Introduction 

Pregnancy and puerperium are one of the most important events in life. Pregnancy loss is a stressful experience and is often associated with psychological outcomes [1]. Annually, 12-15% of known clinical pregnancies are lost due to factors such as abortions, stillbirths, miscarriages, and molar pregnancies [2]. 20 to 50 percent of pregnancies terminate due to abortion before 20 weeks of pregnancy [3]. Annually, 80000 abortions occur in Iran, about 20% of which are spontaneous abortions, 2.6% are intentional abortions, and 0.2% of abortions for medical reasons [4]. Abortion changes women's mental health and is associated with increased levels of anxiety, depression, and psychological symptoms [5]. The rate of depression in the first two weeks after abortion is 42.1% that decreases to 26.8% after three months and 9.8% after one year [6]. Psychological changes after the loss of a fetus or baby [7] and pregnancy loss is a negative experience in pregnant women and can lead to severe anxiety and depression in subsequent pregnancies. It even causes psychological resistance to accepting a new pregnancy in some women [8]. The rate of depression is 4 times and post-traumatic stress disorder is 7 times higher in women with a history of pregnancy loss compared to women with live births [9].

Pregnancy loss in long term results in increased stress in life and personal relationships, marital problems. It is also associated with reduced quality of life, impaired relationships with relatives and friends and children, or pregnancy [8]. Problems of all aspects of mental health in women with a history of abortion and infertility are more severe in these women and disorders of nine psychological dimensions (somatization, sensitivity in interpersonal relationships, depression, paranoid attitude, anxiety, aggression, obsession and compulsion, phobia, psychotic thoughts) are more common in these women [10]. Perceived social support is one of the most important factors influencing mental health [11]. Support is an essential component of good mental health and helps women strengthen their role and ability to adapt and cope with stressors.

Maternal social support during this period can reduce the effects of stress and enable her to cope with stressful situations and prevent the complications of anxiety, preterm delivery, low birth weight, and fetal brain development disorders [12]. Receiving social support from others reduces the psychological complications of stress and improves the conditions [13].

There is a positive association between postpartum depression and social support, so providing social-behavioral interventions to teach kinship communication to provide optimal social support is necessary [14]. The results of a study conducted by Badaghi et al. showed that family support has the largest share in predicting postpartum depression [15]. With increasing the level of social support, the level of health increases. The study conducted by Nazari et al. showed that 43.6% of pregnant women had mental health disorders and the highest mean score related to social dysfunction with 7.81% and the lowest was related to depression with 2.86% [16]. Lack of mutual understanding and conflicts and tensions between family members are the main reasons for the lack of family support [17]. Counseling programs can help reduce the psychological effects of women with lost pregnancy to reduce the symptoms of mental disorders  [18]. Providing care for women with risk factors for anxiety and counseling and referring them for more advanced diagnosis and treatment can improve their quality of life and reduce maternal and neonatal complications [19]. Establishing a dynamic and purposeful relationship helps to plan and continue a successful life.

Group counseling is a type of counseling that is performed in the presence of one or sometimes two counselors with about 8 to 10 participants. This method focuses on problems at the conscious level of clients [20]. Although counseling can be done individually, group counseling is cost-effective and can provide the necessary sense of security for spontaneous and free interaction with group members and reduce the fear and anxiety caused by lack of awareness so that the person gains enough information on the illness process. Support and counseling improve physical condition, reduce anxiety, enhance the perception of life, reduce mood disorders, improve adaptability and adaptive behaviors in a person. Paying attention to mental health-threatening factors in women is an important social issue [21]. Midwifery plays a major role in providing the necessary care during pregnancy, labor, and postpartum and reproductive health. She plays the role of counseling, education, support, and implementation. Providing specialized counseling can help women with a history of pregnancy loss to adapt. No valid and reliable educational content has been designed so far. This study aimed to evaluate the effect of group counseling on the social support and mental health of women with a history of unsuccessful pregnancy.

Materials and Methods

The present study is a quasi-experimental study with a pretest-posttest with control and follow-up group. The statistical population of the study included all non-pregnant women with a history of unsuccessful pregnancy (15-45 years) who referred to the comprehensive health centers of Qods city and obtained a score above 23 in the mental health test. The inclusion criteria of the study included lack of known physical or psychological illness, lack of taking drugs that affected the psyche and the exclusion criterion of the study included being absent in more than one session of group counseling. After obtaining the code of ethics from Iran University of Medical Sciences with the code of IR.IUMS.REC1397.521 and obtaining a letter of introduction for conducting research, the researcher first received a letter of introduction with the number of 98/D/105,2578 from Iran University of Medical Sciences of Qods city and explained the research objectives and procedure and accordingly obtained the consent of authorities. Then, using electronic files in 15 centers and the community health center, women aged 15-45 years and with unsuccessful pregnancy history were identified and if they met the inclusion criteria of the study, they were invited to participate in the study.

