The role of boundary ambiguity: a new understanding on perinatal grief and psychological distress among Chinese women who experience miscarriage after IVF

Abstract

Study question: The current study attempts to examine the role of boundary ambiguity in perinatal grief, psychological distress and coping, as well as to explore the phenomenological experience of boundary ambiguity and family stress among Chinese women who experience miscarriage after IVF. Summary answer: It was found that boundary ambiguity experienced by the miscarrying women after successful pregnancy through IVF, a perceptual state in which an individual is uncertain about who is in or out of the family system, could be able to predict perinatal grief and depression, difficulty in coping, as well as psychological despair. What is known already: Research focusing on boundary ambiguity has been applied to a number of different populations and can be varied among different belief systems and family structures. Little is known among the role of boundary ambiguity in case of miscarriage, which is presumably associated with the psychological wish for a baby to be present when he/she is physically absent, causing maternal stress and impair individual functioning subsequently. Study design, size, duration: A mixed method including a cross-sectional quantitative study and in-depth interviews was conducted. Structured questionnaires included Boundary Ambiguity Scale, Perinatal Grief Scale, and Hospital Anxiety and Depression Scale. Individual interviews were conducted in order to generate their subjective experience of boundary ambiguity and its association with psychological distress. Participants/materials, setting, methods: 41 women (response rate = 46%, mean age = 30, SD = 1.3) experiencing first-trimester miscarriage after successful IVF were recruited at a university-affiliated hospital in Hong Kong. Informed consent was sought during hospital-stay after miscarriage treatment. Twelve agreed to participate a follow-up interview 2 weeks after discharge from hospital. Main results and the role of chance: Quantitative analysis has shown that boundary ambiguity could significantly predict perinatal grief [F(1,39) = 63.87, p < 0.001] and depression [F(1,37) = 4.416, p < 0.05] in miscarrying women. This was consistent with the previous research on boundary ambiguity that the higher the subjective experience of boundary ambiguity, the higher the psychological distress and daily dysfunction among individuals. From the qualitative interviews, four meta-themes emerged as most representative of the phenomenological experiences of miscarriage after successful IVF cycle, namely as (i) difficulty in making sense of the sudden loss; (ii) confusion about the presence of physical body sensation and the absence of the baby; (iii) perceptual difference towards the experience among family member resulting higher ambiguity in family structure; and (iv) and the nature of disenfranchised grief in perinatal loss. Limitations, reason for caution: The lack of available information about the premorbid status of the person before their loss, which allows the researcher to infer the person’s level of functioning prior to pregnancy loss. Self-selection bias was also inevitable in questionnaire survey, and the cross-sectional nature of the study did not permit causal inferences. Wider implications of the findings: The current study adds to the understanding of boundary ambiguity of miscarriage women and their acute perinatal grief in facing pregnancy loss. The nature of ambiguity in case of miscarriage can shed light on the new perspective of counselling by acknowledging the perceptual discrepancy between the psychological presence and physical absence of the baby. The acute experience of perinatal grief and depression highlights the need of psychological support at this critical point of healthcare provision. Study funding/competing interest(s): Funding by University(ies), The University of Hong Kong.