Document Type : Original Article


1 M.Sc. Student of Counselling in Midwifery, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

2 Department of Midwifery, Maternal and Childhood Obesity Research Center, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

3 Department of Epidemiology and Biostatistics, School of Medicine, University of Medical Sciences, Urmia, Iran


BACKGROUND: The loss of a pregnancy can result in grief, guilt, self‑doubt, anxiety, and
post‑traumatic stress disorder (PTSD). Considering the side effects mentioned for mental health
and the fact that the symptoms will linger if left untreated and even adversely affect the subsequent
pregnancies. The current study was designed to assess the impact of individual counseling on stress,
anxiety, and depression in mothers with pregnancy loss.
MATERIALS AND METHODS: The study commenced 100 women who experienced pregnancy loss
(in Urmia/2018-2019); they were enrolled using convenience sampling and block randomization. The
intervention group received four individual counseling sessions (weekly sessions with a duration of
1 h) based on Warden’s principles. The control group received routine care. The Depression Anxiety
Stress Scale (DASS‑42) was filled out at baseline, the pre‑ and post‑intervention. Analyses were
performed using the Chi‑square, paired, or individual t‑tests, when necessary. P value < 0.05 was
considered significant.
RESULTS: There were no significant differences regarding socio‑demographic characteristics and
clinical features between groups at baseline. Intra‑group analysis showed that all outcome measures
in the intervention group were significantly improved. According to inter‑groups analysis, a significant
association was found between pre‑test and post‑test in the intervention group (P < 0.05).
CONCLUSION: Results of this study can clarify the psychological effects of pregnancy loss in these
mothers and help the officials and responsible parties to plan the treatment and rehabilitation of these
women and include them in the healthcare system.


