Demographic characteristics of the sample
Most of the women who completed the survey were between 31 and 39 years old, and lived with their partner and children at the time of the survey. Just under two-thirds of the women had a higher education qualification and, 51% worked in a professional or managerial position. A full description of women’s characteristics can be found in Table 3. Over 70% of participants experienced one miscarriage, while 80% had a miscarriage during the first trimester of the total gestational period and 21% had had more than 3 miscarriages. 96% of the sample conceived their pregnancy naturally while 4% used assisted reproductive therapies. A full description of participants’ previous experience of miscarriage can be found in Table 4.
Table 3
Demographic Information
|
No. of Participants
|
Percentage
|
Age
|
|
|
16–25
|
48
|
6.6%
|
26–30
|
156
|
21.6%
|
31–39
|
420
|
58.1%
|
40–49
|
99
|
13.7%
|
Total
|
723
|
100%
|
Living arrangements
|
|
|
Alone
|
23
|
3.2%
|
With partner and other children
|
507
|
70.1%
|
With partner
|
191
|
26.5%
|
Missing value
|
1
|
0.1%
|
Total
|
723
|
100%
|
Education
|
|
|
Higher Degree
|
170
|
23.5%
|
BSc Degree
|
298
|
41.2%
|
Higher/A-levels
|
93
|
13.1%
|
Standard grade/GCSE
|
64
|
12.9%
|
No formal qualification
|
3
|
0.4%
|
Total
|
723
|
100%
|
Employment status
|
|
|
Managerial/professional
|
370
|
51.2%
|
Skilled worker
|
187
|
25.9%
|
Unskilled worker
|
30
|
4.1%
|
Student
|
23
|
3.2%
|
Stay at home parent
|
68
|
9.4%
|
Unemployed
|
4
|
0.6%
|
Other
|
41
|
5.7%
|
Total
|
723
|
100%
|
Table 4
History of pregnancy loss and reproductive health
Number of miscarriages
|
|
|
1
|
414
|
75.3%
|
2
|
153
|
21.2%
|
3
|
83
|
11.5%
|
4+
|
73
|
10.1%
|
Total
|
723
|
100%
|
Number of weeks when miscarriage occurred
|
|
|
Less than 4 weeks
|
5
|
0.7%
|
Between 4 and 6 weeks
|
92
|
12.7%
|
Between 7 and 12 weeks
|
509
|
70.4%
|
Between 13 and 16 weeks
|
59
|
8.2%
|
Between 17 and 20 weeks
|
38
|
5.3%
|
Between 21 and 24 weeks
|
19
|
2.6%
|
Don’t know
|
1
|
0.1%
|
Total
|
723
|
100%
|
How was the pregnancy conceived
|
|
|
Natural conception
|
692
|
95.7%
|
Assisted reproductive therapies
|
26
|
3.6%
|
Other
|
5
|
0.7%
|
Total
|
723
|
100%
|
Impact of miscarriage on women’s emotional wellbeing
The mean overall score on RIMS for those who completed the survey was 53.78 (SD = 8.5) indicating that miscarriage had a high impact on the sample included. The mean scores for the three sub-scales were: “Isolation/guilt” (M = 18.75, SD = 4.16), “Losing a baby” (M = 17.29, SD = 3.0) and “Devastating event (M = 17.74, SD = 2.69). This indicates the feelings related to guilt and loneliness following the miscarriage, the degree to which miscarriage is viewed as the loss of a baby, and finally the level of “devastation” that miscarriage has on women [26, 30]. As it is shown by the subscale mean scores, women experienced a high impact of miscarriage related to the sense of “guilt and isolation”, “devastating event” and “losing a baby”.
As shown in Figs. 1 and 2, RIMS scores were calculated at different time points as women were asked when they experienced their miscarriage (< 1, 1–2 years, 3–4 years and 5 years). What stands out in Figs. 1 and 2 is that RIMS, “Isolation/Guilt” and “Losing a baby” scores reached a pick after 1–2 years post miscarriage indicating that the impact of miscarriage on women was higher after 1–2 years. Contrary, “Devastating event” scores were higher in women who experienced miscarriage less than a year prior to survey competition.
