Coping Strategies in The Women With Infertility and Miscarriages

To Investigate Attributional Styles and Coping Strategies in The Women With Infertility and Miscarriages

ACKNOWLEDGEMENT

Glory to Allah Almighty, I pay my most humble thanks to Allah, the Beneficent, the Merciful, Who blessed me with great courage and strength to undertake this task.

Apart from efforts of me, success of the project depends largely on the encouragement, prayers and guidelines of many others. I take this opportunity to express my gratitude to the people who have been instrumental in the successful completion of this work. Above them all are my loving parents and my younger sister, whom bundle of prayers, moral support and encouragement throughout these two years, enabled me to fulfill this degree as well as this research work.

I’m heartily thankful and indebted to my dearest friend who was a BIG helping hand for me at every hour of difficulty which started from the selection of the topic till the completion of the entire thesis, who was always there for me with invaluable kind behavior, supervision, support, worry about my work, and with a solution. It was her guidance and support from the initial to the final level that enabled me to develop an understanding and completion of the research work. Without her help this research would surely not have been materialized.

A special gratitude I give to my supervisor and co-supervisor for their valuable supervision, suggestions and encouragement that empowered me to complete this work.

I would like to gratefully acknowledge my lovely friends, whom support encouraged me at every step towards the completion of this work.

I am thankful to the authors and translators of the tools who gave me permission to use their tools. I am also thankful to the participants who actively participated without any gain and gave me their precious time and information for this research project.

Last but not least I am very thankful to the library and computer lab staff and all existing staff of the Institute of Applied Psychology and especially to every individual who directly and indirectly make this task possible for me.

                                                                                             

List of Contents

Title	Page no
Declaration Certificate Acknowledgment Contents List of Tables List of Appendices Abstract	ii iii iv vi viii ix x
Chapter I
Introduction	1
1.1 Infertility	1
1.2 Miscarriage	3
1.3 Attributional Styles	6
1.3.1 Types of Attributional styles	9
1.4 Coping Strategies	10
1.4.1 Types of Coping Strategies 1.4.2 Coping strategies and Defense Mechanisms	12 12
Chapter II
Literature Review	14
2.1 Attributional Styles	14
2.1.1 Attributional Styles and miscarriages	16
2.2 Coping Strategies	17
2.2.1 Coping Strategies and infertility	17
2.2.2 Coping Strategies and Miscarriages	18
2.3 Infertility	19
2.4 Miscarriages	19
2.5 Indigenous researches	20
2.6 Rationale 2.7 Objective 2.8  Hypothesis	23 23 23
Chapter III
Method	25
3.1 Research Design	25
3.2 Sampling Strategy	25
3.3 Sample	25
3.4 Inclusion Exclusion criteria
3.4.1 Inclusion criteria for women with Infertility and Miscarriages	25
3.4.2 Exclusion criteria for women with Infertility and miscarriages with miscarriages	26
3.5 Assessment Measures	30
3.5.1 Demographic Information Sheet	30
3.5.2 Brief Cope Inventory	31
3.5.3 Attribution of problem cause and solution scale	31
3.6 Ethical Consideration	32
3.7 Procedure	32
Chapter IV
Results	34
4.1 Summary of Findings	41
Chapter V
Discussion	43
5.1 Conclusion	46
5.2 Limitations	46
5.3 Suggestions	47
5.4 Implications	47
References Appendices	48

List of Tables

Table 3.1         Demographic Characteristics of sample

Table 4.1          Descriptive statistics of study variables

Table 4.2         Difference of Attributional styles in women with Infertility and miscarriage

Table 4.3         Difference of Coping Strategies in Women with Infertility and miscarriages

Table 4.4         Correlations between Study Variables among infertile women

List of Appendices

Appendix A               Permission letter from the authors of scales

Appendix B                Permission letters from the translators of the scales

Appendix C               Permission latters from the heads of the hospitals

Appendix D               Informed Consent

Appendix E                Demographic data

Appendix F                Assessment Measures

Brief Cope Inventory (BCI)

Attributional Problem Cause and Solution Scale                                                                   (APCSS)

Appendix G               Plagiarism Report

 

Abstract

The present research was conducted to investigate Attributional styles and Coping strategies in the women with infertility and miscarriages. Rate of Infertility and miscarriages is growing day by day so it is important to explore how these women give attributions to both problems and how do they cope with them. It was hypothesized that there is likely to be significant differences of Attributional styles (Internal cause, internal solution, External cause, External Solution) and coping strategies in women with infertility and miscarriages and there is a relationship between attributional styles and coping strategies of them. Between group research design and purposive sampling technique was used. Sample comprised of 48 women (23 infertile women and 25 women with miscarriages). Attributional Problem cause and solution scale and Brief Cope Inventory were used for assessment. Independent sample t-test and Pearson product movement correlation were used to analyze the hypothesis. The results highlighted that there was no difference in attributional styles of women with miscarriages and infertility but the results showed that infertile women use more denial, behavioral disengagement and planning coping strategies as compare to those who have miscarriages. Counseling programs should be arranged for such women to help them deal with their feelings and emotions so that they could overcome such loss with developing better coping.

Chapter I

Introduction

            The present research is conducted to investigate Attributional styles and Coping strategies in the women with infertility and miscarriages. Children are an important ingredient of a happy married life. In every society, men and women are urged and advised to reproduce. Births are celebrated and the children fenced with favor. The term often used for having children is being fruitful and multiply. Couples who cannot have their own babies mostly remain unsatisfied with their marital life and mostly such marriages end up in divorce or husband’s second marriage. Infertility and Miscarriages are common features of not having babies. Both these situations contribute to further dissatisfaction in life. So it is important to explore how these women attribute to both problems and how do they cope with them. The way such women survive these problems or situation is associated with the way they attribute that event and their coping strategies to manage them. An important area of social psychology is concerned how people perceive and attribute own self, others or the events and how do they cope with them.

1.1 Infertility

People who cannot make or conceive a baby refer to as infertile. Infertility is the failure to conceive, (irrespective of cause) after 1 year of unprotected intercourse. Infertility affects nearly 10-15% of reproductive-aged couples. As a woman’s age increases, the incidence of infertility also increases (Puschech, 2012).

Infertility is clustered into two classifications.  Primary infertility talks about couples who have not become pregnant after at least 1 year of unprotected intercourse. Secondary infertility states couples who have been pregnant at least once, but never again. A wide variety of physical and emotional factors can cause infertility. It may be due to problems in the woman, man, or both. Infertility can cause many painful emotions in one or both partners. It may have big emotional effects like depression, anxiety; coping and marriage complications may also occur (Vorvick, Storck, & Zieve, 2012).

Although, in every society, women bear the burden of the blame of infertility, the truth is that male and female factors play equal part in infertility. Researches show that one third of infertility is caused by female factors, male issues are causing one third of infertility, around twenty percent of infertility reasons are unexplained and about fifteen percent is caused by a combination of male and female factors (Perkins, 2007).

Infertility, defined as the inability to conceive after one year of unprotected intercourse, or a failure of a pregnancy to result in a live birth, is estimated to affect approximately one in seven couples in the united states. Moreover, it was found there that infertility among age 20 to 24 has almost tripled since 1965. Due to the infertility there is potential impact on family relations (Perkins, 2007).

