524 Women’s Health Psychology
educated about practical communication strategies when in-
teracting with female patients.
STRESSFUL CONDITIONS
RELATED TO PREGNANCY
Our culture typically associates pregnancy and childbirth
with positive emotions and with motherhood; however, this
is not the case for all pregnancies or for all women. This sec-
tion addresses a different aspect of these reproductive events,
speci“cally focusing on stressful conditions related to preg-
nancy. Whereas postpartum depression has received a great
deal of attention in the literature, other postpartum reactions
and issues relating to infertility have received less, and psy-
chosocial factors related to such phenomenon as miscarriage
and peripartum cardiomyopathy have received even less.
Miscarriage
Miscarriage involves the spontaneous termination of an in-
trauterine pregnancy with the conceptus dead on expulsion,
with most studies de“ning miscarriage as the unintended ter-
mination of pregnancy before 27 completed weeks of gesta-
tion (Neugebauer et al., 1992). Miscarriage occurs in 10% to
20% of clinically recognized pregnancies (Kline et al., 1995),
but risk varies substantially by age (e.g., 9% for women aged
20 to 24 years, but 75% for women over age 45 years; Nybo
Andersen, Wohlfahrt, Christens, Olsen, & Melbye, 2000).
Stillbirth, de“ned as late fetal death with a fetus weighing
more than 500 grams, is not uncommon with a risk of 0.4 to
1.2 per 1,000 in singleton pregnancies (Yudkin & Redman,
2000) and with a higher risk in multiple pregnancies. Risk
factors established or suspected in one or more studies can be
broadly classi“ed as environmental (e.g., caf feine, nicotine,
and other drug use; toxins; electromagnetic “elds; stressful
life events), or biological (e.g., genetic, including chromoso-
mal abnormalities; endocrinologic; anatomic; immunologic;
microbiologic; see Klier, Geller, & Ritsher, 2002, for a
review).
For many women, miscarriage constitutes an unantici-
pated, traumatic experience that can be associated with
considerable physical pain and discomfort and may pose a se-
rious threat to the life of the woman (Saraiya et al., 1999).
Physiologically, miscarriage marks the end of a pregnancy,
and psychologically, may produce fears and doubts about
procreative competence. Psychological reactions to repro-
ductive loss vary, but often include sadness, distress, guilt,
and fear (e.g., Borg & Lasker, 1981). In contrast to the large
body of research on risk for reproductive failure, studies
concerning psychological distress in the aftermath of the loss
event are more limited, and investigations employing appro-
priate comparison groups are sparse (Klier et al., 2002).
However, research including such comparison groups has es-
tablished that miscarriage is a risk factor for depressive reac-
tions ranging from depressive symptoms (Janssen, Cuisinier,
Hoogduin, & de Graauw, 1996; Neugebauer et al., 1992;
Thapar & Thapar, 1992) to minor and major depressive dis-
order (Klier, Geller, & Neugebauer, 2000; Neugebauer et al.,
1997). Speci“cally, miscarrying women•s risk for an episode
of minor depression in the six months after loss is 5.2-fold,
and for major depression, 2.5-fold, that of otherwise compa-
rable community women. History of major depression is a
risk factor for a recurrent episode, but length of gestation at
time of loss or attitude toward the pregnancy do not seem
to play a role (Klier et al., 2000; Neugebauer et al., 1997).
Studies that investigated the development of anxiety symp-
toms following loss found mixed results, although those with
comparison groups suggest that anxiety levels may be sub-
stantial after miscarriage (Beutel, Deckardt, Von Rad, &
Weiner, 1995; Lee & Slade, 1996; Thapar & Thapar, 1992).
In a study of anxiety disorders that employed a cohort design,
Geller, Klier, and Neugebauer (2001) reported that miscar-
riage increases risk for a recurrent episode of obsessive com-
pulsive disorder (OCD), but not for panic disorder or speci“c
phobia. Risk for posttraumatic stress disorder (PTSD) may
also be increased following reproductive loss (Engelhard,
van den Hout, & Arntz, 2001).
Clinical attention in the early weeks after miscarriage may
help to offset more serious psychological and psychiatric
consequences of the loss. Psychological symptoms may also
occur in pregnancies subsequent to a miscarriage, and
health care and mental health professionals should attend to
these concerns as well. Not only is it important to attend
to the psychological sequelae of miscarriage in women, but
also to psychosocial factors such as women•s relationships
with their partners and children, as well as attachment to
future children (Hughes, Turton, Hopper, McGauley, &
Fonagy, 2001; Klier et al., 2002). In addition, since miscar-
riage involves a loss that often remains unknown to all but a
woman•s most intimate con“dants and her health care
providers, the grieving process may be compounded by
limited social support and the challenge of managing feelings
associated with the loss of a potentialchild. After multiple
miscarriages, women may decide to undergo evaluation and
treatment for secondary infertility, which, as discussed next,
may challenge coping resources to an even further degree.
There is a great need for the development and evaluation of
postloss mental health intervention. To develop appropriate
clinical screening methods and treatment protocols for these