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The problem of spontaneous abortion
The problem of spontaneous abortion X.
The efficacy of psychotherapy
WILLIAM H. JAMES, B.Sc. Halifax, Nova Scotia, Canada
IN THE field of psychiatry there is a great deal of controversy about the efficacy of psychotherapy (any form of treatment in which the predominant feature is talk, either by the patient, therapist, or both). One of the principal protagonists in this controversy, H. J. Eysenck, has recently reviewed more than 100 studies on the topic and concluded that, in general, psychotherapy has no effect. 1 However, Eysenck did not consider the results of psychotherapy in the treatment of habitual spontaneous abortion, so it seems appropriate to examine the evidence here. Tupper and Wei! have recently reported on the pregnancy results of 19 habitual abortion patients given "supportive therapy" during their pregnancies, and a control group of 19 habitual abortion patients who received no psychotherapy. 2 It is true that the controls were chosen by virtue of the fact that for various reasons (geographical, etc.) they were unable to take advantage of the therapy; but it would be surprising if a sampling error were thereby created so gross as to cause the observed differences in outcome. The results are summarized in Table I. The premature birth in the experimental group may be classified with the abortions, and the premature birth in the control group may be classified with the full-term live births. Even then the 2 by 2 chi-square value (corrected for continuity) is 8.74, p < 0.01.
Obstetrics is not a field which is bedeviled by methodological nicety, and to my knowledge the study by Tupper and Wei! is the only such study incorporating a control group. During the remainder of this article I shall review further data on the outcome of pregnancies of habitual aborters: (a) those treated psychotherapeutically, and (b) those untreated. First I will deal with some of the results reported with psychotherapy. Javert 3 reported that with an eclectic treatment live births resulted from 81.2 per cent of 154 pregnancies of women who had been primary or secondary habitual aborters. He attributed his success to the psychotherapeutic aspects of his regimen. Bevis 4 reported on 32 pregnant habitual aborters for whom treatment was kept to a minimum. Twenty-six of these women were delivered of live infants and Bevis concluded that "the best form of treatment in such cases is to instil confidence in the patient." Mann 5 reported on 24 pregnant habitual aborters who were given psychotherapy. Twenty of them had live infants and Mann had no doubt that his treatment was at least partially responsible for this. King" reviewed the literature and noted that habitual spontaneous abortion is a disorder for which a remarkably diverse lot of cures had apparently proved efficacious. He concluded that the efficacy of each cure was probably based on small medical, and large psychotherapeutic, elements. Mann 5 echoes this judgment writing "of primary speculative interest is the observation, well documented in the literature, that
From the Department of Psychiatry and Obstetrics and Gynaecology, Dalhousie University Medical School, and Victoria General Hospital. This project is supported by a Canadian Federal Health Grant.
38
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..
•
Volume 85 Number I
Spontaneous abortion
almost any type of treatment, in the hands of certain workers, results in success ... the common factor may well have to do with the therapist's personality." This met a cynical reception from Warburton and Fraser 7 who suggest instead that "The common factor is much more likely to be that the chance of a successful pregnancy without any treatment at all is much higher than these workers realised." I would like to present evidence to suggest that the judgment of Warburton and Fraser may be mistaken in this matter. It is much easier to secure evidence on the outcome of treated pregnancies of habitual aborters than of untreated pregnancies of habitual aborters. It is perhaps for this reason that the first well-known study of recurrence rates in spontaneous abortion remained so long enshrined within the conventional wisdom of obstetrics. 8 Malpas's work has been harshly criticized/• 9 , 10 and it may be taken as established that his methods (as opposed to results) have been justly disavowed. Mal pas concluded that recurrence rates in spontaneous abortion are high, but a recent review article by Goldzieher and Benigno10 testifies that obstetricians have lately become more sanguine about the matter. I have argued elsewhere that this is because they have been calculating recurrence rates from data on treated pregnancies. 11 Warburton has made a good summary of the kinds of bias often associated with the commoner sources of data on spontaneous abortionY She concludes that the best source is a random sample of women interviewed by a skilled interviewer. Through the courtesy of the Trustees of the Institute for Sex Research of Indiana University, permission has been given to present and reanalyze some of their previously published data and
