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Grief and Depression After Miscarriage: Their Separation, Antecedents, and Course
Abstract
Bereavement is a major risk factor for physical illness, grief, depression, and anxiety. In contrast to recent tendencies in the psychiatric literature to equate grief and depression, we propose that a careful discrimination between the two must be made for diagnostic, therapeutic, and investigative purposes. We report the results of a longitudinal study of a frequent but neglected event, miscarriage early in pregnancy, to make this point. Clinical criteria for differentiating grief and depressive reactions were developed based on phenomenological criteria and theoretical considerations. We hypothesized that the detrimental psychological and physical consequences occur only when the miscarriage was not mourned and resulted in a depressive reaction, but not in a grief reaction. In a controlled, representative study, 125 consecutive women were assessed shortly after their miscarriage (before the 20th week of gestation) and 6 months (N = 94) and 12 months (N = 90) later. Assessments included standardized questionnaires for life events, depression, physical complaints, anxiety, and a specific, multidimensional grief scale (Munich Grief Scale) that we had developed previously. Immediately after the miscarriage, the average anxiety and depression scores were elevated when compared with 80 pregnant and 125 age-matched community controls. Twenty percent of the patients who had miscarried showed a grief reaction, 12% showed a depressive reaction, and 20% responded with a combined depressive and grief reaction. The remaining women (48%) reported no changes in their emotional reactions. As predicted, longer-lasting psychological, social, and health status changes followed the initial depressive, but not the grief reactions. Depressive reactions were predicted by a history of previous depression, a lack of social resources, and an ambivalent attitude to the lost fetus. The grief measures were reliable and made it possible to discriminate between grief and depression.
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Ambivalent attitudes toward the pregnancy are associated with more intense grief reactions, and loss of an unplanned pregnancy is often reacted to in the same way.
“As mentioned above, ambivalent attitudes toward the pregnancy were found to be associated with more intense grief reactions, and loss of an unplanned pregnancy was often reacted to in the same way.37,38”
From Complicated grief after perinatal loss (2012) · cites this paper as [38]
No specific relationships could be found between grief and maternal age, marital status, or occupational status after prenatal loss.
“A number of further predictors have been generally associated with psychological morbidity after prenatal loss, but no specific relationships could be found between grief and maternal age, marital status, or occupational status.22,37,38”
From Complicated grief after perinatal loss (2012) · cites this paper as [38]
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Cited by
Sorted by citations
Complicated grief after perinatal loss
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“loss, but no specific relationships could be found between grief and maternal age, marital status, or occupational status.(22,37,38)”
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Lok, I. H., & Neugebauer, R. (2007) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2006.11.007 · Cited by 302
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“Beutel et al., 3 on the other hand, administered standardized independent measures of grief and depression to women who experienced a spontaneous abortion.”
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The psychological impact of early pregnancy loss
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Klier, C. M., Geller, P. A., & Ritsher, J. B. (2002) · Archives of Women's Mental Health · doi:10.1007/s00737-002-0146-2 · Cited by 176
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Social and Professional Support Needs of Families After Perinatal Loss
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Robinson, G. E. (2013) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2013.08.012 · Cited by 142
Beutel, M., Willner, H., Deckardt, R., Von Rad, M., & Weiner, H. (1996) · Journal of Psychosomatic Research · doi:10.1016/0022-3999(95)00520-x · Cited by 141
Self-citationA 1-year longitudinal study of psychological morbidity after miscarriage
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“Sadness after miscarriage can be approached as a transitory grief response warranting supportive care, 39–44 a trigger of clinical depression or posttraumatic stress disorder necessitating treatment, 4,5,9,60 or a situational crisis warranting careful consideration of both responses.”
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“Study Design Nature/Size of Sample Main Measure(s)Used Results Beutel et al Matched group 94 women who miscarried State-Trait Anxiety Scale Women who miscarried (1995) (12) 80 women age-matched in experienced elevated anxiety first 20 weeks of pregnancy compared with matched 125 community controls Anxiety levels compa…”
Predicting Depressive Symptoms after Miscarriage: A Path Analysis Based on the Lazarus Paradigm
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“Previous studies have also shown that talking about pregnancy loss with loved ones can move the grieving process along and that lack of social support can prolong and complicate the grief response [15].”
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“Irrespective of detected prevalence rates, studies have consistently found that, postmiscarriage, women are at increased risk of depression in comparison to community non-pregnant females [22], pregnant women of a similar gestational age [23], or post-partum female controls [24].”
