Background

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].

While it is important to acknowledge that miscarriage is not traumatic for all, there is an extensive body of 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 [1,2,3,4]. 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 [4,5,6]. In fact, the quality-of-care received by women at the time of miscarriage has an impact on their mental health even years after the miscarriage has occurred [7].

Previous systematic reviews in the area have mainly focused on the psychological and emotional implications of miscarriage [8,9,10] and women’s satisfaction with the care provided when attending hospital due to miscarriage [11, 12]. Health professionals play a key role deliverying miscarriage care however, there is a lack of evidence demonstrating how to best support parents in hospital settings [13, 14]. Therefore, 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-related 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.

Methods

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 [15,16,17]. A review protocol was pre-registered on the lead author’s institutional database [18].

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 were included according to the country in which the study was conducted, also recurrent miscarriage was 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 including doctoral thesis and unpublished studies 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.

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, OpenGrey 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, reference lists of included studies were screened for additional relevant articles.

Table 1 Search terms used in CINAHL
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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 abstract 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 [19]. 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 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).

Results

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 [5, 6, 20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47]. The PRISMA flow chart summarises the above process (Fig. 1).

Fig. 1
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PRISMA Flow Diagram

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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 (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 was included in the review of which 1413 were women, 38 men and 83 health professionals. Twelve studies included any pregnancy loss prior to the 24th week of gestation and did not provide information of when the miscarriage occurred. Seven studies included early pregnancy loss (up to 12 weeks), seven studies miscarriage between 5 and 16 weeks, three studies second semester miscarriage (12–19 weeks) and one study late miscarriage (20-24th weeks). One study included women who experienced solely one pregnancy loss.

The studies were conducted in 11 different countries: USA (n = 5), Australia (n = 5), United Kingdom (n = 5), Canada (n = 3), Ireland (n = 4), France (n = 2), China (n = 2), Brazil (n = 1), Denmark (n = 1), Poland (n = 1), and Thailand (n = 1). No studies from low or lower-middle income countries were included. A summary of the studies included can be found in Table 2.

Table 2 Summary of studies included in the review
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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 [5, 20, 30, 31, 45,46,47]. Conversely, twenty-three did not mention if they had such protocol in place [6, 21,22,23,24,25,26,27,28,29, 32,33,34,35,36,37,38,39,40,41,42,43,44]. Sixteen studies declared they had no conflict of interest [5, 20,21,22, 28, 29, 33, 35, 37, 40,41,42,43, 45,46,47] and fourteen did not mention this [5, 6, 23,24,25,26, 30,31,32, 34, 36, 38, 39, 44]. One American and one Australian study provided compensation to participants [6, 47]. Three randomised controlled trials included had a high attrition rate [23, 37, 40]. Only one study, a doctoral thesis, 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) The effect of time; and 3) lack of privacy in hospital environments. Within Theme 1, two sub-themes where identified 1a) Acknowledging the loss; 1b) Provision of information; 1c) Terminology. Within Theme 2, two sub-themes where identified 2a) Time waiting for diagnosis, procedures and treatment; 2b) Time to absorb the news of miscarriage. 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, 24,25,26, 31, 32, 34, 36, 43, 45, 51]. These studies described how women and their partners appreciated health professionals taking time to validate and empathise with their loss [5, 25, 26, 32, 45]. 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 [5, 6, 20, 24,25,26, 31, 32, 34, 36, 43, 45].

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 [34, 45]. 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 [5, 6, 20, 25,26,27, 29, 32,33,34, 36, 42, 43, 45]. 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” [36].

Seven other studies pointed out that women considered the emotional support received as a fundamental aspect of their hospital journey [5, 20, 25, 29, 36, 44, 45]. 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 [6, 48]. 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” [48].

Sub-theme 1B: provision of information

Ten studies reported lack of information throughout the course of miscarriage [25,26,27, 29, 34, 35, 42, 43, 45, 47]. Health professionals were perceived as being deliberately vague and unclear when providing information and this ambiguity affected women’s emotional status [23, 24, 29, 35, 48]. 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 [43]. For example, the following quote from a study conducted in the USA is a typical of comment made: “So it was just frustrating because it was like they were telling me the baby’s okay, then it’s not, then it’s okay, then it’s not. So it’s like a rollercoaster ride” [26]. Two studies explained that health professionals were deliberately withholding information about women’s miscarriage when communicating with women [26, 45].

