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


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


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


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


The participants’ prenatal attachment to her fetus is assessed before and after psychological

intervention using the Romanian version of Maternal-Fetal Attachment Scale (Cranley 1981), which

contains 22 items. MFAS is not just the first, but also one of the most widely used instruments in

measuring prenatal attachment in the world. The items are conceived as sets of affirmations, and each

item measures one of five dimensions or subscales of the prenatal attachment identified by Cranley, that

is Differentiation of Self from Fetus, Interaction with the Fetus, Attributing Characteristics and Intentions

to the Fetus, Giving of the Self, and Role Taking. The response options in the MFAS are ranged from

“Definitely Yes” to “Definitely No”, and are scored from 1-5, with 5 being the most positive statement,

except 21 item for which options are reversed. The fidelity of Romanian version Cranley’s scale, α =

0.73, supports the fidelity α = 0.85 of the original instrument.

In spite of the fact that Cranley’s Maternal-Fetal Attachment Scale was constructed exclusively

based on a sample of pregnant women with gestation ages between 35 and 40 weeks, the data obtained

through relating the scores to variables such as age, socio-economic status, parity, self-confidence,

perceived stress support the idea of hierarchically ordering behaviours specific to the maternal-fetal

attachment and the fact that some dominate over others throughout the various stages of pregnancy. Also,

the administration of MFAS in the first and second trimesters of pregnancy allows for the measurement of

the development stage of each behaviour, which in turn allows for the evaluation of their evolution and

for highlighting any risky situations as far as the maternal-fetal relationship is concerned.


Our study involved 32 pregnant women (10-30 weeks of gestation, m = 22.28, std. deviation =

6.65) with a history of miscarriage, recruited from the database of a private center in Bucharest providing

prenatal service, as well as via online publishing of an information notice regarding this research on blogs

for future parents. All expecting mothers involved in this study are married and aged between 27 and 39,

with an average age of 30.6 years old.

The criteria for including pregnant women as participants were:

i.age over 18;

ii.the existence of at least one previous miscarriage,

iii.confirmed pregnancy;

iv.willingness to participate in this study.

The participants were divided into two groups: one experimental group (N = 16) and one control

group (N = 16). From the experimental group, 11 pregnant women went in previous pregnancy through a

singular experience of miscarriage, 4 of them went through two miscarriages and one pregnant woman

through three miscarriages. The pregnant women in the control group, experienced one single


All participants had completed Romanian version of MFAS in the pre-experiment and post-

experiment stages. The experimental group participated in a psychological intervention program which

we present below, while the control group did not benefit of any psychological intervention.

Description of psychological intervention program

The psychological intervention program was conducted over 10 weeks and included one individual

session and 9 group sessions. During the individual session, the pregnant women have undergone a semi-

structured interview covering three areas: current pregnancy, previous pregnancy / previous miscarried

pregnancies and the experience going through miscarriage. The group sessions were held on a weekly

bases, for 3 hours each. As expressive-creative means used in our intervention we can mention here was:

dancing and movement, collage, creative improvisation, centered on musical rhythm, guided meditation

and the actual story.

During the first group session, information regarding the purpose of the intervention and the

principles of the experimental-unifying orientation on which the intervention that took place after were

presented. Also, we clarified the rules of the group and the administrative aspects regarding the group

sessions: the program, the location, the number of sessions, the duration and frequency of the meetings. In

order to develop a group cohesion, every participant opened up about herself, her pregnancies (current

and previous one/s) and their motivation to participate in the prenatal attachment improvement program

developed by us. After that, using some dies with images on them, the participants working together

formulated a definition of the prenatal maternal-fetal attachment. Finally, they were verbally encouraged

to explore the group experience, process that revealed enlightening insights on the personal significance

attributed to the maternal-fetal relationship.

From the second meeting, all the sessions were held with a common structure composed of four


1) group cohesiveness by free sharing of mutual novelties on the pregnancy evolution of each

participant (e.g. information on the size of the fetus, the results of medical tests, appearance / reduction /

disappearance of physiological discomforts during pregnancy etc.);

2) introducing a provocative exercise specific to experiential psychotherapy, based on art-

therapeutic techniques;

3) analysis and verbal exploration on the experience within the exercise;

4)closing by highlighting new resources, significances, and emotional implications in order to

integrate them within the realistic and healthy actions of the participants during the pregnancy and after.

