Effects of Empowerment on the Attitudes toward Fertility and Childbearing in Women with Failed Pregnancies: A Clinical Trial

Background & Aims: Failed pregnancy is a destructive and common experience associated with physical, psychological, and cognitive complications, including a negative self-image, doubts about one's fertility, considering the body to be inefficient, and feeling of failure in playing the feminine role and fulfilling the feminine identity adequately, which are manifested through reduced sexual activity and unwillingness to become pregnant again. In addition, the lack of sexual drive causes communicational tensions between parents. Therefore, a failed pregnancy affects the approach and attitude toward parenting, and since attitude is the foremost factor in the development of reproductive behavior, changing attitudes toward childbearing decreases fertility. Repeated pregnancy positively influences the stress caused by a failed pregnancy despite a sense of doubt and hesitation in the parents. After fetal loss, the majority of women need consultations and follow-ups regarding the causes of the incident, estimated risk of future pregnancy, and prevention of recurrence, while they may not be presented with the opportunity and receive no training, and the lack of awareness leads to concerns about the recurrence of the incident, unwillingness for another pregnancy, and even the attempt to conceive inappropriately. Therefore, the provision of an educational, care, and support program for these women with an emphasis on their experience of a failed pregnancy is paramount. Knowledge-based empowerment interventions promote the knowledge of fertility, self-efficacy, self-esteem, and self-control, thereby improving social communication, reducing negative emotions, and creating the right attitude to life experiences; in relation to failed pregnancies, such interventions have not been performed in Iran. The present study aimed to evaluate the impact of empowerment on women with a history of failed pregnancies. Materials & Methods: This clinical trial was conducted on 80 women with a history of failed pregnancies who were admitted to Shahid Akbarabadi Hospital in Tehran, Iran within the past 3-6 weeks for the termination of pregnancy during January-May 2020. The inclusion criteria were the age of 18-40 years, basic literacy, no medical prohibition for pregnancy, no children, absence of mental disorders, no pregnancy after a failed pregnancy, history of failed pregnancies up to the maximum of two cases, no history of infertility, and intentional failed pregnancy. The exclusion criteria were stressful events during the study, absence in more than one training session, and pregnancy during the study. The names of eligible subjects were extracted from the hospital medical records unit continuously until the completion of the sample size. The women were invited to participate via phone. After obtaining written informed consent from all the subjects, they were assigned to two groups of intervention and control with four random blocks, and each sample was assigned a specific code. In the intervention group, empowerment training was performed based on the steps of threat perception, problem-solving, training participation, and evaluation in four training sessions and group discussions for four consecutive weeks at Akbarabadi Medical Training Center. Before and six weeks after the intervention, data were collected using Soderberg's attitudes toward fertility and childbearing scale, which was completed by both groups. Data analysis was performed in SPSS version 16 using independent and paired t-test, analysis of covariance (ANCOVA), Chi-square, and Fisher's exact test, and the P-value of less than 0.05 was considered significant. Results: The intervention and control groups had no significant differences in terms of the mean age of the women and their spouses, women's age upon marriage, duration of marriage, women's age in the first pregnancy, fetal age, education level, occupation status of the spouses, cause of the failed pregnancy, gender of the expired fetus, method of pregnancy termination, and current method of contraception (P>0.05). Before the intervention, no significant differences were observed in the mean scores of attitude toward the fertility and childbearing of the women and all the subscales, with the exception of fertility required for the fulfillment of prerequisites (P=0.032) between the intervention and control groups (P>0.05). Six weeks after the intervention, the results of independent t-test and ANCOVA indicated significant differences in the mean scores of attitude toward fertility, female fertility, and all the subscales between the study groups (P<0.001), and the scores of the intervention group were significantly higher compared to the control group. In addition, the results of paired t-test showed significant differences in the mean scores of attitude toward fertility, childbearing, and all the subscales in the intervention group after the intervention as the scores were higher compared to before the intervention (P<0.001), while the difference was not considered significant in the control group (P>0.05). The results of independent t-test also indicated that the increase in the scores of attitude toward pregnancy, childbearing, and all the subscales was more significant in the intervention group compared to the control group six weeks after the intervention than before the intervention (P<0.001). Conclusion: The present study aimed to assess the effects of empowerment on the attitudes toward fertility and childbearing in the women with a history of failed pregnancies. According to the results, the mean total score and mean scores of the subscales of attitudes toward fertility and childbearing were significantly higher in the intervention group after the empowerment training compared to the control group, indicating that the implementation of an empowerment program with the aim of increasing knowledge, motivation, self-esteem, and self-efficacy results in self-control, preventive behaviors, and improved attitudes, which in turn positively influence the promotion of health and quality of life. Although pregnancy could be a pleasurable experience for the mother and family, the awareness of loss and feelings of shock, sadness, anger, and rejection cause tremendous ambiguity and concerns about the consequences of future pregnancies, while also causing negative attitudes toward fertility and childbearing, which may lead to immediate attempts for repeated pregnancy without considering the challenges of a terminated pregnancy and recurrence of failed pregnancy or the unreasonable delay of the next pregnancy regardless of the time limit of female fertility. Therefore, psychological support and training along with physical care by knowledgeable experts could be effective by empowering these vulnerable women through providing correct information to eliminate misconceptions, which in turn enhances healthy fertility by improving the attitudes toward fertility and childbearing. Since midwives have more interaction with these women as one of the most effective healthcare team members, they could use our findings to take effective steps toward improving this crisis and finding proper solutions.