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Influencing Factors of the

Grief, Depression, and

Quality of Life in Taiwanese

Women with Perinatal Loss

Sigma Theta Tau International's 28th International

Nursing Research Congress

Ya-Ling Yang, RN, Ph.D., Assistant Professor

Wen-Yu Hu, RN, Ph.D., Professor

School of Nursing, College of Medicine,

National Taiwan University

2017/07/27

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Introduction

➢ Perinatal loss affect on 11.8 ‰ (n= 2507) of

pregnancies (abortion, therapeutic abortion,

miscarriages, IUFD) among 9.08 ‰ Crude

birth rate (2015) in Taiwan.

➢Chinese culturally not prefer to talk

about perinatal loss.

➢The perinatal loss is devastating,

potentially traumatizing for women

regardless of indications.

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Introduction

- Rational

➢The prenatal genetic screening rate is

increasing, consequently increasing

termination rate.

➢The biopsychosocial-spiritual distress

caused by the perinatal loss.

➢Less evidences to explore the current

status of grief, depression and quality

of life in this population.

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The Aim

(1) explore differences of the grieving

adaptation, depression and quality of life

(QoL) for women at 3 time-range groups (2,

4, 6 months) after perinatal loss.

(2) compare differences between elective and

non-elective indications groups in grieving

adaptation, depression and QoL.

(3) identify predicting factors associated with

grief and QoL.

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Methods A cross-sectional survey for 3 time-range (2,

4, 6 months) groups of women after perinatal

loss.

A teaching hospital in northern Taiwan.

The birth rate is around 3000 NB/ year, among

that perinatal loss rate is 3.6%.

the eligible subjects were recruited from an

OBS-GYN outpatient clinic.

Inclusion criteria:

1.GA≧16 weeks. 2. women aged 20~45 years.

Exclusion criteria:

psychological disease. 2017/07/27

2017/7/24

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➢Dependent Variables (Measuring Scales)

Chinese version

Quality of Life Scale (SF-12)

MOS SF-12 included Physical Health &

Mental Health Summary.

Physical Function (PF), Role Physical (RP), Bodily

Pain (BP), General Health (GH), Vitality (VT),

Social Function (SF),Role Emotional (RE) and

Mental Health (MH) 8 dimensions.

The Cronbach’s alpha was 0.86.

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➢ Independent Variables (Measuring Scales)

Perinatal Grief Scale (PGS)

33-item SVPGS was developed by Potvin,

Lasker, & Toedter, 1989.

SVPGS with three-factor dimensions :

Active Grief, Difficulty Coping, and Despair.

total score ranged 33~165, higher scores

indicating higher grief.

The Cronbach’s alpha was 0.93.

Chinese version

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Becker Depression Inventory (BDI-II)

21-item BDI was included depression symptom

and severity.

Total score ranged 0~63, higher scores

indicating higher severity in depression.

The Cronbach’s alpha was 0.94.

The General Self-Efficacy Scale (GSE) 10-item GSE was developed by Schwarzer, R.

& Jerusalem, M. (1995). to predict coping with

daily hassles and adaptation after experiencing stressful life events. (10~40)

The Cronbach’s alpha was 0.92.

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The participants’ demographic and clinic

characteristics

Self-report questionnaire: including

educational years, marital status, employed

status, gravida, parity, maternal-newborn

touch, and indications.

Medical records: diagnosis, type of

delivery, fetus delivery condition, and

maternal complications after delivery.

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➢ Procedures

• This study was approved by the institutional

ethics review board of the National Taiwan

University Hospital (No. 201404094RINB).

• the participants who submitted and completed

the informed consent, then were provided

study’s questionnaires.

• The participant were divided into elective and

non-elective subgroups, and considered the

time-range after who experienced perinatal loss

(2, 4, 6 months –3 groups).2017/07/27

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➢ Statistical analysis

• Statistical analysis was performed using

SPSS software .

• Descriptive analysis: mean ± standard

deviation (SD), categorical variables -

frequency and percentage.

