Resilience and Coping Strategy after Abortion due to Fetal Malformation: A Web-Based Randomized Controlled Intervention

Background: Today, due to the development of advanced fetal screening techniques, termination for fetal abnormalities has increased, and has caused signicant grief for women which can lead to long-term mental disorders. Self-help intervention with web guide may help provide appropriate education and counseling to women. Therefore, this study was conducted to determine the effect of social network education on resilience and coping strategies of women abortion due to fetal malformation. Methods: This clinical trial studied two groups of 100 qualied pregnant women with abnormal fetuses who referred to Tehran Forensic Medicine Center. Randomly assigned into a randomized blocks list as two intervention group and routine group. Sampling was done by random allocation method by Excel software and blinding in the statistical analysis stage and was done as single-blind. The intervention in the experimental group was done as education through mobile social software (Soroush) and for 6 weeks and three times a week. The control group received routine care and after the second test, the content of the network education was also given to them. Resilience and coping strategies were evaluated before, immediately and three months after the intervention using the Persian version of Connor-Davidson Resilience Scale (CD-RISC-2003) and coping strategies (COPE-1989), respectively. Analysis of variance with repeated measures of ANOVA was used for statistical analysis. Results: The mean resilience score in both control and test groups increased signicantly (P<0.001) which can indicate the effect of time, but the study of the effect of group over time indicated that in the resilience variable there was a signicant difference between the two groups (P<0.001). The simultaneous effect and group on the resilience variable was signicant (p<0.001) and the mean variation of resilience score in the intervention group was signicantly higher than the control group (p<0.001). The mean score of problem-focused coping strategies in the experimental group increased signicantly during 12 weeks (p<0.001) but no signicant difference was observed in the control group (p=0.218). Regarding the emotion-focused strategy, a signicant decrease was observed in the experimental group (p<0.001) but in the control group there was a signicant increase (P=0.001).


Background:
Today, due to the development of advanced fetal screening techniques and increased reproductive age, chromosomal abnormalities and termination for fetal abnormalities have increased (1). According to United Nations population statistics, one of the seven most common causes of miscarriage around the world is fetal malformation. Numerous studies are conducted on the effects of abortion on mental disorders in different countries. Selective abortion can cause mental health disorders in the mother and family (2). Abortion is associated with an increase in a range of mental disorders including depression, anxiety, fear disorders, bipolar disorder, Post-Traumatic Stress Disorder (PTSD), stress and obsessive disorder (3,4), and their quality of life, physical, emotional and social functioning is lower than normal population (5). Many women suffer from post-abortion issues such as avoiding re-pregnancy, fear of unhealthy fetus in the next pregnancy, not knowing the cause of the miscarriage, blaming themselves for the incidence of the event, feeling ashamed, guilty and frustrated (6). Maguire et al. (2015) know guilt, social isolation, skepticism in making decisions, insu cient partner support, low self-e cacy, younger age of parents, pregnancy progression and low social support among the predictors of poor prognosis in these women and have reported increased social support and elimination of misconceptions about the cause of anomalies to be effective in improving women's experiences and reducing their grief (7). The role of healthcare providers is important in facilitating this transition period (8).
The results of the Subramaney study, which examined the factors affecting depression and posttraumatic stress in women after abortion due to fetal malformation, showed that mother's age, termination time, chronic burden, religion and resilience have an effect on predicting depression scores and there is a signi cant relationship between resilience and depression and one of the suggested solutions is resilience education. Resilience is a concept that needs further research (9). Resilience helps to establish a bio-psychological balance in stressful situations and is the adaptive factor in adverse conditions, and leads to better coping, higher self-e cacy and less stress perception (10,11); it gives people the power to cope with coming problems and provides the capacity