Factors Affecting the Emotional Wellbeing of Women and Men Who Experience Miscarriage in Hospital Settings: A Scoping Review

doi:10.21203/rs.3.rs-882652/v1

Background - Miscarriage can be a devastating event for women and men that can lead to short- and long-term mental illness. Studies have reported associations between miscarriage and depression, anxiety, and post-traumatic stress disorder in women. Men can also experience intense grief and sadness following their partner’s miscarriage. While numerous studies have reported hospital-related factors impacting the emotional wellbeing of parents experiencing miscarriage, there is a lack of review evidence which synthesises the findings of current research.

Aims- The aim of this review was to synthesise the findings of studies of emotional distress and wellbeing among women and men experiencing miscarriage in hospital settings.

Methods – A systematic search of the literature was conducted in October 2020 across three different databases (CINAHL, MEDLINE and PsycInfo) and relevant charity organisation websites, Google, and OpenGray. A Mixed Methods appraisal tool (MMAT) and AACODS checklist were used to assess the quality of primary studies.

Results- Thirty studies were included in this review representing qualitative (N=21), quantitative (N=7), and mixed-methods (N=2) research from eleven countries. Findings indicated that women and men’s emotional wellbeing is influenced by interactions with health professionals, provision of information, and the hospital environment. Parents’ experiences in hospitals were characterised by a perceived lack of understanding among healthcare professionals of the significance of their loss and emotional support required. Parents reported that their distress was exacerbated by a lack of information, support, and feelings of isolation in the aftermath of miscarriage. Further, concerns were expressed about the hospital environment, in particular the lack of privacy.

Conclusion –Women and men are dissatisfied with the emotional support received in hospital settings and describe a number of hospital-related factors as exacerbators of emotional distress.

Implications for practice- This review highlights the need for hospitals to take evidence-informed action to improve emotional support services for people experiencing miscarriage within their services.

Endocrinology & Metabolism

Miscarriage

spontaneous abortion

emotional wellbeing

emotional distress

emotional support

hospital

perinatal mental health

scoping review

Miscarriage is the most common complication during pregnancy, affecting around 10–15% of pregnancies. Definitions of miscarriage vary across countries. In Canada, USA and Australia, for example, it is defined as a pregnancy loss occurring before the 21st week of the total 40-week gestational period, while in the United Kingdom (UK) it includes all pregnancy losses from conception up to the 24th week of gestation [1].

There is an extensive literature demonstrating how women who have a miscarriage can experience short- and long-term psychological complications such as depression, anxiety and post-traumatic stress disorder [1–4]. Further, many women and men have reported experiencing intense grief as a result of their pregnancy loss [2, 3]. Experiences in hospital and, in particular, interactions with health professionals (HPs) and provision of information also have an impact on emotional wellbeing [4–6].

Previous systematic reviews in the area have mainly focused on the psychological and emotional implications of miscarriage [7–9]; and women’s satisfaction with the care provided when attending hospital due to miscarriage [10, 11]. It is important to establish which factors might contribute to women and men’s emotional distress or wellbeing while in hospital, to inform provision of appropriate support and reduce the risks of developing psychological morbidities. This scoping review aimed to synthesise the evidence on hospital-realed factors that contribute to parents’’ distress and wellbeing following miscarriage. The objectives of this review are:

To map the available evidence and synthesise findings highlighting factors contributing to women and men’s emotional distress and wellbeing in hospital settings;
To identify areas for further research on how best to support women and men experiencing miscarriage in hospital settings; and
To assess the quality of the available evidence.

This scoping review (ScR) followed guidelines from Joanna Briggs Institute (JBI), Arksey and O’Malley’s recommendations for conducting scoping reviews and the PRISMA extension for ScR to report results [12–14]. A review protocol was pre-registered on the lead author’s institutional database [15].

Eligibility Criteria for Selected Studies

Inclusion Criteria

Inclusion criteria were developed using the Population, Concept and Context (PCC) framework suggested by the JBI [13].

Population

Studies including:

Women and men who experienced miscarriage and attended hospital as a result.
Health professionals’ (e.g. physicians, nurses and midwives, health care assistants, technicians, mental health professionals) with experience of working with women experiencing miscarriage in hospital settings.

Context

Studies referring to any hospital setting including, but not limited to, outpatients’ clinics, emergency departments and obstetrics/gynaecology wards.

Concept

Studies reporting hospital-related factors that contribute to the emotional distress and wellbeing of women and men experiencing miscarriage. All definitions of miscarriage will be included according to the country in which the study was conducted, also recurrent miscarriage will be included in the review.

Types of evidence sources

All types of studies, both quantitative and qualitative, published in English were included, and there were no geographical restrictions. Primary research studies, reviews, guidelines and grey literature were included. Searches were restricted to the last 20 years (January 2009-October 2020).

Exclusion Criteria

Population

Studies including:

Studies of women who experience stillbirth, molar pregnancy or ectopic pregnancy and studies which do not clearly specify the type of pregnancy loss experienced.
General practitioners, family practices and charities who have experiences of working with women experiencing miscarriage in hospital settings.

Context

Any non-hospital related factors which have influenced women and men’s emotional wellbeing.

Table 1

Search terms used in CINAHL
Concept/ Search terms
Miscarriage	Psychological/emotional wellbeing	Hospital setting
Mesh headings 1. Abortion Spontaneous/ OR	Mesh headings 1. Mental Health/ OR 2. Emotions/ OR	Mesh headings 1. Health services/ OR 2. Emergency service, Hospital/ OR 3. Maternal Health Services/ Gynaecology/ OR 4. Obstetrics and Gynaecology Department, Hospital/OR 5. Obstetrics/OR
Key word 1. Miscarriage OR 2. Pregnancy loss OR 3. F?et OR 4. Early pregnancy loss OR 5. Frist trimester loss OR 6. Second trimester loss	Key word 1. Mental OR 2. Psychological OR 3. Emotional OR 4. Need* OR 5. Satisfaction* OR 6. Perspective* OR 7. Experience* OR 8. View* OR 9. Perception* OR 10. Opinion* OR	Key word 1. Healthcare OR 2. Health-care OR 3. Hospital* 4. Emergency unit* OR 5. Emergency department* OR 6. Early pregnancy unit* OR 7. Early pregnancy assessment unit*

Search strategy

Search terms were identified in consultation with a librarian and a three-step search strategy was established. Firstly, MG used key terms (Table 1) to search CINAHL in October 2020 and, subsequently adapted this to replicate the search in MEDLINE, PsycInfo, OpenGray and relevant international and UK based organisational websites including the ‘The Miscarriage Association’, ‘Tommy’s’, the ‘American Pregnancy Association’ and the ‘World Health Organization’ (WHO) websites. Secondly, a Google search was conducted and the results of the first five pages were screened. Thirdly, the reference lists of included studies were screened for additional relevant articles.

Study Selection and data extraction

The systematic review software Covidence was used to carry out removal of duplicates, screening and data extraction. MG screened all titles and abstracts and AA screened a randomly selected 10%. Further, full-text screening was completed by MG with a randomly selected 10% conducted by AA. Any disagreements throughout the process were resolved following discussion between MG and AA.

Data extraction was conducted in Covidence by MG using an adapted version of JBI Template Source of Evidence Details [16]. Studies included where charted systematically including details of the study characteristics.

Summarising and reporting the results

Data were analysed by MG adopting the Narrative Synthesis approach [17, 18]. This method explores relationships amongst data by organising findings from included studies and describing patterns across them. MG used a diary to record and reflect on how the synthesis was conducted to promote reflexivity and transparency in the review process. Synthesis of the data took place in three phases. During data extraction, each selected study was systematically summarised using JBI Template Source of Evidence Details. This facilitated a preliminary synthesis, Phase 1, by providing details of each study in the same order and highlighting possible relationships and differences between them. During Phase 2, Nvivo Software was used to conduct thematic analysis of the study findings. Specifically, initial codes were grouped in three different categories: men, women and interventions. Once this process was completed, new codes were generated by grouping together, for each category, the initial codes according to their meanings. During Phase 3, descriptive themes were created, revised and transformed into analytic themes. During this phase, the robustness of the synthesis was also assessed [19].