• Compare analysis: Nonparametric test-

Mann-Whitney U & Kruskal-Wallis H

• Multivariate linear regression: to examine the

effects of independent variables.

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ResultsDemographic and clinical characteristics

Elective: the foetus is defective/ malformation,

genetic testing abnormally (≦24GA)

Case N=33.2M: 6 (18.2%), 4M:15 (45.5%), 6M:12 (36.4%)

Non-selective: IUFD, Spontaneous abortion,

PPROM, …(≧20GA)

Case N=37.

2M: 3 (8.1%), 4M:16 (43.2%), 6M:18 (48.6%)

Reject rate (%): 70.3%. (6. 2014.~12. 2015) 2017/07/27

Table 1. Demographic and clinical characteristics

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Elective

(n=33)

Non-elective (n=37) Mann-

Whitney U

(Z)Mean ± SD

n (%)

Mean ± SD

n (%)

Age 33.97 ± 4.32 34.49 ± 3.63 592.0 (-.219)

Educational years 15.58 ± 2.09 16.11 ± 1.70 585.0 (-.332)

Employed condition

Yes 26 (78.8) 27 (73.0)

None 7 (21.2) 10 (27.0)

Gravida 2.48 ± 1.73 1.73 ± 0.80 462.5 (-1.843)

Para 0.48 ± 0.57 0.43 ± 0.65 563.5 (-.641)

Primi 18 (54.5) 24 (64.9)

Multi 15 (45.5) 13 (35.1)

GA 19.16± 3.16 21.73 ± 6.51 491.5 (-1.216)

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2 M 4 M 6M

elective Non-elective elective Non-elective elective Non-elective

PCS42.74 ± 7.84 50.61 ± 7.97 52.02 ± 6.41

43.89 ± 7.42 40.44 ± 9.82 52.9 ± 6.39 48.47 ± 8.88 53.98 ± 5.75 50.54 ± 6.65

MCS39.70 ± 8.07 43.12 ± 12.24 41.75 ± 9.30

39.07 ± 9.07 40.97 ± 7.17 44.08 ± 12.29 42.22 ± 12.52 41.99 ± 9.01 41.58 ± 9.80

PGS

(33~165)

97.89 ± 18.87 93.32 ± 18.75 101.02 ± 21.35

98.0 ± 23.65 97.67 ± 5.13 91.0 ± 16.67 95.50 ± 20.82 100.02 ± 26.78 101.5 ± 17.70

Active Grief39.67 ± 9.42 38.97 ± 9.41 41.52 ± 7.0

38.33 ± 9.21 42.33 ± 2.52 38.27 ± 8.88 39.63 ± 10.14 42.13 ± 8.70 41.11 ± 5.84

Difficulty Coping30.67 ± 4.92 29.65 ± 4.34 31.53 ± 6.73

31.5 ± 5.58 29.0 ± 3.61 28.73 ± 3.90 30.50 ± 4.68 30.75 ± 7.26 32.06 ± 6.51

Despair27.56 ± 6.37 24.71 ± 6.72 27.97 ± 9.83

28.17 ± 7.96 26.33 ± 0.58 24.0 ± 5.89 25.38 ± 7.54 27.42 ± 12.55 28.33 ± 7.90

BDI

(0~63)

22.00 ± 13.08 9.74 ± 8.12 12.59 ± 9.26

24.83 ± 14.69 16.33 ± 8.50 7.93 ± 7.97 11.44 ± 8.14 14.0 ± 11.35 11.59 ± 7.67

GSE

(10~40)

25.89 ± 3.30 27.00 ± 4.75 28.37 ± 5.25

25.5 ± 3.15 26.67 ± 5.24 26.33 ± 4.50 27.63 ± 5.04 30.67 ± 3.42 26.83 ± 5.76

Table 2a. The grief, depression, self-efficacy and QoL in

three time-range groups.