of resistance against tensions and increases the ability to adapt and overcome danger and hardships (12). Resilience education program can, improve mental health, develop self-e cacy and the capacity of individuals for emotional regulation (13). Recent studies have suggested the implementation of resilience programs to improve mental health in individual, professional and organizational levels (13)(14)(15). Suspicious screening results have increased the psychological problems of pregnant women, and the lack of knowledge and skills of pregnant mothers in the face of these issues and problems is the main reason for the need to provide health, medical and psychological services to this group. One of the psychological services that is strongly associated with clinical therapies is the education of skills of coping with stress. Today, coping strategies in this group are studied from different angles (16). Coping is a set of behavioral and cognitive activities and processes to prevent, manage and reduce stress. In fact, stress as a psychological phenomenon is one of the important factors in the occurrence and persistence of many mental disorders (17), and it's found that the use of effective coping strategies, plays an important role in reducing the formation and persistence of stressful events such as abortion. Adopting appropriate strategies of coping with stress can reduce its negative effects on mental health and lead to greater adjustment (18). Coping strategies are cognitive-behavioral measures used by a person to manage his or her desires in stressful and di cult situations. Coping efforts help the individual to correct behavior or reduce negative emotions (19). Coping efforts include using problem-focused coping, emotion-focused coping, and avoidantfocused coping in stressful situations. Problem-focused coping is a method used to change or manage stressful situations, and emotion-focused coping is a method used to control emotional reactions related to the stressful factor. The avoidance-focused approach counteracts the objective distance from the stressor and the denial (mental distance) of the stressor (20). The effect of these strategies is temporary and in the long run will cause stress and tension in the person. Problem-focused and rational coping strategies can have a positive effect on people's mental health and can be taught and learned (21).
It should be noted that so far few intervention studies are conducted in the eld of abortion due to fetal malformation (7,22,23). lee Eleanor et al. (2016) with a systematic review of web-based interventions in the prevention and treatment of perinatal mental disorders, studied therapeutic interventions from the beginning of pregnancy to one year after delivery and the results showed that providing services through the Internet can be an available, practical, effective and cost-effective solution for the treatment and prevention of perinatal mental disorders in pregnant women. But further researches in this regard is known to be necessary (24). Swanson emphasizes midwifery counseling after an abortion (25). Many studies consider educational supportive intervention after abortion due to fetal malformation necessary and recommend further researches into the knowledge of how to care for these women and recognize referring of these patients to interdisciplinary teams as an effective strategy to address the intra-and postoperative care gap after the abortion (26,27). There are various methods to provide educational support and counseling to these women to meet their needs, including face-to-face education, multimedia education and social network education, but according to recent studies, we decided to use social network education. The results of a systematic review of Bagheri et al. (2020) showed that there are very few studies on social network education and counseling in abortion (28), and the results of a study that examined the help-seeking behaviors of these women showed that family, friends, colleagues, genetic counselors, psychologists and gynecologists are the source of these mothers' referrals, but due to the advancement of technology, 65% of these women have used the Internet as a helpful source and received their sensitive health issues anonymously, and have emphasized the high potential of online support in these women (1). Today, using mobile technologies available to patients and healthcare professionals, it is possible to provide the necessary support to patients to acquire self-management skills (29). Given that no study is conducted on the effect of virtual learning on resilience and coping skills of women with abortion due to fetal malformation, the present study is designed and implemented to determine the effect of social network education on resilience and coping strategies of women after abortion due to fetal malformation.