Approximately 70% of women self-reported experience of mental health issues such as depression, anxiety, or PTSD. A further 14% reported to have been formally diagnosed with either depression, anxiety, or PTSD.
Women’s perceptions of the interaction with health professionals
The third section of the survey included questions about women’s perceptions of their interactions with health professionals. Responses indicated that 46% of women felt able to express their feelings to health professionals while visiting a hospital facility. However, 40% stated they were not able to express their feelings to HPs, and 14% reported feeling neutral. Similarly, 44% of women thought that their worries and fears were taken into consideration by HPs but 40% stated that HPs had not taken their worries and fears into consideration, and 16% remained neutral.
Sixty-three percent of women thought that the news of miscarriage was communicated sensitively, while 28% thought it was not, and 9% (N = 67) were neutral. A full breakdown of women’s answers can be seen in Table 5.
Table 5
Women’s perception of the interaction with HPs
I was able to express my feeling to HPs
|
|
|
Strongly agree
|
171
|
23.7%
|
Somewhat agree
|
161
|
22.3%
|
Neither agree or disagree
|
104
|
14.4%
|
Somewhat disagree
|
140
|
19.4
|
Strongly disagree
|
147
|
20.3%
|
Total
|
723
|
100%
|
My feelings were take in into account by HPs
|
|
|
Strongly agree
|
170
|
23.3%
|
Somewhat agree
|
183
|
25.3%
|
Neither agree or disagree
|
110
|
15.2%
|
Somewhat disagree
|
125
|
17.3
|
Strongly disagree
|
135
|
18.7%
|
Total
|
723
|
100%
|
My worries and fears were take in to account by HPs
|
|
|
Strongly agree
|
169
|
23.4%
|
Somewhat agree
|
156
|
21.6%
|
Neither agree or disagree
|
112
|
15.5%
|
Somewhat disagree
|
141
|
19.5%
|
Strongly disagree
|
144
|
19.9%
|
Missing data
|
1
|
0.1%
|
Total
|
723
|
100%
|
Women’s experiences of miscarriage in hospital and at home
As noted, women were asked a screening question to determine whether they experienced miscarriage at home or hospital and subsequently divided into two groups: “women who experienced miscarriage at home” (N = 461) and “women who experienced miscarriage in hospital” (N = 262). The majority of women in both groups perceived miscarriage as a lonely experience. A full breakdown of women’s responses can be found in Table 6.
Table 6
Women’s sense of loneliness and isolation in hospital and at home
I felt lonely having while having my miscarriage at home
|
|
|
I felt lonely having while having my miscarriage in hospital
|
|
|
Strongly agree
|
223
|
48.4%
|
Strongly agree
|
72
|
27.5%
|
Somewhat agree
|
136
|
29.5%
|
Somewhat agree
|
58
|
22.1%
|
Neither agree or disagree
|
44
|
9.5%
|
Neither agree or disagree
|
47
|
17.9%
|
Somewhat disagree
|
31
|
6.7%
|
Somewhat disagree
|
40
|
15.3%
|
Strongly disagree
|
27
|
5.9%
|
Strongly disagree
|
45
|
17.2%
|
Total
|
461
|
100%
|
Total
|
262
|
110%
|
I felt isolated while having my miscarriage at home
|
|
|
I felt isolated while having my miscarriage in hospital
|
|
|
Strongly agree
|
212
|
46.0%
|
Strongly agree
|
67
|
25.6%
|
Somewhat agree
|
120
|
26.0%
|
Somewhat agree
|
54
|
20.6%
|
Neither agree or disagree
|
41
|
12.8%
|
Neither agree or disagree
|
53
|
20.2%
|
Somewhat disagree
|
29
|
8.9%
|
Somewhat disagree
|
42
|
16.0%
|
Strongly disagree
|
46
|
6.3%
|
Strongly disagree
|
46
|
17.6%
|
Total
|
461
|
100%
|
Total
|
262
|
100%
|
