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

Abstract

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.

INTRODUCTION

Up to 1 in 4 known pregnancies ends in miscarriage. Miscarriage is defined as an unintended loss or interruption of pregnancy up to the 20th week of pregnancy in the United States and Australia ¹ or 24th week of pregnancy in the United Kingdom. ² Miscarriage is distinct from stillbirth, which refers to an intrauterine fetal death after this gestational age. The annual prevalence of miscarriage is approximately 147,000 in Australia, ³ 750,000 to 1,000,000 in the United States, ⁴ and 200,000 in the United Kingdom. ²

Despite the high frequency of such loss, there is still considerable stigma around miscarriage. ⁵ Women are often not expected to disclose they are pregnant until after the first trimester because of fear of early pregnancy loss. ⁶ As such, friends and family are often not aware of the pregnancy during the early stages. Furthermore, the emotional impact of miscarriage is frequently underestimated, and it can be difficult for women and partners to find acknowledgment from friends, family, or health care providers (HCPs). ⁶ Importantly, research has shown that women frequently experience significant psychological distress, trauma, and grief as a result of miscarriage, which can last weeks, months, or even years. ⁷ , ⁸ , ⁹ Clinically significant depression, anxiety, and posttraumatic stress disorder are also not uncommon. ¹⁰

QUICK POINTS

• ✦Many women and partners report dissatisfaction with emotional care during their experience of miscarriage.
• ✦Women and partners who experience miscarriage identify both similar and different needs, most (but not all) of which are also identified by health care providers.
• ✦To improve the experience of bereaved parents and their health care providers, areas for future research include the evaluation of intervention strategies, setting‐specific needs, joint consideration of different roles, differences in care needs, and predictors of emotional impact.

Over the past 30 years, there has been a substantial increase in research exploring the psychological impact of miscarriage. In 1996, Lee and Slade ¹¹ identified that in addition to the traumatic aspects of the miscarriage itself, there was a general disappointment among women with many aspects of their care. Issues such as long wait times, insufficient information, a lack of acknowledgment of the loss, and absent psychological care were reported. ¹¹

Dissatisfaction with care in the initial stages of treatment is an important finding because the quality of he care, emotional support, and interactions with HCPs can positively or negatively influence the experience of miscarriage. ¹² , ¹³ , ¹⁴ , ¹⁵ Evidence has shown that women and their partners who report satisfaction with their care following miscarriage are less likely to experience depression, anxiety, and perinatal grief. ¹⁶ , ¹⁷

Despite a rapidly growing body of scientific research over the past 2 decades, women and their partners continue to report disappointment with the care they received. Recent systematic reviews reported that both bereaved women ¹⁸ and their partners ¹⁹ felt their miscarriage was not treated as significant, their emotional pain was often not acknowledged, and information and communication weproblematic, with long waiting times exacerbating the traumatic nature of the event. Furthermore, HCPs themselves reported a lack of confidence, ²⁰ , ²¹ knowledge, ²⁰ , ²² and training ²³ , ²⁴ , ²⁵ when providing emotional care to women and partners who experience miscarriage.

The primary aim of this integrative review was to provide a synthesis of miscarriage care world literature from the last 7 years (2015‐2022), integrating the individual perspectives of (1) the woman experiencing the miscarriage, (2) the partner, and (3) the different HCP roles involved in the care. Subsequently, 5 key areas of future research were identified to improve the provision of emotional care around miscarriage.

METHODS

Literature searches were conducted across EBSCOhost Research Databases that included PubMed, CINAHL Plus, MEDLINE, PsycINFO, Scopus, and JSTOR, as well as Google Scholar. The following search terms were used: early pregnancy loss, miscarriage, and perinatal loss, in combination with one or more of the following terms: mental health, emotional well‐being, grief, psychological impact, needs, women, men, lesbian, gay, LGBT/LGBTQ, gender diverse/diversity, healthcare professional, nurses, midwives, obstetricians, private hospital, emergency department. Search terms were chosen to cover literature from a wide range of fields of research. The search was then supplemented by reference tracking from the initial articles. The final search was conducted on February 8, 2022.