Thus, given that parts 1, 3 and 4 of the group sessions are similar in their evolution, further we

shall only describe the challenging exercises.

During the second session we used an exercise inspired from dancing and movement therapy with

musical support from the "Earth Spirit" Carlos Nakai collection for flute. After an exercise on relaxation

and guided meditation, we asked them to position in a circle and greet the entire group via movement. In

return, the group responds the greeting by movement also reflecting it exactly the same.

Then, one by one, each of the pregnant women enters the circle and is encouraged to act and

express through dance and movement the relationship with their unborn baby. To prevent possible

accidents and sustain the attachment theme, each one chooses a partner from the support group to keep

close for physical support and more. Throughout the dance, the other pregnant women, sited in the circle,

carefully pay attention to the movements of the pregnant woman in the center and also to their own

thoughts, questions, emotions, needs, movements. One by one, each pregnant woman is part of the

continuous circle and of the circle’s content as well.

The purpose of the 3rd session of the group was to put the participants in touch with the maternal-

fetal relationship specific rhythm, but also with the rhythm changes that occur during pregnancy. In order

to do this, we introduced a provocative exercise using Boom Whackers polyphonic tubes which are

percussion instruments. First, the participants are invited to play with the chords tubes, hitting them with

their palms, thighs or the floor, and then, each creating a personal musical rhythm, rhythm that can later

be followed by the group. This exercise them in increasing responsiveness to the personal rhythm, rhythm

produced by another person and the changes of pace and awareness of thoughts, moods, needs and

behaviors related to the sender and receiver experience.

In the 4th session we focused on differentiating between the past prenatal experiences, from the

previous to the present pregnancy, from the previously spontaneously stopped evolving fetus and the fetus

currently in the womb. This way, our intervention is in line with J. O 'Leary (2016), who emphasized the

need to support mental representations of the parental role in connection to both the stop evolving fetus

(the deceased baby) and the current one (the unborn baby). After a relaxation exercise, the participants

were challenged by using plastic clay, to mold to a certain form the fetus from the pregnancy that ended

in miscarriage and the fetus form the current one. This way, the pregnant women are actually aware that

they use different symbols and mental representations for their fetuses and that they continue to develop

an attachment relationship with each and every one of them, realizing that "they are parents to two babies,

the one who dies and the one in the present pregnancy "(O'Leary 2016).

The 5th group session, our psychological intervention continues to support the needs of unborn

baby, giving them voice. During the provocative exercise from this session, the participants have

completed sentences / phrases beginning with a given start, as if the current unborn baby would actually

talk to them about his needs.

Considering the temporal interference plans (past with present, previous pregnancy with current

pregnancy) that we noticed during the individual sessions when talking about the ongoing pregnancy, in

the 6th group session we intended to evaluate the status of this interference. For this purpose, we used the

story with a given beginning as a prenatal experience exploring instrument. Each participant received an

A4 sheet of paper on which the introductory sentence of the story was written: "Once upon a time there

was a kangaroo bearing in its pouch a precious crystal ...."

Sessions 7 and 8 beyond the mindfulness exercises, were focused on the interaction with the fetus

through different techniques: singing, speaking, reading, writing, touching, massaging, visualization,

playing in order to stimulate the prenatal attachment behavior through the expressive communication and

creative actions according to their personal resources. The focus was on becoming aware of their own

bodily sensations, emotions and thoughts from here and now, the existence of fetal movements, issues

that we explored verbally later within the group.

In the last group session, we focused through collage technique, on the integration of maternal-

fetal attachment components and on assessment of their prenatal attachment progress during our

psychological intervention program.


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).

Figure 1: Results of MFAS scores: post-experiment stage
Results of MFAS scores: post-experiment stage
See Full Size >

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 ;


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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Psychology, clinical psychology, psychotherapy, abnormal psychology

Cite this article as:

Camelia-Vasilica, C. (2017). Psychological Intervention For Improving Prenatal Attachment Of Pregnant Women With A History Of Previous Miscarriage. In Z. Bekirogullari, M. Y. Minas, & R. X. Thambusamy (Eds.), Clinical & Counselling Psychology - CPSYC 2017, vol 22. European Proceedings of Social and Behavioural Sciences (pp. 89-98). Future Academy.