Australian heterosexual women’s experiences of healthcare provision following a pregnancy loss

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care services: a scoping review

OBJECTIVE

The objective of this scoping review was to investigate and describe what is reported on the role and scope of practice of midwives and registered nurses providing care for women with pregnancy complications under 20 weeks' gestation in acute clinical settings in Australia.

INTRODUCTION

In many high-income countries, women experiencing unexpected complications in early pregnancy attend an acute care service, such as an emergency department, rather than a maternity or obstetric unit. This service structure can impact the care women receive, and determine who provides it. Women and their partners, who are often experiencing emotional distress, have reported difficult experiences when accessing acute services, particularly emergency departments, which are not traditionally staffed by midwives. The role and scope of practice of both midwives and registered nurses providing acute early pregnancy care in most high-income countries, including Australia, is poorly reported. Documenting this area of practice is an important first step in facilitating ongoing research in this important aspect of pregnancy care.

INCLUSION CRITERIA

Published and gray literature that described the role and scope of practice of midwives and/or registered nurses providing care in acute early pregnancy settings in Australia were considered for this review.

METHODS

A scoping review of the literature was conducted following JBI methodological guidance and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist. A 3-step search strategy was conducted to explore evidence from databases and search engines, gray literature sources, and selected reference lists. After screening, data were extracted from records selected for the final review, mapped, and analyzed using content analysis.

RESULTS

The evidence reviewed (n=23) included primary research studies, conference abstracts, and gray literature, such as clinical guidance documents, academic theses, and websites from January 2008 to October 2023. The most common setting for care provision was the emergency department. Midwives' and registered nurses' roles and scope of practice in acute early pregnancy care in Australia can be summarized into 4 areas: physical care, psychosocial support, care co-ordination, and communication. Women's access to midwifery care at this time in pregnancy appears to be limited. Registered nurses, usually employed in emergency departments, have the most prominent role and scope in the provision of care for women with acute early pregnancy complications. Descriptions of midwives' practice focuses more on psychosocial support and follow-up care, particularly in early pregnancy assessment service models.

CONCLUSIONS

This review highlights the inconsistency in midwives' and registered nurses' roles and scope in acute early pregnancy in Australia, a finding which is relevant to other international settings. Both professions could further fulfill role and scope capacity in the provision of supportive, individualized, and timely care for women and families accessing a range of acute early pregnancy services. Emergency departments are the usual practice domain of registered nurses who may be limited in terms of the scope of care they can provide to women with early pregnancy complications. Leaders of the midwifery profession should conduct further research into innovative service models that embed a role for midwives in all settings that provide care for pregnant women, regardless of gestation.

REVIEW REGISTRATION

Open Science Framework osf.io/7zchu.

Parents' experiences and need for social support after pregnancy termination for fetal anomaly: a qualitative study in China

OBJECTIVE

The aim of this study was to explore the experiences and need for social support of Chinese parents after termination of pregnancy for fetal anomalies.

DESIGN

A qualitative study using semistructured, in-depth interviews combined with observations. Data were analysed by Claizzi's phenomenological procedure.

SETTING

A large, tertiary obstetrics and gynaecology hospital in China.

PARTICIPANTS

Using purposive sampling approach, we interviewed 12 couples and three additional women (whose spouses were not present).

RESULTS

Four themes were identified from the experiences of parents: the shock of facing reality, concerns surrounding termination of pregnancy, the embarrassment of the two-child policy and the urgent need for social support.

CONCLUSION

Parents experienced complicated and intense emotional reactions, had concerns surrounding the termination of pregnancy and an urgent need for social support. Paternal psychological reactions were often neglected by healthcare providers and the fathers, themselves. These findings suggest that both mothers and fathers should receive appropriate support from family, medical staff and peers to promote their physical and psychological rehabilitation.