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“Thirteen women were excluded based on the following exclusion criteria: (1) not Norwegianspeaking (n /9); (2) mentally disabled or suffering from serious psychiatric illness (n /3); (3) pregnancy following rape (n /1).”
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“(1995) followed up women up to 1 year after miscarriage and found that bereaved women suffered longer lasting negative psychological, physical and social changes following initial depression [10].”
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“…the quality and the duration of reaction to a miscarriage (Kersting and Wagner, 2012): social and marital support, previous depressive episodes (Beutel et al., 1995, 1996), personality traits (e.g. neuroticism) (Friedman and Gath, 1989), having other children rather than being childless, and a…”
InfluentialUNDERSTANDING AND MANAGING THE EMOTIONAL REACTIONS TO A MISCARRIAGE
Brier, N. M. (1999) · Obstetrics and Gynecology · doi:10.1016/s0029-7844(98)00294-4 · Cited by 82
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“Beutel et al. (1995) used the MGS to measure parental grief at 6 and 12 months after a miscarriage and found that grief scores were significantly lower 6 months postloss.”
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Swanson, K. M., Connor, S., Jolley, S. N., Pettinato, M., & Wang, T.-J. T. (2007) · Research in Nursing & Health · doi:10.1002/nur.20175 · Cited by 73
“Beutel et al. (1995) demonstrated that although gestational age was not correlated with levels of depression, it was associated with prolonged grieving.”
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Nynas, J., Narang, P., Kolikonda, M. K., & Lippmann, S. (2015) · The Primary Care Companion For CNS Disorders · doi:10.4088/pcc.14r01721 · Cited by 72
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Meta-analysis to obtain a scale of psychological reaction after perinatal loss: focus on miscarriage
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ADOLFSSON, A., BERTERÖ, C., & LARSSON, P. (2006) · Acta Obstetricia et Gynecologica Scandinavica · doi:10.1080/00016340500539376 · Cited by 60
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The Miscarriage Experience: More Than Just a Trigger to Psychological Morbidity?
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van den Akker, O. B. (2011) · Expert Review of Obstetrics & Gynecology · doi:10.1586/eog.11.14 · Cited by 56
Perinatal Bereavement Grief Scale: Distinguishing Grief From Depression Following Miscarriage
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Duelo perinatal: un secreto dentro de un misterio
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Motherhood as a vulnerability factor in major depression: the role of negative pregnancy experiences
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Johnson, J. E., Price, A. B., Kao, J. C., Fernandes, K., Stout, R. L., Gobin, R. L., & Zlotnick, C. (2016) · Archives of Women s Mental Health · doi:10.1007/s00737-016-0625-5 · Cited by 46
“A lack of social support has been associated with greater distress and impairment following perinatal loss (Beutel et al. 1995; Biondi and Picardi 1996; Swanson 2003a), and positive social support has been found to be associated with better adjustment to perinatal loss (Abboud and Liamputtong 2005;…”
Rowlands, I. J., & Lee, C. (2010) · Psychology Health & Medicine · doi:10.1080/13548500903440239 · Cited by 41
“hospitalisation for a major injury or illness; break-up with a partner; serious financial difficulties), either during pregnancy or in the year prior to the miscarriage, are associated with more psychological distress (Warsop, Ismail, & Iliffe, 2004), depression (Beutel et al., 1995; Broen, Moum, Bodtker, & Ekeberg, 2…”
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“A history of depression or other psychiatric illness has been found consistently to have a negative impact on adjustment after miscarriage (Beutel et al., 1995; Mann, McKeown, Bacon, Vesselinov, & Bush, 2008; Neugebauer et al., 1997).”
BackgroundPersonal Growth After Severe Fetal Diagnosis
Black, B., & Sandelowski, M. (2010) · Western Journal of Nursing Research · doi:10.1177/0193945910371215 · Cited by 39
A Comparison of Grief as Related to Miscarriage and Termination for Fetal Abnormality
Keefe-Cooperman, K. L. (2005) · OMEGA - Journal of Death and Dying · doi:10.2190/qfdw-lgey-cylm-n4lw · Cited by 38
“It was hypothesized that females who terminated a wanted pregnancy would experience a greater vulnerability for emotional problems as evidenced by a depressive reaction (Beutel et al., 1995).”