I felt relieved that I was able to have my miscarriage at home
|
|
|
I felt relieved that I was able to have my miscarriage in hospital
|
|
|
Strongly agree
|
91
|
19.7%
|
Strongly agree
|
147
|
56.1%
|
Somewhat agree
|
106
|
23.0%
|
Somewhat agree
|
49
|
18.7%
|
Neither agree or disagree
|
140
|
30.4%
|
Neither agree or disagree
|
51
|
19.5%
|
Somewhat disagree
|
53
|
11.5%
|
Somewhat disagree
|
4
|
1.5%
|
Strongly disagree
|
71
|
15.4%
|
Strongly disagree
|
11
|
4.2%
|
Total
|
461
|
100%
|
Total
|
262
|
100
|
I felt comfortable knowing I was able to have my miscarriage at home
|
|
|
I felt comfortable knowing I was able to have my miscarriage in hospital
|
|
|
Strongly agree
|
83
|
18%
|
Strongly agree
|
10
|
3.8%
|
Somewhat agree
|
115
|
24.9%
|
Somewhat agree
|
5
|
1.9%
|
Neither agree or disagree
|
144
|
31.2%
|
Neither agree or disagree
|
44
|
16.8%
|
Somewhat disagree
|
51
|
11.1%
|
Somewhat disagree
|
55
|
21.0%
|
Strongly disagree
|
68
|
14.8%
|
Strongly disagree
|
148
|
56.5%
|
Total
|
461
|
100%
|
Total
|
262
|
100%
|
Isolation and loneliness in women who experienced miscarriage at home (M = 8.04, SD = 2.29) was significantly higher than in those women who experienced their miscarriage in hospital (M = 6.48, SD = 2.05); [t (460) = 75.091, p = .000; t(261) = 37,602, p = .000]. Similarly, women who experienced their miscarriage at home (M = 6.4, SD = 2.52) felt significantly less comfortable and less relieved than those who experienced their miscarriage in hospital (M = 8.45, SD = 2.05); [t (460) = 54.447,p = 0.000; t (261) = 66.508, p = .000). Table 7contains the summary of results.
Table 7
Paired t-test of the experience of miscarriage at home and hospital
Groups
|
t
|
df
|
Sig. (2-tailed)
|
Mean difference
|
95% Confidence interval of Difference
Lower Upper
|
Loneliness at home
|
75.091
|
460
|
.000
|
8.04338
|
7.8329
|
8.2539
|
Looniness in hospital
|
37.602
|
261
|
.000
|
6.48092
|
6.1415
|
6.8203
|
Comfort at home
|
54.447
|
460
|
.000
|
6.40564
|
6.1744
|
6.6368
|
Comfort in hospital
|
66.508
|
261
|
.000
|
8.45420
|
8.2039
|
8.7045
|
The hypothesis of positive correlation between the impact of miscarriage (using RIMS) and women’s perception of loneliness and sense of comfort either at home or in hospital was tested. A Pearson’s correlation test was run to examine the relationship between perceptions of the impact of miscarriage (RIMS) and “Loneliness at home” and “Comfort at home”. Results indicated a moderate correlation between the RIMS and the women’s perception of loneliness and isolation at home (r = .419, p = 0.001) and a statistically significant weak negative correlation, between RIMS and the sense of comfort at home (r= -0.194, p = 0.001).
Results indicated a statistically significant low correlation between the RIMS and the women’s perception of loneliness and isolation in hospital r = .271, p < 0.01. No statistically significant correlation was found between RIMS and the sense of “Comfort in hospital” r= -0.59, p = 0.345.
Satisfaction with emotional support received in hospital and follow- up emotional care
As shown in Table 8, 46% of women were satisfied with the emotional support received, 38% were not, while 16% were neither satisfied nor dissatisfied. Over half of respondents expressed their dissatisfaction with the psychological/ emotional follow- up services after their hospital visit. Of the remaining respondents, 19% were satisfied while 25% remained neutral.