            Although the causes of infertility are significantly physiological, but it results in psychological disturbances too.Individuals who learn that they are infertile often experience upsetting emotions that are common to those who are grieving a loss. Usual reactions include depression, anger, and frustration. It may also have an effect on relationships, not just with the spouse but also with friends and family. Infertility dealing couples may avoid social interactions. Some of the individuals find a way to cope on their own, or they seek  support from their family or friends but many other  people need additional aid such as psychotherapy, relaxation techniques, medication or counseling. No doubt psychological challenges of infertility can be devastating but most of the people struggling with it eventually reach some type of resolution. But it is really hard to reach on a resolution (Miller, 2005).

In spite of the expanding body of literature focusing on medical, psychological, social, and cultural consequences of infertility, there are some issues such as religious and spiritual dimensions of infertility that have received a very little attention. Considering that infertility is a multidimensional and complex problem and often results in many psychological problems too, health professionals should consider all aspects of general care when caring for women with fertility problems. General care considers not only the psychological, social and cultural needs of such individuals, but also their religious and spiritual needs should be considered. Women with infertility problem may use their religious or spiritual beliefs to find meaning, and to cope with the crisis and hope in their suffering (Roudsari, Allan & Smith, 2007).

1.2 Miscarriage

Miscarriage refers to the loss or death of a fetus before 20^th week of pregnancy. Spontaneous abortion is a medical term use for a miscarriage. It was found that almost 50% of pregnancies end up in a miscarriage even before a woman know that she is pregnant. Almost 15 % of the known pregnancies end up in a miscarriage. Having a miscarriage can be emotionally Miscarriage is often considered as an extremely stressful event that can be life changing. Women who have a miscarriage may have grief reaction, depressive and anxiety symptoms. There are also some factors that have a positive effect on the psychological state of a women after a miscarriage, e.g. Social support, psychological counseling, information about specific causes of miscarriage. Women who experience poorer adjustment after a miscarriage are often those who had greater feelings of self-blame for the miscarriage, have problems with the spouse, lack of social support and also have poor self-efficacy and self-esteem (Stoppler, 2005)

Brog and Lasker (1982) state that weather the pregnancy was scheduled or not, wanted or unwanted, weather the parents are young or long time married couples, parents are expecting for the first time or they are parents of many children already, all attribute a miscarriage as a great loss and they grieve for a long time. When a pregnancy ends up in a misfortune, there is a intense disappointment, the collapse of hopes and plans. All preparation became useless and the dreams are destroyed. There are strong emotions of grief and disappointment and it is hard to cope with them. The parents attribute this event as a tragedy and it is hard for them to cope with it. Furthermore, women cope with this traumatic event harder than men.

Miscarriage is one of the most isolating events a woman can experience.  Women mostly stuck in a prolonged depression after a miscarriage and not capable to get their lives back on track. Most of the women start blaming themselves while they do nothing in this matter (McLaughlin, 2005).

Miscarriage (spontaneous abortion) has constantly been a probable consequence of pregnancy. It is a life event that can possibly cause mental grief. Research on psychological responses of women after a miscarriage indicates that many suffer from grief, guilt, depression, and anxiety. It was also found that women’s coping strategies to deal with this trauma are related to their attributional styles. It seems like the way they cope with this trauma depends on how they attribute the event. Women may experience a sorrow reaction after miscarriage that is an adequate reaction to loss (Boren, Moum, Bodtker&Ekeberg, 2004).

No doubt miscarriage is most likely hurting for both parent, but it is seen that women may face many challenges after pregnancy loss. It was found that men accept the loss and overcome the grief quickly than women.  Additionally, researches indicate that women grieve longer than men after a miscarriage. The focus of the study regarding pregnancy loss is, mostly experiences of women because they have to face many unique and challenging circumstances. Rates of miscarriage vary intensely but its rate is increasing day by day (Beil, 1992).

When women realize about having a miscarriage or when diagnosed as infertile may experience anxiety, anger, confusion, grief and sometimes depression too. The way women create meaning about their experience of losing a baby or stigmatized as not having baby facilitates them in coping with that situation (Beil, 1992).

Miscarriage is a very hard event to treat with it. Women do not only have to deal with the physical issues, but also emotional issues. According to Islamic perspective, women think that miscarriage is just Allah’s will and the body’s way of rejecting a deformed fetus (Arshad, Horsfal, Yasin, 2004).

It is challenging for the staff or the family members to give support to the parents who are bereaved following pregnancy loss. When there are different cultures and religions, lack of knowledge and understanding of specific spiritual needs may leave professionals feeling even more helpless, and families may remain dissatisfied.When supporting bereaved Muslim families, it is important for health professionals to be aware of  and have information of  rituals that can put the couples out of grieve on their loss. Islamic requirements may appear complex to non-Muslims, however for providing client-centred care, an understanding of Islamic rituals will help both professionals and families alike (Arshad, Horsfal, Yasin, 2004).

1.3 Attributional Styles

The way people attribute to an event or life incident and the way they cope with it, the patterns through which people can modify or relieve their stress especially about different diseases or disabilities appears increasingly important area for investigation of research. In psychology, many researches have been done to explore people’s ways of coping and responding to stress. Throughout the last few years, a natural attention in the field of research has been developed to delineate numerous factors that can be predictive for how the survivors of traumatic events cope. One of the main questions has been whether causal attributions in relation to traumatic events have any influence on symptoms, and as a result have any predictive value for post-traumatic coping among survivors. According to classical social psychological theories of attributions, people are motivated to believe that the world is controllable and predictable. When experiencing serious unanticipated events, such as traumatic events, people are concerned with explaining why the event took place, what may have caused it to happen, and whom or what was responsible for the event (Downey, Silver &Wortman, 1990).

Attributional style is defined as cognitive personality variable that are individual’s habitual ways to explain any event (Peterson & Seligman, 1984). Explanatory styles are the ways people generally explain different bad or good events involving the self (Peterson &steen, 2002).

Attributions are the efforts to understand the causes behind other’s behavior and sometimes our own behavior. In other words, the concern is not simply that how others have acted, in fact the concern is that why such behavior was done. The process of seeking such information and drawing inferences is known as Attributions (Baron, Branscombe, Byrne &Bhardwaj, 2009).

Attributions refer to the causal explanations usually given by the people for their own or other’s behaviors and events.Explanatory styles are manners in which a person describes the causes of negative or positive events. Attributions have two types, internal or external. People who use pessimistic attribution styles lean towards to attribute a negative event to internal causes (it is my entire fault), to stable causes (it will last forever), and to global causes (it affects all parts of my life) where as Optimistic people explain negative events in terms of external, unstable and specific causes and positive events as internal, stable, global(Baumeister& Bushman, 2008).

Attribution basically looks at how people make sense of their world.  What cause and effect interpretations they make about the behaviors of others and of themselves. The purpose behind making attributions is to achieve cognitive control over one’s environment by explaining and understanding the causes behind behaviors and environmental occurrences (Lin & Peterson, 1990).

People have different explanatory styles. Some people take themselves as a cause of chronic and pervasive events. Other people give more efficient explanation; they perceive the cause of bad events as external. The former people are more pessimistic than the latter one and they are the ones whom explanatory style prompt them to respond the illness, failure, disability, or any frustration with passivity. When such people attribute bad event as internal and stable, it is harder for them to cope with that except those who take such events as external and temporary (Lin & Peterson, 1990).

