Abstract
While previous research has explored the impact of migration status on experiences and attributions about pregnancy loss, less common is comparative research examining similarities and differences between migrants and non-migrants. This paper reports on a cross sectional comparative study of 623 culturally and linguistically diverse (CALD) or non-CALD people living in Australia. Participants completed a survey that asked about experiences of pregnancy loss, support, and attributions about pregnancy loss. There were no differences between the two groups in terms of rates of pregnancy loss, though CALD participants reported greater distress following a loss. CALD participants reported greater reliance on partners and faith communities, and found healthcare professionals to be less supportive. CALD participants were more likely to attribute pregnancy loss to spiritual reasons (among others), and non-CALD participants to fetal abnormalities. The paper concludes by calling for awareness campaigns and professional upskilling to better ensure the needs of CALD communities.
Introduction
It is common to view pregnancy loss as a phenomenon that universally and uniformly affects people who undertake a pregnancy (typically cisgender women, though see Riggs et al., 2020). However, both rates and causes of pregnancy loss are differentiated by multiple factors. A key point of differentiation is migration status. Research has consistently found that people who are migrants to a country (as compared to those who have lived there for more than one generation) experience higher rates of pregnancy loss (Behboudi-Gandevani et al., 2022; Mozooni et al., 2020a). Increased rates of pregnancy loss among those who migrate has been attributed to lower rates of accessing prenatal healthcare, and barriers experienced when accessing healthcare, such as in regard to language (Mozooni et al., 2020b).
Importantly, it is not simply the case that rates and causes of pregnancy loss are differentiated by migration status. Attributions about, and needs arising from, pregnancy loss are also differentiated by migration status. Research has found that those who have lived in their home country for more than one generation commonly report misattributions about pregnancy loss that are related to physiology (e.g., previous contraception use or living heavy objects, Bardos et al., 2015). People who migrate to a country, however, typically attribute pregnancy loss to other causes, such as supernatural causes (e.g., evil forces, Rice, 2000), and the will of God (Kilshaw et al., 2017). Similarly, those who have lived in their home country for more than one generation typically believe that they would seek pregnancy loss-related support from a family member or a friend who has experienced a pregnancy loss (Pollock et al., 2022), while those who have migrated to a new country typically believe that they would seek pregnancy loss-related support from their religious or cultural community (Pearson et al., 2023).
While some of the above research has been conducted in the Australian context (e.g., Mozooni et al., 2020a; Mozooni et al., 2020b; Pearson et al., 2023), missing in the Australian context is research that explores attributions about, experiences of, and support needs related to pregnancy loss, comparing migrant and non-migrant populations. The study reported in this paper was thus designed to capture this overlooked point of comparison, by comparing Australian-born people with Culturally and Linguistically Diverse (CALD) people who are either first- or second-generation migrants. The term CALD is used in this paper following Pham and colleagues (2021), and refers to people born outside of Australia and/or for whom languages other than English are spoken at home.
Methods and Materials
Participants
Ethics approval was granted by the Flinders University Human Research Ethics Committee. Participants were recruited as members of a Qualtrics audience panel. Qualtrics offers a paid service that provides researchers with representative samples of a chosen population. For the present study, the audience panel was weighted to ensure it was representative of both gender and age against Australian population norms. Inclusion criteria were living in Australia, being aged 18 years or older, and having sufficient English language proficiency to complete a survey written in English. Participants did not need to have experienced a pregnancy loss. The survey included cut off rates for CALD or non-CALD participants, to ensure a balance of the two groups. Recruitment occurred over two weeks in March 2021, and closed once the minimum sample size was exceeded (based on the population size of Australia, a 95% confidence level, and a 4% margin of error). Participants were asked to give consent to participation, and were advised that they could withdraw at any time prior to submitting their completed responses. Participants were provided with a list of support groups should they experience any distress when completing the survey. Participants were paid a small honorarium for their time as members of a Qualtrics audience panel.
Materials
Participants completed a survey designed by the authors. Participants were first asked for demographic information: age, gender, whether or not they were currently in an intimate relationship, region of birth, religion, importance of religion in their life (1 = not at all important to 5 = extremely important), highest education, current employment status, current combined household income, and whether or not they were from a culturally or linguistically diverse (CALD) background. The specific question about CALD background was: “Australia’s population includes many people who were born overseas, have a parent born overseas, or who speak a variety of languages. Together, these groups of people are known as culturally and linguistically diverse (CALD) populations, most commonly including people who were born (or whose parents were born) in non-English speaking countries and/or for whom English is not the main language spoken at home. With this definition in mind, would you describe yourself as culturally and/or linguistically diverse?”.