to analyze previously unpublished data as well. The sample of women from which these data were elicited has already been described. 13 The training of the interviewers and the very thorough efforts to gain rapport with the subjects are described elsewhere.14 Although the representativeness of the sample is admittedly incomplete/ 3 it seems unlikely to have affected those features of the sample to be reported. The sample was of 781 white women, each of whom: (a) was 36 or more years old at the time of interview, (b) had married by the age of 30, (c) had never been to prison, and (d) had had at least one pregnancy. This sample includes the 759 gravidas mentioned by Gebhard and co-workersY The additional 22 women were interviewed after the manuscript for the book had been prepared for publication. I shall call the 781 women the ISR sample. An estimate of the abortion probability (i.e., the probability that an untreated pregnancy will abort) of habitual abortion patients can be made by examining the results of those pregnancies which immediately follow an index trio of consecutive abortions. In the ISR sample, 9 women had a trio of consecutive abortions followed by another pregnancy. The outcomes of these 9 pregnancies were 6 abortions and 3 live births, giving an abortion probability estimate of 0.67. This sample is too small to yield any firm conclusion. However, it seems virtually certain that the mean abortion probability of a group of habitual aborters will exceed that of a group of women who have aborted only their last two pregnancies (in contrast to the last three of habitual aborters). So, an estimate of the latter parameter may give an idea as to the order of the abortion probability of habitual aborters. There were 29
Table I. Results in experimental and control groups (after Tupper and Weil) Description Habitual aborters given supportive therapy during pregnancy Habitual aborters interviewed on a maximum of 2 occasions
Premature deliveries (died)
39
Full-term live births
Abortions
Total cases
16
2
19
5
13
19
40 James
women in the ISR sample who had had a pair of consecutive abortions followed by another pregnancy. No woman was counted twice. In those few cases in which a woman had had 2 pairs of consecutive abortions followed by a further pregnancy, the first pair was used as the index pair. Induced abortions, therapeutic or illegal, were ignored. The outcome of these 29 subsequent pregnancies was 16 abortions and 13 live births, suggesting an abortion probability of 0.55. Data on 2 other samples which tend to corroborate these high recurrence rates are as follows: The ISR sample, as previously mentioned, was composed of white women who were interviewed at age 36 or over, and who married at 30 or less years of age. I have data on other women interviewed by the staff of the Institute for Sex Research. Among those white women who had been interviewed before they were 36, or who had married after the age of 30 (or both), there wen· 13 who had had a pair of consecutive abortions followed by another pregnancy. The results of these 13 pregnancies were 8 abortions and 5 live births. Among a similar group of women described by Reed and Kelly.'" there were 8 such women. The outcomes of their pregnancies were 5 abortions and 3 live births. (Stillbirths were counted as abortions and induced abortions were ignored in this assessment.) It seems then that 0.55 is not an unreason-
:\m .
.J.
Januat y l, l9b3 Oh'L & Cyne•.:.
able estimate of the abortion probability of women whose last 2 pregnancies tern1inated in spontaneous abortion. So it may tentatively be concluded that the abortion probability of habitual aborters is more than this value. This analysis has assumed that the pregnancies in the ISR sample and those in Reed and Kelly's sample were untreated. lf some of them were treated (and assuming no iatrogenic effects), then a fortiori the value of 0.55 may be accepted as an underestimate of the abortion probability in untreated habitual abortion patients.
.
Conclusion and summary
Several workers have reported administering psychotherapy to pregnant habitual aborters, and about 80 per cent of these pregnancies resulted in live infants. Evidence has been presented to suggest that without treatment less than 45 per cent of such pregnancies would yield live infants. The inference is that psychotherapy has a beneficial effect on this disorder. I wish to thank Dr. Gebhard, Dr. Pomeroy, Mrs. Christenson, and Mr. Gagnon of the Institute for Sex Research. They were generous with their encouragement and magnanimous with th<>ir data. Additional gratitude is due to Mr. Gagnon, who ('SCorted me on an instructivP tour of the Institute's collections, and to the Trustees of Indiana University for the free use of their computer.