Necessary explanations on the objectives of the research, procedure, confidentiality of the information, and the possibility of leaving the study at each stage were provided to participants. If they were willing to participate in the research, written and informed consent form, demographic information form, mental health questionnaire, and social support questionnaire were completed by participants for initial evaluation. Then, their mental health score was determined, and if they scored 23 or higher, they were selected as the research subjects. Eligible individuals were assigned to the intervention and control groups using a block random allocation method. The required sample size was determined to be 31 people in each group at 95% confidence level and 80% test power, assuming that the effect of group counseling on perceived social support and mental health of women with a history of unsuccessful pregnancy is 4 points compared to the control group to be statistically significant. Given the probability of 10% of dropout in samples, the sample size in each group considered to be 35 people. This standard deviation was obtained based on a study conducted by Golshani et al. under the title of "The effectiveness of life skills training during pregnancy on the mental health of pregnant mothers" [22]. The data were collected through the General Health Questionnaire -GHQ, designed by Goldberg and Hiller in 1979 to screen for mental disorders. This questionnaire includes 30 questions scored on the 7-Likert scale. It included 4 subscales of physical symptoms, anxiety, social dysfunction, and depression. Cronbach's alpha coefficient of this tool was reported at 0.93 [23]. In the study conducted by Yosefi, it was also reported at 0.91. Another tool used to collect the data was the scale of perceived social support from friends and family, which is used to measure the level of perceived social support from friends and family. This tool is divided into two sections by Heller and Procidano. Each section has 20 questions. Alpha Cronbach has been reported at 0.88 and 0.90 for the dimensions of social support of family and friends, respectively. This questionnaire is used separately or together. For each item, there are three answers: yes, no, and I don't know. The answer of I don't know takes the zero score, the answer no in questions 3, 4, 16, 19, and 20 takes to score 1 and the answer yes takes the zero score and in other questions, the answer no takes zero scores and answer yes takes score 1. The total score of the questions is between zero and 20, and the higher score indicates more social support [24, 25]. In the present study, the content validity of the tool and the scientific validity of the educational booklet was corrected and approved by 5 faculty members of the School of Nursing and Midwifery of Iran. The reliability of the tool was assessed by the retest test method with a 2-week interval. Its correlation coefficient was obtained at 0.84. After obtaining their informed consent and assigning them to one of the intervention and control groups, all eligible individuals who met the inclusion criteria of the study completed the data collection tools. Then, the test group was contacted to participate in the study. In an introductory session, they became familiar with the subject of research and the work process, and a summary of the topics was introduced for them. The interventions were performed by the researcher in 6 sessions of 60 minutes once per week. Sessions were held in 8-member groups based on educational content.

At the beginning of each session, the researcher asked a question about the subject of the session and then the desired subject was discussed in the session. During the open-ended questions sessions, members expressed their views and experiences, and based on the contents of the booklet, the education process was guided and people were encouraged to participate in the discussion. The subjects discussed in the first session included the nature of unsuccessful pregnancy, complications, treatment, and the importance of mental health. The second session focused on anxiety and ways to cope with it. The third session focused on the importance of thoughts, defining thought and mood, and its role in behavior and body and breathing exercise and mental imagination.  The fourth session focused on discussing problem-solving skills and their role in life and the problem-solving process. The fifth session focused on the need to being understood and the importance of interpersonal and social relationship skills. The sixth session focused on nutrition, exercise, a healthy lifestyle, and the factors affecting it as physical methods to cope with anxiety. To prevent information exchange between the control and intervention group, educational interventions were held on even days of the week, and participants in the control group received the necessary education on breast and cervix screening. At the end of the sixth session, the questionnaires were re-completed by the intervention and control groups. Six weeks later, in the follow-up period, both groups re-completed the mental health questionnaires and the perceived social support scale. The booklet of educational contents was provided to the control group and for those who were not able to complete the questionnaire in person and completed it via phone call. SPSS version 16 software was used to analyze the data. In this study, descriptive statistics (frequency, percentage of frequency, mean and standard deviation) and inferential statistics (Chi-square, Fisher's exact test, independent T-test, repeated measures ANOVA, and Bonferroni test were used to analyze the data.

Results and Discussion

The mean age of women in the control and intervention groups was 28.94 ± 5.30 and 27.29 ±5.39 years, respectively. The highest frequency of age in the intervention group was 26-30 years (41.2%) and it was 30 years old (37.2%) in the control group. The mean age of the two groups did not show a significant difference (P=0.20). The highest frequency of pregnancy loss type in the intervention group (82.4%) and control group (7.7 85%) was abortion and the two groups were homogeneous in this regard (P=0.93). Pregnancy age at the time of fetal loss in most women in the intervention group (55.9%) and control group (62.9%) was 10 weeks or less. The mean gestational age at the time of fetal loss in the control and intervention groups was 12.26 ± 8.93 and 13.44 ± 8.43, respectively, and the two groups were homogeneous in this regard (P=0.057). The education of most women in the intervention group (61.8%) and control group (51.4%) were diploma and less, and two groups did not have a statistically significant difference in this regard (P=0.38).

Table 1 presents women's perceived social support with a history of unsuccessful pregnancy immediately and 6 weeks after the intervention in the intervention and control groups. Perceived social support before the intervention was not significantly different between the two groups (P=0.12) and despite an increase in perceived social support immediately after the intervention (P=0.46 immediately after intervention and p=0.75 six weeks after the intervention, control, and intervention groups did not show a statistically significant difference in this regard (P >0.05).

Mental health and its subscales in dimensions of mental health (p=0.69) physical health (P=0.05962), anxiety (P=0.35), social dysfunction (P=0.42) and depression (P=0.88) in two groups did not have a significant difference before the intervention (P >0.05).

There was no significant difference between two groups immediately after intervention and 6 weeks after the intervention (P >0.05) in terms of mental health (p=0.18), and its subscales in dimensions of physical health (P=0.62), anxiety (P=0.10), social dysfunction (P=0.39), and depression (0.31) (Tables 2-4).