Fig. 12.1
Frida Kalo, 1929. This is how she drew the experience of her miscarriage. [Reprinted with permission from Frida Kahlo Museums Trust. Av. 5 de Mayo No. 2, Col. Centro, Del. Cuauhtémoc 06059, México, D. F &Banco de México Diego Rivera © 2015]
There are two factors influencing the emotional responses of the women with recurring miscarriages. The first is connected with mourning for the loss and not knowing the cause; these women develop greater anxiety disorders. The second factor is connected to medical anamnesis. The conventional wisdom is that women who have given birth in the past are more resilient to anxiety stemming from RPL. However there is no research supporting this view. Also, the literature describes serious traumatic reactions to the degree of PTSD (Posttraumatic stress disorders ) [12].
There is a long term study examining the prevalence of PTSD in response to RPL. About 1370 women were enrolled in the study during the early stages of their pregnancies and 113 experienced RPL. The interviews to evaluate the extent of the trauma and depression were conducted after 1 month and again after 4 months and the frequency of PTSD was 25 %, and the severity of the symptoms was similar to other trauma populations. Women with PTSD were at a high risk for depression: 34 % of the PTSD cases and 5 % of cases that did not report depression. At 4 months, 7 % met the criteria for PTSD, and half were chronic. In contrast the rate of depression did not decrease. The results show that pregnancy loss has the traumatic potential to contribute to the development of PTSD [17].
A study that examined the difference in the level of anxiety among women after one miscarriage compared to those who experienced two miscarriages shows that the second miscarriage had a stronger effect on the women’s emotional state. In the same study it was found that while the first miscarriage was accompanied by less anxiety there was more anxiety during the next pregnancy. A connection was found between the degree of depression and anxiety in women after a miscarriage and a higher risk to miscarry in the next pregnancy [12, 18].
In a study of 205 women who experienced unexplained RPL 116 got emotional support and the rest didn’t. It was found that among the women who received psychological support the rate of subsequent successful pregnancies resulting in a live birth was 85 % while among those who got no support only 36 % succeeded in becoming pregnant. This study was terminated due to ethical issues but illustrates the significance of psychological support [17, 18].
Understanding the connection between the emotional state of the women and miscarriages brought the European Society of Human Reproduction and Embryology (ESHRE) and the Royal College of Obstetricians and Gynecologists (RCOG) to recommend supportive care during the next pregnancy for women with unexplained miscarriages [11]. There is also a recommendation to offer emotional support during the first 4 weeks after a miscarriage in order to reduce anxiety and the chances for further mental morbidity [16].
As yet there are no set protocols for supportive treatment after recurring miscarriages. In their work Muster et al. [11] examined the preference of women for support during pregnancy after recurring miscarriages. Women were offered about 20 types of support. All indicated that emotional support immediately after a miscarriage at a time when anxiety and the feeling of loss of control was high was very important. Also, they stressed the importance of continuous communication with the attending physician which would allow them to report the next pregnancy immediately in order to plan monitoring and to consult with him during the pregnancy. The women reported that the ultra-sound test which showed the fetus and the fetal pulse gave them support and faith in their bodies. In addition to emotional support they wanted the physician to be serious, available, attentive and understanding of their difficulties. They also noted the importance of the support from the social worker, their family and friends and especially from their husband [11]. They derived great support from the relaxation exercises and from the emotional support which alleviated their feeling of bereavement and anxiety [5, 11].
There is a connection between pregnancy loss and feelings of anxiety and depression after RPL. The literature shows a strong connection between the neuro-immune system , the emotional state of the women and RPL [9, 10, 13]. One of the factors which cause stress and anxiety in Israel is the social pressure from a society which expects a couple to have a baby [3, 4].
Social Aspects of Recurring Miscarriages
Social pressure is a significant factor in the couple’s emotional response after a recurring miscarriage [6]. A couple which experiences difficulty in conceiving is inclined to relate to the fertility problem as a kind of disease due to their experience of malaise, connected on the one hand to the couple’s self image as being infertile, a feeling of lack of control of the body, and on the other hand to the social pressure connected to society’s expectation that they have children [3, 4, 6, 8]. The difficulty in having a baby is interpreted as not meeting the expectations of society, a culture that values heterosexual parenting [19]. Reproduction is perceived as self-evident and the primary and essential factor for a woman’s self-realization, with motherhood perceived as her central function. Many women in Israel put their commitment to their family above their commitment to a career or to developing other fields of interest [3, 4, 7].
A voluntary choice not to have children is almost inconceivable. Society sees such a choice as socially deviant [3, 4, 7]. Studies show that women who have experienced recurring miscarriages experience a personal and social crisis due to the stigma. A woman who despite efforts to have children sees herself as one who is not whole, is damaged and sometimes even inferior. This feeling spreads and infiltrates aspects of her personal and sexual identity and all aspects of life. The stigma of infertility causes couples to try to hide their condition [3, 4, 8].