  1. Jones RK WE, Jerman J. Abortion incidence and service availability
    in the United States. PerspectSexReprod Health 2017;49:17‑27.
    2. Barfield WD. Standard terminology for fetal, infant, and perinatal
    deaths. Pediatrics 2016;137:e20160551.
    3. Cunningham F, Leveno K, Bloom S, Spong CY, Dashe J. Williams
    Obstetrics. 24thed. New York, NY, USA: Mcgraw-hill; 2018.
    4. VogelJ, SouzaJ, MoriR, MorisakiN, LumbiganonP, LaopaiboonM,
    et al. Maternal complications and perinatal mortality: Findings of
    the World Health Organization multicountry survey on maternal
    and newborn health. BJOG 2014;121:76‑88.
    5. Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al.
    National, regional, and worldwide estimates of stillbirth rates in
    2015, with trends from 2000: A systematic analysis. Lancet Global
    Health 2016;4:e98‑108.
    6. Cena L, Stefana A. Psychoanalytic perspectives on the
    psychological effects of stillbirth on parents: A protocol for
    systematic review and qualitative synthesis. FrontPsychol
    2020;11:1216. doi: 10.3389/fpsyg.2020.01216.
    7. Salenius P. Sociological and psychological effects of stillbirth:
    Theory, research, and midwifery. Br J Midwifery 2019;27:616‑9.
    8. Côté‑Arsenault D, Leerkes EM, Zhou N. Individual differences
    in maternal, marital, parenting and child outcomes following
    perinatal loss: A longitudinal study. JReprodInfant Psychol
    9. Herbert D, Young K, Pietrusińska M, MacBeth A. The mental
    health impact of perinatal loss: A systematic review and
    meta‑analysis. JAffective Disord 2022;297:118‑29.
    10. Biggs MA, Brown K, Foster DG. Perceived abortion stigma and
    psychological well‑being over five years after receiving or being
    denied an abortion. PLoSOne 2020;15:e0226417.
    11. Boyle FM, Horey D, Middleton PF, Flenady V. Clinical practice
    guidelines for perinatal bereavement care—An overview. Women
    Birth 2020;33:107‑10.
  2. 12. Burden C, Bradley S, Storey C, Ellis A, Heazell AE, Downe S, et al.
    From grief, guilt pain and stigma to hope and pride–Asystematic
    review and meta‑analysis of mixed‑method research of the
    psychosocial impact of stillbirth. BMC Pregnancy Childbirth
    13. Adib‑Rad H, Basirat Z, Faramarzi M, Mostafazadeh A, Bijani A,
    Bandpy MF. Comparison of women’s stress in unexplained early
    pregnancy loss and normal vaginal delivery. JEducHealth Promot
    2020;9. doi: 10.4103/jehp.jehp_381_19.
    14. Sadock BJ, Ahmad S, Sadock VA. Kaplan & Sadock’s Pocket
    Handbook of Clinical Psychiatry. Alphen aan den Rijn, the
    Netherlands, Wolters Kluwer; 2019.
    15. Boryri T, Navidian A, Zehi FH. Assessing the effect of self‑care
    education on anxiety and depression among pregnant women
    with a history of spontaneous abortion. J Educ Health Promot
    16. Yuen WS, Lo HC, Wong WN, Ngai FW. The effectiveness
    of psychoeducation interventions on prenatal attachment:
    A systematic review. Midwifery 2022;104:103184.
    17. Charrois EM, Bright KS, Wajid A, Mughal MK, Hayden KA,
    Kingston D. Effectiveness of psychotherapeutic interventions
    on psychological distress in women who have experienced
    perinatal loss: A systematic review protocol. SystRev 2020;9:1‑8.
    doi: 10.1186/s13643‑020‑01387‑6.
    18. Fenstermacher KH, Hupcey JE. Support for young black
    urban women after perinatal loss. MCN AmJMatern Child
    19. Shfiabady, A. "Counseling: Methods and Techniques (Clinical
    Interview)." Tehran, Ketab Fekre Noe, 2016.210 P. persian.
    20. Gibson RL, Mitchell M. Interoduction to Counseling and
    Guidance. Tehran: Roshd; 2015. 734 p.
    21. Meredith P, Wilson T, Branjerdporn G, Strong J, Desha L. “Not just
    a normal mum”: A qualitative investigation of a support service
    for women who are pregnant subsequent to perinatal loss. BMC
    Pregnancy Childbirth 2017;17:6. doi: 10.1186/s12884‑016‑1200‑9.
    22. Johnson OP, Langford RW. A randomized trial of a bereavement
    intervention for pregnancy loss. J Obstet Gynecol Neonatal Nurs
    23. Roberts LR, Montgomery SB. Mindfulness‑based intervention for
    perinatal grief in rural India: Improved mental health at 12 months
    follow‑up. Issues Ment Health Nurs 2016;37:942‑51.
    24. Martin TL. Worden, JW. Grief Counseling and Grief Therapy. A
    Handbook for the Mental Health Practitioner. SAGE Publications
    Sage CA: Los Angeles, CA; 2019.
    25. Goldberg DP, Hillier VF. A scaled version of the general health
    questionnaire. Psychol Med 1979;9:139‑45.
    26. Navidian A, Saravani Z. Impact of cognitive behavioral‑based
    counseling on grief symptoms severity in mothers after stillbirth.
    Iran J Psychiatry Behav Sci 2018;12. doi: 10.5812/ijpbs.9275.
    27. Lovibond PF, Lovibond SH. The structure of negative emotional
    states: Comparison of the depression anxiety stress scales (DASS)
    with the beck depression and anxiety inventories. Behav Res Ther
    28. Afzali A, Delavar A, Borjali A, Mirzamani M. Psychometric
    properties of DASS‑42 as assessed in a sample of Kermanshah
    High School students. J Res Behav Sci 2007;5:81‑92.
    29. Swanson KM, Chen H‑T, Graham JC, Wojnar DM, Petras A.
    Resolution of depression and grief during the first year
    after miscarriage: A randomized controlled clinical trial
    of couples‑focused interventions. J Women’s Health
    30. Mosayeb Moradi M JF, Seyed Fatemi N, Montazeri A. The effect of
    counseling on anxiety levels of women with spontaneous abortion.
    Payesh J 2016;15:174‑9.
    31. Hajnasiri H, Behbodimoghddam Z, Ghasemzadeh S, Ranjkesh F,
    Geranmayeh M. The study of the consultation effect on depression
    and anxiety after legal abortion. Iran J Psychiatr Nurs 2016;4:64‑72.
    32. Navidian A, Saravani Z, Shakiba M. Impact of psychological grief
    counseling on the severity of post‑traumatic stress symptoms in
    mothers after stillbirths. Issues Ment Health Nurs 2017;38:650‑4.
    33. Koert E, Malling G, Sylvest R, Krog M, Kolte A, Schmidt L, et al.
    Recurrent pregnancy loss: Couples’ perspectives on their need
    for treatment, support and follow up. HumReprod 2019;34:291‑6.
    34. Shaohua L, Shorey S. Psychosocial interventions on psychological
    outcomes of parents with perinatal loss: A systematic review and
    meta‑analysis. Int J Nurs Stud 2021;117:103871. doi: 10.1016/j.
    35. Kong G, Chung T, Lok I. The impact of supportive counselling on
    women’s psychological wellbeing after miscarriage–Arandomised
    controlled trial. BJOG 2014;121:1253‑62.
    36. Coffey H. Parents’ experience of the care they received following
    a stillbirth: A literature review. Evidence Based Midwifery
    37. Lisy K, Peters MD, Riitano D, Jordan Z, Aromataris E. Provision
    of meaningful care at diagnosis, birth, and after stillbirth:
    A qualitative synthesis of parents’ experiences. Birth 2016;43:6‑19.
    38. Peters MD, Lisy K, Riitano D, Jordan Z, Aromataris E. Caring
    for families experiencing stillbirth: Evidence‑based guidance for
    maternity care providers. Women Birth 2015;28:272‑8.
    39. Biggs MA, Neuhaus JM, Foster DG. Mental health diagnoses
    3 years after receiving or being denied an abortion in the United
    States. AmJPublic Health 2015;105:2557‑63.
    40. Ridaura I, Penelo E, Raich RM. Depressive symptomatology
    and grief in Spanish women who have suffered a perinatal loss.
    Psicothema 2017;29:43‑8.
    41. Zaraj H, Vakilian K, Rezveh FM. Reducing anxiety of pregnant
    women with a history of pregnancy loss‑a randomize clinical
    trial. Curr Women’s Health Rev 2020;16:160‑6.
    42. Fernández‑Basanta S, Movilla‑Fernández M‑J, Coronado C,
    Llorente‑García H, Bondas T. Involuntary pregnancy loss and
    nursing care: A meta‑ethnography. Int J Environ Res Public Health
    2020;17:1486. doi: 10.3390/ijerph17051486.
    43. Burden C, Bradley S, Storey C, Ellis A, Heazell AE, Downe S, et al.
    From grief, guilt pain and stigma to hope and pride–Asystematic
    review and meta‑analysis of mixed‑method research of the
    psychosocial impact of stillbirth. BMC Pregnancy Childbirth
    2016;16:9. doi: 10.1186/s12884‑016‑0800‑8.