The present study is a randomized controlled trial of parallel type and the inclusion criteria are: having a license for abortion due to fetal malformation, literacy, having no history of known mental illness, none use of psychiatric drugs, lack of any event that caused grief, anxiety and depression, such as the death of loved ones, etc. in the last 2 months, having no history of infertility and having a smart phone, and the exclusion criteria are: refusal of participating in the study, pregnancy during the study, the occurrence of an accident in a person's life during the study, lack of feedback to the content of social network education for more than two sessions, the use of consulting services outside the research during the study process.
The sample size was determined to be 100 by considering 0.05% type I error, Type II error β = 0.2 and the drop level of 20%. Participants were registered by a forensic researcher midwife from qualified clients and sampling was continuous. Randomization was done with Excel software by an IT expert colleague in advance and the sample allocation table was prepared and the samples were allocated into two groups of intervention (n = 50) and control (n = 50).
Sampling of women referring to Tehran Forensic Medicine Center was done in the fall of 2019 and data collection was done through an electronic questionnaire in the virtual space of Soroush mobile phone software. Informed and free written consent to participate in the study was completed in the first face-to-face meeting at the forensic medicine center, then the participants received the telephone number of the researcher midwife and contacted the midwife after the abortion and all the participants first completed pre-test questionnaires. Evaluation of samples was done in three times: first, for pre-test for both groups, electronic questionnaires of personal information (age, occupation, education, place of residence, etc.) and midwifery (number of pregnancies, number of children, week of pregnancy, cause of fetal malformation, family history, termination method, place of abortion, etc.) were sent and completed, and both groups were evaluated in terms of coping strategies with Conner-Davidson Resilience Scale (CD-RIS) and in terms of coping strategies with the Cope Operation Preference Enquiry (COPE) (1989) and the scores were considered as a pre-test. The CD-RIS consists of 25 questions that are scored on a Likert scale between zero (completely incorrect) to five (always correct). Test scores range from zero to 100. Higher scores indicate more resilience of the subject. Connor and Davidson reported a Cronbach's alpha coefficient of the Resilience Scale of 89%. Also, the reliability coefficient obtained from the re-test method in a 4-week interval was reported to be 87% (30). This scale is standardized in Iran by Mohammadi (2005) (31). In a study conducted by Samani et al. among students, their reliability was reported to be 0.93 and validity (by factor analysis method and convergent and divergent validity) was achieved by test constructors in different normal and at-risk groups (32). The COPE was developed by Carver et al. in 1989 and was designed to examine the Lazarus model of stress and the self-regulation and behavioral adjustment model (33). This enquiry was translated for the Iranian population in 1992 by Zolfaghari et al. (34). It includes 60 questions and three general categories, which are: problem-focused coping, emotion-focused coping, and inefficient and ineffective coping, each of which has 20 questions. This questionnaire is a self-report tool and is set in a four-point Likert scale from never (score one) to high (score four); the sum of scores in each of the scales is considered as a measure of the use of that coping strategy. This questionnaire does not have a total score (33). Differential validity of this test has been reported with structures such as toughness, optimism, control and strong self-confidence. The reliability coefficient of the whole test using Cronbach's alpha method in the study of Mollazadeh, which was performed on 422 people in the age range of 18 to 34 years, is reported to be 0.83 by Cronbach's alpha method (35). Due to the fact that the validity and reliability of COPE adjustment and coping tools in Iran is reviewed and confirmed, no reassessment was performed in the present study.
The educational content chapter, which was compiled and developed by the research team (consisting of a doctor of medical and midwifery education, a psychiatrist, a master of clinical psychology, and a master of counseling in midwifery), includes information about abortion and the care after that, the necessary care and education for re-pregnancy, skills to increase resilience and problem-focused coping skills, anger management skills, courage skills, investigating the causes of fetal abnormalities, the prevalence of fetal abnormalities and the possibility of recurrence, ways to prevent fetal abnormalities, ways of screening and diagnosis of fetal abnormalities (first trimester screening, second trimester screening, cell free DNA, amniocentesis, Chorionic Villi Sampling (CVS), contraceptive selection counseling that is listed in table number one for each session.
The intervention in the experimental group was presented by the researcher (consulting midwife) as a social network education in Soroush social network and three times a week for six weeks. The content of the education was sent to each participant in the form of clear, legible and attractive messages along with related images and videos, in such a way that the content was sent to them first and then enough time was given to the individual to observe and think about it and to perform the embedded tasks in order to consolidate and support the techniques and educational materials, discuss and exchange views and questions and answers with the consulting midwife, and this interactive relationship lasts up to six weeks and three times a week after the abortion due to fetal malformation. In addition to national routine care, the experimental group also underwent educational supportive intervention by the researcher. The control group did not receive any intervention in the study process, but only received routine healthcare, and the researcher sent them breast and cervical screening files to keep in touch, and morally and to benefit from the study, after completing the questionnaires in the second stage, the content of the sessions was virtually provided to the control group. Post-test was performed twice (6 weeks later and 12 weeks later) for both groups with electronic resilience questionnaires and coping strategies. The groups were analyzed as intra- and inter-group with each other using SPSS-16 software and Chi-square, Mann-Whitney, independent t-test and analysis of variance with repeated measures of ANOVA with a significance level of 0.05.
Table 1
Social network education program for 6 weeks (three times a week)
Week
|
Educational content
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Homework
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Frist
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Welcoming, expressing the goals and topics, information about abortion and its physical complications, the time to start sexual intercourse, asking questions about patients’ concerns and ambiguities and resolving them as much as possible
|
|
Emotional evacuation, self-awareness skills, teaching the correct methods of emotional evacuation, assessment of cognitive errors
|
|
Relaxation skills (with music), diaphragmatic breathing techniques, anxiety and stress management techniques
|
- Practicing progressive relaxation technique
- Reviewing stress and discussing it and finding answers to it at home
|
Second
|
Reviewing homework and reviewing the previous week, defining grief and its steps, coping strategies
|
|
Defining coping and its types, problem solving skills education
|
|
Anger control skills education, courage education skills
|
When was the last time you became angry, write down your reaction.
|
Third
|
Definition of resilience
|
What do you think are the characteristics of resilient people? Please write down your answer.
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Characteristics of resilient individuals: (conscious acceptance, acceptance of barriers, sources of internal control, problem solving, strong social relationships, lack of self-assessment, request for timely assistance)
|
|
Four main characteristics of resilient people from a psychological perspective: (feeling of worth, problem-solving skills, social adequacy, optimism and empathy)
|
|
Fourth
|
Educating resilience strategies: (having meaning and purpose, developing communication, flexibility to change, nutrition and healthcare)
|
|
Continuing education resilience strategies: (Educating healthy skills to deal with problems, educating positive emotion-focused coping skills and problem-focused coping skills)
|
Name a stressful event that triggers your emotions and write down your feelings about that event.
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Continuing the provision of solutions to create resilience: (optimism, creating positive attachments, strengthening spirituality), summarizing and reviewing resilience education
|
|
Fifth
|
Defining and investigating the causes of abnormalities in the fetus, the prevalence of fetal abnormalities and the possibility of recurrence, ways to prevent the occurrence of abnormalities in the fetus
|
|
Ways of screening and diagnosis of fetal abnormalities: (first trimester screening, second trimester screening, cell free DNA, amniocentesis, Chorionic Villi Sampling (CVS)
|
|
Advice on choosing a contraceptive method
|
|
Sixth
|
Necessary preparations for re-pregnancy, review of previous articles
|
|
Answering questions
|
|
Run the post-test and complete the education program
|
|