Table 8
Women’s satisfaction of the emotional support in hospital settings and follow up care
Indicate the level of satisfaction with the emotional support received in hospital
|
|
|
Extremely satisfied
|
117
|
16.2%
|
Satisfied
|
219
|
30.3%
|
Neither satisfied nor dissatisfied
|
114
|
15.7%
|
Not satisfied
|
131
|
18.1%
|
Extremely dissatisfied
|
142
|
19.6%
|
Total
|
723
|
100%
|
Indicate the level of satisfaction with the emotional support received after being discharged
|
|
|
Extremely satisfied
|
51
|
7.1%
|
Satisfied
|
85
|
11.8%
|
Neither satisfied nor dissatisfied
|
179
|
24.8%
|
Not satisfied
|
179
|
24.8
|
Extremely dissatisfied
|
228
|
31.5%
|
Total
|
723
|
100%
|
Emotional support received at the time of miscarriage in hospital was found to have a weak positive correlation with total score on the RIMS (r = .24, p < .01), meaning that reporting lower satisfaction was associated with greater distress.
Women who were dissatisfied with the emotional support received in hospital at the time of miscarriage had a higher overall RIMS score. Further, a Pearson’s Correlation coefficient assessed whether there was a correlation between the RIMS total score (M = 53.78, SD = 8.59) and the satisfaction with the psychological/emotional follow-up received after hospital visit (M = 3.62, SD = 1.23). The analysis revealed a low positive correlation (r = .22, p < 0.01). Women who were dissatisfied with the emotional support received at the follow- up at the time of miscarriage had a higher overall RIMS score (i.e. perceived the impact of their miscarriage to be greater).
Correlation between RIMS, demographic characteristics and satisfaction with emotional support
A multiple regression model was run to test the hypothesis that the RIMS score would be influenced by age, level of education, number of weeks of pregnancy loss, number of miscarriages, level of satisfaction with the emotional support in hospital settings and follow-up emotional support (see Table 9). All the variables entered in the linear regression model were significant predictors of RIMS (p < 0.01). Further, the standardised B coefficients indicates that variables “satisfaction with emotional support in hospital” (B = .195), “weeks of pregnancy” (B = .177) and “Numbers of miscarriage” (B = .165) represent the higher predictor for this module.
Table 9. Linear Regression between RIMS, participants’ demographic characteristics and satisfaction with emotional support.
Model
|
R
|
R Square
|
Adjusted R Square
|
Std. Error of the Estimate
|
R Square
Change
|
F Change
|
df1
|
df2
|
Sig. F Change
|
1
|
.404a
|
.164
|
.156
|
7.37069
|
.166
|
23.102
|
6
|
715
|
.000
|
aPredictors: (Constant: Satisfaction with emotional support received from hospital staff at the time of miscarriage and psychological/ emotional follow-up, Age, living arrangement, level of education, number of miscarriage and weeks of pregnancy loss.
ANOVAa
|
Sum Square
|
df
|
Mean Square
|
F
|
Regression
|
7530.476
|
6
|
1255.079
|
23.102
|
Residual
|
38517.875
|
709
|
62.196
|
|
Total
|
53318.340
|
715
|
|
|
Coefficientsa
|
Unstandardised
B
|
Coefficients
Std Error
|
Standardised Coefficients
Beta
|
t
|
Sig.