This review was limited to articles that were published in English within international scientific peer‐reviewed journals between 2015 and 2022. Both empirical and review articles were included. Review articles published during this period that cited primary sources from before 2015 were included, consistent with recommendations for integrative reviews. ²⁶

The inclusion criterium was that studies covered the experiences around miscarriage care of any combination of 3 groups: women, partners, and HCPs. Articles using either quantitative or qualitive methods were included. Study titles and abstracts were first screened, and if the article was ineligible based on title or abstract, it was discarded. Otherwise, the full text was reviewed, and eligibility was reassessed. All researchers were involved in this process. Any uncertainty was discussed until consensus was reached.

For each of the 3 groups, articles covering the corresponding perspective were examined by 2 independent researchers. Themes identified by the 2 researchers were then compared and organized into main themes and subthemes. Any differences were resolved by adjudication by a third researcher.

The authors recognize that a person who physically experiences pregnancy loss may have a gender identity other than female. For clarity in this review, the term woman is used when referring to the individual who physically experienced the miscarriage. The term partner is used when referring to the significant other and is intended to include all self‐identified genders.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses Statement was followed in reporting this review (Figure 1). ²⁷ A total of 60 articles met the inclusion criteria, comprising 17 from the United States, 13 from Australia, 12 from Europe (United Kingdom, Ireland, Denmark, Turkey, Spain, France, Sweden, Belgium), 6 from Canada, 1 study with data from both Sweden and the United States, and 11 international review articles.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta‐Analyses Flow Diagram.

The majority of studies (n = 35) used qualitative methodology, with semistructured interviewing as the most common method. There were 9 quantitative studies and 4 that incorporated mixed methods. The remaining articles comprised one priority‐setting partnership and 11 review articles. Please see Supplementary Table 1 for a detailed summary of this literature. Themes and subthemes identified for each of the 3 perspectives (women, partners, and HCPs) are depicted in Figure 2.

Figure 2.

Themes and Subthemes Identified in This Review of Recent Literature Covering Emotional Care Around Miscarriage, from the Perspective of Women, Partners, and Health Care Providers.

Themes of women and partners covered each group's own needs (indicated in blue and green, respectively). For HCPs, one theme covered the needs of HCPs themselves (orange), and 2 further themes (yellow) covered HCPs’ perspectives about quality care (components and constraints).

Abbreviation: HCP(s), health care provider(s)

Experiences of Women

A total of 37 articles covered the perspectives of women who experienced miscarriage. Two main themes were identified: (1) a need for more information and (2) a need for acknowledgment through empathic treatment.

Need for More Information

Some women found the information provided about causes, symptoms, and frequency of miscarriage to be inadequate in helping them navigate through the unfamiliar and sudden circumstance of miscarriage. ¹⁸ , ²⁵ , ²⁸ , ²⁹ , ³⁰ , ³¹ Some reported seeking out further information regarding causes, symptoms, and frequency of miscarriage to better understand their situation. ¹⁴ , ²⁵ , ³² , ³³ , ³⁴ Others reported needing information about what to expect throughout the miscarriage process, and needing to understand treatment and management options and the associated risks. ¹⁴ , ²⁵ , ³⁵ , ³⁶ Many believed this would provide a sense of control and self‐determination ¹⁵ , ²⁹ , ³⁷ , ³⁸ and that having more information about the causes of the miscarriage would alleviate some of the guilt experienced. ¹⁵ , ²⁹ , ³⁶ , ³⁷ , ³⁸ , ³⁹

Women also reported desiring information about their physical recovery and possible complications, ²⁵ , ²⁹ , ³³ , ⁴⁰ as well as the emotional journey ahead, including the grieving process and emotions derived from self‐blame. ¹² , ¹³ , ¹⁴ , ¹⁸ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³³ , ³⁴ , ⁴¹ They reported seeking additional information through helplines, websites, online forums, support groups, grief counselors, and psychological services. ¹² , ¹³ , ¹⁴ , ¹⁸ , ²⁹ , ³⁴ , ⁴⁰ , ⁴² Many also indicated wanting to know when they could expect their menstruation to resume, ³³ when it would be safe to attempt another pregnancy, and the risks of miscarriage occurring again. ¹⁴ , ¹⁵ , ²⁹ , ³³ , ³⁵ , ³⁸ , ³⁹ , ⁴¹

