factor or

moving from week to week in pregnancy is not always enough to reach a strong and secure maternal fetal

attachment. Depending on the type and number of previous losses, structure of personality, social

support, reaching a strong prenatal attachment requires or not involvement of pregnant women in

psychological programs to support and improve their relationship with unborn babies.

In this regard, gynecologists should pay special attention to pregnant women with a history of

prenatal loss and encourage them to participate in therapy groups focused on psychological counseling in

order to optimize their maternal-fetal attachment.

Also, because there are pregnant women who have been through not only early but also late

miscarriages (which occurred after the 13th week of gestation) or recurrent (minimum 3 miscarriages), it

is necessary that gynecologists work closely with psychologists, who in return to provide the most

specific psychological interventions, responding to psychophysiological peculiarities of the participating

pregnant women.

The limitations of our study are considering the small number of expecting mother involved, and

the lack of standardization of some variables (i.e.: age, abortion history, age of gestation, etc.), and for

this reason is necessary to extend this psychological intervention to a larger group of pregnant women

with miscarriage in history.

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