Participants were then asked if they (or a partner) had ever been pregnant and if it was a planned pregnancy. Participants were then asked if they or a partner had experienced a pregnancy loss, and if they answered yes they were directed to a separate screen to answer questions related to the pregnancy loss. Participants who responded that they or a partner had not experienced a pregnancy loss were directed to the fourth measure outlined below. In terms of those who indicated they or a partner had experienced a pregnancy loss, the following questions were asked: how many pregnancy losses they had experienced, what type of pregnancy loss they had experienced, whether or not they have any surviving children, the gestational age at which the loss occurred (in weeks), the time since the loss occurred (in years), whether or not they were in an intimate relationship at the time of the loss (and if they were still in the same relationship), and how upsetting they found the pregnancy loss both at the time of the pregnancy loss and now (using a sliding scale where 0 = not upsetting and 100 = extremely upsetting).
Participants who had experienced a pregnancy loss (or whose partner had) then completed three measures. The first three were developed by the authors and have been validated previously (Riggs et al., 2021). Of these measures one asked participants to rate the degree to which they “could trust, talk openly to, and share your feelings about the pregnancy loss with” a diversity of sources, the second asked participants to rate the degree to which “you felt supported by” a diversity of sources, and the third asked participants to rate the degree to which “you felt satisfied with the support you received” from a diversity of sources. For each of these the list of sources were: partner, other family members, friends, people with similar experience, psychologist, social worker, midwife/obstetrician, pregnancy loss support organisation, and Pastor/Chaplain/Imam/other religious counsel. Each was rated on a 5-point Likert scale ranging from 1 = not at all to 5 = totally.
All participants then completed a measure adapted from the work of Bardos et al. (2015), and asked participants to indicate whether they agree, disagree, or were unsure about whether or not a diversity of examples are likely causes of a pregnancy loss. The examples given were God’s will, getting into an argument, lifting heavy objects, woman not wanting the pregnancy, pre-marital sex, sexual intercourse during pregnancy, past use of birth control, jealousy (i.e., one partner being jealous of the other for any reason during the pregnancy), longstanding stress, a stressful event, genetic abnormalities in the foetus, having had a sexually transmitted infection in the past, having had an abortion in the past, spiritual causes such as destiny or fate, concerns related to the parents’ age.
Analysis Strategy
All data were exported into SPSS 29.0. Of the 820 people who commenced the survey, 197 completed no or minimal items and were removed from the sample. Of the remaining 623, each participant completed a sufficient number of key items (about pregnancies and pregnancy loss) to be included in the final sample. Descriptive statistics were generated for all demographic data, separated by CALD status. Chi Square tests or t-tests were run to determine if there were any statistically significant differences between the two groups in terms of demographic variables.
The planned analysis strategy for inferential statistics involved using Chi Square or t-tests to examine any differences between the two groups (CALD or non-CALD) for experiences of pregnancy loss, ratings of being able to share feelings about a pregnancy loss with each of the sources, feeling supported by each of the sources, feeling satisfied with each of the sources, and views on the causes of pregnancy loss. Supplementary correlations and Two-Way ANOVAs were run to further examine the intersections of religiosity, CALD status, and pregnancy loss.
Results
Participants
Participant Demographics N = 623.
The average age of participants was 47.33 years (SD = 17.02). There were no statistically significant differences between the two groups in terms of age. In terms of the importance of religion to people’s life, there were statistically significant differences between the two groups. CALD participants reported that religion was more important (M = 2.84, SD = 1.45) than did non-CALD participants (M = 2.10, SD = 1.32), t = 6.23, p = .001.
Experiences of Pregnancy Loss
Experiences of Pregnancy Loss.
The average gestational age at which pregnancy losses occurred was 10.68 weeks (SD = 7.14), though the range was 8 weeks–38 weeks. The number of years since a pregnancy loss had been experienced was 16.61 years (SD = 16.42), though the range was 1 year–60 years. There were no statistically significant differences between the two groups for these variables.
In terms of how upsetting the pregnancy loss was at the time of the loss, there was a statistically significant difference between the two groups, with CALD participants reporting that the loss was more upsetting (M = 75.36, SD = 29.24) than non-CALD participants (M = 66.27, SD = 35.45), t = 2.14, p = .001, and there was a weak positive correlation between degree of religiosity and how upsetting the pregnancy loss was at the time, r = .133, p = .047. The more religious participants were the more upsetting they found the experience of a pregnancy loss at the time. There were no statistically significant differences between the two groups in terms of how upsetting the pregnancy loss was now (M = 38.38, SD = 22.01).
Experiences with Support Sources
Mean Ratings of Sources With Whom Feelings About Pregnancy Loss Could be Shared.
Mean Ratings for Feeling Supported by Sources.
Mean Ratings for Feeling Satisfied With Support From Sources.
Attributions About Pregnancy Loss
Views on Causes of Pregnancy Loss.
Discussion
The findings reported in this paper demonstrate key points of both sameness and difference between CALD and non-CALD people living in Australia. Compared to previous research, which has found elevated rates of pregnancy loss among people who have migrated (e.g., Behboudi-Gandevani et al., 2022; Mozooni et al., 2020a), the present study found no differences in rates or timing of pregnancy loss. This finding may be explained by the fact that the present study did not ask about the length of time in which participants had lived in Australia. Previous research has found that those who have lived in a country longer and thus ‘acculturated’ to healthcare systems and expectations report lower rates of pregnancy loss (Mozooni et al., 2020a).