Pregnancy loss following miscarriage and termination of pregnancy for medical reasons during the COVID-19 pandemic: a thematic analysis of women's experiences of healthcare on the island of Ireland

BACKGROUND

Losing a baby during pregnancy can be a devastating experience for expectant parents. Many report dedicated, compassionate healthcare provision as a facilitator of positive mental health outcomes, however, healthcare services have been severely impacted during the COVID-19 pandemic.

AIM

To explore women's experiences of healthcare service provision for miscarriage and termination of pregnancy for medical reasons (TFMR) on the island of Ireland during the COVID-19 pandemic.

METHODS

Findings combine data from elements of two separate studies. Study 1 used a mixed methods approach with women who experienced miscarriage and attended a hospital in Northern Ireland. Study 2 was qualitative and examined experiences of TFMR in Northern Ireland and Ireland. Data analysed for this paper includes open-ended responses from 145 women to one survey question from Study 1, and semi-structured interview data with 12 women from Study 2. Data were analysed separately using Thematic Analysis and combined for presentation in this paper.

RESULTS

Combined analysis of results indicated three themes, (1) Lonely and anxiety-provoking experiences; (2) Waiting for inadequate healthcare; and (3) The comfort of compassionate healthcare professionals.

CONCLUSIONS

Women's experiences of healthcare provision were negatively impacted by COVID-19, with the exclusion of their partner in hospital, and delayed services highlighted as particularly distressing. Limited in-person interactions with health professionals appeared to compound difficulties. The lived experience of service users will be helpful in developing policies, guidelines, and training that balance both the need to minimise the risk of infection spread, with the emotional, psychological, and physical needs and wishes of parents. Further research is needed to explore the long-term impact of pregnancy loss during a pandemic on both parents and health professionals delivering care.

'An extra level of kind of torment': Views and experiences of recurrent miscarriage care during the initial phases of COVID-19 in Ireland-A qualitative interview study

INTRODUCTION

Maternity services underwent much change during the COVID-19 pandemic. Research on the impact on miscarriage care and experiences during this time is sparse. Within a national evaluation of recurrent miscarriage care, we qualitatively explored stakeholder views and experiences of recurrent miscarriage services in Ireland. This study describes the impact of the COVID-19 pandemic on those experiences and perceptions of care.

METHODS

People with professional and lived experience of recurrent miscarriage and service engagement were actively involved in this qualitative study from idea generation to analysis and reporting. We recruited women and men with two or more consecutive first-trimester miscarriages, and people involved in the management/delivery of recurrent miscarriage services and supports. We used purposive sampling to ensure that perspectives across disciplinary or lived experience, geographical, and health service administrative areas, were included. We conducted semi-structured interviews, virtually all due to COVID-19 restrictions, between June 2020 and February 2021. These were audio-recorded, and data were transcribed, and subsequently analyzed using reflexive thematic analysis.

RESULTS

We interviewed 42 service providers and 13 women and 7 men with experience of recurrent miscarriage. We actively generated two central themes during data analysis. The first-'Disconnected'-describes how many women navigated miscarriage diagnosis and management and care in subsequent pregnancies alone; many felt that this resulted in increased trauma. At the same time, men struggled with not being present to support their partners and described feeling disconnected. The second theme highlighted 'The perceived dispensability of recurrent miscarriage services and supports'. Some service providers felt that service reduction and redeployment demonstrated a lack of value in the service. Virtual clinics facilitated access to services, but a preference for in-person care was highlighted.

CONCLUSION

Our analysis provides rich insights into the significant impacts that the COVID-19 pandemic has had on the way recurrent miscarriage care is provided and experienced, with important implications for early pregnancy, miscarriage and recurrent miscarriage care. Services have undergone significant changes and, while these may be temporary, how services should be delivered in the future requires consideration, particularly given the deficits in care and care experiences highlighted prepandemic.

PATIENT OR PUBLIC CONTRIBUTION

Members of the multidisciplinary RE:CURRENT Project Research Advisory Group (including four parent advocates, two of whom are co-authors on this article) were actively involved throughout the study, including the generation of topic guides and the refining of themes.