Emotional Support After RPL
Support Tools
Women occasionally are reluctant to seek emotional support due to a feeling of being labeled mentally ill [11]. As the literature shows, emotional support for women after RPL is related to many areas in a woman’s life. There are many ways to tender support. In this paper we will describe a number of useful tools.
1.
NLP (Neuro Linguistic Programming ) and Guided Imagery.
2.
CBT (Cognitive Behavior Therapy ).
3.
Mindfulness Based Stress Reduction MBSR .
It is possible to use one method or to use them in combination according to the patient.
The literature stresses that women with RPL can experience trauma , anxiety, depression, and even PTSD [13]. Studies show that there is an improvement in the emotional state and a decrease in the stress level in therapy for anxiety disorders and PTSD using NLP and CBT [20]. There are no articles describing the use of these methods specifically for treating women with RPL.
NLP (Neuro Linguistic Programming) and Guided Imagery
NLP is a scientific method whose aim is to help a person achieve a change in his perceptions and experience. It is a collection of processes observed in areas of the brain (neurology) and in the use of language (linguistics) and their programming (the manner in which such information is organized in the brain). This method was developed in the 1970s by Professor John Grinder, a linguistics professor and Dr. Richard Bandler a computer specialist and a psy chotherapist [21–23]. They determined the concept of NLP.
The term NLP is comprised of:
N-Neuro reflects the nervous system (the brain) through which our experiences are processed by the senses: vision, hearing, touch, smell, and taste. They are processed and translated into experiences. For example, when we watch a movie and cry the information is comprehended through the senses of sight and hearing and it is translated into an experience which stimulates our neurological system [22, 23].
L-Linguistic —comprises verbal communications, how we express our thoughts and feelings; how language structures reflect internal and external communications which include thought processes and oral communication as formulated by the person. It is possible to express the same idea in a number of ways where each way creates a different experience. For example, you can say to a woman with unexplained RPL that it is a great challenge to succeed in achieving a live birth. Or you can say to her that although her miscarriage is a result of unexplained reasons experience shows that in similar situations over 75 % succeed in having a successful pregnancy with a live birth. The same statement but the experience is different. When the experience is different the neurological system responds differently [22, 23].
P-Programming —The encounter between what is understood by the neurological system through the five senses, and from language. The programming organizes the results of the analysis of neurological and linguistic events [22, 23].
NLP serves as a diagnostic tool and treatment method for problems requiring a change in behavior and habits, phobias, anxieties, PTSD, allergies, transferring excellence, etc. This therapeutic approach works within a short time and the therapy is very brief [23]. In the case of Bigley [22] it was found that the treatment by NLP effectively dealt with patients who suffered from anxiety attacks and claustrophobia during MRI testing [23]. In one pilot study it was tested whether NLP could lessen symptoms of PTSD among soldiers and those in emergency services. Twenty-nine subjects participated in the study. Their level of anxiety and depression was tested before and after the intervention which included a variety of NLP techniques. It was found that the anxiety level decreased significantly after the NLP consultation [20, 21].
NLP uses the healing power of the imagination. The human brain does not make distinctions between the real and the imaginary. In many different studies similar neural responses have been observed (using MRI) whether the action was purely imaginary using all the senses or it was something that happened in reality. In both cases, the brain chemistry changes and organizes cells and the connections between the cells to create appropriate motor or verbal skills, in order to perform the same action [24, 25]. A woman with RPL begins to write herself a “script” imagining a variety of future catastrophes. Understanding that the brain does not distinguish between the imaginary and the real allows us to help women imagine for themselves better scripts which improve the neurological system and improve their chances for success [24–27]. Through NLP and guided imagery people suffering from depression and anxiety can be treated and supported using tools which identify their internal resources and strengthen them. The use of imagination to raise consciousness and achieve personal well-being has been in use for a long time in the therapeutic professions treating both body and soul [25–27].
Cognitive Behavior Therapy (CBT) is a treatment aimed at lessening psychological distress. The treatment is goal oriented. The cognitive behavior approach diagnoses the psychological problem according to measurable criteria based on research and defines the success of the treatment according to these criteria. The treatment is brief. The patient is an active participant in the treatment process [28].
CBT is a technique which emphasizes the connection between an event, its meaning and its emotional and behavioral consequences. The basic assumption is that thought is the interpretation of the event. The thought creates emotion and the emotion generates behavior. From the beginning of the treatment the therapist shares the logic of the therapeutic process with the patient aiming to make him an active partner in the process and to be aware of its results.
CBT therapy is found to be effective in a wide variety of problems such as different anxiety disorders, depression, eating disorders, and PTSD [28]. The aim of the treatment is to teach the patient to pay attention to negative feelings and thoughts, to deal with them and regulate them while simultaneously paying attention to positive feelings and to grant them significance [28]. The thoughts which accompany a woman with RPL are generally negative. Mostly the woman feels “certain and believes” that she is not able to stay pregnant and will not be able to and therefore she miscarries. This kind of thinking is accompanied by negative feelings of fear and anxiety concerning another failure, frustration, anger, loss, despair, depression, lack of self-esteem [11, 17, 29].
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