The reformulated model of learned helplessness suggest that depression is a major risk factor when use pessimistic explanatory style, because perceiving the event negatively make it difficult to cope with that (Abramson, Seligman & Teasdale, 1978). Many recent researches have concluded that it has several other negative consequences too, like poor adjustment, satisfaction, work performance (Seligman & Schulman, 1986), academic failure (Peterson & Barrett, 1987), and difficult managing the event or trauma. Above of all, poor health is one of the interesting outcomes newly attributed to pessimistic explanatory style. Studies have shown that the people more falls ill when they feels difficulty in managing the problem  who explain bad events in negative, destructive or pessimistic fashion as compared to those who are positive, progressive or optimistic in their thinking patterns (Peterson &Bossio, 1990).

The way one chooses to respond to or cope with a stressful situation may be influenced by one’s interpretation, drawing causes and explanation of that event. Past work suggests that individuals have stable dispositional tendencies to use positive or negative attributional, or explanatory, styles to interpret and explain the events that occur in their lives (Welbourne, Eggerth, Hartley, Andrew, & Sanchez, 2007).

A positive attritional style leads one to view causes of positive events as internal, stable, and global (rather than situation-specific), and causes of negative events as external, temporary, and situation-specific. The opposite explanatory pattern occurs for a negative attritional style: positive events are viewed as being caused by external, unstable, and situation-specific factors; while negative events are seen as stemming from internal, stable, and global factors. A negative attritional style has been associated with depression and physical symptoms, poorer physical health, and even mortality. Making attributions gives order and predictability to our lives and helps us to cope.(Welbourne, Eggerth, Hartley, Andrew, & Sanchez, 2007).

1.3.1 Types of Attribution

According to Hartman (n.d), there are three main types of attributions, the first is explanatory attribution, the second type is predictive attributions and the third type is interpersonal attributions.

Explanatory attribution is when Individuals attempt to make sense of the world and look for explanations to understand why a particular event has occurred. Second one is Predictive attribution which is used when an individual attempts to understand why an event happened, but also wants to be able to make it happen again or prevent it from happening. Third one is Interpersonal attribution, usually happens between two or more people. It involves an individual presenting himself in a positive light when explaining something or representing himself to others (Hartman, n.d).

1.4. Coping Strategies

Thoughts and behaviors that are used to manage the internal and external demands of situations which are considered as stressful, is defined as Coping and it has been a center of research in the social sciences for more than three eras. The dramatic increase of coping research has laid healthy debate and offered insight into the question of why some individuals fare better than others do when come across through the same stressful event in their lives (Folkman & Moskowitz, 2003).

The methods used to explain the causes of a stress, trauma, illness or disease help people to cope with that event. Taylor (1998) states coping strategies as specific efforts, both behavioral and psychological, that people use to master, tolerate, minimize or reduce stressful events. It indicates that there is a contact between the people and how they attribute and cope in the environment.

Coping strategies refers to management styles to deal with situations in which there is a perceived discrepancy between stressful demands and available resources for meeting those demands (Carr, 2004). Coping Strategies can also defined as logical and conscious ways of dealing with problems and situations of life that produce anxiety (Reber, & Reber, 2001).

Coping is a behavior that guards people from being psychologically harmed by challenging or problematic social experiences. Coping acts like protective function that can act in three ways. It can be used for limiting or modifying any stressful condition, perceptually controlling the meaning of the stressor or by keeping emotional consequences of the problem within boundaries. According to these definitions, coping strategies are efforts to manage the problem in a positive manner (Pearlin&Schooler, 1978).

Coping strategies are cognitive and behavioral tools used by people in their routine lives to deal with different upsetting emotions, hindrances, disabilities and illnesses. All these cause problematic challenges to people. Therefore coping has a core part in a person’s life. It is necessary for the health and happiness of a person to solve or reduce the disturbing effects of the problem. Successful coping does not mean that the problem is solved. In fact it means that it is managed (Lazarus &Folkman, 1984).

Coping can be explained as something that is done by an individual to deal effectively with a stressful event. One stressor after another can have long term negative impact on a person.  Close relationship can support a person cope with stress successfully. In such relationships people can disclose and discuss problems, share their concerns and receive advice that is keyed to their needs. Consequently, dealing successfully with the stressors, lead the individual towards better performance and good mental health (Singh &Shyan, 2007).

According to the Lazarus and Folkman (1984) coping refers to the effort of individual to remove stress and restore physical and emotional stability. Positive and adaptive coping mechanisms can contribute individuals in managing perceived threats and challenges and in gaining control over their disease.  Coping effectiveness is conceptually defined as the degree to which coping influences a person’s functioning.

According to Lazarus, people adopt coping strategies because they help to reduce harmful environmental conditions and enable the person the person to stand or adjust to negative life events or realities. The strategies a person use to cope in a situation play a vital role to maintain a positive self-image and uphold the emotional stability (as cited in Seaward, 2006).

Coping is defined as constantly changing of cognitive and behavioral efforts to manage specific internal or external demands that are evaluated as exceeding the person’s resources. Coping actions and thoughts are always according to the particular conditions. To understand or evaluate coping, it is most important to know what the person is coping with. Particular coping processes are linked with contextual demands. Therefore coping is a shifting process in which , at certain times, a person rely more heavily on one form of coping e.g. defensive strategy and at other times on problem solving strategy (Lazarus &Folkman, 1984)

1.4.1 Types of Coping

There are seven classes of coping skills used by people adjusting to physical illness. These coping skills contain denying or minimizing the significance of the disaster, obtaining relevant information, learning specific technique that are illness related, requesting reassurance and emotional support, setting up limited concrete goals, reviewing alternating outcomes and thinking a general purpose or pattern in the course of events (McCrea & Costa, 1986).

1.4.2. Coping Strategies and Defense Mechanisms

The study of coping has a long history. Psychodynamic psychotherapist including Freud discussed this topic earlier; they called them as Defense Mechanisms. Later this term was discussed by cognitive therapist in relation to mental health. They work on coping strategies to improve health. Some authors proposed that the term ‘Defense Mechanisms’ should be reserved for coping strategies used by immature people while the term ‘Coping Strategies’ should be used for the useful coping efforts used by mature people (Domback, &Wells-Morrran, 2006).

In Freudian paradigm, concept of psychological defenses is described as involuntary and unconscious process that come into action to prevent an individual from threatening and dangerous instinctual desires. The consequential defense mechanisms refer to the forces or drives that must mediate the emerging conflict between impulse gratification, inner moral structure and reality (Wolfe, 2005).

Our conscious efforts related to adjust to a stress or anxiety in a positive and a constructive way is known as coping styles. Sometimes the word coping applies similar to ‘defense mechanisms’. These coping mechanisms are used by the ego, to prevent from the id, superego or the outer environment, and to reduce the corresponding anxiety (Domback, & Wells-Morrran, 2006).

Chapter II

Literature Review

This part of the thesis contains numerous researches taken from the west as well as from Pakistan that would be helpful in understanding the topic from different cultural perspectives.

In a study Kolibas (2007) found that marital quality improved for men and women once children were born and raised. Furthermore it is concluded that If they have a baby, there is higher levels of satisfaction for both men and women if in regards to aspect of with love, affection, and friendship, there was greater satisfaction with the marriage as a whole.

2.1 Attributional styles

Fresco, alloy & Harrington (2006) conducted two researches to examine the relationship of attributional styles for negative and positive events with depression and anxiety. The studies revealed that pessimistic attributional style was correlated with depressed mood and negative effect. Second study shows that emotional distress occurs in anxiety relevant situations, in the people who use pessimistic attributional style.