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Time period

n (%)

2M 4M 6M Kruskal-Wallis

test

(Chi- square)9 (13.24) 31 (45.59) 28 (41.18)

SF-12

PCS

42.74 ± 7.84 50.61 ± 7.97 52.02 ± 6.41 8.581*

BDI 13.08 ± 4.36 9.74 ± 8.12 12.59 ± 9.26 9.664**

Mann-Whitney Test

Z

PCS

6M VS. 2M: -2.974**

4M VS. 2M: -2.445*

BDI

6M VS. 2M: -2.218*4M VS. 2M: -3.017**

Table 2b. Changing and the differences among three

measuring-time subgroups in measurements

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Table 3. Compared the differences between elective

and non-elective subgroups in measurements

Elective

(n=33)

Non-elective

(n=37)Mann-

Whitney U

Z

SF-12 PCS 51.65 ± 7.20 48.73 ± 8.22 467.5 -1.350

MCS 42.41 ± 10.50 41.82 ± 10.71 563.5 -0.172

PGS 98.59 ± 18.40 95.65 ± 21.79 544.0 -0.783

Active Grief 27.76 ± 4.42 27.16 ± 5.24 587.5 -0.271

Difficulty Coping 39.68 ± 9.21 40.57 ± 7.75 525.0 -1.001

Despair 29.97 ± 5.57 31.14 ± 5.55 553.0 -0.678

BDI 13.21 ± 12.02 11.92 ± 7.83 587.5 -0.073

GSE 27.76 ± 4.12 27.16 ± 5.24 553.5 -0.673

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Table 4a. The influencing factors for PGS

Mode R R square Adjusted R square F

2 .974 .949 .947 631.1**

The predictors Standardized coefficients β t

Age .715 7.006**

GA .267 2.615*

Variables

✓Educational years, Gestational age (GA), Maternal

Age

Dummy---

✓Para & Gravida (multi VS primi), time-range (2 & 4

VS. 6), indication, delivery method, M-C attachment,

employed status.

* p < 0.05; ** p < 0.01

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Table 4b. The predictor for factors of PGS

Mode R R square Adjusted R square F

Active grief 2 .975 .951 .950 664.28**

Despair 2 .950 .902 .899 313.49**

Predictors Standardized coefficients β t

Active grief Age .664 6.672**

GA .319 3.207**

Despair Age .675 4.780**

GA .283 2.003*

Mode R R square Adjusted R square F

Difficulty coping 2 .977 .955 .954 729.056**

Predictor Standardized coefficients β t

Age .513 2.831**

Educational years .467 2.574**

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Table 5a. The influencing factors for MCS of quality of

life (SF-12 )

Mode R R square Adjusted R square F

4 .803 .65 .62 29.57**

The predictors Standardized coefficients β t

Active grief (PGS) -.446 -5.269**

BDI -.363 -4.352**

GSI .244 3.001**

Age -.172 -2.263*

Table 5b. The influencing factors for PCS of quality of

life (SF-12 )Mode R R square Adjusted R square F

1 .328 .107 .094 8.18**

The predictors Standardized coefficients β t

BDI -.328 -2.86**

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Discussions - 1

• Age is a good predictor in grief and MCS.

• The time change among the three time-range

groups only in PCS and BDI were different.

• The grief, depression, GSI and quality of life

were no difference between elective and non-

elective mothers.

• The grief responses were still bothering the

participant at 6 months after they

experiencing stressful life events (perinatal

loss). 2017/07/27

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Discussions - 2

Limitation

1.Only one medical center was involved in

this study and this might limit the variation

of participant’s responses.

2.The partner responses to perinatal loss

should be considered as an influencing

variable of maternal grief and quality of life.

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Discussions – 3

Clinical Implication

• The woman’s attitude toward the role

function and meaning of a mother crucial to

the psychological consequences after

perinatal loss.

• The result is helpful for the doctors and

nurses to assess and counsel the mother

contemplating termination or undergo

failure in tocolysis.

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Acknowledgements

The author would like to thank

1.The participants for their

cooperation in completing the study

questionnaires.

2.The National Science Council of

Taiwan (MOST 103-2629-B-002-001)

provided financial support for this

study.2017/07/27

Thank you for your

attention!!24