Some women reported that their experience of care was strongly affected by how they received information. Information that provided clear, immediate, and reliable answers that were easy to understand and relevant for partners and families was preferred. ¹² , ¹⁴ , ¹⁸ , ²⁸ , ²⁹ , ³³ , ³⁴ , ³⁹ , ⁴⁰ , ⁴³ , ⁴⁴ Women appreciated when HCPs gave a clear diagnosis ²⁸ , ⁴⁰ , ⁴¹ and checked for understanding when explaining medical processes. ⁴⁵ Information that was not overly clinical or medicalized ¹² , ²⁸ , ³⁴ and presented in a way that was not overly “bright” or “melancholy” ^{34 , p.121} was preferred. It was also considered important that information and advice regarding prognosis, follow‐up procedures and implications for future pregnancies was consistent across the care team. ¹² , ²⁵ , ²⁹ , ³⁰ , ³³ , ³⁸ , ³⁹ , ⁴⁰ , ⁴⁵ , ⁴⁶

Finally, women expressed limitations in their capacity to process and retain verbal information because of their emotional state, especially for complex medical terminology and processes. ³³ , ⁴⁴ , ⁴⁵ They indicated that it would be helpful to receive supporting written information, including a list of resources or health care services to contact if needed, so they would be able to process the information when ready. ³³ , ³⁹ , ⁴⁰ , ⁴⁶ , ⁴⁷

Need for Acknowledgment Through Empathic Treatment

Women rated care favorably when they felt that HCPs treated them as individuals experiencing something meaningful and distressing, acknowledging both the emotional and physical components of the loss. ¹² , ¹³ , ¹⁵ , ²⁵ , ²⁸ , ³⁰ , ³¹ , ³³ , ³⁶ , ⁴⁰ , ⁴¹ , ⁴⁵ Women reported they were not looking for specialized counseling skills, but rather that HCPs were just present, actively listening to their experience, and taking the time to identify their feelings and needs. ¹² , ³⁰ , ³³ , ⁴¹ , ⁴⁴ , ⁴⁵ This offered a sense of validation for their thoughts and feelings. ⁴⁵ Many women further reported empathic communication with their HCPs to be paramount in effective care. ¹² , ²⁸ , ³⁰ , ⁴⁰ , ⁴¹ , ⁴⁵ Compassion was recognized through eye contact, open body language, tender toneof voice, and use of supportive touch. ¹⁸ , ⁴⁵ Many women reported being sensitive to comments and behavior that diminished the emotional impact of their loss, including the specific language used to describe their experience. This included referring to their lost child as “tissue,” “clots,” “failed conception,” “products of conception,” “missed abortion,” “reproductive wastage,” or “dead fetus” ¹² , ¹⁴ , ⁴⁵ and comments such as “it was just a miscarriage,“ or ”you can just have another baby.” ¹³ , ¹⁴ , ²⁵ , ²⁸ , ⁴⁰ , ⁴⁵ , ⁴⁸

Women reported feeling acknowledgment in the hospital when they and their partners were placed in environments that provided privacy to process their situation. ¹² , ¹⁸ , ³³ , ³⁶ , ⁴⁰ , ⁴⁹ Specifically, women appreciated when HCPs recognized that physical proximity to pregnant women or newborns could amplify their feeling of loss. ¹² , ¹⁴ In general, women reported appreciating reduced wait time as an acknowledgment of their bereavement, ¹⁴ , ¹⁵ , ¹⁸ , ⁴⁰ , ⁴¹ especially in emergency departments (EDs). ³³ , ⁴⁰ Follow‐up appointments addressing emotional and practical needs also provided acknowledgment for the significance of the loss. ¹² , ¹⁴ , ²⁵ , ³⁰ , ³³ , ⁴⁰ , ⁴² , ⁴³

Many women reported valuing care that was individualized and sensitive to their choices and needs. ¹² , ¹³ , ¹⁴ , ²⁵ , ³⁰ , ³¹ , ³³ , ⁴⁰ , ⁴¹ , ⁴² Some reported desiring support and follow‐up options tailored to the cultural and spiritual needs of their family. ²⁵ Cultural differences in grief and the perception of motherhood and perinatal loss ⁵⁰ influenced the individual needs of women and partners. ⁵¹ Women from diverse racial and ethnic groups also reported different ways of coping with loss. ⁵¹ Furthermore, both heterosexual and LGBTQ (lesbian, gay, bisexual, transgender or queer)  couples with histories of infertility or pregnancy loss reported that the experience of grief associated with pregnancy loss was amplified by the additional processes, practices, and time required to achieve pregnancy, as well as the emotional and material investment made in the anticipation of parenthood. ¹¹ , ⁵²

Some women reported memorials as a potentially powerful way to validate their loss, and identified such experiences as significant in helping them cope. ¹⁴ Remembrance services were often sought out by families who had experienced miscarriage. ³⁴ , ³⁶ The opportunity to create meaning for the loss resolved some of the ambiguity associated with miscarriage, helping women come to terms with their lost identity as a parent‐to‐be of this child. ³⁴

Experiences of Partners

Twenty‐one articles were included that explored the experiences of miscarriage in partners. The majority of these studies included and described exclusively male partners, with 2 studies investigating partners in LGBTQ relationships. Two main themes relevant to partners were identified: (1) a need for more information and (2) a need for recognition.