In the same way Sweeney(1996) worked on Attributions about Self and Others in Depression. The attributional reformulation of the learned helplessness model of depression holds that depression-prone individuals are characterized by a certain attributional style. Specifically, they are seen as making internal, stable, and global attributions for negative outcomes. One implication of the attributional model tested by the present study is that depression-prone persons do not exhibit this attributional style for negative outcomes that occur to others. Depressed subjects made self-attributions for negative outcomes that were significantly more internal, stable, and global than those of non-depressed subjects, while no differences were observed when both groups made attributions for the negative outcomes of a target other.

Similarly Isaacowitz& Seligman (2001) found interaction between explanatory style and life stressors in their research. They examined two senses in which pessimism might be a risk factor for depressive mood in older adults. The first was that when pessimistic explanatory style combined with stressful life event it will lead towards depressive symptoms. The second one is that depressive symptoms are associated with pessimistic thinking style that bad events will happen in the future. It was also found that optimists were at higher risk for depressive symptoms after negative life events.

Likewise another study by Kamen& Seligman (1987) examined Explanatory style and health. Explanatory styles are the the habitual ways an individual explains the causes of bad and good events, is reliably associated with future health. Evidence was gathered from three studies which demonstrate a significant relationship between pessimism (the belief that bad events are caused by internal, stable, and global factors and good events are caused by external, unstable, and specific factors) and an increased risk for infectious disease, poor health, and early mortality. It was suggested that two possible mechanisms might mediate the link between pessimism and poor health. Finally it was proposed that interventions aimed at changing a pessimistic outlook might lower the probability of future illness.

Another study was done by Jind (2003) to explore the attributional processes and the effect of various causal attributions on post-traumatic symptomatology among parents who had lost an infant. Study was focusing on parental reactions to the loss of an infant, several relationships between attributional processes and other factors in terms of contextual factors and post-traumatic symptomatology were examined. The results first showed that women experienced more self-blame and felt more responsibility for the death than did men. The number of living children was positively correlated to thinking that fate was responsible for the loss. The importance of attributing responsibility was associated with several post-traumatic symptoms, as was searching for meaning in the death. Attributions to oneself, others, or God were positively and significantly associated with numerous post-traumatic symptoms. The positive correlation between blaming others and post-traumatic symptomatology was found which shows that blaming others is associated with poorer coping among victims of trauma. Attributions of loss to fate were positively correlated with various post-traumatic symptoms as women blaming fate had significantly higher post-traumatic symptoms. An additional description for the results could be that the belief that chance or fate is responsible for the death of the baby is the only possible alternative to a probably far more painful feeling of being responsible for the death oneself.

2.1.1 Attributional styles and Miscarriage

An investigation was done to search Internal and External Attributions Following Miscarriage by Madden (1988). Myths about behavioral and emotional causes of miscarriage lead to a variety of attributions by victims. Among external attributions, responsibility to husband and age of oldest child predicted depression, supporting other studies relating depression and blame of others. Among internal attributions, feeling that one could act to avoid a future miscarriage was positively related to depression.

2.2 Coping strategies

Roesch&weiner (2001) established a research on the relationship between causal attributions, coping, and psychological adjustment in individuals with physical illnesses or undergoing medical procedures. Results suggested that internal, unstable, and controllable attributions were indirectly associated with positive psychological adjustment through the use of Approach and Emotion-Focused coping. In addition, stable and uncontrollable attributions were indirectly associated with negative psychological adjustment through the use of Avoidance coping. It is concluded that these results suggest that attributions guide some motivated cognitions and behaviors within the context of illness, and are related to specific coping strategies. The discussion focuses on the predictive validity of these findings using the proposed theoretical model.

2.2.1 Coping Strategies and infertility

A research was conducted in china that aimed to explore the correlation among coping style, social support, and negative emotion in Chinese infertile women. Results showed that anxiety is negatively correlated to the positive coping, subjective support, objective support and extent of using the support while positively correlated to the scores of negative coping. Depression was negatively correlated to the positive coping, subjective support, objective support, and extent of using the support. Results also showed that positive coping had direct and negative effect on negative emotions while negative coping had direct and positive effect on negative emotions. It was concluded that Coping styles have direct and indirect effects on negative emotions for the infertile women. As a mediator, social support regulates the relationship between coping styles and negative emotions. Using positive coping more frequently while using negative coping less frequently can alleviate the negative emotions of the infertile women through improving social support levels directly or indirectly (Li, Yan, Zhu, Cheng, He & Lei, 2011).

Likewise Coping strategies of women with infertility was accessed by Donkor&Sandall (2009). Aim of the study was to access coping strategies of women seeking infertility treatment in southern Ghana. Infertility is a health problem faced by an estimated 15% of pregnant women in Ghana. This study explores the coping strategies adopted by women seeking infertility treatment in southern Ghana. The findings of the study suggest that the majority of the women preferred to keep issues of their fertility problems to themselves. The reason could be due to the associated stigma of infertility. Furthermore, the majority of the women coped through drawing on their Christian faith. Others also coped through the support they received from their husbands, their occupation by way of achieving economic independence, and some avoided situations that reminded them of their infertility problem. The findings should have implications for health personnel as some strategies infertile women use may do more harm than good.

2.2.2 Coping Strategies and Miscarriages

Mcgreal, Barry & Burrows (1998) piloted a study on gender differences in coping following loss of a child through miscarriage or stillbirth. Parental grieving for the loss of a baby following miscarriage or stillbirth can involve intense emotional distress and have implications for the quality of the relationship shared by the grieving parents. Evidence suggests that a relationship may be placed at risk during the grief process, with different forms and rates of grieving between the couple creating barriers to effective communication and increasing feelings of vulnerability. Results suggested not only gender differences in chosen coping strategies, but also differences between women depending on the type of loss experienced (ie miscarriage or stillbirth). While men tended to worry, use social support and ignore the situation, women were more likely to seek spiritual support, use tension reduction, wishful thinking and seek support from others who had experienced the same loss. A tendency to use self-blame was also evident in the responses of the female subjects, in particular women who had suffered a miscarriage.

2.3 Infertility

Bell (1981) in one of the earlier studies on the impact of infertility on various psychosocial variables, found infertile couples to be more likely to report sexual dysfunction, emotional disturbance, impaired social adjustment and deterioration in their marital relationship. Findings of the study reveal that women who suffer from unexplained recurrent miscarriages have a good chance of having a pregnancy and live birth than that did not carry the mutation. So they are not to lose hope and give up trying for a baby. The study shows that this would be helpful in counseling these women to hope and to attempt for future pregnancy. Results of the study shows that women with recurrent miscarriage can be reassured that their time to a subsequent conception is not significantly longer than that for fertile women without a history of miscarriage.

2.4 Miscarriages

A research was conducted to study on women’s reaction to miscarriage by James and Kristiansen (2006). They examined the role of Attributions, coping styles and knowledge in the reaction towards miscarriage. Analyses revealed that women’s attributions were tied to their reactions, in that the more women blamed their own character or doctor, the more severely they reacted. Examining the interrelations of these variables revealed that the amount of women’s knowledge before miscarriage was related to less wishful thinking, and their knowledge after the event was related to less problem avoidance. Women’s attributions were also related to their coping strategies, e.g. blaming one’s character, behavior, or doctor were positively related to self-criticism and social withdrawal, and negatively related to support from doctors and significant others.

Another 2-year follow-up study on Psychological impact on women of miscarriage versus induced abortion was done by Broen, Moum, Bodtker&Ekeberg (2004). Objective of the study was to compare the psychological trauma reactions of women who had either a miscarriage or an induced abortion, in the 2 years after the event. The short-term emotional reactions of the women with miscarriage appear to be larger and more powerful than those who did Induced abortion. In the long term, however, women who had induced abortion reported significantly more avoidance of thoughts and feelings related to the event than women who had a miscarriage.

