DOI: https://doi.org/10.21203/rs.3.rs-1598534/v1
Recurrent miscarriage is an unpredictable trauma in a woman's life, and they experience despair and frustration. The purpose of this research was to evaluate the experience of South Korean women after miscarriage.
This study conducted to understand the meaning of recurrent miscarriage using a qualitative thematic analysis method based on the posttraumatic growth theory. A total of 23 participants who had repeated miscarriages three or more times participated in this study. The data were collected through in-depth interviews conducted from May to July 2017.
We identified five properties as follows: 1) confusing as like muddy water, 2) self-reflection on daily life, 3) creating a new relationship through empathy, 4) the culture`s inherent animism or shamanism, and 5) transforming for internal growth were derived.
Based on the results of this study, it was found that the participants suffering from miscarriage can recover from their losses through resilience and intervention strategies and ultimately improve their quality of life through emotional support. The findings indicated the value of enhanced recovery education, which might help women understand the changes in their lives after miscarriage.
There are various ways in which women can experience losing someone in theirs` lives. Loss is defined as a real or potential trauma in which a person cannot approach or be approached by an object or person (Rosenblatt 2000). Unexpected miscarriage in some women can be the trauma, whereby they suffer a great feelings of guilt, heartbreak and unspeakable sadness (Robinson 2014).
Miscarriage is the termination of life within the 20th week of gestation, at which point a fetus does not have the ability to survive outside of the mother's body (Wyckoff and Metwally 2020). It occurs primarily in the early stages of chromosomal anomalies; however, it can also occur due to various unknown maternal and environmental factors. In general, those who had experience recurrent miscarriage be in a situation with negative physical and psychological stress such as exhaust, fear, despair, and chaos (Wang et al. 2021). One of the key point of miscarriage is that it is likely to repeat (Andersen et al. 2016), and women who had experience recurrent miscarriages lose confidence in their bodies. They also felt that sometimes had skepticism about their roles as mothers and women, they believed that miscarriages equated to loss of femininity (Kim et al. 2017). In addition, after the miscarriage, they had conflicts with her partner, the relationship deteriorated, and the relationship was severed (Farren et al. 2021).
According to previous study, the experience of miscarriage suggested that post-traumatic stress disorder(PTSD) could be diagnosed. PTSD is a psychological condition that is triggered by a horrific event that you experience or witness (Abu-Raisi et al. 2019). Psychological interventions for people who experiencing traumatic events relieve symptoms, but if left untreated, they can have a fatal impairment in performing daily activities (Sin et al. 2017). Meanwhile, By the posttraumatic growth (PTG) theory, the traumatic event of loss can lead to PTG, a positive psychological change which leads to a different outlook on life (Tedeschi and Calhoun 1996). That means deliberate rumination is an important factor influencing positive change. As cancer is also a type of trauma, a meaning-centered intervention focused on the meaning and spirituality of patients with advanced and terminal cancer has been reported to be effective in improving the quality of life and reducing negative emotions such as depression and anxiety (Kang et al. 2018).
Thus, in this study, a semi-structured question was completed based on the theory of PTG for women who had experienced recurrent miscarriage, and based on this, we attempted to in‐depth grasp the meaning of their experience and transformation in life as a woman.
Research design
This study is a qualitative study that analyzed data using a qualitative thematic analysis method (Braun and Clarke 2006) to explore the changes and meanings of repeated miscarriage by women in South Korea .
Participants
The present study included 23 women who had experienced repeated miscarriage over three times. After listening to an explanation of the in‐depth interview, they completed the application form and the interview agreement.
Data Collection
In‐depth interviews were conducted with research participants from July to December 2017 to collect data. In‐depth interviews were conducted with the participants who voluntarily agreed to participate in the study in writing, and the interview was recorded and then a transcription process was performed, and interviews were conducted using semi‐structured questions, and specific interview questions as follows. The researchers made the questionnaire, and the validity of the content was verified by experts in theme analysis and qualitative research (Table 1) . The location of interviews conducted was at places designated by the study participant for comfortable conversation, and the average interview time was 90 minutes and the number of interviews was from 1 to 3 times
Data Analysis
This study used an inductive thematic analysis method (Braun and Clarke 2006) , and the research was conducted according to the evaluation criteria of qualitative research (Guest et al 2011, Braun and Clarke 2019). To secure factual value, after the in‐depth interview was over, the researcher summarized the interview details to the participants, confirming that the interview contents were not different from the facts, and there was a procedure for showing the results of the analysis to the participants and confirming their meaning.
