Experiences of women with threatened abortion: a qualitative study of pregnant women and health providers in Iran

Abstract

Background

There are significant health and psychological consequences associated with threatened abortion (TA). Women who lose desired pregnancies due to abortion are at risk of experiencing grief, anxiety, guilt, and self-blame. In Iranian society, psychological support for pregnant women is low, and as a result, women with TA experience high stress. This study aimed to investigate the experiences of pregnant women with TA and health providers in maternity healthcare services.

Methods

This exploratory-descriptive qualitative study was conducted using semi-structured interviews and purposive sampling. 13 pregnant women and seven key informants (husband and health care providers) were selected from February 2023 to July 2023. Data was analysed using qualitative content analysis with MAXQDA software (version 18).

Results

The most critical causes of concern for women included medical, psychological, social, and financial issues and a lack of sufficient information about their current situation (spotting- bleeding). The participants used constructive coping strategies, such as regular visits to the doctor, and unconstructive coping strategies, like a lack of communication with others, to reduce their worries. Key informants proposed two methods for reducing the concerns of the women, including improving information sharing about abortion and therapeutic support available to pregnant women.

Conclusions

The study proposed that maternity healthcare providers, alongside medical care, should pay attention to techniques for improving the psychological support of women with TA.

Introduction

Abortion is one of the most common complications during early pregnancy. It is estimated that abortion occurs in 20% of all clinically recognized pregnancies and up to half of all pregnancies [1], with threatened abortion (TA) as a subset of abortion [2]. The incidence of TA is increasing every year. Factors involved in this issue include changing lifestyles and eating habits, increasing severe environmental pollution, increasing job and work stress among women and elderly pregnant women, and reducing the quality of oocytes [3]. Unfortunately, half of the women who are threatened with abortion experience a complete abortion [4].

There are significant health and psychological consequences associated with TA. The rate of antepartum hemorrhage, membrane ruptures before delivery, preterm birth, and intrauterine growth restriction was higher among women who had TA than among those who did not [5]. Apart from the medical complications associated with abortion, more attention should be paid to the psychological consequences of abortion, which can take a long time [6]. It may adversely affect subsequent pregnancies. According to a study done in 2014 in Canada country, women who lose desired pregnancies due to miscarriage, stillbirth, or genetic termination are at risk of experiencing grief, anxiety, guilt, and self-blame. This issue may appear in subsequent pregnancies [7]. Also, in a study done in 2021 in Iran, most participants in both induced and spontaneous abortion groups had moderate levels of stress, which could be due to the lack of attention to mental health and the lack of counseling support [8].

Unlike other types of abortion, where patients are allowed to grieve, this is not the case for women who are at risk of losing their pregnancy. It means that parents are concerned about their unborn child's unknown and worrying fate during pregnancy. While the emotional impact of pregnancies lost through abortion is well documented, the effect of TA on the mental health of mothers and fathers is less studied [9]. In various studies, emotional support for women with TA has been mentioned, but no recommendations have been made on what this advice or support might include [10].

The complex emotional and physical experiences of abortion-affected women provide a roadmap for those who want to know how to help them [11, 12]. Therefore, understanding the emotional and physical impact of women's experience of TA is essential to their health management. Women's experiences with TA also help healthcare providers deal with their psychological problems apart from their medical issues, remove the threat of abortion, and alleviate women's concerns using psychological treatments.

Little is known about the concerns of women with TA. This is the first qualitative study about the concerns of Iranian pregnant women with TA. Thus, this qualitative study aimed to investigate the concerns of women with TA and healthcare providers in maternity healthcare services.

Methods

Study design

This was a descriptive exploratory qualitative study. The Consolidated Criteria for Reporting Qualitative Research guidelines were followed for study reporting [13] (See Supplementary 1).

Settings

The study was conducted at two maternity healthcare centers in the north of Iran (Babol) recruited for this study from February 2023 to July 2023.

Population

Pregnant women with TA, under 15 weeks of gestation, and suffering from depression and anxiety disorders were invited to partake. The diagnosis of anxiety and depression disorders was based on the Mini International Neuropsychiatric Interview (MINI) conducted by the first author [14].