A Mixed Methods appraisal tool (MMAT) was used to assess the quality of primary studies. MMAT includes two screening questions applicable to all types of study designs. If studies do not pass this stage it is not feasible to proceed further with the quality appraisal. Grey literature was appraised using the AACODS checklist (Authority, accuracy, coverage, objectivity, date, significance).

The search yielded 2080 results and 22 articles were identified from additional sources. After removing 520 duplicates, the title and abstracts of 1560 articles were screened and a further 1432 were excluded. Finally, 128 full-text articles were screened and thirty studies were included in this review [20–49]. The PRISMA flow chart summarises the above process (Fig. 1).

Characteristics of included studies

The studies included in this review were mainly qualitative (N = 21), with fewer quantitative (N = 7), or mixed- methods (N = 2). Twenty- six of the studies included women as participants (N = 28), a small number of studies included couples (N = 5), health professionals (N = 7) and men (N = 2). A total sample of 1534 people were included in the review of which 1413 were women, 38 men and 83 health professionals. The studies were conducted in 11 different countries: USA (n = 6), Australia (n = 5), United Kingdom (n = 5), Canada (n = 4), Ireland (n = 4), France (n = 2), China (n = 2), Brazil (n = 2), Denmark (n = 1), Poland (n = 1), and Thailand (n = 1). A summary of the studies included can be found in Table 2.

Table 2

Summary of studies included in the review
Author	Country	Study design	Setting	Population	Study aim	Summary of findings
Baird et al., 2018	USA	Qualitative- interviews	Emergency Department	Women N = 10 Age range 20–41 Early pregnancy loss (< 13 weeks)	To better understand why women present to Emergency Departments for early pregnancy loss and their overall experience during and after their visit.	The study identified multiple areas for improvement in quality of care, including more complete and empathetic communication, additional information, and follow up care planning. Providers in primary care and ER settings can work together to provide improved patient-cantered care to women experiencing Early Pregnancy Loss.
Bellhouse at al., 2019	Australia	Qualitative- Interviews	Hospital setting -not specified	Women N = 15 (18–50) who experienced miscarriage 3 months to 10 years prior to interview.	To explore women’s healthcare support experiences and how these experiences impacted women’s psychological distress following miscarriage.	Women experienced both positive and negative interactions with healthcare providers throughout their miscarriage journeys. All women interviewed expressed their increased distress following negative experiences with healthcare providers. Women commonly expressed concerns with the lack of causative information provided, a lack of follow-up from health- care professionals, insensitive comments and terminology relating to their miscarriage, dismissive or insensitive attitudes, and a general lack of emotional support from a variety of healthcare professionals. Positive interactions with healthcare professionals included those in which women were provided with emotional support, the offer of follow-up or further testing and opportunities to express their grief through memorial services. While almost all women had some positive experiences in their interactions with healthcare professionals, most women’s stories involved significant negative experiences with healthcare providers, which caused them further distress.
Chaloumsuk, 2013	Thailand	Qualitative- Interviews with women and focus group with medical staff.	Hospital setting -not specified	Women who experienced miscarriage N = 11 (20–30 years old) Doctors N = 10 and nurse-midwives N = 11	To gain an understanding of experiences of miscarriage and termination of pregnancy for foetal anomaly among a group of Thai women	Women need more in-depth knowledge and empathetic care from health professionals. Involving family members to support women in the labour unit can reduce the feelings of loneliness and insecurity.
Cullen et al., 2017	Republic of Ireland	Qualitative	Maternity Hospital	Women N = 9 and their partners N = 5, aged between 30–42 who experienced second semester miscarriage (15–19 weeks).	To explore parents’ experiences of second trimester miscarriage and clinical care received in the hospital from the time of diagnosis through to follow-up.	Overall, the participants were very positive about how they were cared for during an extremely difficult time. However, a number of parents described negative experiences owing to insensitivity on the part of some staff, which added to their distress. Empathy and sensitivity were described by parents as ways that hospital staff recognised and helped to alleviate their suffering following a second-trimester miscarriage.
Cullen et al., 2018	Republic of Ireland	Qualitative	Maternity Hospital	Women N = 9 and their partners N = 5 aged between 30–42 who experienced second semester miscarriage (15–19 weeks).	To explore parents’ experiences of second trimester miscarriage and clinical care received in the hospital from the time of diagnosis through to follow-up.	Overall, parents were satisfied with the medical treatment they received; however, some parents highlighted issues in relation to medical treatment. A number of parents commented on how busy the casualty department was and described long waits to see a doctor. Five of the women talked about difficulties in taking bloods and reported numerous attempts by staff before blood was taken successfully. The local hospital policy when a second trimester miscarriage is diagnosed is to administer mifepristone and allow the mother to go home for 48 hours. Five of the women experienced this care pathway. Parents described this period of time as very difficult, but it was also acknowledged that the time allowed the parents the opportunity to begin to adjust to the loss. Being separate from pregnant women appeared to be very important to bereaved parents during outpatient appointments, casualty visits and when admitted to the hospital. Parents discussed the importance of honest and open communication with medical staff. Some parents highlighted the negative impact when communication with hospital staff was not clear.
Domingos et al., 2011	Brazil	Qualitative	Hospital setting (not specified)	Women (N = 13) aged between 18–38 who experienced spontaneous abortion (weeks not specified). Nurses (N = 7) who assisted women in the situations.	To explore what is the meaning of miscarriage is for women and what they expect from HPs who care for them. To establish if there is a difference in type of care provided between public and private health care institutions. To explore how nurses feel when caring for women who experience miscarriage.	Women acknowledge that when experiencing miscarriage they require attention, support and information from the professionals. Regardless of whether they have health insurance or not, women should be treated with respect, dignity and have the right to health and citizenship guaranteed.
Edwards et al., 2018	Australia	Qualitative- interviews	Emergency Department	Women N = 3 and their partners N = 2 who presented to ED with first trimester bleeding. Nurses N = 6	To examine approaches to care provided to women who present to non-metropolitan EDS with first trimester bleeding.	The process of providing optimal care relies on the provision of nursing care that incorporates the experiences and expectation of the women and their partners as well as those nursing staff in this context.
Emond et al., 2019	Canada	Qualitative	Emergency Department	Parents who have presented to the ED with miscarriage (N = 14, Women = 3). ED nurses (N = 7) and nurse managers (N = 2).	To identify the needs of parents, factors influencing their experience of care when attending ED due to miscarriage.	Parents who visit the ED during a miscarriage report multiple physical, cognitive and emotional needs. Physical health needs include a desire to undergo diagnostic testing as rapidly as possible to determine the viability of the pregnancy and to be referred for a follow-up appointment with a healthcare professional. Parents’ cognitive needs consisted of a desire to receive a detailed explanation at the time of diagnosis, information to assist recovery, and written materials regarding the miscarriage experience and available resources and services. Finally, the emotional needs of parents include care centred on emotional health, a more private space in the ED, and, for the women experiencing miscarriage, their partner's support.
Iwanovicz-Pakus et al., 2014	Poland	Quantitative- survey	Hospital setting (not specified)	Women who experienced miscarriage N = 303	To recognise the options care for women after miscarriage in relation to support and assistance from medical staff providing care during hospitalisation.	28.71% of the women in this study admitted that they did not receive sufficient psychological support from physicians and the 22.44% definitely did not obtain such support. 41.58% of respondents reported that after miscarriage midwives showed adequate skills, and provided them with necessary informative support. Statistical analysis showed that respondents who could freely express their emotions during hospitalization evaluated physicians and midwives providing them care in significantly higher terms (p < 0.001) and support provided by physicians who had no such an opportunity or did not remember the fact. Respondents who evaluated their psychological status after miscarriage as severe, expressed better evaluation of assistance and support provided by physicians (p < 0.001) and midwives ( p < 0.01), compared to those who evaluated their status as moderate or light ( p < 0.001). More than a half of the respondents needed peace and quiet during hospitalisation (58.09%), half required understanding (50.50%), nearly one-third expected seclusion (31.68%) and the same number wanted conversation (31.68%) (Table 5). Based on statistical analysis, the mean evaluation of the respondents’ needs during hospitalization was 15.22 ± 3.21 (5–20 scores). Respondents who evaluated their psychological status after miscarriage as severe had more intensified needs during hospitalization than the respondents who evaluated their psychological status as light or moderate (p < 0.0001). Respondents who at the time of pregnancy loss were married had significantly more intensified needs compare to those who were single (p < 0.01). The results of this study showed a significant correlation between the level of intensity of needs during hospitalisation and evaluation of physicians (R = 0.23; p = 0.00005) and midwives (R = 0.23; p = 0.02). The higher the intensity of patients’ needs, the more positive the evaluations of physicians and midwives providing them with care. Statistical analysis showed that the respondents who received complete and sufficient instructions from the medical staff concerning follow-up assistance after the loss of a baby evaluated both physicians and midwives in more positive terms, compared to those who had insufficient information or did not obtain any information at all (p < 0.0001).
Johnson et al., 2015	USA	RCT	Obs-Gyne Clinic and ED	40 women who experienced miscarriage between 8/40 and 20/40 weeks and attended the emergency room	To build an intervention to ease the potential negative consequences of grieving. The intervention was delivered in the emergency department at the time miscarriage occurred.	Findings from the study indicated that women who received the bereavement protocol reported lesser levels of overall grieving.
Klein et al., 2012	United Kingdom	Quantitative	EPAU	67 women and their partners miscarriage before 24th week of gestation IG (N = 33 reduced to N = 19 post- randomization) CG (N = 34 increased to N = 48 post-randomization)	To establish the feasibility of undertaking a large multicentre trial using a modified PRPP design to evaluate the effectiveness of a web-based intervention in promoting the mental wellbeing of women and partners after miscarriage.	Results indicated that the IG group was significantly less anxious and depressed at the 3-month follow-up (HADS anxiety, P = 0.01; HADS depression, P = 0.02). IG group reported significantly higher levels of emotional wellbeing (SF-36 vitality, P = 0.018; SF-36 emotional role, P = 0.005; SF-36 mental health, P = 0.008; and SF-36 MCS score, P = 0.005).
Kong et al., 2013	China	RCT	Hospital setting (not specified)	180 women suffering miscarriage managed by either surgical, medical and expectant	To investigate the clinical and psychological outcomes of surgical, medical and expectant management of first trimester miscarriage	In terms of satisfaction with the mode of treatment, there was no significant difference in the satisfaction scores between groups. Significantly more women who received either surgical or medical evacuation expressed worries of weakening or even damage to their bodies as a result of the treatment. Significantly more women with successful treatment scored higher on CSQ-8 compared with women having unsuccessful treatment. Fewer women with successful treatment expressed worries about the treatment damaging their bodies. There were no significant differences in psychological outcomes measured in terms of psychological well-being (GHQ-12), depression (BDI), anxiety (STAI) and fatigue symptoms (FS) at the time of treatment and four weeks after treatment among three treatment modalities. There was no significant correlation between randomised treatment modalities on the psychological outcome measures. Women with active intervention (both surgical and medical evacuation) had a significantly higher CIES-R score at the time of treatment when compared with women in the expectant management group. The traumatic psychological impact lessened in the subsequent follow-up at Day 28.
Kong et al., 2014	China	RCT	Hospital setting (not specified)	N = 280 women who were admitted to hospital with a diagnosis of miscarriage Counselling group (N = 140, 8 withdrawn after randomization N = 132). Control group N = 140, 4 withdrawn after randomization N = 136).	To assess the effectiveness of supportive counselling after miscarriage.	A session of supportive counselling with a trained nurse counsellor, delivered immediately and at 2 weeks after diagnosis for miscarriage, did not show a statistically significant effect in reducing psychological distress of women after miscarriage. It also failed to show any additional effect. 30% reduction in the proportion of women with high GHQ-12 scores (indicative of definitive psychological distress) was evident by 3 months post miscarriage in the counselling compared with the standard care group, suggesting a potential clinical beneficial effect, albeit not a statistically significant one. Among the subset of women who had high baseline scores on the GHQ-12 and BDI questionnaires, there was a statistically significant difference was observed between counselling group and standard care groups, in terms of lower scores and reduced proportions of women scoring highly at 6 weeks in the counselling group. This suggests that a ‘selective’ counselling programme aimed at women with high baseline levels of psychological distress might be beneficial for improving emotional wellbeing in this group in the first weeks after miscarriage.
Larivière-Bastien et al., 2019	Canada	Qualitative – Interviews	Emergency Department	Women (N = 48) who experienced miscarriage (20 weeks or less) in the past 4 years and had consulted one of the 4 ED where the study took place.	To identify characteristics of care management that may have contributed to the difficulties experienced by women presenting with miscarriage in the emergency department.	Analysis of the data revealed the experience of women who miscarried in the emergency department was characterized by lack of information at 3 critical junctures: announcement of the miscarriage, course of the miscarriage, and ED discharge. Respondents identified lack of information throughout the process as a recurrent factor that exacerbated the already difficult nature of this event. Although lack of information negatively influenced participants’ experiences in different ways, they shared the belief that having more information would have alleviated their difficulties. The majority of participants reported feeling unprepared emotionally and physically at the time of discharge, with long-term effects on their psychological well-being.
Linnet Olesen et al., 2015	Denmark	Qualitative- Interview	Hospital setting (not specified)	Women who experienced miscarriage and chose and completed either medical, surgical or expectant management of miscarriage.	To gain insight into the decision-making process for the treatment of miscarriage and the circumstances that may affect it.	Unspoken emotional considerations dominated women’s reasons for choosing a specific treatment, despite pre-treatment counselling that provided detailed information about the different treatments’ efficacy and risk of side effects. Sometimes, these reasons were grounded in unrealistic beliefs about the course of the treatment. Women kept their reasons to themselves, and the HCPs did not explore them.