BackgroundRisk factors and interventions for psychological sequelae in women after miscarriage
Athey, J., & Spielvogel, A. M. (2000) · Primary Care Update for OB/GYNS · doi:10.1016/s1068-607x(00)00023-8 · Cited by 38
Shrouds of silence: three women’s stories of prenatal loss
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Parental behavior after perinatal death: twelve years of observations
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Mothers' Perceptions of Benefits of Perinatal Loss Support Offered at a Major University Hospital
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Interconception Care for Couples After Perinatal Loss
Moore, T., Parrish, H., & Black, B. (2011) · The Journal of Perinatal & Neonatal Nursing · doi:10.1097/jpn.0b013e3182071a08 · Cited by 32
Mendes, D. C. G., Fonseca, A., & Cameirão, M. S. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1188060 · Cited by 31
“(8), 48% of the women participating had no significant emotional reactions the first days after the loss, but more recent studies support that a significant number of women end up experiencing very sad feelings after pregnancy loss in general, and for some, these emotions can be very intense (3, 9, 10).”
BackgroundDilemmas Related to Pregnancy Loss
Robinson, G. E. (2011) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e318225f31e · Cited by 31
“Beutal et al. (1995), however, found that 48% of the 125 women they studied had no change in their emotional reactions.”
BackgroundThe miscarriage circle of care: towards leveraging online spaces for social support
Alqassim, M. Y., Kresnye, K. C., Siek, K. A., Lee, J. R., & Wolters, M. K. (2022) · BMC Women s Health · doi:10.1186/s12905-022-01597-1 · Cited by 33
Quality of Life in Women Undergoing Medical Treatment for Early Pregnancy Failure
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Spiers, M. V., Geller, P. A., & Kloss, J. D. (2013) · Wiley eBooks · doi:10.1002/9781394260454 · Cited by 29
Screening for post-miscarriage psychiatric morbidity
Lok, I. H., Lee, D. T. S., Yip, S., Shek, D. T. L., Tam, W. H., & Chung, T. K. H. (2004) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2004.01.003 · Cited by 28
Women's experience of early miscarriage: a phenomenological study
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“Similar findings have been supported in other studies of depression following miscarriage (Beutel et al 1995; Prettyman et al 1993).”
BackgroundResultThe Reproductive Story: Dealing with Miscarriage, Stillbirth, or Other Perinatal Demise
Jaffe, J. (2014) · Springer eBooks · doi:10.1007/978-3-319-05116-1_9 · Cited by 26
Applying Heidegger’s interpretive phenomenology to women’s miscarriage experience
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Kim, H.-J. J., & Hupka, R. B. (2002) · Cross-Cultural Research · doi:10.1177/10697102036003003 · Cited by 25
Miscarriage at advanced maternal age and the search for meaning
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Depressive Symptoms in a Sample of Women Following Perinatal Loss
Adeyemi, A., Mosaku, Ajenifuja, O., Fatoye, Makinde, & Ola (2008) · Journal of the National Medical Association · doi:10.1016/s0027-9684(15)31548-0 · Cited by 25
Pregnancy loss: a major life event affecting emotional health and well‐being
Boyce, P. M., Condon, J. T., & Ellwood, D. A. (2002) · The Medical Journal of Australia · doi:10.5694/j.1326-5377.2002.tb04399.x · Cited by 24
Kukulskienė, M., & Žemaitienė, N. (2022) · Healthcare · doi:10.3390/healthcare10010079 · Cited by 23
Rich, D. E. (2000) · Illness, Crisis & Loss · doi:10.1177/105413730000800303 · Cited by 22
“Parents who experience pregnancy loss are at increased risk of suffering serious psychological disturbance, which may take the form of a variety of psychological symptoms and is likely to impair daily living skills functioning (Beutel et al. 1995, 1996; Garel et al. 1994).”
BackgroundDevelopment and evaluation of a miscarriage follow-up clinic
Nikčević, A. V. (2003) · Journal of Reproductive and Infant Psychology · doi:10.1080/0264683031000154999 · Cited by 21
“answers to questions related to the medical aspects of miscarriage (e.g. "why?", "what are the chances of it happening again?"), as well as discussing the emotional aspects of their loss. Such findings seem to suggest that follow-up services which would correspond to these women's needs should include both medical and…”
MethodResultMeasuring the Meaning of Miscarriage: Revision of the Impact of Miscarriage Scale
Huffman, C., Swanson, K. M., & Lynn, M. R. (2014) · Journal of Nursing Measurement · doi:10.1891/1061-3749.22.1.29 · Cited by 20
“When followed prospectively, most individuals have a gradual decline in depression and grief over the course of a year, with levels at 1 year, similar to comparison populations (Beutel et al., 1995; Lok, Yip, Lee, Sahota, & Chung, 2010).”