Five studies reported that women left hospitals still unsure about whether they experienced a miscarriage [23, 32, 45, 46, 48]. This quote from a study based in the UK described an example of unclear communication around miscarriage “There was no baby. I only know because I looked it up. If I hadn’t looked it up I wouldn’t understand what the hell was going on; didn’t’ have a clue. That was not a good experience” [32]. 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, 35, 42, 43, 45,46,47]. 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, 35].

Sub-theme 1C: terminology

Eight studies highlighted an important issue about the use of insensitive terminology and lack of lay terms used by health professionals [5, 22, 23, 25, 28, 35, 43, 47]. 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 included “termination or abortion pills” or the word “miscarriage” when referring to late pregnancy loss and these increased women’s emotional distress [22, 28]. This quote from an Australian study reported how a man found the term “miscarriage” distressing when referring to the loss of his baby who was over 20th weeks, “because she hadn’t reached 24th week, it wasn’t’ legitimate” [25].

Theme 2: effect of time

Sub-theme 2A: time waiting for diagnosis, procedures and 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 [6, 20, 24,25,26,27, 29, 32, 33, 36, 42, 43, 45, 47, 48]. 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 report feeling as if they were forgotten and not a priority [47, 48]. 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?” [43] Many women pointed out how waiting long hours in hospital to receive a diagnosis of miscarriage increased their anxiety [26, 48]. Further, one study noted that the longer women had to wait, the more their partners’ anger and anxiety grew and, often, this was directed towards staff members [45].

Sub-theme 2B: time to absorb the news of miscarriage

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 [6, 36, 44].

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, 42, 43, 47]. 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, 42, 43, 48]. 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, 44]. 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, 45, 46]. These quotes, from a woman and a man respectively, are representative of a shared experience among parents 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”; “Going out to the toilet and there was pregnant women sitting right outside your door...you could have some kind of separate part … because that was literally the hardest thing” [48].

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, 37,38,39,40]. Four studies targeted women [23, 37,38,39], one both parents [40] 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, 37, 39]. 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 [38]. A summary of the intervention findings can be found in Table 3.

Table 3 Summary of interventions
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Discussion

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, 49, 52]. Being exposed to perinatal loss on a daily basis might lead HPs to view this issue as primarily medical [6, 50]. However, this review highlighted a discrepancy in perceptions of the emotional implications of miscarriage between parents and HPs, with the latter often underestimating the impact that pregnancy loss may have on women [10, 53, 54]. Parents expressed the importance of acknowledging miscarriage as a significant loss [55] and recognising both the emotional and physical implications of it [56]. Further, our review highlighted that men’s needs also need to be considered by health professionals while attending hospital with their partners as they can often feel excluded [36, 45]. These findings are in line with other systematic reviews conducted on the experience of parents’ hospital journeys [12, 57]. Four of the six 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, 37, 39, 40]. 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 [8].

Further, bereavement care guidelines emphasise the significance of communicating clearly and sensitively with women after pregnancy loss [55, 58]. Different protocols to communicate bad news stress the importance of health professionals preparing themselves before delivering difficult news by planning and providing patients with a private environment [57,58,59,60]. Further, simulation training for medical staff on how to deliver news of pregnancy loss has demonstrated a positive impact on parents, reducing psychological morbidities following miscarriage [21, 61]. However, studies in our review highlighted that both women and men are not always satisfied with how information is delivered [38, 48, 51, 62,63,64,65]. It has been reported that providing sufficient levels of information could reduce the distress associated with miscarriage [39, 62, 63]. 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 ‘fetus’ can be perceived by women as negatively impacting their emotional wellbeing [28].

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 for 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 [46, 66]. Therefore, HPs should assess a parent’s level of understanding when delivering a diagnosis of miscarriage and ensure that enough time is provided to assimilate the news before moving on to making a shared decision about their care [67].

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 [12]. Our findings highlight how important it is for women to have access to private toilets, particularly when experiencing miscarriage. 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 in hospitals and beyond 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 and beyond. 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 in compassionate care for HPs, in consultation with the wider community of organisations who might provide them with such, as well as considered guidelines for practice, are also 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 same sex couples their perspectives on how they should be supported by health professionals during their partner’s miscarriage.

Strengths and limitations

To 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 2009 were included in the review and this might have resulted in the exclusion of some relevant studies.

Conclusions

The development of parent’s emotional distress and adjustment post-miscarriage is likely to be influenced by the emotional support provided by HPs as well as their hospital culture. None of the papers highlighted that women nor men were not emotionally distressed. This could be attributed to the fact that the main the focus of the papers was the experience of miscarriage per se and not the psychological implications of it. 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.