The criteria for entering the study were age over 18 years, threats of abortion, being fluent in Farsi, Iranian nationality, and written informed consent. Thirteen eligible pregnant women with TA were included by purposive sampling. In addition, seven key informant interviews) KIIs(were chosen, including five healthcare providers (one gynecologist and four midwives) and two husbands of the women who were threatened with abortion.

Recruitment and data collection

Before the study, a specialist psychologist from the research team (author, MF) trained a clinical psychologist (first author) with pregnancy-related expertise to conduct the interviews. Until data saturation, the purposeful sampling method with maximum diversity (age, occupation, education, and duration of pregnancy) was used. The psychologist interviewed pregnant women and key informants to collect the data.

• 1) Interviews with pregnant women: At the maternity healthcare services, the interviewer explained the study's goals and methods to 35 eligible pregnant women with TA, 20 of whom declined to participate. Their reasons for not entering the study were not having time for an hour-long conversation with a psychologist, not being satisfied with the recording of the interview, having spotting or bleeding, and feeling stressed from talking about their condition. The interviewer asked about the patient's feelings after TA symptoms, reaction to the TA, medical and emotional needs, and how to obtain informational and emotional support. Some examples of questions are given in Table 1.

  Table 1 Semi-structured interview guide

• 2) Interviews with key informants: Key informants included five healthcare providers who were involved in the care of women at risk of abortion in maternity healthcare services, including a gynecologist and four midwives. Two of the husbands of these women were also interviewed. We used Persian to collect the data. The interviewer asked questions about the key informant's views on the emotional and informational needs of the patients with TA, how to provide emotional and informational support, and the number of hospital facilities and equipment to meet the medical and emotional needs. Examples of questions are given in Table 1.

The entire interview session was recorded so that the researchers could examine the pertinent issues. Participants were interviewed in-depth for 35 to 50 minutes with semi-structured questions. After obtaining written consent from all participants, recordings were made, and data were collected until saturation. The participants were assured that their recordings would only be listened to by the research team, deleted after use in the research, and not stored anywhere. All interviews are reviewed anonymously. Interviews were conducted with outpatients in the private practice of gynecologists collaborating in the project and the hospital, respecting ethical principles and preserving patient privacy. The interviews continued until no new code was obtained.

Trustworthiness

The quality criterion for this qualitative research was "Trustworthiness". This method included credibility, transferability, dependability, and conformability [15, 16].

Credibility

The study used four strategies for credibility, including prolonged engagement, persistent observation, triangulation, and member check. Regarding prolonged engagement criteria, an interviewer who was a clinical psychologist trained in qualitative research and interview techniques (First author) investigated sufficient time to become familiar with the settings and context, to test for misinformation, and to build trust. Also, she engaged with the participants in a lengthy interview. All the team researchers focused in detail on characteristics and elements most relevant to the problem or issue under study (persistent observation). The study had triangle criteria for triangulation, including using different data sources, investigators, and data collection methods. The study was implemented in various settings (two maternity healthcare centers). Also, 5 researchers made coding, analysis, and interpretation decisions. For different data collection criteria, the researchers sought to select female participants with the most significant age difference from extended or nuclear families and urban and rural backgrounds. Finally, membership validation was used at the end of the study for member check criteria. Data from the survey, analytical categories, interpretations, and conclusions were returned to participants, and the accuracy of the data was compared against experience.

Transferability

The study provided a "thick description" of the participants and the research process to enable the reader to assess whether the findings are transferable to their setting.

Dependability and conformability

We had an "audit trail" strategy for this criterion. In the first study, the records of interviews were coded individually by the authors, and then the interpretations were compared. If there are different interpretations, the researchers discuss them until a consensus is reached. At the end of the study, membership validation and peer review methods were used. Membership verification methods return hard copies to participants and verify the accuracy of the data against experience. Subcategories were extracted after transcripts, codes, and categories were sent to five impartial midwifery, psychology, and fertility professors using a peer-review method to verify category reliability. Finally, in addition to recordings and transcripts, multiple data sources were used, including field notes, observations, notes, and diaries.