The age range of the participants was 28–42 years. The mean frequency of miscarriage was 3.87 times, ranging from 3 to 10 times per participant (Fig. 1) (Table 2).
The first theme, 'Confsuing as like muddy water' is the experiences the participants after repeated misccarige. All participants tended to experienced a stage of strong denial upon everytime miscarriage. They attempted to undergo visit other hospitals to the diagnosis of healthy pregnancy. Howewver participants experienced greater feelings of anger increased with repeated miscarriage as their expectations for a healthy pregnancy were. As time progressed, participants reported that their degree of depressive mood worsened. Most of the participants were feeling defeated or guilty in isolation, and this heightened the feeling of confusing in the mind.
“I think the pregnancy test is wrong. Others can easily have a good baby, even when they do not want a baby. I wonder why this is happening only to me who really wants a child, and I am so angry”.
I cried a lot and thought that I was wrong and that it was my fault. I had a lot of self-defeating thoughts... It's like my womb was buried in the mud.
“I felt like I was walking through a dark tunnel from which I could not easily get out”.
Afterwards, the most frequently mentioned and emphasized by the participants was `Self-reflection on daily life'. Looking back on past time was related to reflection on habits and behaviors that had been unintentionally performed in life. Also, they tried to analyze carefully what was the problem of repeated miscarriage, including what kind of food they ate over the past time, how did slet well, and what was traumatic events for the fetus. In addition, they had a time to reflect on what stressful situation they had experiences after pregnancy. Furthermore, it was attempted to check whether these eating habits in evereday and behaviors in everytime were the cause of miscarriage.
I remembered all the fast food which had eaten such as cupramen and hamberg, and regretted whether such behavior was a problem.
Since I was married at 40, I should have been more careful with my actions and more stress-free every moment.
II became to look back to see if there was any of wrong doing which harmed others in my life... also I looked back on my every action to see if there was shocking stimulus to the fetus without my recognition.
The third theme, ‘Creating a new relationship through empathy,’ began in the process of obtaining information on miscarraige as well as reflecting on daily life by the research participants. All of the research participants searched through the internet, where necessary information can be easily accessed, and through this process, it was found that women who had been diagnosed with habit miscarraige in the past or who were currently experienced with misccaraige joined social media meetings without hesitation. Above all, the participants had a strong sense of empathy in finding and acquiring information from the actual story based on the recurrent miscarraige. They had no social relationship in the past, but the only reason that they had the commonality of misccariage was that they were empathizing with each other, understanding and encouraging each other, and forming new social relationships voluntarily. Sometimes through social media, they communicate more actively than with people who have formed and maintained social relationships, and they tried to maintain a strong sense of bond with common interests. Moreover, they said that they were able to feel relief and comfort by expressing their worries and anxieties that they could not even tell their family on social media.
After the third miscarriage, I was afraid that I would miscarry again; thus, I stayed in my house and quit my job. I spent most of my time on the bed for 6 months. I joined the peer group who experienced miscarrage through internet and listened to various case stories. That has been a great comfort to me.
When I had a miscarriage, I saw my husband cry too. Knowing that my husband is also struggling, I could not easily tell my husband about my pain. However, I was able to fully express my feelings on online social networking group. It also gave me hope because it was possible to obtain information about how pregnant women succeeded in giving birth.
The comfort of someone who experienced the same pain as me was more helpful to me than the friends who gave birth baby.
The fourth theme, regardless of their religions, 'The culture`s inherent Animism or Shamanism', was pray for aborted fetuses, accptance of recurrent miscarriage and resilience to hope for future possibilities. Participants were placed in a situation of constant stress and trauma because of repeated miscarriage experiences that they could not resolve on their own. They tried to turn into a future-oriented view from the dilemma and psychological exhaustion by forming an attachment to the lost fetus. In addition, the participants tried to find the meaning of the lost fetus through animism, or shamanism related to reincarnation and angels.