Quality of included studies

All but one[25] of the thirty studies reported receiving ethical approval. All studies used either purposive or snowball sampling, however, this is expected due to the nature of the topic under study. Seven studies had a distress protocol in place due to the sensitiveness of the topic [20, 30, 31, 46–49]. Conversely, twenty-three did not mention if they had such protocol in place [21–29, 32–45]. Sixteen studies declared they had no conflict of interest[20–22, 28, 29, 33, 36, 38, 41–44, 46–49] and fourteen did not mention this [23–26, 30–32, 34, 35, 37, 39, 40, 45, 49]. One American and one Australian study provided compensation to participants [34, 48]. Three randomised controlled trials included had a high attrition rate [23, 38, 41]. Only one study was assessed using the AACODS checklist [20]. The study was assessed and considered trustworthy, accurate and meaningful.

Synthesis of evidence

Three main themes arose from the studies: 1) interactions with health professionals; 2) time waiting for diagnosis, procedures and treatment; and 3) lack of privacy in hospital environments. Within Theme 1, two sub-themes where identified 1a) Acknowledging the loss; 1b) Provision of information. Six intervention studies were included in the review and these are discussed separately below.

Theme 1: Interactions with health professionals

Sub-theme 1A: Acknowledging the loss

Eleven studies reported how health professionals did not acknowledge miscarriage as a loss and the extent of the emotional pain associated with it having a negative impact on parents’ emotional well-being [20, 24–26, 31, 32, 35, 37, 44, 46, 50]. These studies described how women and their partners appreciated health professionals taking time to validate and empathise with their loss [25, 26, 32, 46, 49]. Eleven studies highlighted that recognising the impact of miscarriage was considered fundamental by women and men who expressed the need to be cared for with compassion and empathy [20, 24–26, 31, 32, 34, 35, 37, 44, 46, 49].

Two studies reported that men’s experience of miscarriage was characterised by a lack of acknowledgment by health professionals who often direct their attention only towards women [32, 43]. This quote from an Australian study is representative of men’s experience “No, I was there but it wasn’t directed at me um.. . yeah um most of the time I was sitting there, and I was not even acknowledged” [32].

Sixteen studies described miscarriage care as lacking in emotional support where HPs neglected to explore parents’ emotions [20, 25–27, 29, 32–35, 37, 43, 44, 46, 49]. Remaining unheard by HPs was a shared experience among women who reported to be unable to openly talk about their feelings. The following quote from an Australian study is representative of common experiences:

“I just think when you go in there and there is absolutely no acknowledgment of any sort of emotional thing happening, and it’s all very cut and dry”[37].

