A descriptive cross sectional study on mental health outcome and perceived care needs following miscarriage in a tertiary care hospital in Sri Lanka

a Professor in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka b Senior Lecturer, Department of Psychiatry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka c Professor of Psychiatry, Department of Psychiatry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka d Registrar in Medicine, General Hospital, Batticaloa, Sri Lanka Abstract


Introduction
Miscarriage increases women's risk for psychiatric disorders such as depression, anxiety and stress and can also lead to a threat to life.Hospital environment and provision of appropriate clinical information to the client is an important determinant in prevention of psychological distress.The aim of our study was to describe the psychosocial consequences of miscarriages, its correlates and perceived needs in the care provided by the hospital.

Method
A descriptive cross sectional study was carried out in the Colombo South Teaching Hospital in 405 consecutive women admitted with first trimester miscarriages to the Gynaecology wards.An intervieweradministered study specific questionnaire was used to collect information on demographic details and Depression Anxiety Stress Scale (DASS) was used to assess psychosocial consequences.

Results
Out of the 405 women studied, 55.7% met the cut-off scores for depression, 66.6% for anxiety and 50.2% for stress.The symptoms of depression, anxiety and stress were severe in 14%, 40% and 18% respectively.Women who have taken treatment for subfertility had significantly higher depressive (p=0.01) and anxiety symptoms (p=0.02).The attending doctors not listening to concerns, not explaining the condition and not explaining the treatment methods were significantly associated with symptoms of depression, anxiety and stress.(p=0.02).

Discussion
Anxiety was the most common psychological condition detected following miscarriage followed by depression and inadequacies of service provision at the hospital have contributed significantly to the experience of emotional distress.Provision of correct information, validation of distress and psychological debriefing, may be useful in enabling women to adjust emotionally following miscarriage.

Introduction
Miscarriage is a pregnancy loss prior to viability 1 , the loss of a fetus weighing less than 500 g (World Health organization -WHO), and loss of an embryo or fetus at 20 weeks gestation or less 1 .Nearly one in four pregnancies can end in miscarriage 2 .It is considered as an isolated medical problem and treated in a mechanical and physical manner by either the medical community or the woman's social support network, considering that the woman will quickly recover with no lasting psychological effects 3,4 .
As with other stressful events, the effects of miscarriage vary considerably across individuals 5 .Most women and their partners consider miscarriage as a tragic, complicated, and life-altering experience causing emotional and psychological distress result with significant suffering [6][7][8][9][10][11] .Women who experience miscarriage also worry about future pregnancies and some may perceive subsequent pregnancies as "precious and valuable" 7 .
Miscarriages also increases women's risk for psychiatric symptoms and disorders and can also lead to a threat to the life.Previous literature has described grief, depression and anxiety to occur frequently following miscarriage.Post Traumatic Stress Disorder and obsessive compulsive disorder has also been reported 8 .Childlessness, planned pregnancy, past psychiatric history, receiving surgical treatment following pregnancy and seeing a viable fetus on ultrasound scan prior to miscarriage have all been reported to be associated with a higher rates of psychological morbidity but there is controversy where and when the levels of depressive symptoms are elevated 9,10 .Expression of grief and depression may show cultural variation and coping strategies may differ depending on culture, racial or ethnic background 11,12 .When open expression of emotions such as sadness is considered inappropriate in certain cultures they may tend to somatize their distress 13 .
Previous literature has shown that women were dissatisfied about how they were treated in both hospital and community settings.Associations between the attitude of healthcare staff and the physical and emotional recovery of women following miscarriage have been documented 14 .Lack of clear-cut medical explanations about the miscarriage and its causes have been noted to promote parental guilt and self-blame 15,16 .
Miscarriage, although a common event in pregnancy, a very few studies have been carried out in Sri Lanka with regard to the psychosocial effects following miscarriages.The aim of our study is was to describe the psychosocial consequences of miscarriages, its' correlates and perceived needs in the care provided by the hospital, and this could shed some light on possible preventive strategies.

Method
A descriptive cross sectional study was carried out in the Colombo South Teaching Hospital.Four hundred and five consecutive women, admitted to the three Gynaecological wards with first trimester miscarriage during March to September 2017 were recruited.The socio-demographic details, the participants experience of care received at the hospital and perceived care needs of participants were collected using specifically designed questionnaires.The DASS was used to collect data on psychological morbidities.The DASS is a 21item self-report instrument designed to measure the three related negative emotional states of depression, anxiety and tension/stress 17 .The validated Sinhalese translation was used for this research 18,19 .In completing the DASS, the individual is required to indicate the presence of a symptom over the previous week.Each item was scored from 0 ("did not apply to me at all over the past week") to 3 ("applied to me very much or most of the time over the past week").It was also designed to get data on the perceived care they received at the hospital and their expectations about the services at the hospital.
A trained physician collected data shortly before the participants were discharged from the hospital.Completion of the questionnaire took about 20-30 minutes.The Ethical Review Committee of the University of Sri Jayewardenepura granted ethical approval and written permission to carry out the study was obtained from the hospital director and consultants in charge of wards.Informed written consent was obtained from all participants.Women identified with specific psychological morbidities were referred to a psychiatrist.
Percentages, 95% confidence intervals, significances using t tests and chi-squared tests were calculated using Statistical Packages for Social Sciences version 20.