Method:
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 quali ed 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 rst face-toface 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 rst completed pre-test questionnaires. Evaluation of samples was done in three times: rst, 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 ve (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 coe cient of the Resilience Scale of 89%. Also, the reliability coe cient 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, emotionfocused coping, and ine cient 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-con dence. The reliability coe cient 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 con rmed, 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 ( rst 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 rst 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 les to keep in touch, and morally and to bene t 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 signi cance level of 0.05. Results: Six weeks after the study, two individuals in the control group and two in the experimental group did not respond to the messages, and nally 48 people remained in each group. Shapiro-Wilk test was used to evaluate the normality of the data (quantitative variables) and a signi cance level of (p < 0.05) was considered ( Table 1); variables of women's age, emotion-focused strategy score and ine cient strategy score at the beginning of the study and week 6 of data distribution was normal in the experimental and control groups and it was abnormal in the form of data distribution for at least one of the groups.
Nonparametric tests were used to test and compare the groups. Information about the demographic characteristics of the samples showed that the two experimental and control groups were homogeneous in terms of demographic characteristics (p < 0.05). (Table number three -Appendix).  Table 3 and there was an interaction effect between resilience and domains of adjustment and coping and the trend of changes over time depended on the intervention group. Due to the signi cant interactions, analysis and comparison were performed at each time point (at the beginning of the study, 6 weeks and 12 weeks, and for each group, changes over time were tested).
To evaluate the resilience score and each of the areas of adjustment and coping between the two groups, analysis of variance was performed at the beginning of the study, 6 weeks, and 12 weeks later. To prevent the increase of the rst type error, Bonferroni correction was used and the signi cance level of 5% was decreased to 0.017 (0.05/3 = 0.017). At the beginning of the study, the difference between the groups was not signi cant, but in 6 weeks and 12 weeks after the intervention, the mean resilience and all areas of adjustment in the two groups were signi cantly different. The results are shown in Table 4. To examine whether there has been a change in resilience, problem-focused coping, emotion-focused coping, and avoidance coping of participants over time (trend), trend, univariate, and multivariate tests were done for each group using T 2 hotelling statistics. And to prevent the increase of the rst type error, the signi cance level was reduced from 5% to 0.017 (0.05/(3*1) = 0.017). The results are given in Table 5. Table 5 Univariate and multivariate test results using T 2 hoteling statistics to examine the trend of changes in resilience score and each of the areas of adjustment and coping by study groups.  The results of analysis of variance with repeated measures showed that the mean score of problemfocused strategy in the experimental group before the intervention to 6 weeks later and 12 weeks later was statistically signi cant and increasing (p < 0.001), but from 6 weeks later, at the same time with the completion of the social network education, compared to 12 weeks later, the mean score of problemfocused strategy in the experimental group was stable and there was no signi cant difference. In the control group, the mean score of problem-focused strategy at different times was not signi cantly different (P = 0.218) and there was no change in the score of the problem-focused strategy of this group. Comparison of the results of the two groups based on Mann-Whitney test showed that in the pre-test stage the mean score of the problem-focused strategy was not statistically signi cant (p = 0.287) and the groups were homogeneous, but in the stage of 6 weeks after and 12 weeks after the study, there was a signi cant difference (P < 0.001).
The mean score of emotion-focused strategy with analysis of variance with repeated measures in the experimental group in the pre-intervention times to 6 weeks later and 12 weeks later was statistically signi cant (p < 0.001) and had a decreasing trend. The control group also had a statistically signi cant difference (p = 0.001) and an increasing trend in the mean score of emotion-focused strategy at different times. Comparison of the results of the two groups based on independent t-test showed that in the pretest stage the mean score of emotion-focused strategy was not statistically signi cant (p = 0.333) and the two groups were homogeneous, but in 6 weeks and 12 weeks after the study there was a signi cant difference (P < 0.001), and the score of emotion-focused strategy in the experimental group was lower than the control group.
The mean score of ine cient strategy with repeated measures analysis of variance test in the experimental group had a signi cant difference in the time before the intervention to 6 and 12 weeks later (p < 0.001) and had a decreasing trend, while In the control group, the mean score of ine cient strategy at different times was not statistically signi cant (p = 0.066) and there was no change in the score of ine cient strategy in this group. Comparison of the results of the two groups based on independent t-test showed that in the pre-test stage the mean score of the ine cient strategy was not statistically signi cant (p = 0.287) and the groups were homogeneous, but at 6 weeks and 12 weeks after the study there was a signi cant difference between the groups (P < 0.001). Discussion: The aim of this study was to examine the effect of social network education on resilience and coping strategies of women after abortion due to abnormal fetal abnormalities. The results in the effect of social network education on resilience of women after abortion due to fetal malformation showed that social network education led to increased resilience in the group of women in the experimental group more than before the intervention. This ndings were consistent with the results of the researches by Shalkoohi, Afshari, Seyed Fatemi et al. (36)(37)(38), and results of the researches by Sriarporn, Heler, Lee, Kersting, Fanseca, Johnson, Bagheri, Golmakani, Haj Nasiri et al. (24,(39)(40)(41)(42)(43)(44)(45) who studied the effect of speci c education on the improvement of mental states after giving up pregnancy. Explaining the signi cant increase in resilience in the control group after 12 weeks from the beginning of the study, it can be said that over time, the rate of psychological complications after abortion decreases, such as anxiety. But it's declining is faster in people who are consulted and followed up. Therefore, these people can achieve mental health before the abortion. Almost all studies have proven the existence of psychological complications after abortion, but the rate of reduction of psychological and emotion-focused coping behaviors. Healthcare providers, especially midwives, can reduce the level and severity of psychological complications after medical abortion by providing social network education and counseling and identifying women at risk, and can play a signi cant role in improving the health of women and society. This low cost and available intervention, and in the present era, with the rapid access of people to virtual networks, the content of this educational program can be widely used for women after abortion due to fetal malformation.

Declarations:
Ethics approval and consent to participate: This study was registered in the ethics committee of the School of Nursing and Midwifery of Iran University of Medical Sciences under the number IR.IUMS.REC.1398.172 and informed consent was received from all participants before the study, which was in writing and in person at the rst meeting for sampling.

Consent for publication:
Not Applicable Availability of data and material: The data sets generated and/or analyzed during the present study are not publicly available for some reason, but the data are available in encrypted form at the request of the author.

Competing interests:
There is no con ict of interest for the authors of this article. Funding: The nancial resources of this research were provided by Iran University of Medical Sciences.