Seven other studies pointed out that women considered the emotional support received as a fundamental aspect of their hospital journey [20, 25, 29, 37, 45, 46, 49]. As expressed in this quote from a study conducted in the UK “she (the midwife) didn’t do anything medical for me, she couldn’t do anything medical for me but she did a lot more just by addressing the emotional issues related to the miscarriage” [25]. Further, two studies involving men confirmed that they expressed the same appreciation when treated with sensitivity and compassion [34, 51]. In this quote, from a study conducted in Ireland, a man explains that his miscarriage “was dealt with such good sensitivity that it made us feel a lot more comfortable… with that care, that made a bad situation that bit more bearable”[51].

Sub-theme 1B: Provision of information

Ten studies reported lack of information throughout the course of miscarriage [25–27, 29, 35, 36, 43, 44, 46, 48]. Health professionals were perceived as being deliberately vague and unclear when providing information and this ambiguity affected women’s emotional status [23, 24, 29, 36, 51]. During miscarriage diagnosis, for instance, some studies reported that HPs did not explain clearly to women that they were miscarrying or were going to have a miscarriage [44]. The following quote from a study conducted in the USA is a typical of comment made: “They did the ultrasound too, and they were talking amongst each other, didn’t really tell me, you know like “oh this is what we see” [26]. Two studies explained that health professionals were deliberately withholding information about women’s miscarriage when communicating with women as they [26, 46].

Four studies reported that women left hospitals still unsure about whether they experienced a miscarriage [20, 43, 44, 48]. This quote from a study based in the USA described one, presumably extreme, case “I guess they didn’t want to hurt my feelings or something, they didn’t tell me verbally that I am having a miscarriage… I just found out on my way home, it was on the paper. It was written on the paper”[48]. Seven studies highlighted that not providing practical information on topics such as bleeding, pain, causes and prevention of miscarriage left women unprepared to deal with its aftermath [27, 36, 43, 44, 46–48]. Further, another two studies explained how women felt the need to receive extensive information about the management of miscarriage prior to making an informed decision [24, 27, 36].

Eight studies raised an important issue about the use of insensitive terminology and lack of lay terms used by health professionals [22, 23, 25, 28, 36, 44, 48, 49]. These studies suggested that HPs may lack compassion and sensitivity when communicating, which can increase parents’ distress. The use of what parents considered insensitive terms such as “termination or abortion pills” or the word “miscarriage” when referring to late pregnancy loss increased women’s emotional distress [22, 28].

Theme 2: Time waiting for diagnosis, procedures, treatment

Fifteen of the studies reported that time represented an important aspect in women’s experiences in hospital. For a variety reasons, time was relevant - time spent waiting for diagnoses, scans and procedures, or the need to be given more time to assimilate the news of miscarriage and consider treatment options [20, 24–27, 29, 32–34, 37, 43, 44, 46, 48, 51]. Having to wait in hospital while facing an unknown situation was reported to have a negative impact on women’s emotional well-being [29]. Further, waiting for long hours made women reported feeling as if they were forgotten and not a priority [48, 51]. This quote from a study based in Canada is an example of what women experienced while in hospital: “There was definitely no rush, I said to myself, “Why are they making me wait until tomorrow to see the gynaecologist?”[44] Many women pointed out how waiting long hours in hospital to receive a diagnosis of miscarriage increased their anxiety [26, 51]. However, two studies reported that women also required time to assimilate the news of miscarriage before moving on to deciding about their care. [20, 32]. Three other studies highlighted how women appreciated a rapid resolution of miscarriage by receiving treatment on the same day they received their diagnosis [34, 37, 45].

Theme 3: Lack of privacy in hospital environments

Five studies based at emergency departments (ED) reported that women felt distress due to a ‘chaotic’ environment. When attending the ED women had to wait in communal areas, at times with visible symptoms of miscarriage, such as bleeding, and this increased their distress [26, 33, 43, 44, 48]. Four other studies indicated that being able to access private toilet facilities was considered essential by some women who were afraid of having (or did have) their miscarriage in a shared toilet [31, 43, 44, 51]. Further, five studies reported that women expressed the need to be cared for in a private area where they could be able to be with their partners or simply away from other people [20, 29, 30, 33, 45]. This quote from a study based in Thailand described a shared feeling among women: “I cried and cried when I knew the result. A nurse took my husband and me to a small room. She said to me that my condition wasn’t urgent to treat, I and my husband could stay in this room until we felt relieved from sadness. If we needed any help, I could call her any time. This is the nursing care that I need”[20].

Four studies raised concerns on how women and their partners’ distress increased when sharing facilities with other pregnant women while in hospital [25, 29, 46, 47]. This quote from an Irish study is representative of a shared experience women had in hospital: “I was getting more and more upset ... I couldn’t really understand why the hospital didn’t have a more separated area ... It is not something a woman in any miscarriage situation should have to do”[51].

Interventions for miscarriage in hospital settings

Six intervention studies were included in this review, all of which took into consideration different aspects of miscarriage care in hospital settings [21, 23, 38–41]. Four studies targeted women [23, 38–40], one both parents[41] and one health professionals [21]. Four of these studies were behavioural interventions investigating whether psychological support offered after miscarriage might help with improving women’s emotional wellbeing [23, 38, 40]. One study based in France highlighted how communication training delivered to medical staff at the emergency department can improve parents’ mental well-being after miscarriage [21]. Another RCT highlighted that management of miscarriage per se did not impact on women’s psychological wellbeing, but the effectiveness of the treatment did [39]. A summary of the intervention findings can be found in Table 3.