Similarly Obi, Onah&Okafor (2009) worked on Depression among Nigerian women following pregnancy loss or a miscarriage. The objective of the study was to determine the level of depression in Nigerian women following spontaneous pregnancy loss and the coping strategies used by such women. Results shows that two-thirds of the pregnancy losses occurred before 20 weeks of gestation and one-third occurred after 20 weeks. The majority of respondents had minimal depressive symptoms, very few respondents had moderate, and some had severe symptoms. Risk factors for moderate to severe depression included having previous pregnancy loss, loss of a male fetus, childlessness, and losses after 20 weeks. Presence of a woman’s husband, children, parents and relatives, friends, and religious observance were identified as positive coping strategies. It was concluded that most significant risk factors for Nigerian women who suffer some level of depression following pregnancy loss are those who have no living children and had a miscarriage after 20 weeks of pregnancy.

In similar context, Swanson (2000) worked to develop and test a model that would enable prediction of the intensity of women’s depressive symptoms at 4 months and at 1 year after miscarriage. Findings of this study confirm that women are at high risk for increased depressive symptoms after miscarriage and they attribute high personal significance to miscarriage, have lack of social support, have lower emotional strength, they use passive coping strategies, have lower incomes, and do not conceive or give birth by 1 year after loss.

2.5 Indigenous Researches

            Liaqat, Kamran & Ghazal (2008) conducted a research on the effects of attributional styles for causing depression in married vs. single females. Results of the research showed that there is a highly significant difference between attributional styles and depression levels of married and unmarried females. Married females reported more dysfunctional attitude style and depression as compared to the females who are single.

A study on social support and coping strategies in acute MI patients was piloted by Saif&Najam(2008). The results indicated that there was a positive relationship between social support and coping strategies in acute myocardial infraction patients. There were no gender differences found in social support except perceived social support  and religious and acceptance coping strategies.

Similarly Gulraiz& Kamran (2008) conducted a research on the effects of optimism on coping strategies of diabetic patients. Analysis revealed that satisfaction with life effects coping strategies of diabetic patients. There were no significant gender differences in coping strategies of diabetic patients. Religious coping strategy was mostly used by females than male diabetic patients. Active practical coping strategy was most commonly used strategy by diabetic patients.

Likewise Chaudhry and Masood (2009) investigated gender differences in coping strategies used by blood cancer patients. It was concluded that male blood cancer patients tend to prone to use problem-focused coping strategies than the female patients and the female blood cancer patients tend to use more emotional-focused coping strategy than male patients. The results also showed that female used more positive reinterpretation, mental disengagement, venting, denial, religious, acceptance and emotional social support coping whereas male patients used more active coping and suppersion of competing activities.

Similarly Iqbal and Kausar(1997) examined marital conflicts and related demo-graphical variables as determinants of psychological distress in infertile people. This study investigated the gender differences in psychological distress and predictors of psychological distress in infertiles. Findings revealed that about half of the participants had been experiencing psychological distress. Moreover, infertile females were more psychologically distressed than infertile males. In marital relationships, conflict with in-laws emerged as a strong predictor of distress. Domestic problems and outgoing interest of the spouse also emerged as significant determinants of psychological distress in infertile people along with the respondent’s education and duration of treatment after diagnosis. Findings have important implications for distress and impact of marital conflicts on psychological health of infertile people.

The research was conducted by Malik and Khalid (2000) on the Relationship among psychological distress and social support among infertile females. Female patients who have already been diagnosed as infertile by the medical doctors working at infertility center of Hameed Latif Hospital. Findings of the data revealed that there is no significant link between social support and psychological distress among infertile women.

Waqar&Najam (2008) designed research to investigate the effect of infertility on marital adjustment. It was hypothesized that there is an effect of infertility on marital adjustment. Findings were consistent with the hypothesis and it was found that there is an effect of infertility on the marital adjustment.

From the above given literature review, it has been concluded that any negative event that happens in life, bring major changes in different aspects of life. Same in the present study, infertility and miscarriages are such negative happenings that play an important role in changing thinking and actions of females. Females have more pessimistic attributional styles then males when they do not conceive baby or loss the pregnancy. These negative events lead them towards pessimistic attributions styles as it was also found by Jind (2003). They lose hope for even any positive event. Literature revealed that both of the sample women (infertile and women with miscarriages) attribute the lose internally as well as externally (James & Kristiansen, 2006; Madden & Pierce, 2003; Mcgreal, Jevans, Burrows, 1998). Sometimes they start self-blaming and sometimes they give responsibility on external factors like doctors, other family members or the spouse etc. Many of the females try to cope better so their life becomes stable even after a big loss. Infertile women as well as women with miscarriage use coping strategies in different manners from each other and according to the situation and circumstances they faced. Therefore, it is difficult to conclude about the exact coping strategies of infertile women as well as women with miscarriages.

2.6 Rationale

The present study examined attributional styles and coping strategies in infertile women and those who have miscarriages. Miscarriages are happening many times more, than in past. There is a strong need to focus on psychological issues related to infertile women and those who have miscarriages. It is important to provide awareness to their family and husbands that there is no fault of their wives and it is also possible that infertility is in husbands. This research was conducted in order to identify how Pakistani women attribute and cope with these two types of pregnancy problems. When an illness is labialized on any family member, it is very important that how she herself attributes her illness and this has an effect on coping of the person with the situation and may cause psychological problems.

2.7 Objective

The purpose of the present study was to explore the difference of Attributional styles and coping strategies in the women who don’t conceive babies or those who have miscarriages due to any reason.

2.8 Hypotheses

Following hypotheses has been purposed for the present research:

• There is likely to be difference in coping strategies of women with infertility and miscarriages.
• There is likely to be difference between attributional styles of women with infertility and miscarriages.
• There is likely to be relationship between attributional styles and Coping strategies of infertile women.
• There is likely to be relationship between attributional styles and Coping strategies of women with miscarriages.

Chapter III

Method

This study has been designed to investigate attributional styles and coping strategies in women with Infertility by comparing them with those who have miscarriages.

3.1 Research design

Between group research design was used to examine attributional styles and coping strategies in women with Infertility by comparing them with those who have miscarriages.

3.2 Sampling Strategy

Purposive sampling was used in the study and selection of the sample was depending upon the availability and consent of the participants.

3.3 Sample

The sample was comprised of women (N=48), women who don’t conceive baby (n=23), women who have miscarriages (n=25). Sample was recruited from Sir Ganga Ram Hospital and Hamid Latif Hospital, Lahore.

The sample was drawn on the basis of the following inclusion exclusion-criteria:

3.4.1 Inclusion criteria for women with infertility and miscarriages

• Sample was comprised of women ranging from the age of 25 to 45 years.
• Women who were not conceiving baby at least after one year of marriage while the spouse was living together were included for the sample of infertility.
• Women who suffered from at least one miscarriage were included for the sample of miscarriages.