After the loss of my baby, I went to the [Buddhist] temple and gave a hundred-day prayer despite having no religion. I've been doing this type of ritual to lead the soul to heaven for 3 years. Even now, at the time, I pray and make an offering…
I placed the photo of the Three Goddess of Birth governing childbirth in the refrigerator. Sometimes I felt like stranger because of my unusual behavior... but, I had my hopes projected there.
“No matter the lost fetus is my child. I still keep the pregnancy test results and early ultrasound pictures. maybe I constantly think of the one I lost. As an invisible angel is always by my side.” (P9, 30s)
The participants did not remain in the pain of lost the fetus and sought to convert their trauma into greater or lesser inner growth. The fidth theme, 'Transforming for internal growth' was acting as a motive for continuing changes in the perspective of life as a woman. Participants were able to switch to a new perspective on women they had not previously considered. They have a transformative view of pregnancy and childbirth that was taken for granted as a woman. Moreover, they became grateful for their`s lives and their mothers. Furthermore, they were able to accept women` various types of lives such as unmarried women, divorced women, and transgender et so on. They said that they came to appreciate the preciousness of life again and were able to grow better and cope better with the current situation.
“I am now over 40 years old. But I think I've just become an adult. Before, it was thought that pregnancy and childbirth were easy and natural for women. My mother looks great and how grateful for her... My point for now is that I am growing up”.
The experience of miscarriage is like mud in water... I don't think it can be cured. Nevertheless, I think that the experience is meaningful. I became more grateful for my life and started to think about what I would do as a good woman.
“Previously, I was not allowed to live a woman's life in different ways. But I also live an unpredictable life... so it could be... There is not only one way in a woman's life...”
One of the basic assumptions of positive psychology is that everyone ultimately pursues internal growth (Seligman 2002). This is similar to the theory of PTG, which also leads to positive thinking following a traumatic experience, giving rise to a new perspective on life (Tedeschi and Calhoun 1996). In this study, women who experiemced reccurent miscarriage does not only cause them to experience the negative meaning of loss, but it turns out that it makes them experience a new change that reminds them of their appreciation and value for a given life by looking reflection as well.
A miscarriage is a trauma, and it is a shocking traumatic event that disrupts lives (Swift et al. 2021). However, in Korea's family-oriented society, the occurrence of natural miscarriage increases not only sadness but also guilt as women take greater responsibility. Thus, for women who experience recurrent miscarriage can lead to deprivation and social isolation as a woman in South Korea (Kim 2018). Although the number of women experiencing recurrent miscarriages is increasing worldwide, it is still a trauma that is not easily resolved for women (Haas et al. 2019).
Meanwhile, most of us living in modern society use the Internet and social networ services(SNS) almost every day. Participants in this study also used the Internet and SNS in their daily life. After the recurrent miscarriage, their use of SNS has changed to a special meaning of ‘Creating a new relationship through empathy.’ Recently, SNS users are actively forming peer groups with similar hobbies or purposes, and social influence is also increasing through it (Qin et al. 2018). Although the SNS activities of the participants in this study started with the purpose of obtaining information, they experienced that as recurrent miscarriage became common, it developed into emotional empathy beyond the dimension of information sharing. In the formation of social relationships, empathy is known to play a key role in the process of mutual self-disclosure (Huang 2016). Such self‐exposure is more easily achieved in the same group or groups with common elements, and through this, it was found that it plays a positive buffer against stress or negative psychological state experienced by individuals (Wang et al. 2014).
On the other hand, participants in this study continued to show attachment to their lost fetus. Attachment is an individual's tendency to seek intimacy with a person based on strong emotional bonds (Bowlby 1977). Participants believed that they could catch a lost fetus and bring it back in the form of a new birth. The participants of this study tried to find the meaning of repeated miscarriage in 'The culture’s inherent animism or shamanism' that permeated Korean traditional culture beyond realistic and physical facts. The baby is a psychological symbol that connects generations, and the baby plays a powerful role in protecting the souls of ancestors (Lim 2016), and this is also because it is one of the important aspects of the wellthy (Arthur and Mair 2017).