"'
REFERENCES
1. Eysenck, H. J.: In Eysenck, H. J., editor: Handbook of Abnormal Psychology, New York, 1961, Basic Books, Inc. 2. Tupper, C., and Wei!, R. J.: AM. J. 0BsT. & GYNEC. 83: 421, 1962. 3. ]avert, C. T.: Spontaneous and Habitual Abortion, New York, 1957, McGraw-Hill Book Company Inc. 4. Bevis, D. C. A.: Lancet 2: 207, 1951. 5. Mann, E. C.: Obst. & Gynec. 7: 589, 1956. 6. King, A. G.: Obst. & Gynec. 1: 104, 1953. 7. Warburton, D., and Fraser, F. C.: J. Obst. & Gynaec. Brit. Comm. 68: 784, 1961. 8. Malpas, P.: J. Obst. & Gynaec. Brit. Emp. 45: 932, 1938. 9. American Medical Association Council on Pharmacy and Chemistry: ]. A. M. A. II4: 2214, 1940.
10. Goldzieher, J. W., and Benigno, B. B.: AM. J. 0BST. GYNEC. 75: 1202, 1958. 1I. James, W. H.: ]. Obst. & Gynacc. Brit. Comm. 69: 606, 1962. 12. Warburton, D.: Factors in the Aetiology of Spontaneous Abortion, unpublished Ph.D. Thesis, McGill University, Montreal, 1961. 13. Gebhard, P. H., Pomeroy, W. B., Martin, C. E., and Christenson, C.: Pregnancy, Birth, and Abortion, New York, 1958, Harper & Bros. 14. Kinsey, A. C., Pomeroy, W. B., and Martin, C. E.: Sexual Behavior in the Human Male, Philadelphia, 1948, W. B. Saunders Company, Ch. 2. 15. Reed, T. E., and Kelly, E. L.: Ann. Human Genet. 22: 165, 1958.
.,
The efficacy of psychotherapy
WILLIAM H. JAMES, B.Sc. Halifax, Nova Scotia, Canada
IN THE field of psychiatry there is a great deal of controversy about the efficacy of psychotherapy (any form of treatment in which the predominant feature is talk, either by the patient, therapist, or both). One of the principal protagonists in this controversy, H. J. Eysenck, has recently reviewed more than 100 studies on the topic and concluded that, in general, psychotherapy has no effect. 1 However, Eysenck did not consider the results of psychotherapy in the treatment of habitual spontaneous abortion, so it seems appropriate to examine the evidence here. Tupper and Wei! have recently reported on the pregnancy results of 19 habitual abortion patients given "supportive therapy" during their pregnancies, and a control group of 19 habitual abortion patients who received no psychotherapy. 2 It is true that the controls were chosen by virtue of the fact that for various reasons (geographical, etc.) they were unable to take advantage of the therapy; but it would be surprising if a sampling error were thereby created so gross as to cause the observed differences in outcome. The results are summarized in Table I. The premature birth in the experimental group may be classified with the abortions, and the premature birth in the control group may be classified with the full-term live births. Even then the 2 by 2 chi-square value (corrected for continuity) is 8.74, p < 0.01.
Obstetrics is not a field which is bedeviled by methodological nicety, and to my knowledge the study by Tupper and Wei! is the only such study incorporating a control group. During the remainder of this article I shall review further data on the outcome of pregnancies of habitual aborters: (a) those treated psychotherapeutically, and (b) those untreated. First I will deal with some of the results reported with psychotherapy. Javert 3 reported that with an eclectic treatment live births resulted from 81.2 per cent of 154 pregnancies of women who had been primary or secondary habitual aborters. He attributed his success to the psychotherapeutic aspects of his regimen. Bevis 4 reported on 32 pregnant habitual aborters for whom treatment was kept to a minimum. Twenty-six of these women were delivered of live infants and Bevis concluded that "the best form of treatment in such cases is to instil confidence in the patient." Mann 5 reported on 24 pregnant habitual aborters who were given psychotherapy. Twenty of them had live infants and Mann had no doubt that his treatment was at least partially responsible for this. King" reviewed the literature and noted that habitual spontaneous abortion is a disorder for which a remarkably diverse lot of cures had apparently proved efficacious. He concluded that the efficacy of each cure was probably based on small medical, and large psychotherapeutic, elements. Mann 5 echoes this judgment writing "of primary speculative interest is the observation, well documented in the literature, that
From the Department of Psychiatry and Obstetrics and Gynaecology, Dalhousie University Medical School, and Victoria General Hospital. This project is supported by a Canadian Federal Health Grant.