Factors that shape recurrent miscarriage care experiences: findings from a national survey

BACKGROUND

Learning what matters to women/couples with recurrent miscarriage (RM) is essential to inform service improvement efforts and future RM care practices. Previous national and international surveys have examined inpatient stays, maternity care, and care experiences around pregnancy loss, but there is little focus on RM care. We aimed to explore the experiences of women and men who have received RM care and identify patient-centred care items linked to overall RM care experience.

METHODS

Between September and November 2021, we invited people who had experienced two or more consecutive first trimester miscarriages and received care for RM in Ireland in the ten-year period prior to participate in a cross-sectional web-based national survey. The survey was purposefully designed and administered via Qualtrics. It included questions on sociodemographics, pregnancy and pregnancy loss history, investigation and treatment for RM, overall RM care experience, and patient-centred care items at various stages of the RM care pathway such as respect for patients' preferences, information and support, the environment, and involvement of partners/family. We analysed data using Stata.

RESULTS

We included 139 participants (97% women, n = 135) in our analysis. Of the 135 women, 79% were aged 35-44 years (n = 106), 24% rated their overall RM care experience as poor (n = 32), 36% said the care they received was much worse than expected (n = 48), and 60% stated health care professionals in different places did not work well together (n = 81). Women were more likely to rate a good care experience if they had a healthcare professional to talk to about their worries/fears for RM investigations (RRR 6.11 [95% CI: 1.41-26.41]), received a treatment plan (n = 70) (RRR 3.71 [95% CI: 1.28-10.71]), and received answers they could understand in a subsequent pregnancy (n = 97) (RRR 8 [95% CI: 0.95-67.13]).

CONCLUSIONS

While overall experience of RM care was poor, we identified areas that could potentially improve people's RM care experiences - which have international relevance - such as information provision, supportive care, communication between healthcare professionals and people with RM, and care coordination between healthcare professionals across care settings.

"Death is a sensitive topic when you are surrounded by life": Nurses experiences with pregnancy loss

OBJECTIVE

Although there is increasing evidence on the psychosocial adjustment and experiencing pregnancy loss from the patient's perspective, few studies have investigated the nurses' experience perceptions. This study aimed to understand the experience of nurses involved in pregnancy loss care based on the self-fulfillment model of communication.

METHODS

A qualitative approach was developed through semi-structured interviews to 16 nurses working in an Obstetrics and Maternal-Fetal Department of a local hospital. Based on grounded theory approach, data was analyzed with NVivo 12 software.

RESULTS

The analysis revealed three major themes and 11 sub-themes: i) stressful work conditions, comprising care management and institutional practices; ii) personal characteristics, including discomfort with loss, communication skills, work experience and empathy; and iii) the patient's journey, containing the partner's ambiguous role, timing, respect for the patient's individuality, viewing the fetus and facilitating grief rituals.

CONCLUSION

Nurses daily involved in providing care to patients suffering pregnancy loses have a demanding challenge in trying to assure that patients get the appropriate and better care and ensuring they keep their level of engagement in their profession. Interventions to improve communications skills with patients and with other health professionals are needed to enhance professional realization.

Fatal fetal anomaly: Experiences of women and their partners

OBJECTIVE

This study explored the care experiences of parents whose pregnancy was diagnosed with a fatal fetal anomaly following the legalisation of termination of pregnancy in 2019 in Ireland.

METHODS

A qualitative study using in-depth semi-structured interviews and interpretative phenomenological analysis was undertaken. Purposeful sampling was used to recruit 10 parents, six women and four of their male partners. Parents recruited included those who terminated and continued the pregnancy.

RESULTS

Three superordinate themes were identified: 'Attachment and coping', 'There's no place for you in the pregnancy world' and 'Consistency of quality care'. Parents shared the different approaches and level of attachment to their baby that supported their coping. Regardless of the level of attachment, many parents benefited from the acts of remembrance. Parents expressed how they no longer felt they belonged in the 'pregnancy world' and described a need for healthcare professionals to recognise their loss and create a safe and supportive environment in which they could share their grief. Despite this, parents' accounts highlighted variations and inconsistencies in care and service provision.