Need for More Information

Some male partners reported seeking biological explanations, clear facts, and statistics to rationalize and cope with the distress associated with the loss. Partners valued statistics more than women seemed to need this specific information. ²⁵ , ³⁶ , ⁴⁹ , ⁵³ Partners often reported feeling helpless while observing the loss, which may explain some partners’ increased need to understand the process and etiology of the loss. ⁴⁹ , ⁵⁴ Several indicated that they preferred answers to be “hard, fast, and short” ⁴⁴ , ⁴⁹ and that it was appreciated when additional resources were accessible on mobile devices to maintain privacy from others. ²⁵ , ⁴⁹ Some also reported wanting to know where to obtain information about how to support their partners, as well as themselves. ⁵⁴ , ⁵⁵

Need for Recognition

Some partners reported that being the partner, rather than the person physically experiencing the miscarriage, contributed to making them feel that they should not experience or communicate their emotions. ²⁵ , ⁵³ , ⁵⁵ They expressed that as partners, they needed to be recognized as also experiencing a significant loss. ⁴⁹ Compassionate and sensitive care from HCPs, such as expressions of personal warmth, empathy for bereavement, and access to follow‐up, helped partners cope with their own grief. ²⁵ , ³³ , ³⁶ , ⁴⁹ , ⁵⁵ , ⁵⁶ It was also reported that memorial items, services, or rituals validated their loss as a partner. ³⁶ , ⁴⁹

Many partners additionally reported significant tension, stress, apprehension, and internal conflict from needing to reconcile being both a grieving parent and a supportive partner. ²⁵ , ⁴⁹ , ⁵⁷ , ⁵⁸ Some reported needing emotional support to negotiate fear, frustration, and disappointment caused by the loss ⁵³ and a need to share experiences with others who could relate to the internal conflict of balancing roles. ⁴⁹ , ⁵⁷ Several male partners particularly valued activities that allowed fathers to support and connect with those who had similar experiences. ³⁶ , ⁵⁹

Some partners indicated that the perceived expectation that they suppress their feelings to support their partner left them feeling isolated in their grief. ⁴⁹ , ⁵⁹ , ⁶⁰ Although some male partners reported that they found retreating into perceived gender roles helpful in distracting from grief, other male partners reported that gender role expectations made it difficult to grieve when confronted with a miscarriage ⁵⁶ , ⁵⁷ , ⁶¹ and prevented them from seeking and accessing support. ⁵³ It was therefore particularly helpful when HCPs specifically included them in hospital care and support, instead of implicitly expecting them to take on the role of support for the woman. ⁵⁹ , ⁶⁰ As such, hospital practices that actively provided validation from HCPs and minimized the disenfranchisement of (male) partners’ grief were reported to be appreciated. ⁵⁵

Experiences of HCPs

Twenty articles examining the perspective of HCPs involved in the provision of care for women and partners who experience miscarriage were analyzed. The majority were nurses and midwives (90%), with obstetricians and general practitioners composing only 6% and 3%, respectively. Three main themes were identified: (1) a need for additional training, (2) components of quality care, and (3) barriers and limitations to providing that care.

Need for Additional Training

In a number of studies, HCPs reported feeling insecure and unprepared when providing emotional care because of a lack of training. ²² , ⁶² Many reported that the focus of their training was on physical management ²¹ and that the provision of emotional care had to be learned through experience. ²¹ , ²³ , ²⁴ For example, in one study, only 6% of registered nurses indicated feeling adequately prepared to provide support to parents experiencing a miscarriage. ⁶³ In another study, 88.6% of surveyed midwives wanted extra training on the subject, and 72.4% believed they had insufficient knowledge to provide effective support. ²⁰ Some HCPs indicated that they felt they lacked communication skills and bereavement counseling techniques ²⁴ , ²⁵ and that they did not know what to say and when to say it, or what information to provide to patients. ²⁰ , ³³ They reported that their perceived inadequacy and lack of clinical experience in emotional miscarriage support translated to a personal sense of incompetence. ²⁰