3.4.2 Exclusion Criteria for women with infertility and miscarriages

• Women living without their husbands (in case living out of station)
• Secondary infertile women were not included for infertility sample (women who have babies, but desire to have another).
• Unmarried women were not included in the sample for miscarriages

Table 3.1

Demographic characteristics of sample

Characteristics	Infertility n = 23			Miscarriages n = 25
	f (%)			f(%)
Age in years M( SD)	31.08(5.81)			29 (4.94)
Age of Husband in years M( SD)	35.76(6.46)			30 (13.12)
Duration of Marriage in months M( SD)	87.04(55.91)			73 (62.65)
Duration of Pregnancy before pregnancy loss in weeks M( SD)	___			14 (7.65)
No. of Miscarriages M ( SD)	___			2 (2.15)
Type of loss	23 (46)			25(54)
Education
Primary	2(8)			4(16)
Middle	4(16)			2(8)
Matric	3(12)			3(12)
F.A	3(12)			5(20)
B.A	6(24)			3(12)
M.A and Above	6(24)			7(28)
Missing	1(4)			1(4)

	f (%)	f(%)
Education of Husband
Primary	1(4)	3(12)
Middle	3(12)	2(8)
Matric	6(24)	5(20)
F.A	4(16)	4(16)
B.A	8(32)	3(12)
M.A	2(8)	4(16)
Missing	1(4)	4(16)
Profession
Housewife	18(72)	22(88)
Teacher	6(24)	3(12)
Arch. Eng.	1(4)	___
Profession of husbands
Labor	7(28)	6(24)
Business	3(12)	5(20)
Teacher	2(8)	2(8)
Engineer	2(8)	1(4)

	f (%)	f(%)
Private job	__	2(8)
Others	11(44)	5(20)
Missing	__	4(16)
Family System
Joint	19(76)	14(56)
Nuclear	6(24)	11(44)
Type of Marriage
Love	2(8)	1(4)
Arranged	23(92)	24(96)
No. of Children
0	23(92)	10(40)
1	__	10(40)
2	__	2(8)
3	__	1(4)
4	__	2(8)

	f (%)	f(%)
Family History
0	17(68)	19(76)
1	4(16)	4(16)
2	2(8)	__
3	2(8)	2(8)

Note: M= mean, SD= Standard Deviation, f = frequency, %= percentage

3.5 Assessment Measures

Following tools was used for the purpose of collecting data.

3.5.1 Demographic questionnaire

The demographical form enquiring about age, husbands age, education, husbands education, occupation, husband’s occupation, total income, Family system, type of marriage, duration of married life, age of marriage, type of loss, Duration of treatment in case of infertility, age of pregnancy in case of miscarriage, number of miscarriages, duration of last miscarriages, number of children and behavior of husband after diagnosis was used. This demographical information was taken to assess the personal information of the participants that was helpful in analysis.

3.5.2 Brief Cope Inventory

The Brief COPE (Carver, 1997) is a self-report questionnaire used to assess a number of different coping behaviors and thoughts a person may have in response to a specific situation. It is made up of 14 subscales: self-distraction, active coping, denial, and substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. In a brief cope version 28 coping behaviors and thoughts (2 items for each subscale) are rated on frequency of use by the participant with a scale of 1 (I haven‘t been doing this at all) to 4 (―I‘ve been doing this a lot).Translated version of the scale was used ( Rafiq&Rafiq, 2010).

3.5.3 Attribution of Problem Cause and Solution Scale

Stepleman, Darcy, & Tracey, (2005) created the Attribution of Problem Cause and Solution Scale (APCSS). The APCSS uses Brickman’s (1982) model of attribution. Translated version of the scale was used (Qureshi& Fatima, 2013).  This scale measures attribution on four subscales, that internal and external attributions: one for problem causes and one for problem solutions. Externalproblem cause items include 11 items, e.g., other people are responsible for the cause. Internal problem cause items include 13 items e.g., I feel guilt for having caused this problem. Internal problem solutions have 4 items e.g., Solving this problem is my responsibility while external problem solution consists of 16 items e.g., Solving the problem is someone else’s responsibility.

3.6 Ethical Considerations

• To initiate the study, formal permission was taken from the director of theInstitute.
• Permission for the use of the tool was taken from both authors.
• Translated tool was required for the study so permission was also taken from the translators of both tools.
• The procedure and purpose of the study was explained to the participants.
• Permission for participation and assurance of confidentiality and anonymity of the researchwas done through consent forms.
• In the case of withdrawal, participants were assured to not be threatened.
• Calm environment was tried to provide to the participants.
• Accurate reporting of the results was done.

3.7 Procedure

Formal permission was taken from the director of the Institute of Applied Psychology. Permission for the use of the tools was taken from both authors (Appendix A). Translated tools were required for the study, since they were already translated by the students of Institute of Applied Psychology, University of the Punjab, Lahore, Pakistan. So permission was also sorted out from the translator of Brief cope Inventory (Rafique&Rafiq, 2010) and Attribution for Problem Cause and Solutiona Scale (Qureshi& Fatima, 2013) (Appendix B). Researcher obtained an authority letter from Institute of Applied Psychology to start data collection. The letter authenticated researcher’s identity and topic of the research. This authority letter was presented to the heads of Sir Ganga Ram and Hamid Latif Hospital, Lahore. Official permission was sought from the administration (Appendix C). Inclusion and exclusion criteria were told by the researcher to the staff of the hospitals, so the sample was referred to the researcher according to that criteria.

The selected tools Brief Cope Inventory and Attribution of Problem Cause and Solution Scale (Appendix F) along with demographics (Appendix D) and Consent Form (Appendix E ) form were administered on (N=48)  women in Sir Ganga Ram Hospital and Hamid Latif Hospital, Lahore. The participants were brief about the purpose of the research. Consent was taken from the participants and they were given freedom to leave the research if they don’t want to participate anymore. The researcher assured the participants about confidentiality of all the information obtained from them. The Participants were instructed to mark only one option against each item that best reflect their feelings. Total time to assess a participant was between 15 to 20 minutes, response rate was almost 80%.

Chapter IV

Results

The present research examined the differences in coping strategies and Attributional Styles of infertile women and women with miscarriages. The data strategy involved performing: (i) Reliability and Descriptive analysis of study variables; (ii) Independent sample t-test was used to analyze the differences for coping strategies and Attributional Styles of infertile women and women with miscarriages (iii) Pearson-product moment correlation was used to analyze the relationship between subscales of Attributional styles (Internal cause, Internal solution, External cause, External Solution) and subscales of Coping strategies (Self-Distraction, Active Coping, Denial, Substance use, Behavioral Disengagement, Use of Instrumental Support, Venting, Positive Reframing, Use of Emotional Support, Planning, Humor, Acceptance, Religion, Self-blaming) of infertile women and women with miscarriages.

Table 4.1

Descriptive Statistics of Study Variables (N = 48)

Variables	α	Number of items	M(SD) (n=23)	Minimum	Maximum
Attributional Styles
Internal Cause	.89	13	3.07 (1.39)	1.00	6.54
Internal Solution	.69	4	4.17 (1.68)	1.00	7.00
External Cause	.79	11	4.33 (1.20)	1.09	6.73
External Solution	.92	16	3.49  (1.47)
Coping Strategies
Self-Distraction	.16	2	2.87 (0.74)	1.00	4.00
Active Coping	.36	2	3.57(0.59)	1.50	4.00
Denail	1.00	2	2.21 (0.91)	1.00	4.00
Substance use	.08	2	1.04 (0.29)	1.00	3.00
Use of Emotional Support	.45	2	3.34 (0.65)	1.50	4.00
Use of Instrumental Support	-.22	2	3.34 (0.65)	1.50	4.00
Behavioral Disengagement	.87	2	1.86 (0.66)	1.00	3.00
Venting	.41	2	3.28 (0.96)	1.0	4.00
Positive Reframing	.51	2	3.28 (0.96)	1.00	4.00
Planning	.54	2	3.42 (0.72)	1.00	4.00
Humor	-.10	2	1.07 (0.23)	1.00	2.00
Acceptance	.65	2	3.09  (0.96)	1.00	4.00
Religion	.76	2	3.68 (0.52)	2.00	4.00
Self-blaming	.56	2	1.92 (0.85)	1.00	4.00

Note: M=mean, SD= standard deviation

It was hypothesized that there would be significant differences in Attribution styles (    Internal cause, internal solution, external cause, external Solution) in infertile women and women with miscarriage. Independent sample t-test was used to analyze the differences as shown in table 4.2.