|
Constant
|
46.618
|
2.042
|
|
22.825
|
.000
|
Age
|
-1.026
|
.386
|
-.097
|
-2.655
|
0.008
|
Leve of Education
|
-.833
|
.228
|
-.130
|
-3.649
|
.000
|
Weeks of Pregnancy loss
|
1.706
|
.343
|
.177
|
4.971
|
.000
|
Number of miscarriages
|
1.304
|
.284
|
.165
|
4.593
|
.000
|
Level of satisfaction with emotional support delivered in hospital
|
1.132
|
.255
|
.195
|
4.444
|
.000
|
Level of satisfaction of emotional follow-up care
|
.874
|
.283
|
.135
|
3.082
|
.002
|
Previous studies reported high RIMS scores following miscarriage echoing that this is perceived by women to have a devastating and isolating event impacting on emotional wellbeing [26, 29]. This study further added that the Reversed Impact Miscarriage Scale and its subscales reached its highest peak after 1–2 years from the event. This outcome contradicted a previous study which found that RIMS scores decreased over time [26]. It is particularly interesting how this study showed that the subscale “Isolation and guilt” reached its highest point at 1–2 years post miscarriage. The experience of miscarriage has been described by women as lonely [32] and increased guilt has been previously linked with the development of PTSD symptoms [33]. In this context, it might be particularly important to stress the importance of women engaging in support groups [34] to address their emotional needs and prevent the development of psychological morbidities linked to their loss.
This study has established an association between social demographic characteristics and the impact of pregnancy loss on emotional wellbeing [35, 36]. As with another cross-sectional study conducted in USA [37], our multiple regression model indicated that higher RIMS scores were influenced by age, level of education, number of weeks of pregnancy loss and, number of miscarriages. Age is associated with the development of emotional distress, with younger women manifesting higher levels of depressive symptoms and despair [36, 38]. Some have argued that age influences resilience, with younger women demonstrating lower resilience skills [39]. Others indicate that the presence of other children might predict better psychological outcomes following miscarriage (Kersting and Wanger, 2012).
Lower education [11, 35] is also a risk factor associated with the development of psychological distress post-miscarriage. A history of mental health issues [40, 41] infertility, and previous miscarriage have also been shown to predict the development of psychological distress [30, 42].
As previously stated, health professionals play a key role in shaping women’s experience of miscarriage [41, 43, 44]. Our findings are clear that women’s experience of HPs is that their emotional needs are not always met, and importantly that this affects their emotional wellbeing [44–46]. Almost half of the women included in our study felt they could not express their worries and fears to health professionals, or their worries and fears were not addressed. It has been previously documented that women highlighted the need to be involved in their maternity care by having their wishes considered [47]. A recent survey-based study found that women who experience stillbirth expressed a higher appreciation of care when they felt able to freely express their emotions [48]. Additionally, patients’ clinical outcomes improve when they are able to speak about their emotions [49].
Miscarriage represents a traumatic event and perinatal trauma could occur when pregnancy outcomes did not meet expectations [50]. Trauma theories hypothesise that if memories and emotions cannot be processed verbally, they may later trigger pathological trauma responses [51, 52]. In this light, it is important for health professionals to ensure women are supported to express their feelings and emotions while in hospital, for example by allowing them enough time to ask questions and by providing a safe space with privacy when interacting with them.
Our findings showed that women who were less satisfied with the emotional support received in hospital and after their hospital visit reported higher RIMS scores. This indicates a possible higher negative impact of miscarriage on women who were not satisfied with emotional support received in hospital and following their discharge. Satisfaction with quality of care provided in hospital and support received could influence women’s emotional wellbeing [53, 54] and lead to better psychological outcomes [55]. A recent study concluded that women report having a higher quality of life after miscarriage when they received emotional support, independently of the kind of support received [56]. However, to date there has been a lack of interventions aimed at supporting women’s emotional needs in hospital settings [14]. Not being able to openly talk about miscarriage might increase the stigma surrounding pregnancy loss [57] and increase the sense of isolation [44].
The experience in hospital is often described by women as “lonely” [58]. The RIMS subscale included in our study “Isolation/guilt” (further shows how the event of miscarriage has a high impact on women’s sense of isolation and guilt. A recent qualitative study documenting women’s sense of isolation stressed the importance of engaging in support groups [34]. Our findings highlighted that women who were discharged home experience a higher sense of isolation and loneliness compared to those who were admitted to hospital. However, results of the study do not explain which factors might have impacted and influenced women’s higher sense of isolation. Further studies are required to explore causes of isolation when discharged home.