CONCLUSION

Our study highlighted parents' need for consistent, well communicated, and comprehensive care, which encourages an individualised perinatal palliative care approach to meet parental needs.

Toward Optimal Emotional Care During the Experience of Miscarriage: An Integrative Review of the Perspectives of Women, Partners, and Health Care Providers

INTRODUCTION

Miscarriage is frequently associated with significant emotional impact, causing psychological distress, trauma, and grief. Unfortunately, women and partners frequently report dissatisfaction with care around miscarriage, and health care providers report feeling ill-prepared and underequipped to provide emotional support. This integrative review synthesizes the individual perspectives of the woman experiencing the miscarriage, the partner, and the different health care provider roles involved in the care to better understand what future research is necessary to improve the experiences of bereaved parents and their health care providers.

METHODS

Electronic databases were searched for studies that covered emotional care around miscarriage from the perspective of women, partners, or health care providers. The review included studies published in English between 2015 and 2022, using either quantitative or qualitative methods. Thematic analysis was carried out, and conclusions from these articles were integrated into themes and subthemes.

RESULTS

A total of 60 studies met the inclusion criteria. Two main themes were identified for women: (1) a need for more information and (2) a need for acknowledgment of their loss. Two main themes were likewise identified for partners: (1) a need for more information and (2) a need for recognition. Three main themes were identified for health care providers: (1) a need for additional training, (2) components of quality care, and (3) perceived barriers to providing care.

DISCUSSION

There is broad overlap in the needs identified by bereaved parents and their health care providers, as well as general agreement regarding the barriers to providing effective care. Five areas of future research priority were identified to understand how best to meet these needs: empirical evaluation of strategies to meet identified needs, investigation of setting-specific needs, integrated consideration of all relevant roles, investigation of the care needs of diverse groups, and an investigation of the predictors of emotional impact.

Early Pregnancy Assessment Services in Australia: What psychosocial support is available? A qualitative study

PROBLEM

Women commonly experience emotional distress following miscarriage but do not receive the support they need from healthcare providers.

BACKGROUND

Miscarriage can result in psychological morbidity; however, appropriate support at the time of a miscarriage can lead to better psychological outcomes. Early Pregnancy Assessment Services (EPASs) are dedicated outpatient services considered the "gold standard" for miscarriage care. Little is known about the psychosocial support EPASs provide in Australia.

AIMS

The aim of this study was to explore the provision of psychosocial support in Australian EPASs.

METHODS

Semi-structured interviews were conducted with 29 purposively sampled key-informants from 13 EPASs. Interviews were audio-recorded, transcribed, and thematically analysed.

FINDINGS

Considerable variation was found in how EPASs functioned and their provision of psychosocial support. Many services were co-located with antenatal services, run by doctors with limited experience and most did not offer any psychosocial training to staff specific to EPAS. Referrals for additional support were generally not offered for first trimester miscarriages, and follow-up typically focused on physical management rather than emotional wellbeing. All EPAS staff demonstrated a strong commitment to providing best possible care to women within their own clinical setting and acknowledged the need for improved psychosocial support.

CONCLUSION

This study provides the first exploration of Australian EPASs' provision of psychosocial support. It has shown that while health care professionals working in EPASs are dedicated to providing the best possible care to women within their clinical setting, psychosocial support is very limited and could be improved.

Women's experiences of health care utilization in cases of early pregnancy loss: A scoping review

BACKGROUND

Approximately 25% of pregnancies end in miscarriage, most occurring within the first trimester (<13 weeks). For many women early pregnancy loss has implications for short- and long- term mental health, and women's well-being following early pregnancy loss is impacted by their experiences within the healthcare setting. To improve quality of care, it is crucial to understand women's' experiences within the healthcare system in cases of early pregnancy loss.

QUESTIONS

What does the research literature tell us about the experiences of early pregnancy loss within healthcare settings? Are these experiences positive or negative? 'How can care improve for those experiencing early pregnancy loss?'