Ethical consideration

This study was approved by the ethics committee of Babol University of Medical Sciences, Babol, Iran, with code IR.MUBABOL.REC.1401.158. All patients signed the free and informed consent form.

Participants were assured that all interviews would be conducted anonymously. Their recordings will only be listened to by the research team, deleted after use in the research, and not stored anywhere.

Data analysis

The resulting data were analyzed using conventional content analysis with MAXQDA software (version 18, VERBI Software, Berlin, and Germany). After each interview, the answers were entered verbatim into an MS Word document (version 2018) and the MAXQDA software (version 18). The transcribed text was then decomposed into semantic units while the concepts reflected in the text were summarized. Units of meaning were abbreviated and given appropriate codes. The codes were divided into subgroups based on similarities and differences, and categories were extracted. Ultimately, a theme was extracted based on the concepts identified in the text.

Results

Table 2 shows the demographic characteristics of women threatened with abortion. The participants have a wide range of demographic characteristics. The average age of the participants was 31 years. 70% of the participants were self-employed and 30% were employees. The average gestational age was 12 weeks. 53% of the participants had a diploma, and 47% had a bachelor's degree or higher.

Table 2 Demographic characteristics of the participants study (pregnant women with TA)

Table 3 shows the demographic characteristics of key informants, consisting of two midwives, two midwifery supervisors, one gynecologist, and two women's wives who were threatened with abortion.

Table 3 Demographic characteristics of the participant's study (key informants)

After data analysis, 70 codes, 12 categories, and four themes were identified. Table 4 presents the two themes, including causes of worry based on patient views and coping strategies based on patients'views.

Table 4 Themes, category, and codes of worries of women with TA extracted from the data analysis (views of pregnant women)

Table 5 presents the two themes, including causes of concern based on key people's views and coping strategies based on key informants' views.

Table 5 Themes, category, and codes of worries of women with TA extracted from the data analysis (views of key informants)

The causes of the threat of abortion from the point of view of the patients

Among the four main themes, this one appeared the most frequently.

Physical problems

Many mothers considered the cause of their threatened miscarriage to be their physical problems, such as back pain, excessive activity, previous comorbidities, and old age. Women who have a chronic disease perceive their pregnancy as high-risk and require increased monitoring and follow-up.

"Well, I'm old; I should have been more careful. I think age has much influence on abortion threats. I should have observed more. I should have worked less. We live in a village where there are many heavy activities. I think one of the reasons for my bleeding is excessive activity." (P4: WWTA)

"I think my history of heart disease and taking warfarin was the reason for my TA. Of course, I have a history of one miscarriage, and I was taking medicine at that time. Now that I'm spotting again, I think that my illness is making my miscarriage worse. I am apprehensive because this pregnancy was on my own accord, and the doctors did not allow me to get pregnant." (P4: WWTA)

Family issues

Many patients suffer from family problems that make them more worried, such as lack of family support and incorrect information, low economic status, worry about other children, unwanted pregnancy, and remarriage. Having sufficient and correct knowledge of the patient's family about her condition and her relatives' timely and informed support will reduce these women's worries.

"This pregnancy is the result of my second marriage. I have a child from my first marriage who lives with his father, and I don't see him. I miss him, and being separated from my child makes me anxious." (P4: WWTA)

"I did not tell my family that I was pregnant. I didn't tell them because my previous pregnancy was also aborted. I didn't want my family to be bothered. Of course, it's hard for me to think that I can't have a good pregnancy in front of my husband's family. I'm ashamed. I just told my mother. She suffers from heart disease, and I don't want to upset her either." (P8: WWTA)

Medical procedures

Misdiagnosis, incorrect doctor action, low support of healthcare providers, failure to prescribe required medicine, and use of assisted reproductive methods are other concerns of pregnant women, as well as the threat of abortion.

"The skill of the doctor is also essential for women threatened with abortion. The energy I get from my new doctor, I don't get from anyone. I believe in her and am confident that whatever she says is based on her experience and delivered with care and knowledge." (P2: WWTA)

*Lack of understanding and support from society

"I was threatened with abortion and needed complete rest. Because I am also working, I feel stressed. They gave me a week's sick leave, but it was very little. I was terrified and wanted more time off because I had a history of miscarriage. Unfortunately, this was impossible, and my employer disagreed with my leave." (P1: WWTA).