Table 3

Summary of interventions
MacWilliams et al., 2016	Canada	Qualitative- Interview	Emergency Department	Women (N = 8) who had sought treatment in ED while actively miscarrying and subsequently experienced a completed miscarriage. Age from 21 to 36 years old. Gestation at time of the loss 5–14 weeks.	To explore the experience of women who attended the ED while experiencing miscarriage	Participants reported feeling isolated during discharge and after leaving the emergency department because of the lack of support and acknowledgment from HCPs, family, and friends. Having a miscarriage and receiving treatment for a miscarriage in the emergency department was a traumatic experience that had a lasting emotional impact on all the women in this study.
McLean and Flynn, 2013	Australia	Qualitative	Hospital setting (not specified)	Women (N = 6) who attended a hospital for a miscarriage in the first 20 weeks of pregnancy age ranged (31–41) years old	To establish a localised knowledge from a social work perspective of women’s experiences of hospital treatment after miscarriage	Such work has revealed that the medicalisation of miscarriage has excluded likely emotional and psychological effects from consideration. Women subsequently experience a lack of acknowledgement and compassion from the attending hospital staff, who treat them in an inconsistent, ad hoc fashion.
Meaney et al. 2017	Republic of Ireland	Qualitative	Maternity Hospital	Women (N = 10) and Men (N = 6) who experienced miscarriage ( 5–16 gestational weeks)	To explore the experiences of women and men of miscarriage diagnosis and management	Analysis of the data indicated six superordinate themes in relation to the participant’s experience of miscarriage: acknowledgement of miscarriage as a valid loss, misperceptions of miscarriage, the hospital environment, management of miscarriage, support and coping, reproductive history and implications for future pregnancies.
Miller et al., 2019	USA	Mixed-methods	Emergency Department/Ambulatory settings	Women (N = 54) who had an ultrasound diagnosis of anembryonic gestation or embryonic or foetal demise in the first trimester (5–12 completed weeks of gestation). 1st group 25 attended the ED for miscarriage- within this group 20 completed an interview 2nd group 29 an ambulatory setting- within this group 25 completed an interview	Sought to characterise the timeline from presentation to resolution in patients with miscarriage attending ED and ambulatory settings, as well as patient satisfaction with miscarriage management among these two groups.	ED patients who were more likely to meet criteria for post- traumatic stress disorder reveals that this group were not only socioeconomically but also psychosocially vulnerable. The ED patient experience was qualitatively associated with greater patient confusion and less satisfaction, similar to other qualitative studies of miscarriage care in the ED where patients reported poor communication, unfriendly environment, and a lack of emotional support. Participants who sought care in the ED had longer time to miscarriage resolution and a greater number of care teams involved in the miscarriage diagnosis and management.
Miller et al. 2019	Australia	Qualitative	Hospital setting (not specified)	Men (N = 10) aged between 29–49 years old who’s partner experienced miscarriage	To explore miscarriage from a male partner perspective, and men’s needs for additional support.	Men commonly reported a lack of emotional support from healthcare and social networks at the time of miscarriage. Men may have even less support around them at the time of miscarriage, with many stating that healthcare providers, and family and friends directed their acknowledgement and support toward their partners rather than themselves at the time of their loss. Support services and information were also largely targeted at women, leaving men feeling very isolated and alone at the time of miscarriage, and consequently turning to online forums for support and to share their experiences of miscarriage.
Murphy and Merrell, 2009	United Kingdom	Qualitative	Gynaecological Unit	Women (N = 8 30–59 years old) who had an early miscarriage Health professionals (N = 16)	To explore women’s experience of having an early miscarriage in a hospital gynaecological unit.	The hospital settings emerged as highly influential in shaping the care that was given to women and influencing their experiences. Three clear phases emerged in women’s experience of miscarriage: first signs and confirmation of miscarriage, losing the baby and aftermath.
Murphy and Philpin, 2010	United Kingdom	Qualitative	Early Pregnancy Assessment Unit	Women (N = 8 30–59 years old) who had an early miscarriage Health professionals (N = 16)	To explore women’s experience of having an early miscarriage in a hospital gynaecological unit.	The findings presented here focused on the woman’s experience of their miscarriage with the physical symptoms of pain and blood loss being very important. There was a tension between the idea of early miscarriage as losing a baby and the actual reality of their physical experience.
Nash et al., 2018	Republic of Ireland	Qualitative	Maternity Hospital	Midwives (N = 8) caring for women with early pregnancy loss	To explore the perception of midwives caring for women experiencing early pregnancy loss.	There were three main themes identified in the data analysis. These were: midwives coping with the experience of early pregnancy loss; resourcing compassionate for women; and what midwives found difficult. This study reported that exposure to early pregnancy loss can have a profound emotional effect on midwives, with a potential for this to influence the care provided to women.
Norton and Lynn, 2018	United Kingdom	Qualitative	Early Pregnancy Assessment Unit	Women (N = 10), 21–44 years old who experienced miscarriage within the first 12 weeks of gestational period and had not experienced a previous miscarriage	To explore how women experience care within an early pregnancy assessment unit and how they are helped to understand, reconcile and make sense of their loss and make informed decisions about how they care will be managed following first trimester miscarriage.	Findings from this study have some important implications for managing the care of women and their partners from the point of seeking initial help from their midwife or GP through to the provision of care in the EPAU. Individualised care is required to ensure that women and their partners do not feel ‘dehumanised’ in a system that they do not understand. The provision of individualised care, respect for women’s opinions and appropriate clinical information is imperative to those experiencing miscarriage. This is important because women respond to miscarriage differently. Furthermore, staff need to give equal consideration to women’s emotional needs as well as their physical needs to help them relieve their level of distress which in turn may help their recovery after miscarriage.
Punches et al., 2019	USA	Qualitative	Emergency Department	Women had to be between 18 and 45 years old who had experienced a pregnancy loss and were discharged home to self-care from ED department. Age between 21 and 34	To describe the contemporary perspectives of women experiencing a pregnancy loss in the ED.	Women perceived that healthcare workers are withholding information and that the providers do not understand their experience. Additionally, the participants described methods of assisting with the grieving process that were beneficial, as well as some that were disconcerting.
Rowlands and Lee, 2010	Australia	Qualitative	Hospital setting (not specified)	Women (N = 9) who had experienced miscarriage in the previous 2 years and aged between 35 and 42 years old	To identify how to support Australian women after miscarriage.	Findings suggest that this lack of empathy and recognition can have a profound effect on the woman’s grieving process. Acknowledging the loss has been identified as an important part of coping with miscarriage. Two women in our study found that formal and informal ceremonies provided them with some closure and provided a meaningful way to acknowledge the loss. Acknowledging the loss has been identified as an important part of coping with miscarriage. Two women in our study found that formal and informal ceremonies provided them with some closure and provided a meaningful way to acknowledge the loss.
Schreiber et al. 2016	USA	Mixed-methods	Emergency Department	Women (55 participants in total for quantitative part 15 interviewed) who experienced miscarriage. A patient was eligible to participate if she was 1) 18 and over, 2) had an ultrasound diagnosis of an anembryonic gestation or embryonic or foetal demise in the first trimester (5–12 completed weeks of pregnancy) confirmed by 2 clinicians, neither of whom were the investigator of record, 3) willing to provide informed consent, and was 4) English speaking	To synthetise a better understanding of patients level and physician level factors that might impact treatment choice and ultimate satisfaction with the goal of informing improvements in patient-cantered care miscarriage care	Results suggested specifically that women new to pregnancy rely more heavily on their clinician for guidance, and that they might benefit most substantively from care from providers with expertise in miscarriage management experiences and outcomes. Women reported the importance of having control and self-determination in concluding their miscarriage in a timely manner. Satisfaction with management is driven by the experience with the care received, rather than one specific therapeutic option over another. Satisfaction was mainly driven by efficiency of care, confidence in quality of care, sensitive providers, and effective two-way communication. Both the physician and patient-level data show alignment in considering the individual needs of the patient as well as her external demands when choosing a course of treatment.
Sejourne et al., 2010	France	Quantitative	Semi-private clinics	Women who had undergone DC or VA for the uncomplicated and anticipated loss of a pregnancy 134 women included in the study 66 assigned to one group 68 assigned to second group	To verify if a single-session intervention based on CBT techniques including psychoeducation along with empathetic emotional support would be beneficial for women dealing with miscarriage. If CBT can be applied to preventing the psychological distress associated with a miscarriage	At 3 weeks post-miscarriage, the women in the DI group had higher scores on anxiety. There were no significant differences at either 10 weeks or 6 months post-miscarriage with regards to symptom intensity. At 10 weeks, more women in the DI group showed elevated scores on depression
Smith et al. 2020	United Kingdom	Qualitative	Hospital setting (not specified)	Parents who had a miscarriage between 20 to 24th weeks of gestation. 38 parents (10 parent pairs; 18 mothers)	To explore the healthcare experience of parents whose baby died either before, during or shortly after birth between 20 and 20th weeks of gestation in order to identify practical weys to improve healthcare provision	The key overarching theme to emerge from the interviews with parents was the importance of terminology used to refer to the death of their baby. Parents who were told they were “losing a baby” rather than “having a miscarriage” were more prepared for the realities of labour, birth experience and for making decisions around seeing and holding their baby. Appropriate terminology validated their loss, and impacted on parent’s health and wellbeing immediately following bereavement and in the long term.
Verhaeghe et al., 2020	France	Quantitative	Emergency Department	Women (N = 72) who had a confirmed diagnosis of first trimester pregnancy loss. Intervention group 45 consultation before the training Control group 27 consultation after the training	To address the impact of a simulation training program for residents for the disclosure of diagnosis on the psychological experience of couples following a first trimester pregnancy loss.	Significant improvement in the couples’ personal experience and a significant decrease in the psychological morbidity associated with the disclosure following training. Attitude of the physician announcing the pregnancy loss was significantly improved, and the global perinatal grief score was significantly lower after training. Information provided was more complete and easier to understand, with fewer patients requiring an additional consultation to address uncovered issues. Overall, the study showed an objective improvement in the patients’ psychological morbidity following simulation training of the residents announcing the diagnosis, thus demonstrating a direct benefit of simulation training for patients.