Results
Nearly 80% of the sample was less than 35 years of age and majority (66.6%) of them were employed.Our sample mainly consisted of multigravida (61%) and half of them had at least one living child (Table1).Most of the pregnancies (58%) were planned and 23% of women had experienced at least one miscarriage in the past.Only 5 percent of the study population had a previous subfertility.In the present pregnancy, 19 percent of women had a complete miscarriage and 55% had incomplete miscarriage (Table 2).Depression, anxiety and stress were significantly less among women admitted with miscarriage who were satisfied with the care received at the hospital (Table 5).
Leading article symptoms persist, and these patients could be referred for psychiatric services for further assessment.In Sri Lanka, one possibility of achieving this maybe by arranging follow-up visits by a Public Health Midwife with administration of a structured screening tools at regular intervals.
As less satisfaction with service provision was associated with the presence of psychological distress, consideration should be given on how to improve the current practice to reduce the psychological burden on patients.Our study suggests that validating the patients concerns and giving more explanations about the miscarriage and its treatment would be useful in reducing psychological distress.Previous studies propose that better preparation for a miscarriage by increasing awareness of the frequent occurrence of miscarriages, an empathetic and sensitive approach by the staff, and providing reassurance about future pregnancies may be useful.Increasing awareness among hospital staff about the high frequency of depressive symptoms, anxiety and stress following miscarriage would be important; as it would help the medical staff to adopt a more sensitive approach towards their patients.
Evaluation of the emotional response of the male partner may also be important as previous studies have indicated that male partners were emotionally affected and went through a grieving process.

Discussion
Seventy two percent of women who presented with a miscarriage had some psychological disturbance with anxiety (66.6%) being the commonest, followed by depression (55.7%) and stress (50.2%).Severe depression, anxiety and stress found in our study were 14%, 40% and 18% respectively.Previous studies carried out from 1990 to 2003 revealed anxiety to be around 40-50% and depression around 20% in women, who had experienced a miscarriage 20 .Even though, our finding is comparable with the international literature, a previous study done in Sri Lanka showed lower rates of psychological morbidity, with only 42.4% screening positive for psychological morbidity by the GHQ-30 21 .Previous literature has shown depressive symptoms in 20-50% and anxiety symptoms in 20-40% of women shortly after miscarriage.As past literature has shown the psychological distress is highest shortly after the miscarriage and decreases with time, one explanation of this difference maybe the difference in timing of the assessment.Earlier the assessment the more severe the psychological morbidity would be 20 .Anxiety, stress, early complicated grief may also have an overlapping effect on relatively high rate of psycho-logical morbidities in our study.
In the present study, a history of subfertility was the only patient factor that was significantly associated with higher rates of depression and anxiety.In contrast, several factors related to patients' experience of service provision was significantly associated with symptoms of depression, anxiety and stress.Patients who felt that their concerns were not listened to and that the information provided about the miscarriage and its treatment was not adequate had significantly more stress, anxiety and depressive symptoms.
As a high percentage of women experience depressive and anxiety symptoms following miscarriage, screening women presenting with miscarriages for psychological distress would be an important step in identifying those at risk of developing these disorders and would be helpful in deciding whether a referral to a mental health services is appropriate.Previous literature has revealed that the level of anxiety and depressive symptoms gradually decrease with time and return to normal by about 12 months 14 .Therefore, follow-up of these women for longer periods once discharged from the hospital would be helpful in identifying those whose and safe storage of the data was provided both orally and in writing.The participants were informed that they could withdraw their participation at any time without consequence.Confidentiality was protected as the interviews were conducted in a private room where conversations could not be overheard, and only researchers involved in the study had access to the interview material.

Consent for publication
Not applicable

Availability of data and materials
The datasets used and analyzed as part of this study are not publicly available in order to maintain the confidentiality of the participants.
However, all transcripts are available from the corresponding author on reasonable request.

Funding
This study was self-funded

Authors' contributions
PRP was the principal investigator and conceived the hypothesis for this manuscript.PRP, RYM and KST designed the research and sought ethical approval.RYM conducted all face-to-face interviews with support from PRP and KST.NAAN performed the statistical analysis under the guidance of PRP and RYM and KT and contributed to the interpretation of the findings.All authors have critically revised and approved the final version of the manuscript.

Table 4 . Association of variables with types of psychological morbidities
ContinuedSeventy two point one percent of women experienced either depression, anxiety or stress and 41.3% experienced a combination of all three (Table3).Women who conceived following treatment for subfertility had significantly more depressive (p=0.01) and anxiety (p=0.02)symptoms.