Table 4.2

Difference of Attributional styles in Infertile Women and those with Miscarriage (N=48)

	Infertile Women (n=23)		Women with Miscarriages (n=25)					95% CI		Cohen’s d
Measures	M	SD	M	SD	t (df)		P	LL	UL
Internal Problem Cause	3.39	1.31	2.28	1.43	1.54 (46)		.13	-.19	1.41	0.05
Internal Problem Solution	4.45	1.30	3.81	1.92	1.58 (46)		.12	-.20	1.69	0.40
External Problem Cause	4.46	1.01	4.19	1.37	.76 (38.63)		.45	-.45	0.99	0.28
External Problem Solution	3.47	1.63	3.51	1.34	-.08(46)		.93	-.90	0.83	-0.03

Note: M=mean, SD= standard deviation

Results of study showed that there were no differences in attributional styles (Internal cause, Internal solution, External cause, External Solution) of infertile women and those who have miscarriages. Therefore, the hypothesis was not accepted.

It was hypothesized that there would  be difference in coping strategies (Self-Distraction, Active Coping, Denial, Substance use, Behavioral Disengagement, Use of Instrumental Support, Venting, Positive Reframing, Use of Emotional Support, Planning, Humor, Acceptance, Religion, Self-blaming) of infertile women and those with miscarriages. Independent sample t-test was applied to test the hypothesis as shown in table 4.3.

Table 4.3

Difference of Attributional styles in Infertile Women and those with Miscarriage (N=48)

Measures	Infertile Women (n=23)		Women with Miscarriages (n=25)				95% CI		Cohen’s d
	M	SD	M	SD	t (df)	P	LL	UL
Self-Distraction	2.98	0.66	2.78	0.80	.91 (45)	.37	-.24	.63	0-.08
Active Coping	3.63	0.59	3.52	0.60	.64 (46)	.53	-.24	.46	.38
Denial	2.50	0.74	1.94	0.98	2.23 (42.64)	.03	.05	1.07	.61
Substance use	1.09	0.42	1.00	0.00	1.00 (22)	.33	-.10	.27	.29
Behavioral Disengagement	3.02	0.79	3.26	.77	-1.06 (46)	.29	-.69	.21	.79
UIS	3.24	0.78	3.44	0.49	0.49	-1.06	.30	-.59	-.23

Venting	2.09	0.60	1.66	0.66	2.35 (46)	.02	.06	.80	.59
Positive Reframing	2.75	0.69	(0.64)		2.22 (46)	.03	.04	.82	-.13
UES	3.17	1.05	3.38	0.88	-.74 (46)	.46	-.77	.36	-.24
Planning	3.65	0.51	3.20	0.81	2.32 (40.68)	.03	.06	.85	.68
Humor	1.04	0.14	1.10	0.29	-.87 (35.88)	.39	-.19	.08	-.35
Acceptance	2.93	1.07	3.24	0.84	-1.10 (46)	.28	-.86	.25	-.42
Religion	3.70	0.58	3.66	0.47	.24 (46)	.82	-.27	.34	.15
Self-blaming	2.24	0.93	1.62	0.65	2.66 (39.06)	.01	.15	1.09	.50

Note: M= mean, SD= standard deviation

Results of the study showed that infertile women use more denial, venting, positive reframing, planning and self-blaming coping strategies as compare to those who have miscarriages. The results showed that hypothesis was partially approved.

It was hypothesized that there would be relationship between attributional styles (Internal problem cause, Internal problem solution, External problem cause, External problem Solution) and Coping strategies (Self-Distraction, Active Coping, Denial, Substance use, Behavioral Disengagement, Use of Instrumental Support, Venting, Positive Reframing, Use of Emotional Support, Planning, Humor, Acceptance, Religion, Self-blaming) of  infertile women and women with miscarriages. Pearson product moment correlation was used to analyze the results as shown in table 4.4.

Table No. 4.4

Correlations between Study Variables among women with infertility and miscarriages (n=48)

Variables	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17
1. IPC	__	.54**	-.15	-.004	-.08	-.17	.21	-.42*	-.32	.01	-.19	-.21	.30	-.31	-.08	.18	.75**
2. IPS	.36	__	.24	.04	-.05	-.05	.16	.004	-.01	-.04	-.05	-.48	.33	-.38	.11	-.05	.66**
3. EPC	.15	.49*	__	.14	.02	.40	-.36	.03	.32	.13	.12	-.08	.31	-.28	.21	.08	.06
4. EPS	.43*	.52**	.44*	__	.14	.13	.40	.39	.19	.08	.13	.08	.36	-.15	.57**	.004	-.11
5. SD	.19	.56**	.25	.22	__	.07	.03	.51*	.33	.27	.38	.12	.05	.01	-.03	-.08	-.15
6. Active	-.04	.29	.47*	.07	.29	__	.11	.34	.25	-.23	.30	.05	.42*	-.34	.18	.26	-.10
7. Denial	.29	.09	.37	.44*	-.07	-.07	__	.12	.06	.08	.15	-.22	.06	-.11	.35	.05	.17
8. UOES	-.35	.05	.42	.004	-.09	.60**	-.31	__	.52*	-.08	.39	.23	.22	-.11	.20	-.01	-.26
9. UOIS	-.35	.04	.17	.14	.05	.36	-.23	.35	__	.27	.22	.25	-.04	-.20	.51*	.24	-.22
10. BD	.58**	.24	.43*	.47*	.13	.07	.56**	-.13	-.26	__	-.03	-.39	-.42*	.35	.01	-.32	.13
11. Venting	.06	-.03	12	.12	-.06	.20	.30	.21	.33	.27	__	.07	.04	-.24	.09	-.09	.01

12. PR	-.36	.04	.50*	-.24	-.009	.73**	-.18	.73**	.50*	-.18	.14	__	.08	.02	.23	.45	-.51*
13. Planning	.20	.42*	.66**	.16	.24	.61**	.30	.33	-.02	.33	.23	.51**	__	-.40	.14	.36	.30
14. Humor	.20	.02	-.009	.06	.28	-.07	.44*	-.22	-.18	.41*	.16	-.16	.000	__	-.06	-.38	-.25
15.Acceptance	-.13	.10	.33	-.17	.37	.32	.04	-.02	.01	.003	-.21	.32	.53**	-.27	__	.06	-.17
16. Religion	-.24	.17	.07	-.03	-.03	.21	-.03	.05	.18	-.15	.17	.27	.10	-.19	-.02	__	-.07
17. Self-blaming	.53**	.22	-.09	.32	.31	.02	.33	-.28	-.34	.54**	.23	-.34	.11	.32	-.09	.21	__

Note: IPC= Internal problem cause, IPS= Internal problem solution, EPC= External problem cause, EPS= External problem solution, SD= Self-distraction, AC=Active coping, SU=Substance use, BD= Behavioral disengagement, UOI=Use of instrumental coping, PR=Positive reframing, UOES= Use of Emotional Support, SB= Self-blaming. *P<.05, **p<.01.