Strategies for coping with worries

This theme included two categories, namely, unconstructive coping and constructive coping. Almost all unconstructive coping strategies were significantly associated with anxiety, worry, and depression during bleeding and spotting.

Unconstructive coping

Crying, decreasing or increasing sleep or eating, lack of communication with others, impatience, and not doing personal and household chores were among the coping strategies used by this group of women.

"I was very stressed, sad, and afraid that my fetus would miscarry when I had spotting. My sleep was disturbed, my eating was reduced, and I didn't like to go out or even do anything at home. I wanted absolute rest." (P1: WWTA).

Constructive coping

Some women had constructive coping strategies in the situation of TA, which included regular visits to the doctor and clinic, correct and regular use of medicine, obtaining sufficient information from the doctor, listening to music and dancing, and praying and trusting in God.

"I took my midwife's advice, and it was extremely beneficial to me. I relaxed by listening to music. I used the experiences of people around me." (P4: WWTA).

"When I was worried about my spotting, I would do things to calm myself down, such as listening to music or dancing. I used to distract myself with these things, but I calmed down when my doctor gave me information, took time, and talked to me." (P4: WWTA).

The causes of the worries based on the views of Key Informant

Insufficient patient support

This item was the most common reason for pregnant women to worry about the threat of abortion from the point of KIIs. The evidence from this review shows that women in less developed countries still face significant inequalities in quality and access to services, as the World Health Organization recommended.

"Treatment facilities should be available to women threatened with abortion. These women should not worry about the availability of doctors and midwives. Patients who come from hard-to-reach places and are threatened with abortion are worried about the long distance. Medicines such as progesterone should be available in all villages, and insurance coverage of drugs is also important. Some drugs, such as imported progesterone, are expensive." (p1:KI).

"These women believe that if they don't have a child, their lives will be unstable, and they are afraid of losing their husbands and lives. They consider having a child as the greatest success of their lives." (p2:KI).

"One of the treatment measures that are performed for patients is a vaginal examination, which is performed to determine their condition. They think that these examinations will speed up the abortion process. Therefore, they resist a lot and get stressed. Most patients expect that the doctor will give them medicine to prevent abortion, which is also due to their lack of knowledge." (p3:KI).

General problems and society

Among other things, the reason pregnant women are concerned about the threat of abortion from the point of view of KIIs is the general problems of society. Sometimes, some countries do not have easy access to the imported equipment needed for their treatment because they are embargoed.

"Ultrasound is not always available 24 hours a day in the hospital. Emergency cerclage equipment should be available. Quality threads for cerclage are one of the essential needs of these patients, which sometimes cannot be found due to the embargo on Iran and the fact that this device is imported, and it causes trouble for us."(p5:KI).

"Women threatened with abortion consider this bleeding and spotting as a threat to their lives. Because abortion happens more often in the early stages of pregnancy, the pregnant mother and her fetus have not yet had a deep psychological connection unless it is the second or third pregnancy. Pregnant women with their first pregnancy usually have more fear. Of course, lower education and knowledge are associated with higher levels of stress, and they want more psychological support." (p4:KI).

Strategies of coping with worries based on the view of key Informants

According to key informants, two types of strategies can be used to reduce patient anxiety. Many patients rely on their healthcare professionals. Searching for the necessary scientific information about one's illness and carefully following up on the danger signs from doctors is a consistent coping strategy in these patients.

Education of women

From the point of view of key Informants, a large part of the anxiety of these women can be controlled by holding educational classes in Maternity Healthcare Services from the beginning of pregnancy.

"In my opinion, these patients must hold training classes to familiarize them with the psychological aspects of the threat of abortion. If women become aware of their problems, they can inform their families. Training classes and coping with stress for pregnant women and their husbands play an important role in reducing their anxiety." (p2:KI).

"Upon the arrival of the referring women, we should fully explain the situation to them and establish verbal communication with them. Psychologically prepare them for examination and other treatment measures. Let's tell the truth. We must teach them the danger signs; they should return if the bleeding becomes severe." (p3:KI).