METHODS

A scoping review of the research literature was undertaken. Three research databases were searched for relevant articles published in English since 2009, with key words related to 'Experience', 'Healthcare' and 'Early Pregnancy Loss'. A thematic analysis was undertaken to identify and summarize key findings emerging from the research literature.

FINDINGS

Twenty-seven (27) articles met our inclusion criteria. Three main themes were identified: (1) issues related to communication, (2) challenges within care environments, and (3) inadequacies in aftercare.

DISCUSSION

The literature suggests that women's experiences related to healthcare for early pregnancy loss are largely negative, particularly within emergency departments. Recommendations to improve women's experiences should extend beyond attempts to improve existing care structures, to include emerging environments and providers.

CONCLUSION

Women's experiences identified within the literature provide further insights on what women are seeking from their care, and how care models can be improved.

Men, trans/masculine, and non-binary people's experiences of pregnancy loss: an international qualitative study

Background

Growing numbers of men, trans/masculine, and non-binary people are becoming gestational parents, yet very little is known about experiences of pregnancy loss among this diverse population.

Methods

The study employed a cross sectional design. Interviews were undertaken with a convenience sample of 51 trans/masculine and non-binary people who had undertaken at least one pregnancy, living in either Australia, the United States, Canada, or the European Union (including the United Kingdom). Participants were recruited by posts on Facebook and Twitter, via researcher networks, and by community members. 16 (31.2%) of the participants had experienced a pregnancy loss and are the focus of this paper. Thematic analysis was used to analyse interview responses given by these 16 participants to a specific question asking about becoming pregnant and a follow up probe question about pregnancy loss.

Results

Thematic analysis of interview responses given by the 16 participants led to the development of 10 themes: (1) pregnancy losses count as children, (2) minimizing pregnancy loss, (3) accounting for causes of pregnancy loss, (4) pregnancy loss as devastating, (5) pregnancy loss as having positive meaning, (6) fears arising from a pregnancy loss, (7) experiences of hospitals enacting inclusion, (8) lack of formal support offered, (9) lack of understanding from family, and (10) importance of friends.

Conclusions

The paper concludes by outlining specific recommendations for clinical practice. These include the importance of focusing on the emotions attached to pregnancy loss, the need for targeted support services for men, trans/masculine, and non-binary people who undertake a pregnancy (including for their partners), and the need for ongoing training for hospital staff so as to ensure the provision of trans-affirming medical care.

The need for improved emotional support: A pilot online survey of Australian women's access to healthcare services and support at the time of miscarriage

PROBLEM

Women need improved emotional support from healthcare professionals following miscarriage.

BACKGROUND

Significant psychological morbidity can result following miscarriage and may be exacerbated by poor support experiences. Women frequently report high levels of dissatisfaction with healthcare support at this time.

AIM

This study was developed to pilot a survey aimed at exploring women's access to healthcare services and support at the time of miscarriage.

METHODS

Women over 18 years, residing in Australia, who had experienced a miscarriage in the past two years completed a 29-item online survey.

FINDINGS

A total of 399 women completed the survey. Two key findings arose: 1) More than half of women (59%) were not offered any information about miscarriage or pregnancy loss support organisations or referral/access to counselling services at the time of miscarriage, despite almost all reporting they would have liked various forms of support from items listed 2) More than half (57%) did not receive follow up care, or emotional support at this time, beyond being asked how they were coping emotionally. Other findings showed 3) Women accessed various healthcare services at the time of miscarriage and 4) Women often saw a general practitioner at the time of miscarriage despite having a private obstetrician.

CONCLUSION

There is clear mismatch between the support women want at the time of miscarriage and the care they receive from healthcare professionals. Despite considerable structural barriers, it seems likely there is scope within healthcare professionals' usual practice for improved support care through simple measures such as increased acknowledgement, information provision and referral to existing support services.