Some HCPs also reported a lack of knowledge or formal training on culture‐specific needs ²⁴ and that cultural barriers sometimes prevented them from providing appropriate care to women and families with different ethnicities. ⁶³ For example, HCPs working within Asian communities noted that perinatal death was considered taboo as a topic for discussion, and perinatal death was seen as a failure. ⁵⁰ As a result, they struggled to broach the topic with bereaved families. Likewise in Australia, some HCPs reported feeling unable to provide adequate education for certain populations, such as women from remote Aboriginal communities. ²⁵

Components of Quality Care

Many HCPs emphasized the importance of providing emotional support to women and their families as part of care. ²⁰ , ⁶² , ⁶³ , ⁶⁴ Specifically, HCPs reported this involved simply being present and taking time to listen and discuss. ²² , ³³ , ⁶² , ⁶⁵ In general, HCPs believed they should adjust their care according to individual needs. ¹⁵ , ²⁴ , ⁴⁴ , ⁵⁹ , ⁶⁴ Some HCPs mentioned that being empathetic and engaging with parents’ individual needs and experiences helped them develop an emotional connection ⁶⁰ and recommended following the family's lead, not making assumptions, and giving the family opportunities to reconsider and change their decisions. ⁴⁴ Some HCPs specifically reported that it was important to understand and include partners as individuals with unique styles of grieving. ⁶⁰

Many also considered the provision of information in written form to be paramount. ²⁰ , ²³ , ²⁵ , ³³ , ⁶³ They believed that written information would help educate women and their families ²⁵ and provide comprehensive information on the physical and medical management of the miscarriage, as well as psychological symptoms ²⁰ such as possible depression and grief. ⁶³ Some HCPs reported that written information helped them circumvent time constraints, because important information could be provided and read at a later time. ²³ , ⁴⁴ Written information also helped direct patients to other available resources, such as online support networks and discussion groups. ²³ , ³³

Finally, HCPs emphasized the importance of follow‐up care. In several studies, HCPs believed that follow‐up care should be offered to all women and their families, ⁶³ as either a telephone or outpatient appointment. ³³ It was noted that in many cases, follow‐up care was currently lacking, particularly in public hospitals. ²¹

Perceived Barriers and Limitations to Providing Quality Care

Several HCPs described struggling to be emotionally present when caring for women and their families, because of compassion fatigue or for self‐protection. ²¹ , ⁶² , ⁶⁵ They reported that they struggled at times to handle patients’ emotional reactions such as anxiety, sadness, grief, and fear. ²³ , ²⁴ , ⁶⁵ Some believed staying professional by compartmentalizing the grief and remaining task‐focused was helpful. They also identified the specific challenge of moving between attending births on labor and delivery and caring for bereaved families back to back. Having to switch between experiences and displays of joy and grief was described as emotionally draining. ²² , ²³ , ⁶²

HCPs frequently highlighted staffing deficits ²³ and a lack of time as a barrier to building rapport with women and their families and providing adequate psychosocial support, ²⁰ , ²¹ , ⁶⁴ especially in ED settings. ⁶² Some midwives reported feeling that they overloaded their patients with information and, because of time constraints, were ultimately unable to provide the continuity of care they felt was crucial. ⁴⁴

Furthermore, HCPs felt that privacy and sensitivity around physical space was important for women and partners experiencing miscarriages, ³³ , ⁶⁴ noting that space constraints, especially in the ED, sometimes prevented them from meeting the privacy needs of grieving families. ²⁵ They also indicated that providing miscarriage treatment alongside other maternal services ²³ , ³³ or in proximity to other pregnant women ⁶³ could not always be avoided.

Several HCPs highlighted that policies or relevant guidelines around miscarriage care were unavailable ³³ , ⁶³ or were perceived as prioritizing cost‐efficiency, rather than emotional aspects of care. ²² Without standard procedures or guidance for miscarriage care available, some HCPs reported relying on prior personal experience, which they believed resulted in care that was inconsistent across staff. ²⁰ Others highlighted a structural lack of professional counseling and debriefing opportunities for staff involved in providing bereavement support. ²⁴ , ⁴⁴ , ⁶⁴

DISCUSSION

Based on the available scientific literature, considerable overlap exists in the needs identified by bereaved parents and their HCPs (Figure 3). There is also general agreement regarding the barriers to providing effective care, such as the constraints imposed by time, space, and other hospital resources. In addition, in several themes, the self‐reported needs of women or partners did not align with the components of quality care identified by HCPs. For example, bereaved parents asked for additional information, which was not a need identified by HCPs. Likewise, bereaved parents identified memorial services as a potential way to acknowledge their loss, whereas HCPs did not.