Author	Country	Research Design	Target Population	Intervention	Control Group	Outcomes
Verhaeghe et al. 2020	France	Uncontrolled prospective single centre before-after study	Doctors	Simulation training for doctors regarding the communication of miscarriage	None	Significant improvement in the couples’ personal experience and a significant decrease in the psychological morbidity associated with the disclosure following training. Attitude of the physician announcing the pregnancy loss was significantly improved.
Johnson et al. 2015	USA	Experimental, post-test only, control group design	Women	One-hour long bereavement sessions for women based on Guidelines for Medical Professionals Providing Care to the Family Experiencing Perinatal Loss, Neonatal Death, DIDS or other Infant Death.	Routine miscarriage care	Women who received the intervention showed less signs of grief and were 50% less likely to display despair than women in the control group. Women in both groups reported high levels of active grieving.
Kong et al. 2014	China	RCT	Women	Supportive counselling from aa single nurse counsellor in the hospital before discharge and 2 weeks later by telephone.	Routine miscarriage care	A session of supportive counselling with a trained nurse counsellor, delivered immediately and at 2 weeks after diagnosis of miscarriage, did not show a statistically significant effect in reducing the psychological distress of women after miscarriage. It also failed to show any additional effects. Among the subset of women who had high baseline scores on the GHQ-12 and BDI questionnaires, a statistically significant difference was observed between counselling and standard care groups in terms of lower scores and reduced proportions of women scoring highly at 6 weeks in the counselling group.
Kong et al. 2013	China	RCT	Women	Women were divided into 3 groups according to treatment chosen (medical, surgical, expectant) to measure the psychological outcomes according to treatment	N/A	Significantly more women who received either surgical or medical evacuation expressed worries of weakening or even damage to their bodies as a result of the treatment. Significantly more women with successful treatment scored higher on CSQ-8 compared with women having unsuccessful treatment. Less women with successful treatment expressed worries about the treatment damaging their bodies. There were no significant differences in psychological outcomes measured in terms of psychological well-being (GHQ-12), depression (BDI), anxiety (STAI) and fatigue symptoms (FS) at the time of treatment and four weeks after treatment among three treatment modalities. Women with active intervention (both surgical and medical evacuation) had a significantly higher score of CIES-R at the time of treatment when compared with women in the expectant management group. The traumatic psychological impact had lessened in the subsequent follow-up at Day 28.
Klein et al. 2012	United Kingdom	RCT	Parents	Women received a study pack containing participant information about “Miscarriage Matters” website and its contents (online answers from clinical experts, interactions with others as a means of support via a Forum, contact details of voluntary agencies who provide support after miscarriage)	N/A	Results indicated that the IG group was significantly less anxious and depressed at the 3-month follow-up. Similarly, the IG group reported significantly higher levels of emotional wellbeing.
Séjourné et al. 2010	France	RCT		All women were asked to participate in a support intervention consisting of one psychological session of CBT on the day of the surgical intervention	No CBT session and provided with a support intervention at 3 months post-miscarriage	At 3 weeks post-miscarriage, the women in the control group had higher scores on anxiety. There were no significant differences at either 10 weeks or 6 months post-miscarriage with regards to symptom intensity. At 10 weeks, more women in the DI group showed elevated scores on depression.

In this review we mapped the available evidence on factors contributing to women and men’s emotional distress and well-being when experiencing miscarriage in hospital settings. The evidence included strongly suggests that the care provided in hospital can negatively affect parents’ emotional wellbeing.

One of the key findings of this review was that health professionals (HPs) play a key role in shaping men and women’s experience of miscarriage and influencing their emotional wellbeing [5, 52, 53]. Being exposed to perinatal loss on a daily basis might lead HPs to view this issue as primarily medical [6, 54], however, this review highlighted a discrepancy in perceptions of the emotional implications of miscarriage between parents and HPs, with the latter underestimating the impact that pregnancy loss may have on women [10, 55]. Parents expressed the importance of acknowledging miscarriage as a significant loss [56] and recognising both the emotional and physical implications of it [57]. These findings are in line with other systematic reviews conducted on the experience of parents’ hospital journeys [11, 58]. The four interventions included in the review have shown that providing emotional support following miscarriage can contribute to the reduction of psychological morbidities in both men and women [23, 38, 40, 41]. However, all four-interventions adopted different approaches and study designs, highlighting the importance of conducting further research in this field. Also, a previous Cochrane review investigating the best psychological support following miscarriage reached “empty results” due the lack of interventions in this area [7].

Further, bereavement care guidelines emphasise the significance of communicating clearly and sensitively with women after pregnancy loss [59]. Different protocols to communicate bad news stress the importance of health professionals to prepare themselves before delivering difficult news by planning and providing patients with a private environment [60–62]. Further, simulation training for medical staff on how to deliver news of pregnancy loss has demonstrated positive impacts on parents, reducing psychological morbidities following miscarriage [21, 63]. However, studies in our review highlighted that women are not always satisfied with how information is delivered [50, 51, 64–68]. It has been reported that providing sufficient levels of information could reduce the distress associated with miscarriage [64, 65, 69]. This also arose from our findings, as the provision of information was considered essential to parents not only to promote their understanding but also their knowledge of miscarriage.

Data from this review shows the importance of using sensitive terminology when communicating to parents as many medical words such as “miscarriage” and “termination of pregnancy” can be perceived as offensive by parents. This result is in line with another review which highlighted that the use of words such as ‘foetus’ can be perceived by women as negatively impacting on their emotional wellbeing [70].

Time represented an important aspect of parents’ journey. As other reviews and research studies previously highlighted, waiting while facing the unknown has a negative impact on parents’ psychological wellbeing. We further added that women identified the need of time to process the news of miscarriage before moving on to treatment options. Studies have demonstrated that miscarriage represents a traumatic event for women and their partners [71, 72]. Therefore, HPs should assess the level of understanding of women when delivering a diagnosis of miscarriage and ensure to that enough time is provided to assimilate the news before moving on to making decision about their care [73].

Finally, the results of this review suggested that it appears to be extremely distressing for parents to be in areas where privacy is lacking, for example, waiting in shared facilities with evident symptoms of miscarriage. These results mirrored another systematic reviews that highlighted the lack of private amenities accessible to women in the hospital environment [11]. Our findings highlights the importance for women to access private toilets in particular when experiencing miscarriage as this seems to be particularly distressing for them. Further, findings from this review indicate how parents’ distress can be increased if cared for along with other pregnant women.

RECOMMENDATIONS FOR PRACTICE

Health professionals should acknowledge and recognise the emotional implications of miscarriage for parents, by providing compassionate care and adequate information. Communicating empathically, without using medical terms and insensitive comments could reduce women’s anxiety while in hospital. It is also important to provide adequate time to women to process information and to give them opportunities to ask questions. The provision of training for HPs in relation to these issues and considered guidelines for practice are urgently needed.

RECOMMENDATIONS FOR FURTHER RESEARCH

This review has revealed research which clearly indicates the need for action to improve the provision of care for those experiencing miscarriage in hospital. To guide evidence-informed guidelines and interventions for health professionals and patients, there is a need for robust research that involves the development and evaluation of evidence-based interventions. There is a particular need for interventions which can reduce the anxiety and negative emotions associated with the hospital environment. There is also a significant lack of studies involving men and their perspectives on how they should be supported by health professionals during their partner’s miscarriage.

To the best of our knowledge this is the first scoping review focusing on factors impacting on emotional wellbeing of parents who experience miscarriage and attend hospital settings. This review used a systematic process to map and assess the quality of the international literature, including primary studies and grey literature and this provided the opportunity to highlight gaps to inform practice and further research. This review also had some limitations. Only articles in English, published since 2010 were included in the review and this might have resulted in the exclusion of some relevant studies.

The development of emotional distress post-miscarriage and emotional adjustment may be influenced by the emotional support provided and a culture of respect and understanding in hospital settings. Further research on how to better support women in hospital settings when experiencing miscarriage is needed to inform policies and guidelines. However, this review highlighted that women and their partners need health professionals to recognise the emotional implications of miscarriage, deliver clear and effective information, and be cared for in an environment where privacy is maintained.

ACKNOWLEDGEMENTS

We would like to thank the subject librarian who helped us to develop the search strategy.

FUNDING

This ScR review was conducted as part of a Doctoral Degree funded by the Department of Economy and sponsored by Queen’s University Belfast.

CONTRIBUTIONS

MG and ÁA led the conceptualisation and design of the review with input from GM and MT. MG led the database searches, article screening, data extraction and data synthesis, with input from ÁA. MG wrote the manuscript, with input from ÁA. Critical review of manuscript drafts was provided by ÁA, GM and MT. All authors approved the final version of the manuscript.

ETHICS AND APPROVAL AND CONSENT TO PARTICIPATE

Not applicable

CONSENT FOR PUBLICATION

Not applicable

COMPETING INTERESTS

None declared.

AVAILABILITY OF DATA AND MATERIALS

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

AUTHORS DETAILS

¹School of Nursing & Midwifery, Queen’s University Belfast, Northern Ireland, UK. ²Institute for Life Course Health Research, Stellenbosch University, South Africa.