ResultPsychiatric disorders following fetal death: a population-based cohort study
Munk‐Olsen, T., Bech, B. H., Vestergaard, M., Li, J., Olsen, J., & Laursen, T. M. (2014) · BMJ Open · doi:10.1136/bmjopen-2014-005187 · Cited by 18
“After 6 months, these two groups differed substantially according to depression scores, anxiety scores and somatisation, but the differences were not statistically significant after 12 months, which is in line with the results reported by Beutel et al.33 A recent study from China compared women who miscarried (miscarr…”
ResultDepressive Störungen bei körperlich Kranken
Arolt, V., & Rothermundt, M. (2003) · Der Nervenarzt · doi:10.1007/s00115-003-1629-8 · Cited by 40
The Effect of an Expressive Writing Intervention on Pronouns: The Surprising Case of I
Dunnack, E. S., & Park, C. L. (2009) · Journal of Loss and Trauma · doi:10.1080/15325020902925084 · Cited by 15
Psychology of Reproduction: Pregnancy, Parenthood, and Parental Ties
Leon, I. G. (2008) · The Global Library of Women s Medicine · doi:10.3843/glowm.10419 · Cited by 15
Brisch, K. H., Munz, D., Kächele, H. U., TERINDE, R., & Kreienberg, R. (2005) · Journal of Loss and Trauma · doi:10.1080/15325020590908849 · Cited by 14
“The elevated level of anxiety could indicate that these previous events were not worked through and were then reactivated by the new pregnancy—regardless of whether or not it was complicated (Beutel et al., 1995; Franche & Culow, 1999).”
Psychologie et perte de grossesse
Legendre, G., Gicquel, M.-C. C., Lejeune, V., Iraola, É., Deffieux, X., Séjourné, N., Bydlowski, S., Gillard, P., Sentilhes, L., & Descamps, P. (2014) · Journal de gynécologie, obstétrique et biologie de la reproduction. Supplément/Journal de gynécologie obstétrique et biologie de la reproduction · doi:10.1016/j.jgyn.2014.09.019 · Cited by 15
Tuyl, R. V. (2024) · Women s Health · doi:10.1177/17455057231224180 · Cited by 15
Nikčević, A. V., & Nicolaides, K. H. (2013) · Psychology and Health · doi:10.1080/08870446.2013.823497 · Cited by 12
Psychological aspects of spontaneous and recurrent abortion
Bagchi, D., & Friedman, T. (1999) · Current Obstetrics and Gynaecology · doi:10.1016/s0957-5847(99)90068-9 · Cited by 12
Tung, I., Beardslee, J., Pardini, D. A., Chung, T. A., Keenan, K. E., & Hipwell, A. E. (2019) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13112 · Cited by 11
Miscarriage: Women's Experience and its Cumulative Incidence
Adolfsson, A. (2006) · Cited by 11
Moreira, D. S., Azeredo, A. A. C., Moreira, D. S., Fávero, M., & Sousa‐Gomes, V. (2022) · European Psychologist · doi:10.1027/1016-9040/a000490 · Cited by 14
The Aborted Time: A Temporal View on the Trauma of Pregnancy Loss
Slobodin, O. (2014) · Journal of Depression & Anxiety · doi:10.4172/2167-1044.1000163 · Cited by 10
“The painful aftermath of miscarriage is further complicated by the insufficient support these women often experience [25].”
BackgroundCharrois, E. M., Mughal, M. K., Arshad, M., Wajid, A., Bright, K. S., Giallo, R., & Kingston, D. E. (2022) · Journal of Affective Disorders · doi:10.1016/j.jad.2022.03.055 · Cited by 9
Dayan, J., Andro, G., Dugnat, M., Thessier, N., Milijkovitch, R., & Rosenblum, O. (2014) · Elsevier eBooks · doi:10.1016/b978-2-294-71024-7.00017-7 · Cited by 9
Depression bei körperlichen Erkrankungen
Arolt, V., & Rothermundt, M. (2004) · Steinkopff eBooks · doi:10.1007/978-3-662-12845-9_19 · Cited by 9
PREDICTORS OF GRIEF AND DEPRESSED MOOD AMONG GAY MEN FOLLOWING AN AIDS-RELATED LOSS
Wayment, H. A., & Kemeny, M. E. (2004) · Journal of Loss and Trauma · doi:10.1080/15325020490458327 · Cited by 7
Correlates of miscarriage among young women in the Australian Longitudinal Study on Women's Health
Rowlands, I. J., & Lee, C. (2008) · Journal of Reproductive and Infant Psychology · doi:10.1080/02646830701806313 · Cited by 7
“, 1995 ) and during the following three months (e.”