Figure 3.

Joint and Disjoint Needs for the Provision of Quality Emotional Care Around Miscarriage, as well as Barriers to Meeting Those Needs, from the Perspectives of Women, Partners, and Health Care Providers

Abbreviation: HCP(s), health care provider(s)

Given the broad consensus on the needs of women and partners who experience miscarriage, the question arises why these bereaved parents continue to report dissatisfaction with emotional care. ¹⁴ , ¹⁸ The reviewed literature suggests that what might be missing is not the identification of needs, but a systematic investigation and evaluation of how those needs can best be met. This distinction was not often made explicit. For example, interventions that might seem intuitive, such as HCPs offering statistics to normalize the loss, could result in feelings of marginalization of the loss for some women. Evidence evaluating such interventions is limited, which supports the need for additional research aimed at quantifying specific outcomes of these strategies.

Limitations

There are a number of limitations to this review. First, none of the included studies differentiated the specific type of miscarriage (eg, spontaneous vs discovery of a nonviable pregnancy at antenatal appointment) or the management approach (expectant, medical, or surgical). Studies also differed widely in the recency of participants’ miscarriage experience, ranging from a few weeks ¹² , ⁶⁶ to many years. ¹⁴ , ³⁴ , ⁴⁶ Because the setting and management approach dictate time and space constraints, as well as the HCP roles involved in care, it is therefore unknown to what degree the needs identified here are specific or generalizable to each type of miscarriage or management approach.

Furthermore, there is a potential for bias in the reviewed literature, as a result of both sampling bias and selection bias. Bereaved parents who were especially dissatisfied with the care they received might conceivably be more likely to volunteer to participate in studies investigating satisfaction with care than bereaved parents who were satisfied, potentially resulting in an overrepresentation of dissatisfied participants. In addition, reported dissatisfaction with care in a given hospital or setting might itself be a motivator for research: there is likely to be more incentive to investigate the needs of patients in a hospital or department where patient satisfaction is low rather than where it is high. This too would result in an overrepresentation of dissatisfied participants in the literature.

Implications for Practice and Research

The themes identified in this review suggest 5 promising areas for future research. First, there is a significant lack of research on the effectiveness of interventions and guidelines designed to improve the emotional care of women and partners experiencing miscarriage. ²¹ Only 3 intervention studies in the past 7 years met the inclusion criteria of this review, and although they report promising results, each had important limitations. Johnson and Langford designed a one‐hour bereavement program for women experiencing miscarriage in an obstetric emergency center in the United States. Results indicated the intervention was successful in reducing women's grief at 2 weeks post‐loss. ⁶⁶ Doherty et al investigated the impact of a one‐day bereavement care workshop for student midwives in Ireland. ³² Participants reported an increase in confidence providing bereavement care 3 months postworkshop. The absence of a control group, however, makes it difficult to exclude the possibility that the increase in confidence may have been a result of ongoing training. The final intervention study investigated the effect of an intervention designed to help nurses provide individualized care to pregnant women in Turkey who had previously experienced pregnancy loss. ¹⁶ This care approach was highly effective in reducing the anxiety and depression among pregnant women, and increased their attachment to the current pregnancy. Women who have recently experienced miscarriage and are not currently pregnant, however, would not have the continued contact with nursing staff necessary to implement this care approach. Although these intervention studies are promising, more research is needed to determine the efficacy of interventions aimed at meeting specific needs. Furthermore, additional research is necessary to determine how the well‐being, confidence, and expertise of HCPs translates to bereaved parents’ satisfaction with care and subsequent emotional well‐being.