Men's grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model

BACKGROUND

Emotional distress following pregnancy loss and neonatal loss is common, with enduring grief occurring for many parents. However, little is known about men's grief, since the majority of existing literature and subsequent bereavement care guidelines have focused on women. To develop a comprehensive understanding of men's grief, this systematic review sought to summarise and appraise the literature focusing on men's grief following pregnancy loss and neonatal loss.

METHODS

A systematic review was undertaken with searches completed across four databases (PubMed, PsycINFO, Embase, and CINAHL). These were guided by two research questions: 1) what are men's experiences of grief following pregnancy/neonatal loss; and 2) what are the predictors of men's grief following pregnancy/neonatal loss? Eligible articles were qualitative, quantitative or mixed methods empirical studies including primary data on men's grief, published between 1998 and October 2018. Eligibility for loss type included miscarriage or stillbirth (by any definition), termination of pregnancy for nonviable foetal anomaly, and neonatal death up to 28 days after a live birth.

RESULTS

A final sample of 46 articles were identified, including 26 qualitative, 19 quantitative, and one mixed methods paper. Findings indicate that men's grief experiences are highly varied, and current grief measures may not capture all of the complexities of grief for men. Qualitative studies identified that in comparison to women, men may face different challenges including expectations to support female partners, and a lack of social recognition for their grief and subsequent needs. Men may face double-disenfranchised grief in relation to the pregnancy/neonatal loss experience.

CONCLUSION

There is a need to increase the accessibility of support services for men following pregnancy/neonatal loss, and to provide recognition and validation of their experiences of grief. Cohort studies are required among varied groups of bereaved men to confirm grief-predictor relationships, and to refine an emerging socio-ecological model of men's grief.

TRIALS REGISTRATION

PROSPERO registration number: CRD42018103981.

Follistatin-like 3, an activin A binding protein, is involved in early pregnancy loss

BACKGROUND

Early pregnancy loss (EPL), a common and severe complication in pregnancy, has a long-term personal and social impact. It was previously reported that follistatin-like 3(FSTL3), an activin A binding protein, contributes to the invasion and migration of trophoblast. Simultaneously, activin A induces the release of FSTL3 and the elevated activin A is found to be associated with pregnancy loss in women. This study aimed to identify the roles of FSTL3 in the establishment and maintenance of pregnancy, and to determine whether FSTL3 is involved in the pathophysiology of EPL.

METHODS

Endometrial Ishikawa cells and JAR cells were cultured and FSTL3 siRNA was used to silence FSTL3. The trophoblast spheroids mimicking embryos were used in an embryonic adhesion system. The system aimed to investigate the role of FSTL3 silence on embryonic adhesion onto endometrial cell in vitro. The ICR mice model in vivo was used to investigate whether the FSTL3 works in embryonic implantation. The western blotting was used to determine the expression of FSTL3 and activin A.

RESULTS

In the in vitro study, silence of FSTL3 in JAR cells significantly reduced the number of trophoblast spheroids adhered onto Ishikawa cells compared with the scramble siRNA. For the in vivo study, the number of embryos implanted in the uterine horn injected with FATL3 siRNA mixture was significantly less than that in control group. In the case control study, both the expression of FSTL3 and activin A in EPL women were significantly higher than that in controls.

CONCLUSIONS

FSTL3 plays a biological role in the establishment and maintenance of normal pregnancy. Moreover, FSTL3 may be involved in the early pregnancy loss via neutralizing the elevated activin A.

Men's grief and support following pregnancy loss: A qualitative investigation of service providers' perspectives

This study explores service providers' experiences of supporting men following a miscarriage or stillbirth in Australia. In-depth, semi-structured interviews were completed with seven service providers including midwives, grief counselors and social workers. Participants highlighted that, despite the individual nature of men's grief, there is a need to recognize and address the additional expectations and responsibilities that may compound their experience. Within an environment focused on woman-centered care, participants described creative strategies and inclusive language to promote engagement of men. Further research exploring men's grief is needed to inform training and guidelines for healthcare professionals who work with bereaved families.