Martina Galeotti, corresponding author, email address: [email protected]

RcOG. The Investigation and Treatment of Couples with Recurrent First-trimester and Second-trimester Miscarriage. RCOG Green-top Guideline No. 17. 2011;:1–18. doi:10.4103/2230-8210.107834.
Kerstin A, Wanger B. Complicated grief after perinatal loss. Dialogues in Clinical Neuroscience. 2012;14:187–94.
Williams HM, Topping A, Coomarasamy A, Jones LL. Men and Miscarriage: A Systematic Review and Thematic Synthesis. Qualitative health research. 2020;30:133–45. doi:https://dx.doi.org/10.1177/1049732319870270.
Simmons RK, Singh G, Maconochie N, Doyle P, Green J. Experience of miscarriage in the UK: Qualitative findings from the National Women’s Health Study. Social Science and Medicine. 2006;63:1934–46.
Bellhouse C, Temple-Smith M, Watson S, Bilardi J. “The loss was traumatic… some healthcare providers added to that”: Women’s experiences of miscarriage. Women and birth: journal of the Australian College of Midwives. 2019;32:137–46. doi:https://dx.doi.org/10.1016/j.wombi.2018.06.006.
Murphy F, Philpin S. Early miscarriage as “matter out of place”: an ethnographic study of nursing practice in a hospital gynaecological unit. International journal of nursing studies. 2010;47:534–41. doi:https://dx.doi.org/10.1016/j.ijnurstu.2009.10.011.
San Lazaro Campillo I, Meaney S, McNamara K, O’Donoghue K. Psychological and support interventions to reduce levels of stress, anxiety or depression on women’s subsequent pregnancy with a history of miscarriage: An empty systematic review. BMJ Open. 2017;7:1–8.
Murphy FA, Lipp A, Powles DL. Follow-up for improving psychological well being for women after a miscarriage. Cochrane Database of Systematic Reviews. 2012.
Farren J, Mitchell-Jones N, Verbakel JY, Timmerman D, Jalmbrant M, Bourne T. The psychological impact of early pregnancy loss. Human Reproduction Update. 2018;24:731–49.
Geller PA, Psaros C, Kornfield SL. Satisfaction with pregnancy loss aftercare: are women getting what they want?. Archives of women’s mental health. 2010;13:111–24. doi:https://dx.doi.org/10.1007/s00737-010-0147-5.
Freeman A, Neiterman E, Varathasundaram S. Women’s experiences of health care utilization in cases of early pregnancy loss: A scoping review. Women and Birth. 2020;:1–9.
Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Annals of Internal Medicine. 2018;169:467–73.
Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: Scoping reviews - JBI Manual for Evidence Synthesis - JBI GLOBAL WIKI. JBI Manual for Evidence Synthesis. 2020. https://wiki.joannabriggs.org/display/MANUAL/Chapter+11%3A+Scoping+reviews. Accessed 26 Aug 2020.
Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology: Theory and Practice. 2005;8:19–32.
Galeotti M, Aventin Á, Mitchell G, Tomlinson M. Factors contributing to emotional distress and wellbeing among women and men who experience miscarriage and attend hospital settings. A systematic scoping review protocol — Queen’s University Belfast. Belfast; 2020. https://pure.qub.ac.uk/en/publications/factors-contributing-to-emotional-distress-and-wellbeing-among-wo. Accessed 28 Jul 2021.
JBI. Appendix 11.1 JBI template source of evidence details, characteristics and results extraction instrument - JBI Manual for Evidence Synthesis - JBI GLOBAL WIKI. 2020. https://wiki.jbi.global/display/MANUAL/Appendix+11.1+JBI+template+source+of+evidence+details%2C+characteristics+and+results+extraction+instrument. Accessed 16 Sep 2020.
Pope Catherine, Mays Nicholas and PJ. Synthesizing Qualitative and Quantitative Health Research. McGraw-Hill Education; 2007. https://ebookcentral-proquest-com.queens.ezp1.qub.ac.uk/lib/qub/detail.action?docID=316315. Accessed 14 Sep 2020.
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., … Duffy S. Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme. 2006. https://www.researchgate.net/publication/233866356_Guidance_on_the_conduct_of_narrative_synthesis_in_systematic_reviews_A_product_from_the_ESRC_Methods_Programme.
Braun V, Clarke V. Qualitative Research in Psychology Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3:77–101. http://www.tandfonline.com/action/journalInformation?journalCode=uqrp20%5Cnhttp://www.tandfonline.com/action/journalInformation?journalCode=uqrp20.
Chaloumsuk N. WOMEN’S EXPERIENCES OF MISCARRIAGE AND TERMINATION OF PREGNANCY FOR FETAL ANOMALY IN THAILAND: A PHENOMENOLOGICAL STUDY. 2013.
Verhaeghe C, Gicquel M, Bouet PE, Corroenne R, Descamps P, Legendre G. Positive impact of simulation training of residents on the patients’ psychological experience following pregnancy loss. Journal of Gynecology Obstetrics and Human Reproduction. 2020;49.
Smith LK, Dickens J, Bender Atik R, Bevan C, Fisher J, Hinton L. Parents’ experiences of care following the loss of a baby at the margins between miscarriage, stillbirth and neonatal death: a UK qualitative study. BJOG: An International Journal of Obstetrics and Gynaecology. 2020;127:868–74.
Séjourné N, Callahan S, Chabrol H. The utility of a psychological intervention for coping with spontaneous abortion. Journal of Reproductive and Infant Psychology. 2010;28:287–96.
Schreiber CA, Chavez V, Whittaker PG, Ratcliffe SJ, Easley E, Barg FK. Treatment Decisions at the Time of Miscarriage Diagnosis. Obstetrics and Gynecology. 2016;128:1347–56.
Rowlands IJ, Lee C. “The silence was deafening”: Social and health service support after miscarriage. Journal of Reproductive and Infant Psychology. 2010;28:274–86.
Punches BE, Johnson KD, Acquavita SP, Felblinger DM, Gillespie GL. Patient perspectives of pregnancy loss in the emergency department. International Emergency Nursing. 2019;43:61–6.
Linnet Olesen M, Graungaard AH, Husted GR. Deciding treatment for miscarriage - experiences of women and healthcare professionals. Scandinavian Journal of Caring Sciences. 2015;29:386–94.
Nash M, Barry M, Bradshaw C. Midwives’ experiences of caring for women with early pregnancy loss in an Irish maternity hospital. 2018.
Norton W, Furber L. An exploration of how women in the UK perceive the provision of care received in an early pregnancy assessment unit: An interpretive phenomenological analysis. BMJ Open. 2018;8.
Murphy F, Merrell J. Negotiating the transition: Caring for women through the experience of early miscarriage. Journal of Clinical Nursing. 2009;18:1583–91.
Murphy F, Philpin S. Early miscarriage as “matter out of place”: An ethnographic study of nursing practice in a hospital gynaecological unit. International Journal of Nursing Studies. 2010;47:534–41.
Miller CA, Roe AH, McAllister A, Meisel ZF, Koelper N, Schreiber CA. Patient Experiences with Miscarriage Management in the Emergency and Ambulatory Settings. Obstetrics and Gynecology. 2019;134:1285–92.
Meaney S, Corcoran P, Spillane N. Experience of miscarriage: an interpretative phenomenological analysis Setting: A large tertiary-level maternity hospital in. BMJ Open. 2017;7:11382. doi:10.1136/bmjopen-2016.
Miller EJ, Temple-Smith MJ, Bilardi JE. “There was just no-one there to acknowledge that it happened to me as well”: A qualitative study of male partner’s experience of miscarriage. PLoS ONE. 2019;14.
McLean A, Flynn C. “It’s not just a pap-smear”: Women speak of their experiences of hospital treatment after miscarriage. Qualitative Social Work. 2013;12:782–98.
Larivière-Bastien D, deMontigny F, Verdon C. Women’s Experiences of Miscarriage in the Emergency Department. Journal of Emergency Nursing. 2019;45:670–6.
MacWilliams K, Hughes J, Aston M, Field S, Moffatt FW. Understanding the Experience of Miscarriage in the Emergency Department. Journal of Emergency Nursing. 2016;42:504–12.
Kong GWS, Chung TKH, Lok IH. The impact of supportive counselling on women’s psychological wellbeing after miscarriage–a randomised controlled trial. BJOG: an international journal of obstetrics and gynaecology. 2014;121:1253–62.
Kong GWS, Lok IH, Yiu AKW, Hui ASY, Lai BPY, Chung TKH. Clinical and psychological impact after surgical, medical or expectant management of first-trimester miscarriage - A randomised controlled trial. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2013;53:170–7.