Results showed that internal problem cause attributional style was positively related to self-blaming but it was negatively related to use of emotional support coping strategy. Internal problem solution was positively related to self-blaming. Results further revealed that external problem Solution was positively related to Acceptance coping strategy. Thus, it was found that a hypothesis stated above was partially approved. Results of correlation in women with miscarriages showed that there was positive correlation between internal problem cause and behavioral disengagement. Internal problem solution had a positive relationship with self-distraction and planning coping strategy. External problem cause had a positive relationship with active coping, positive reframing, planning and behavioral disengagement coping.  External problem solution had a positive relation with denial and behavioral disengagement coping. Thus, it was found that hypothesis mentioned above was partially approved.

4.6 Summary of the Findings

• No differences were found of attributional styles in women with infertility and miscarriages.
• Differences were found in the use of denial, behavioral disengagement and planning coping as they are mostly used by infertile women rather than those who have miscarriages.
• It was found that internal attributional styles were positively correlated with self-blaming while negatively correlated with positive emotions and internal problem solution was positively related to self-blaming.
• External problem Solution was found to be positively correlated with accepting coping strategy in women with infertility.
• Findings suggested that internal problem cause was positively related with behavioral disengagement and internal problem solution had a positive relationship with self-distraction and planning coping strategy in women with miscarriages.
• External problem cause had a positive relationship with active coping, positive reframing, planning and behavioral disengagement coping while external problem solution had a positive relation with denial and behavioral disengagement coping strategy.

 

Chapter V

Discussion

The core aim of current research was to study the differences between Attributional styles and coping strategies of women with infertility and miscarriages.

It was hypothesized that would be significant differences in Attribution styles (Internal cause, internal solution, external cause, external Solution) in infertile women and women with miscarriage. Results revealed no significant difference of Attributional styles in both sample. These findings were consistent with previous literature as Jind  (2003) found that women with miscarriages often blame others for their loss and it was further associated with poorer coping among the victims of the trauma. Same results are reported by Mendola, Tennen,Affleck, McCann and Fitzgerald (1990), that women with infertility attribute biomedical causes as external factors for not conceiving babies.

It was hypothesized that there would be a difference in coping strategies (Self-Distraction, Active Coping, Denial, Substance use, Behavioral Disengagement, Use of Instrumental Support, Venting, Positive Reframing, Use of Emotional Support, Planning, Humor, Acceptance, Religion, Self-blaming) of infertile women and those with miscarriages. Results showed significant difference of only three specific coping strategies that are denial, behavioral disengagement and planning. These findings were in same line with the findings of  James& Annette (2002); Gourounti, anagnostopoulos, &Lyleridou (2013) and Davis &Dearman. They found in their researches that both type of women use almost all coping strategies depending on the situations and type of loss. Many cultural differences were found in population of Pakistan and Western countries. A major diversity in educational level, income and private or government hospital might had influence the findings of current research.

Results showed that there was a positive relationship between internal problem cause attributional style and self-blaming in infertile women. It has been generally observed that women with infertility mostly blame to themselves, when they considered themselves as the victim of their infertility, they automatically used self-blaming coping strategy. As Roesch and Weiner(2001) found that overall, internal, unstable, and controllable attributions were indirectly associated with positive psychological adjustment through the use of Approach and Emotion-Focused coping. When they tried to satisfy them-selves, they tried to cope at emotional level, and this act of self- blaming and to attribute themselves lead them towards better psychological adjustment as this was clearly defined by Roesch and Weiner(2001). Whitford and Gonzalez (1995) found that couples without children receive comments that they perceive as unsupportive and result in more fear around disclosure, feelings of isolation and withdrawal from social situations, which could then impact on emotional status. When women with infertility tried to cope with environment, they actually tried for better psychological adjustment.

Results of the current study revealed that internal attributions styles were negatively associated with positive reframing. Positive re-framing is considered as optimist thinking and it is generally observed that infertility is a problem in which most of the women loss positive thinking as Kleanthi;  Fotios;  Grigorios (2010) depending on previous literature described pessimism as a predictor of infertile related stress. They have been always negative comments about themselves.

Results also revealed that external problem Solution was positively related to Acceptance coping strategy. External attributional styles are considered as explanatory attributional styles. When an infertile women blame others or blame external factors, she tried to accept her this short coming through using acceptance as a coping strategy that helps in decreasing their stress as suggested by Farahani (2001).

It was hypothesized that there would be a  relationship between attributional styles (Internal problem cause, Internal problem solution, External problem cause, External problem Solution) and Coping strategies (Self-Distraction, Active Coping, Denial, Substance use, Behavioral Disengagement, Use of Instrumental Support, Venting, Positive Reframing, Use of Emotional Support, Planning, Humor, Acceptance, Religion, Self-blaming) of  women with miscarriages. Results of correlation in women with miscarriages showed that there was positive correlation between internal problem cause and behavioral disengagement. Results were consistent with the findings suggested by Helström& Victor (1987); Jind (2003) that women with miscarriages mostly used internal attributions but findings were not consistent for specific coping strategies as Gourounti, anagnostopoulos, & Lyleridou (2013) reported in their article that women with miscarriages used all coping strategies at different times. This difference may be occurred due to cultural differences or situational factors.

Further findings suggested that there was a positive relationship between internal problem solution and self-distraction and planning coping strategies. It was generally observed that women with miscarriages who blame themselves for this loss try to engage themselves in other chores and further plan to solve the problem. Results showed that there was a positive relationship between external problem cause and active coping, positive reframing and planning. It was observed in our society that women, who use external attributions, plan and actively work to cope with the loss, look positively what happened to them.

5.1 Conclusion

To sum up the whole discussion, it was concluded that women with infertility and miscarriages had their own experience and therefore their attributional styles and coping strategies. These variations were not only because of the nature of their loss but also their environmental factors play a key role in their life. And when these both factors were combined, cause the changes in their thinking and living patterns.

5.2 Limitation

Several limitations have been noted in the present research:

• Time period was too short to collect the data.
• Sample size was too short because of limited time period.
• The participants were drawn from one city of Pakistan, only from Lahore, therefore the sample was small in diversity, and this factor may limit the generalizations of results.
• It was also hard to get permission from the heads of the hospitals and heads of gyne wards. Some of the hospitals respond too late that time for data collection was over.
• Duration of pregnancy loss was from one day to eight years, the large difference in the time duration might affect the findings of the study. 
  

5.3 Suggestions

Suggestions in the light of these limitations were given for future researches, regarding improvement of research work.

• The results of the study would be more generalized if sample size would be increased.
• In future, sample should be taken from different cities of Punjab Province so that it could be more generalized.
• For such study, period of time for data collection should be long enough to collect data from large sample.

5.4 Implications

Findings of the current study suggest that

• It should be spread to the family to get them aware about the psychological problems of such women. It is important for the family and friends of the surviving women to be aware of the person’s grief, and to become more supportive and encourage them to seek help for extended grief symptoms such as prolonged depression or uncontrolled crying.
• Counseling programs should be arranged for such women to help them overcome such loss by adopting better coping strategies.
• The women with such losses should provide supportive and religious awareness because our religion induces motives to eliminate all psychological conflicts like stress, anger, frustration, strengthen will power and to cope with their stressors.
• This research will lay ground for the future researches in Pakistan to focus emotional and behavioral problems of women after pregnancy loss or infertility.

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