Second, the majority of scientific studies investigating miscarriage have done so in the context of the ED. The specific hospital setting dictates procedural limitations, such as time constraints in the ED or a lack of privacy away from other pregnant women on a labor and birth unit. The specific care location will also correlate with the timing of the diagnosis, any preceding symptoms (such as cramping or blood loss), the level of urgency around management, and possible preexisting care relationships with the HCPs involved. Because the needs of women, partners, and HCPs differ by hospital and practice setting, the predominance of literature based on the ED portrays an incomplete picture of needs and care. ³⁰ , ³³ , ⁴⁰ Given the joint needs identified in this review around time, space, and privacy, understanding the experiences of women, partners, and HCPs in specific settings is essential. Further research specifically considering the needs of bereaved parents and HCPs in different settings is therefore necessary to develop role‐ and setting‐specific interventions.

Third, both women and HCPs identified the importance of consistency among HCPs across the care team. However, miscarriage care involves a complex interaction between women, partners, and multiple HCP roles. The majority of studies in this review considered either the parents’ ¹⁸ , ¹⁹ , ⁵³ , ⁵⁶ , ⁵⁸ or the HCPs’ view ²² , ⁵⁰ separately, with few studies considering all parties concurrently in the same setting. ²⁵ , ³³ , ⁴⁴ Furthermore, studies in this review primarily described the experiences of nurses and midwives. Acknowledging the specific care practices and experiences of other HCP roles (eg, sonographers and generalist or specialty physicians) might uncover specific challenges these groups face around emotional care. In many healthcare systems, for example, sonographers interact with patients without formally providing a diagnosis, creating the unique dilemma of what and how much to say when a nonviable pregnancy is detected. ⁶⁷ To ensure consistency of care, it would therefore be valuable for future studies to include the perspectives of the multiple different HCP roles that bereaved partners interact with during their hospital experience.

Fourth, a clear gap exists in the available literature exploring the miscarriage care experiences of individuals from different social, cultural, ethnic, and socioeconomic groups and those who identify as LGBTQ. Most studies have focused solely on the experiences of heterosexual English‐speaking families with high incomes. ¹⁹ , ⁴⁰ , ⁵³ However, the experiences of low‐income families might be compounded by limited access to educational resources and health care. ⁶⁸ LGBTQ parents might similarly face specific challenges during their pregnancy and miscarriage journey, creating unique care needs. The 6 studies that included mixed ethnicities in their samples did not discuss the implications of cultural or ethnic backgrounds in depth. ¹⁵ , ²⁸ , ³⁷ , ⁴¹ , ⁴⁵ , ⁶⁹ This highlights a need for research exploring the miscarriage care experiences and needs of families from diverse groups.

Finally, a clear joint need evident in the literature was the importance of providing emotional care for women and partners that is tailored to the individual. Given the significant psychological distress, trauma, and grief that can result from miscarriage, ⁷⁰ and the prevalence of subsequent clinically significant depression, anxiety, and posttraumatic stress disorder, it seems particularly important to identify the factors that determine the emotional impact of miscarriage. Although gestational age is commonly thought to predict the emotional impact of miscarriage, evidence is mixed, with scientific consensus that postmiscarriage grief is independent of gestational age ⁷¹ for both women ⁷² , ⁷³ and partners. ¹⁹ , ⁵⁵

Importantly, The perceived quality of medical care and interactions with HCPs in the initial stages of miscarriage treatment have been reported as vital in shaping women's ongoing health outcomes, ¹² , ¹³ and satisfaction with care following miscarriage may reduce consequent symptoms of depression, anxiety, ¹⁶ and perinatal grief. ¹⁷ Satisfaction with care therefore might constitute a predictor for psychological outcomes following miscarriage. However, further research is necessary to quantify this relationship and investigate other potential predictors, such as reproductive history, availability of a social support network, previous mental health challenges, and social and cultural factors. Having a better understanding of the factors that contribute to or predict the emotional impact of miscarriage would not only allow HCPs to better tailor care but also help identify which women and partners are most at risk of developing later mental health problems and would therefore benefit most from additional bereavement care.

CONCLUSION

Overall, there is consensus in the literature that miscarriage can be associated with significant emotional impact for bereaved parents, and satisfaction with care around miscarriage may have short‐ and long‐term consequences for women's and partners’ emotional well‐being. This review examined 7 years of scientific miscarriage literature (2015‐2022), integrating the individual perspectives of women, partners, and HCPs. Based on themes in this literature, 5 areas of future research priority were identified. These 5 areas have the greatest potential to further improve the emotional care for women and partners facing this significant form of bereavement, as well as support and empower the different HCPs who provide that care.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Supporting information

Table S1. Overview of Reviewed Studies