38
...
. ~'
..
•
Volume 85 Number I
Spontaneous abortion
almost any type of treatment, in the hands of certain workers, results in success ... the common factor may well have to do with the therapist's personality." This met a cynical reception from Warburton and Fraser 7 who suggest instead that "The common factor is much more likely to be that the chance of a successful pregnancy without any treatment at all is much higher than these workers realised." I would like to present evidence to suggest that the judgment of Warburton and Fraser may be mistaken in this matter. It is much easier to secure evidence on the outcome of treated pregnancies of habitual aborters than of untreated pregnancies of habitual aborters. It is perhaps for this reason that the first well-known study of recurrence rates in spontaneous abortion remained so long enshrined within the conventional wisdom of obstetrics. 8 Malpas's work has been harshly criticized/• 9 , 10 and it may be taken as established that his methods (as opposed to results) have been justly disavowed. Mal pas concluded that recurrence rates in spontaneous abortion are high, but a recent review article by Goldzieher and Benigno10 testifies that obstetricians have lately become more sanguine about the matter. I have argued elsewhere that this is because they have been calculating recurrence rates from data on treated pregnancies. 11 Warburton has made a good summary of the kinds of bias often associated with the commoner sources of data on spontaneous abortionY She concludes that the best source is a random sample of women interviewed by a skilled interviewer. Through the courtesy of the Trustees of the Institute for Sex Research of Indiana University, permission has been given to present and reanalyze some of their previously published data and
to analyze previously unpublished data as well. The sample of women from which these data were elicited has already been described. 13 The training of the interviewers and the very thorough efforts to gain rapport with the subjects are described elsewhere.14 Although the representativeness of the sample is admittedly incomplete/ 3 it seems unlikely to have affected those features of the sample to be reported. The sample was of 781 white women, each of whom: (a) was 36 or more years old at the time of interview, (b) had married by the age of 30, (c) had never been to prison, and (d) had had at least one pregnancy. This sample includes the 759 gravidas mentioned by Gebhard and co-workersY The additional 22 women were interviewed after the manuscript for the book had been prepared for publication. I shall call the 781 women the ISR sample. An estimate of the abortion probability (i.e., the probability that an untreated pregnancy will abort) of habitual abortion patients can be made by examining the results of those pregnancies which immediately follow an index trio of consecutive abortions. In the ISR sample, 9 women had a trio of consecutive abortions followed by another pregnancy. The outcomes of these 9 pregnancies were 6 abortions and 3 live births, giving an abortion probability estimate of 0.67. This sample is too small to yield any firm conclusion. However, it seems virtually certain that the mean abortion probability of a group of habitual aborters will exceed that of a group of women who have aborted only their last two pregnancies (in contrast to the last three of habitual aborters). So, an estimate of the latter parameter may give an idea as to the order of the abortion probability of habitual aborters. There were 29
Table I. Results in experimental and control groups (after Tupper and Weil) Description Habitual aborters given supportive therapy during pregnancy Habitual aborters interviewed on a maximum of 2 occasions
Premature deliveries (died)
39
Full-term live births
Abortions
Total cases
16
2
19
5
13
19
40 James
women in the ISR sample who had had a pair of consecutive abortions followed by another pregnancy. No woman was counted twice. In those few cases in which a woman had had 2 pairs of consecutive abortions followed by a further pregnancy, the first pair was used as the index pair. Induced abortions, therapeutic or illegal, were ignored. The outcome of these 29 subsequent pregnancies was 16 abortions and 13 live births, suggesting an abortion probability of 0.55. Data on 2 other samples which tend to corroborate these high recurrence rates are as follows: The ISR sample, as previously mentioned, was composed of white women who were interviewed at age 36 or over, and who married at 30 or less years of age. I have data on other women interviewed by the staff of the Institute for Sex Research. Among those white women who had been interviewed before they were 36, or who had married after the age of 30 (or both), there wen· 13 who had had a pair of consecutive abortions followed by another pregnancy. The results of these 13 pregnancies were 8 abortions and 5 live births. Among a similar group of women described by Reed and Kelly.'" there were 8 such women. The outcomes of their pregnancies were 5 abortions and 3 live births. (Stillbirths were counted as abortions and induced abortions were ignored in this assessment.) It seems then that 0.55 is not an unreason-
:\m .