Beyond similarities, however, there were also notable differences. Those with a CALD background reported that at the time, a pregnancy loss was experienced as more upsetting than was the case for non-CALD participants. This may again speak to length of time since migration, with those who have more recently migrated potentially having fewer support sources and a reduced understanding of how to access formalized support networks (Mozooni et al., 2020b). Differences in experiences of feeling upset may also speak to cultural differences in terms of both the expression of emotion and the moral values attached to pregnancy loss. For example, cultural values around reproductivity may lead CALD people who experience a pregnancy level to feel high levels of shame and stigma, and thus high levels of distress related to a pregnancy loss (Batool & Azam, 2016; Omar et al., 2019). Interestingly, however, while religiosity was correlated with feeling upset at the time of a pregnancy loss, this was true for all participants, and was not specific to CALD participants only.
In terms of support, there were differences between CALD and non-CALD participants. While formalized sources of support were valued by all participants (e.g., healthcare professionals, pregnancy loss support groups), CALD participants were more likely to value support from partners and friends, and less likely to feel supported by formalized sources of support (specifically healthcare professionals). Again, it would seem to be the case that potential barriers to accessing healthcare services, and barriers experienced in those services, negatively impacted CALD people, echoing previous research (e.g., Mozooni et al., 2020b; Pearson et al., 2023). Due to language barriers, for example, CALD people may feel less able or comfortable in sharing their experiences of pregnancy loss with healthcare professionals, and conversely may feel more able and comfortable in sharing their experiences with members of their community.
Finally, in terms of attributions about pregnancy loss, there were clear differences between the two groups. While non-CALD participants were more likely to attribute pregnancy loss to genetic abnormalities in the foetus, CALD participants were more likely to attribute pregnancy loss to a host of reasons that are not typically considered causal factors. Given the demographic differences between the two samples in terms of education and religiosity, the differing attributions may be explained by lack of knowledge about pregnancy loss, and increased likelihood of attributing pregnancy loss to spiritual causes.
Limitations
While the findings reported in this paper make a useful contribution to the topic of pregnancy loss by adopting a comparative approach, some limitations must be noted. First, the data are cross sectional, and cannot demonstrate causation in terms of the role of migration in experience, support and attributions about pregnancy loss. Further, and as noted above, CALD participants were not asked how long they had lived in Australia, meaning that this could not be examined as a potentially explanatory variable. In relation to this, the survey was in English, meaning that potential participants who were not proficient in English are unlikely to have participated. And for those who did participate, the survey did not explicitly ask about levels of English proficiency, a factor that likely further impacts experiences of pregnancy loss. Finally, the single item measure of distress related to pregnancy loss may not have captured the depth of pregnancy loss experienced, as compared to a measure such as the Perinatal Grief Scale (Toedter et al., 1988).
Implications for Practice
While in Australia there have been campaigns aimed at increasing awareness about pregnancy loss (Gordon et al., 2020) – with the present study seemingly demonstrating their efficacy in terms of non-CALD participant understandings of the causes of pregnancy loss – it would also seem to be the case that campaigns focused on pregnancy loss may fail to engage CALD Australians, meaning that their understandings of pregnancy loss are reduced. Further, while it would seem that following a pregnancy loss CALD participants had support sources whom they perceived as useful, it is troubling that healthcare professionals were perceived as less than useful. This may speak to cultural differences and differences in English-language proficiency at the point of referral, while accessing services, and during interactions with healthcare professionals (Mozooni et al., 2020b).
All of the above would suggest the importance of pregnancy loss campaigns tailored towards CALD people. This would require concerted engagement with CALD community leaders, and those who play either formal or informal roles in terms of knowledge and supported related to pregnancy loss. Given that in Australia access to publicly-funded healthcare can be contingent on visa status, some CALD people living in Australia may have reduced access to formalized healthcare following a pregnancy loss. This suggests an important role for CALD community members in providing support. For those people who do have access to publicly-funded services, it is vital that healthcare professionals are equipped with knowledge about supporting CALD people. Research in the Australian context suggests that CALD people value services where cultural knowledge is valued and centered, and where healthcare professionals are themselves community members (Lang et al., 2020; Pearson et al., 2023)
Conclusion
This paper provides important insights into differing attributions, experiences, and support needs through a comparative lens for people living in Australia. While pregnancy loss is often presumed to be a universal and uniform experience, it would appear to be the case that while physiologically this is true, experientially it is not. Given that those who migrate to Australia make a valued contribution to Australian communities, including in terms of population growth, it is vital that they are adequately supported when a pregnancy does not go as planned, and that they have access to information that helps them more accurately parse their experience of a pregnancy loss.
Footnotes
Acknowledgements
The authors acknowledge that they live on the unceded lands of the Kaurna people, and acknowledge their sovereignty as First Nations people.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research reported in this paper was supported by an Australian Research Council Future Fellowship, FT 130100087.