Therapeutic support

Key informants stated that appropriate and timely therapeutic support alleviates much of the anxiety and worry of patients. From their point of view, therapeutic support includes:

Establishing medical allowances and having supplementary insurance by Maternity Healthcare Service, paying attention to psychological issues along with physical problems, appropriate treatment measures, such as prescribing medicine and cerclage, the need for ultrasound and 24-hour diagnostic procedures in the hospital, proper treatment, empathy, and psychological support and providing suitable hospitalization conditions with companionship.

"Psychological support during hospitalization for these women should be considered. They should feel that they are not alone and that special services are given to them. Even if we can have sections for this group of women that are calmer and have the possibility of having a companion, it is good psychological support for them." (p2:KI).

"As a wife, I do everything that comforts him, such as verbal support, hugging, kissing, and touching. Help with housework. Let's do other children's work. It would be great if there were systems where a woman could raise her question and get an answer during her pregnancy. For example, they can use artificial intelligence to create an application that at least answers frequently asked questions similar to pregnancy, which is very good." (p6:KI).

Discussion

The present study was conducted to investigate the concerns of pregnant women threatened with abortion in maternity healthcare services. The causes of concern differ from the patient's and key informants' perspectives.

According to the current study, patients were concerned about physical issues such as back pain, physical diseases, high activity, and old age. They believed that these factors play an important role in spotting and threatening their abortion. In another study, the role of excessive activity was mentioned as a factor in the threat of abortion. In that study, spontaneous abortion was mainly attributed to activities that require the use of excessive energy and traveling on bad roads by pregnant women [17]. Along with physical problems, psychological problems were also the leading causes of concern. In the present study, the most critical psychological problems that the patients stated were a history of infertility, first pregnancy and lack of experience, and stress and anxiety during pregnancy. Many infertile women want to become mothers, and several qualitative studies have shown that motherhood is a central concern for them [18, 19].

This study revealed that family issues and unpleasant experiences significantly impact patients' concerns. The financial burdens of infertility, the lack of social and economic support, aging and its effects on fertility, the low likelihood of remarriage for infertile women, and the dislike of single life in conventional societies; women are immobilized by these challenges in their quest for solutions [20]. Anxiety, a history of mental illness, smoking, drug and alcohol abuse, a lack of social support, and a poor quality relationship with a spouse have all been identified as risk factors for anxiety disorders during pregnancy [21]. Mothers who have benefited from the emotional support of their husbands, families, and even social networks during pregnancy have fewer complications after childbirth. These mothers are less likely to suffer from mental problems such as worry, anxiety disorders, and depression, and they have fewer premature births and miscarriages [22].

Additionally, Yao and co-workers' research shows that motherhood and childrearing were turning points in women's lives, and they understand how important it is to have children to maintain a successful marriage and a healthy family [23]. During the period when mothers are threatened with abortion, they not only experience physiological and hormonal changes but also may not be able to control the new and upcoming conditions psychologically. Therefore, they are in dire need of social support so that they can overcome their problems.

According to the findings of this study, low financial and economic status, as well as a low level of family income, are among the most critical concerns of pregnant women, along with the threat of abortion. The high costs of multiple ultrasounds for fetal follow-up and specialized tests have added to pregnancy problems. If special facilities were considered for pregnant women who experience the threat of abortion, less stress would be imposed on them. A 2017 United States study examined the relationship between financial stress and birth weight. Their results showed that financial strain was positively related to symptoms of depression, anxiety, perceived stress, and pregnancy-specific distress, while it was negatively associated with birth weight. Depression mediates the relationship between financial stress and birth weight [24]. In this regard, in the qualitative study, lack of financial preparedness in pregnancy was one of the subclasses of inability to accept the parental role. Also, in the qualitative research of Arfai and co-workers, economic problems were among the main concerns of mothers [25]. It seems that community and family financial support for these women has a vital role in reducing their anxiety.