.J.
Januat y l, l9b3 Oh'L & Cyne•.:.
able estimate of the abortion probability of women whose last 2 pregnancies tern1inated in spontaneous abortion. So it may tentatively be concluded that the abortion probability of habitual aborters is more than this value. This analysis has assumed that the pregnancies in the ISR sample and those in Reed and Kelly's sample were untreated. lf some of them were treated (and assuming no iatrogenic effects), then a fortiori the value of 0.55 may be accepted as an underestimate of the abortion probability in untreated habitual abortion patients.
.
Conclusion and summary
Several workers have reported administering psychotherapy to pregnant habitual aborters, and about 80 per cent of these pregnancies resulted in live infants. Evidence has been presented to suggest that without treatment less than 45 per cent of such pregnancies would yield live infants. The inference is that psychotherapy has a beneficial effect on this disorder. I wish to thank Dr. Gebhard, Dr. Pomeroy, Mrs. Christenson, and Mr. Gagnon of the Institute for Sex Research. They were generous with their encouragement and magnanimous with th<>ir data. Additional gratitude is due to Mr. Gagnon, who ('SCorted me on an instructivP tour of the Institute's collections, and to the Trustees of Indiana University for the free use of their computer.
"'
REFERENCES
1. Eysenck, H. J.: In Eysenck, H. J., editor: Handbook of Abnormal Psychology, New York, 1961, Basic Books, Inc. 2. Tupper, C., and Wei!, R. J.: AM. J. 0BsT. & GYNEC. 83: 421, 1962. 3. ]avert, C. T.: Spontaneous and Habitual Abortion, New York, 1957, McGraw-Hill Book Company Inc. 4. Bevis, D. C. A.: Lancet 2: 207, 1951. 5. Mann, E. C.: Obst. & Gynec. 7: 589, 1956. 6. King, A. G.: Obst. & Gynec. 1: 104, 1953. 7. Warburton, D., and Fraser, F. C.: J. Obst. & Gynaec. Brit. Comm. 68: 784, 1961. 8. Malpas, P.: J. Obst. & Gynaec. Brit. Emp. 45: 932, 1938. 9. American Medical Association Council on Pharmacy and Chemistry: ]. A. M. A. II4: 2214, 1940.
10. Goldzieher, J. W., and Benigno, B. B.: AM. J. 0BST. GYNEC. 75: 1202, 1958. 1I. James, W. H.: ]. Obst. & Gynacc. Brit. Comm. 69: 606, 1962. 12. Warburton, D.: Factors in the Aetiology of Spontaneous Abortion, unpublished Ph.D. Thesis, McGill University, Montreal, 1961. 13. Gebhard, P. H., Pomeroy, W. B., Martin, C. E., and Christenson, C.: Pregnancy, Birth, and Abortion, New York, 1958, Harper & Bros. 14. Kinsey, A. C., Pomeroy, W. B., and Martin, C. E.: Sexual Behavior in the Human Male, Philadelphia, 1948, W. B. Saunders Company, Ch. 2. 15. Reed, T. E., and Kelly, E. L.: Ann. Human Genet. 22: 165, 1958.
.,