BackgroundNelson, S. K., Robbins, M. L., Andrews, S. E., & Sweeny, K. M. (2015) · Sex Roles · doi:10.1007/s11199-015-0564-z · Cited by 12
“Though this gives cause for optimism, the negative emotional impact of miscarriage can be lasting (Beutel et al. 1995 [Germany]), and may contribute to distress as men and women attempt to conceive following a miscarriage.”
BackgroundLiving Through an Early Pregnancy Loss: an Autoethnographic Account
Chaudhary, A. (2019) · Human Arenas · doi:10.1007/s42087-019-00059-9 · Cited by 6
Warsop, A., Ismail, K., & Iliffe, S. (2004) · Psychology Health & Medicine · doi:10.1080/13548500410001721873 · Cited by 6
“The few prospective studies conducted to date indicate that an ambivalent attitude to the pregnancy (Buetel et al., 1995), and the fact that the pregnancy is unplanned (Prettyman, 1993) are significantly associated with higher levels of anxiety at follow up.”
BackgroundFriedrichs, J. B., Daly, M., & Kavanaugh, K. L. (2000) · Illness Crisis & Loss · doi:10.1177/105413730000800306 · Cited by 6
“In a study of miscarriage, Beutel et al. (1995) presented findings that differentiated grief from depression and identified risk factors for depressive reactions.”
BackgroundBarbe, C., Boiteux-Chabrier, M., Charillon, E., Bouazzi, L., Maheas, C., Merabet, F., Graesslin, O., Auer, J., Hammami, S., Rolland, A.-C., et al. (2023) · BMC Psychology · doi:10.1186/s40359-023-01421-x · Cited by 5
“In reported studies, anxiety scores tend to normalize after around 6 months, compared to non-pregnant women [11–13].”
ResultColeman, P. (2009) · Current Women s Health Reviews · doi:10.2174/157340409788185785 · Cited by 6
“Oxytocin, a nanopeptide hormone seems to play a role in the emergence of maternal attachment behavior across pregnancy and the postpartum [47, 48].”
BackgroundGrief Following Pregnancy Loss – Literature Review
Bangal, V. B., Sachdev, S., & Suryawanshi, M. (2013) · International Journal of Biomedical Research · doi:10.7439/ijbr.v4i4.250 · Cited by 5
Nath, K., Bhattacharya, A., Sinha, P., & Praharaj, S. K. (2014) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2014.12.007 · Cited by 5
“features during subsequent pregnancies (Beutel et al., 1995; Hamama et al., 2010; Chalana and Sachdeva, 2012).”
Navigating grief and pregnancy loss through online story telling
Jones, A. E., Scoresby, K. J., & Duong, C. C. (2022) · Qualitative Social Work · doi:10.1177/14733250221108634 · Cited by 4
“Following a miscarriage, grief behaviors have been identified as preoccupation and yearning of the lost child, sadness at seeing pregnant women or newborns, guilt at not being able to protect the baby, and feeling empty (Beutel et al., 1995).”
BackgroundInfluential
Metadata
- Authors
- Beutel, M., Deckardt, R., von Rad, M., & Weiner, H.
- Affiliations
- University of California, Los Angeles (US)
- ORCID
- Beutel, Manfred
- Venue
- Psychosomatic Medicine
- Published
- 1995
- Volume
- 57
- Issue
- 6
- Pages
- 517-526
- ISSN
- 0033-3174 (ISSN-L)
- OpenAlex
- W2010032202
- Cited by
- 140
- References
- 23
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 3 · 2023: 2 · 2022: 7 · 2021: 3 · 2020: 2 · 2019: 4 · 2018: 2 · 2017: 2 · 2016: 2 · 2015: 8 · 2014: 10 · 2013: 7 · 2012: 7
- FWCI
- 0.99
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychosomatic Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
- Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
- Keywords
- miscarriage, grief, depression, bereavement, differential diagnosis, anxiety, physical complaints, social support, longitudinal follow-up
- MeSH terms
- Abortion, Spontaneous, Adaptation, Psychological, Adolescent, Adult, Anxiety Disorders, Bereavement, Depressive Disorder, Diagnosis, Differential, Female, Gestational Age, Grief, Humans, Life Change Events, Middle Aged, Pregnancy, Psychiatric Status Rating Scales, Psychometrics, Surveys and Questionnaires, Risk Factors
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