Johnson OP, Langford RW. A Randomized Trial of a Bereavement Intervention for Pregnancy Loss. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2015;44:492–9.
Klein S, Cumming GP, Lee AJ, Alexander DA, Bolsover D. Evaluating the effectiveness of a web-based intervention to promote mental wellbeing in women and partners following miscarriage, using a modified patient preference trial design: An external pilot. BJOG: An International Journal of Obstetrics and Gynaecology. 2012;119:762–7.
Iwanowicz-Palus G, Rzonca E, Bien A, Wloszczak-Szubzda A, Walczuk E. High evaluation of medical staff by women after miscarriage during hospitalization. Tohoku Journal of Experimental Medicine. 2014;232:155–62.
Edwards S, Birks M, Chapman Y, Yates K. Bringing together the ‘Threads of Care’ in possible miscarriage for women, their partners and nurses in non-metropolitan EDs. Collegian. 2018;25:293–301.
Emond T, de Montigny F, Guillaumie L. Exploring the needs of parents who experience miscarriage in the emergency department: A qualitative study with parents and nurses. Journal of Clinical Nursing. 2019;28:1952–65.
Domingos S, Merighi M, Jesus M. Expereince and care in miscarriage: a qualitative study. Online brazJ.nurs. 2011;10. http://www.objnursing.uff.br/index.php/nursing/article/view/3236.
Bellhouse C, Temple-Smith M, Watson S, Bilardi J. “The loss was traumatic… some healthcare providers added to that”: Women’s experiences of miscarriage. Women and Birth. 2019;32:137–46.
Cullen S, Coughlan B, McMahon A, Casey B, Power S, Brosnan M. Parents’ experiences of clinical care during second trimester miscarriage. British Journal of Midwifery. 2018;26:309–15.
Baird S, Gagnon MD, deFiebre G, Briglia E, Crowder R, Prine L. Women’s experiences with early pregnancy loss in the emergency room: A qualitative study. Sexual and Reproductive Healthcare. 2018;16:113–7.
Exploring parents’ experiences of care in an Irish hospital following second-trimester miscarriage. 2017.
Cullen S, Coughlan B, Casey B, Power S, Brosnan M. Exploring parents’ experiences of care in an Irish hospital following second-trimester miscarriage. British Journal of Midwifery. 2017;25:110–5. http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=121086938&site=ehost-live.
Cullen S, Coughlan B, Casey B, Power S, Brosnan M. Parents’ experiences of clinical care during second trimester miscarriage. British Journal of Midwifery. 2018;26:309–15.
Bellhouse C, Temple-Smith MJ, Bilardi JE. “It’s just one of those things people don’t seem to talk about.” women’s experiences of social support following miscarriage: A qualitative study 11 Medical and Health Sciences 1117 Public Health and Health Services. BMC Women’s Health. 2018;18:1–9.
Jensen KLB, Temple-Smith MJ, Bilardi JE. Health professionals’ roles and practices in supporting women experiencing miscarriage: A qualitative study. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2019;59:508–13.
Stratton K, Lloyd L. Hospital-based interventions at and following miscarriage: Literature to inform a research-practice initiative. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2008;48:5–11.
Engel J, Rempel L. Health Professionals’ Practices and Attitudes About Miscarriage. MCN The American journal of maternal child nursing. 2016;41:51–7. doi:https://dx.doi.org/10.1097/NMC.0000000000000207.
Meaney S, Corcoran P, Spillane N, O’Donoghue K. Experience of miscarriage: an interpretative phenomenological analysis. BMJ open. 2017;7:e011382. doi:https://dx.doi.org/10.1136/bmjopen-2016-011382.
Radford EJ, Hughes M. Women’s experiences of early miscarriage: Implications for nursing care. Journal of Clinical Nursing. 2015;24:1457–65.
Obst KL, Due C. Men’s grief and support following pregnancy loss: A qualitative investigation of service providers’ perspectives. Death studies. 2019;:1–9. doi:https://dx.doi.org/10.1080/07481187.2019.1688430.
Department of Health Social Services and Public Safety. Regional Bereavement Guidance on evidence-based, holistic care of parents and their families after the experience of miscarriage, stillbirth or neonatal death Acknowledgements. 2014.
Fine RL. Keeping the patient at the center of patient- and family-centered care. Journal of Pain and Symptom Management. 2010;40:621–5. doi:10.1016/j.jpainsymman.2010.06.008.
Monden KR, Gentry L, Cox TR. Delivering Bad News to Patients. Baylor University Medical Center Proceedings. 2016;29:101–2. doi:10.1080/08998280.2016.11929380.
Buckman R, Kason Y. How to Break Bad News: A Guide for Health Care Professionals. Toronto: University of Tornont Press ; 1992. https://books.google.co.uk/books/about/How_to_Break_Bad_News.html?id=mTRrAAAAMAAJ&redir_esc=y. Accessed 9 Mar 2021.
Brann M, Bute JJ, Scott SF. Qualitative Assessment of Bad News Delivery Practices during Miscarriage Diagnosis. Qualitative health research. 2020;30:258–67. doi:https://dx.doi.org/10.1177/1049732319874038.
Jacobs J, Harvey J. Evaluation of an Australian miscarriage support programme. British journal of nursing (Mark Allen Publishing). 2000;9:22–6.
Larivière-Bastien D, deMontigny F, Verdon C. Women’s Experiences of Miscarriage in the Emergency Department. JEN: Journal of Emergency Nursing. 2019;45:670–6. http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=139526784&site=ehost-live.
MacWilliams K, Hughes J, Aston M, Field S, Moffatt FW. Understanding the Experience of Miscarriage in the Emergency Department. Journal of emergency nursing. 2016;42:504–12. doi:https://dx.doi.org/10.1016/j.jen.2016.05.011.
Rowlands IJ, Lee C. “The silence was deafening”: Social and health service support after miscarriage. Journal of Reproductive and Infant Psychology. 2010;28:274–86. doi:10.1080/02646831003587346.
Emond T, de Montigny F, Guillaumie L. Exploring the needs of parents who experience miscarriage in the emergency department: A qualitative study with parents and nurses. Journal of clinical nursing. 2019;28:1952–65. doi:https://dx.doi.org/10.1111/jocn.14780.
Robinson J. Provision of information and support to women who have suffered an early miscarriage. British Journal of Midwifery. 2014;22:175–80.
Anolak H, Thornton C, Davis D. What’s wrong with using the F word? A systematic integrative review of how the fetus is talked about in situations of fetal demise or high risk of fetal loss. Midwifery. 2019;79:N.PAG-N.PAG. http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=139472900&site=ehost-live.
Armstrong DS. Emotional distress and prenatal attachment in pregnancy after perinatal loss. Journal of Nursing Scholarship. 2002;34:339–45.
Lee C, Slade P. Miscarriage as a traumatic event: a review of the literature and new implications for intervertion. Journal of Psychosomatic Research. 1996;40:235–44.
Boyle FM, Horey D, Middleton PF, Flenady V. Clinical practice guidelines for perinatal bereavement care — An overview. Women & Birth. 2020;33:107–10. http://search.ebscohost.com/login.aspx?direct=true&db=jlh&AN=141938256&site=ehost-live.

No competing interests reported.

Factors Affecting the Emotional Wellbeing of Women and Men Who Experience Miscarriage in Hospital Settings: A Scoping Review

Status:

Version 1

Abstract

Figures

Background

Methods

Eligibility Criteria for Selected Studies

Inclusion Criteria

Population

Context

Concept

Types of evidence sources

Exclusion Criteria

Population

Context

Search strategy

Study Selection and data extraction

Summarising and reporting the results

Results

Characteristics of included studies

Quality of included studies

Synthesis of evidence

Theme 1: Interactions with health professionals

Sub-theme 1A: Acknowledging the loss

Sub-theme 1B: Provision of information

Theme 2: Time waiting for diagnosis, procedures, treatment

Theme 3: Lack of privacy in hospital environments

Interventions for miscarriage in hospital settings

Discussion

RECOMMENDATIONS FOR PRACTICE

RECOMMENDATIONS FOR FURTHER RESEARCH

Strengths And Limitations

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1