Medical procedures were discovered to be one of the concerns of women threatened with abortion in the current study. Sometimes, inappropriate diagnosis and action of the doctor, incorrect prescription of medicine, and use of assisted reproductive methods increase the worry of women threatened with abortion. Along with this study, a qualitative similar survey was conducted on women suspected of fetal abnormalities. Study results showed concern about medical diagnosis processes was the most common source of concern among women suspected of having fetal abnormalities, followed by uncertainty about the diagnosis by the doctor [26]. It seems that by more accurately diagnosing the possibility of continued pregnancy or its impossibility, the doctor has removed the uncertainty for women threatened with abortion so that they can make the best decision in the shortest possible time and deal with the psychological consequences of any outcome.

One of the sources of uncertainty is the nature of the abortion threat. It is tough to diagnose early miscarriage definitively, so it is not surprising that the women in the study experienced great uncertainty and sometimes conflicting opinions about whether their pregnancies would continue. Similar to the findings of our research, in another study, pregnant women who were threatened with premature birth had a similar experience and experienced uncertainty [27].

Pregnant women with TA used constructive and unconstructive coping methods to deal with their worries. Abortion stress varies from woman to woman; some females report experiencing mental health issues, while others report coping well or even growing as a person as a result of their abortion [28]. The differing qualities of women's psychological experience are affected by several factors, including the reasons for the abortion, gestational age at abortion, attitude toward abortion, social setting, and whether there are concurrent stressors (like destitution, domestic violence, and mental health concerns) [29]. They hoped not to lose their pregnancy and sought to obtain sufficient information from the doctor, the treatment staff, and the experiences of women similar to them. The results of another study showed that the overarching theme was one of searching for hope and understanding when experiencing a threatened miscarriage [10]. Due to their particular conditions, these women need exceptional understanding and support from the people around them and doctors.

This study found that some pregnant women use religious coping and prayer to deal with their worries. Personality effects (self-esteem, control, and optimism) seem effective in adjusting to TA. When dealing with stressful life events, religious people can be less harmed by having a sense of belonging to a divine source, trusting that God will provide help when life becomes difficult and stressful, and taking advantage of spiritual support [30]. Therefore, religious counseling by midwives or healthcare professionals can increase mothers' mental health and even help them adapt to conditions like TA.

This study has clinical implications for maternal healthcare providers. Psych educational support and medical treatment are the primary strategies for reducing the patients' worries. Our findings suggested that holding training classes or psychotherapy sessions for women facing abortion threats could alleviate a large part of their concerns. In another study conducted on women who had recurrent miscarriages, counseling sessions reduced depression, anxiety, and stress in women with recurrent miscarriages [31]. In another study in Iran, counseling sessions based on Fordyce's happiness program were conducted for eight sessions with women who had abortions. There was a significant difference in anxiety and depression levels between the intervention and control groups immediately after the intervention and one month later. Women with spontaneous abortions were found to be less anxious and depressed after participating in Fordyce's happiness counseling program [32].

One of the existing problems for the threatened women in attending the educational class was that, due to the bleeding and spotting that these women have, they may not be able to participate in the training classes. Therefore, according to the suggestions of key Informants, these classes can be held online because many women with TA are on absolute rest and do not have the conditions to attend face-to-face classes. In a study conducted on 123 pregnant women, the results showed that an eight-week online mindfulness intervention was effective in reducing symptoms of depression and anxiety [33]. Therefore, online psychotherapy sessions can be used as a low-cost and accessible method to help reduce the stress and worry of pregnant women threatened with abortion, as well as significantly decrease the number of unnecessary visits to the clinics. Of course, our study had some limitations. First, the causes of some worries, such as financial concerns and a lack of facilities, are related to the society under study and may not be generalizable to other institutions. Also, these women's coping strategies are influenced by their society's religion, culture, and social issues.

Conclusions

The results of this study revealed that the most critical concerns of pregnant women with TA in maternity healthcare services include medical, psychological, social, and financial issues and a lack of sufficient information. Also, patients used both constructive and non-constructive coping strategies to reduce their worries. This study proposed two methods for reducing women's worries, including improving information about abortion and therapeutic support from healthcare providers. The study emphasized that maternal healthcare providers, alongside medical treatment, should pay attention to strategies for reducing the worries of women with TA.