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LETTER TO THE EDITOR |
Department of Psychiatry, University of Muenster, Muenster, Germany
Department of Gynecology and Obstetrics, University of Muenster, Muenster, Germany
We read with great interest the important paper of Broen et al. (1) in which they compared the psychological trauma reactions of women who had had either a miscarriage or an induced abortion. The aim of the study was threefold: 1) to compare the course of the psychological stress responses (IES scores) in a 2-year-prospective follow-up study; 2) to compare the intensity of feelings; and 3) to identify variables related to the psychological stress responses at 10 days and at 2 years. Although the response rate was low at only 47% and the representative nature of the findings is therefore open to critical discussion, the study does give an impression of the psychological response of women after miscarriage and induced abortion, especially as 93% of the enrolled women were followed for a 2-year period. As this study investigates an important research topic, we would like to discuss some issues arising on closer examination of the paper and to supplement the report with our own findings.
First, we wonder why the authors formed a new nonvalidated Mental Health scale rather than using a validated instrument such as the SKID Interview (2) for the purpose of a clinically relevant psychiatric diagnosis. The same applies to the assessment of feelings connected to the pregnancy termination, by means of which variables associated with the psychological stress response were to be identified. In this case, too, the authors failed to make use of validated measuring instruments that would have permitted international comparability. Instead, the women were asked to rate their feelings of grief, guilt, etc., on a 5-point scale at the time of the interview when asked to think about the pregnancy termination. Quite apart from the lack of comparability of the recorded data, we consider this procedure problematic, as probands cannot necessarily be assumed to associate with a given term (eg, grief) that specific construct that is to be rated from the interviewer’s standpoint. A review of the literature dealing with validated instruments for measuring grief shows, for example, that there is only little agreement on the core symptoms of grief, even in the scientific literature (3–5). Further problems are inherent in the differential-diagnostic differentiation of grief and other constructs such as depression. We find this especially significant in the light of the findings reported by Broen et al., as the authors identified these "feelings indexes" as significant predictors of high intrusion 2 years after termination of pregnancy in the Results section of their study. We feel that it would have been more helpful to use an internationally recognized, validated instrument such as the Perinatal Grief Scale (6) for registering grief.
To lend support to the authors’ findings and to underscore the psychological impact of miscarriage and induced abortion, we would like to supplement the presented results with the findings of one of our own studies. Within the framework of a retrospective study, we interviewed 83 women 2 to 7 years after termination of pregnancy due to fetal malformation with respect to the degree of traumatic experience (IES-R) (7), grief (MTS, German validated version of the PGS) (8), and experienced mental stress (SCL-90) (9) to which they had been subject (10). Compared with the findings presented by Broen et al., we found a markedly higher number of cases of intrusion (n = 33, 39.8%) and avoidance (n = 20, 24.1%), with 39 women (47%) displaying both intrusion and avoidance. This higher number of cases might be due to the fact that the women interviewed by us had undergone a termination of pregnancy in the second or third trimester, when the bonding with the child might well have been more intensive than at an early stage in the pregnancy, as was the case in the sample investigated by Broen et al. A multiple linear regression analysis revealed conformity with the findings of Broen et al. in that sadness (ß = 0.423, p = .000) and guilt (ß = 0.381, p = .002) (MTS scales) had a significant influence on the degree of intrusion. The experience of guilt (ß = 0.360, p = .002) and anger (ß = 0.238, p = .050) had moreover (MTS scales) a significant influence on the degree of avoidance. A further factor with a significant influence on the degree of intrusion was anxiety (ß = 0.165, p = .050, SCL 90 R), whereas no SCL-90 scale showed a significant influence on avoidance.
Overall, these results indicate that miscarriage and termination of pregnancy may induce an intense psychological stress response. We offer these observations in the hope that they may contribute toward building up a reliable comprehensive knowledge base concerning the psychological sequelae for women who have lost a child during pregnancy. Longer trials involving representative samples and validated self-measuring and objective rating scales are warranted to confirm and consolidate the presented findings.
REFERENCES
Department of Behavioral Sciences in Medicine, University of Oslo, Oslo, Norway
We appreciate very much the interest in our article and the comments about it in the letter to the editor.
We agree that it may be a limitation of our study that we relied on a nonvalidated scale to ascertain the women’s previous mental health. We might have used SCID or other similar diagnostic instruments for lifetime prevalence. However, from a practical point of view, we had to use a method not requiring too much time and effort from the women, as the first interview was rather long and time-consuming as it was. The advantage of our method was that the self-reported scale was easy to use and administer. The interviewer, being a psychiatrist, could ask more probing questions in order to arrive at a lifetime psychiatric evaluation. The time used on this part of the interview seemed to be well tolerated by the women, and their cooperation was important to carry out the whole study, including the follow-up interviews.
Concerning the comment that we should have used the Perinatal Grief Scale (PGS) in order to ascertain grief in our women: In our study, we wanted to assess the intensity of several feelings, among them several that are not included in the PGS: loss, grief, missing the fetus/child, emptiness, guilt, shame, feeling let down, anger, and relief. We were convinced that such feelings would be significant in portraying the emotional responses of women experiencing either miscarriage or induced abortion.
We find the results of the studies by the German research group very interesting, especially that they found an even higher percent of cases on intrusion and avoidance on Impact of Event Scale than we did. We share their view that the higher percent in their study probably had to do with the fact that the women had the termination of the pregnancy later, in the second and third trimester.
Studies with longer follow-up time are needed in this field. We are now analyzing the results from a 5-year follow-up study.
We most certainly agree that it is important to build up a reliable, comprehensive knowledge base concerning the psychological sequelae for women who have experienced a miscarriage or an induced abortion in the first, second, or third trimester of pregnancy.
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