PTG describes an individual's experience of recovering from trauma. That is, after a period of emotional distress not only returns to pre-traumatic function, but also as an opportunity for personal development (Tedeschi and Calhoun 1996, Tusaie and Dyer 2004). Those in the study also said they were growing inwardly through repeated miscarriages. This is consistent with previous studies that resilience to traumatic experiences or traumatic events can lead to PTG, which can reduce negative emotions and provide a new perspective on life (Ha et al. 2014). According to the PTG theory, reflection on trauma brings about positive change in another dimension of the world and promotes the achievement of wisdom with a new perspective on life (Tedeschi and Calhoun 1996). Instead of focusing on the negative emotions associated with recurrent miscarriage, such as guilt, sadness, fear, and depression, women take a new perspective on life and consequently illuminate inner growth and change (Nakano et al. 2013, Robinson 2014). It is also important to note that repeated miscarriage experiences in this study also changed women's views of life. This provides evidence confirming that PTG can positively influence relationships with others as social beings. As a result, women suffering from miscarriage can recover from their losses through resilience and intervention strategies and ultimately improve their quality of life through emotional support and education (Teo et al. 2013).
This study has the following limitations. First, as the results of this study are the results of in-depth interview with women in South Korea, there is a limit to generalization on behalf of all. Second, in analyzing the results of this study, as questions that can grasp the relationship between lost the fstus and PTG taking into account the obstical characteristics of participants, such as marrige age, etiology of miscarriage, and infertility diagnosis, are not addressed, there is a limitation in not being able to grasp the context in detail. Therefore, based on the results of this study, it is necessary in the future to compare and analyze the internal growth changes of women who experience recurrent miscarriage by applying various conditions such as national, regional, and individual characteristics in depth.
The woman who has suffered more than three miscarriages had time to reflect on the muddy confusion, self-reflectionon daily life, and at the same time to creating a new relationship through empathy among the peer group of SNS. On the other hand, despite the trauma of repeated miscarriage, they tried to find a future-oriented view based on the cultural animism and shamanism. And in the study of participants consistently achieved transforming internal growth along with a change in their perspective on life as women. Therefore, it is necessary to comprehensively explore the experience of repeated miscarriage in an unexpected crisis situation in the future women's life cycle, and to seek research strategies that can help women's health behavior.
Compliance with ethical standards
Conflict of interest The authors declare that there is no conflict of interest.
Ethics approval
This study was conducted after obtaining approval from the IRB of University in South Korea (1041078‐201704‐HRSB‐065‐01). After providing a sufficient explanation of the purpose of the study, confidentiality of the data, and disposal of the data after completing the study, we received the written consent of voluntary participation in the study.
Consent to publication
All authors agree to publish the study.
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Table 1. Examples of interview questions
|
“What changes have you had in your daily attitude after experiencing repeated miscarriages?” “What changes have you had in your relationship with family after experiencing repeated miscarriages?” “What changes have you had in your social interpersonal relationships after experiencing repeated miscarriages?” “What changes have you had in your view of life as a woman after experiencing repeated miscarriages?'' |
Table 2. The characteristics of participants in this study
(N= 23)
|
Participant |
Age (years) |
Number of Miscarriages |
Job |
Education level |
|
1 |
32 |
3 |
No |
Above college |
|
2 |
34 |
3 |
Yes |
High school |
|
3 |
40 |
3 |
Yes |
High school |
|
4 |
36 |
5 |
No |
Above college |
|
5 |
42 |
3 |
No |
Above college |
|
6 |
41 |
3 |
No |
Above college |
|
7 |
28 |
3 |
Yes |
Above college |
|
8 |
30 |
3 |
No |
High school |
|
9 |
32 |
5 |
No |
Above college |
|
10 |
29 |
3 |
No |
Above college |
|
11 |
40 |
3 |
Yes |
Above college |
|
12 |
34 |
3 |
No |
High school |
|
13 |
36 |
4 |
Yes |
Above college |
|
14 |
35 |
3 |
No |
Above college |
|
15 |
28 |
3 |
Yes |
High school |
|
16 |
41 |
7 |
No |
Above college |
|
17 |
30 |
3 |
Yes |
Above college |
|
18 |
32 |
3 |
No |
High school |
|
19 |
33 |
5 |
Yes |
Above college |
|
20 |
39 |
3 |
No |
Above college |
|
21 |
33 |
3 |
Yes |
Above college |
|
22 |
31 |
5 |
No |
High school |
|
23 |
39 |
10 |
No |
Above college |