Service evaluation of an early pregnancy loss support clinic in an inner London early pregnancy unit

Abstract

Background

Early pregnancy loss (EPL) can have profound implications for physical and psychological health. In the UK, significant variation in service provision exists for women affected by EPL. There is very little guidance on what hospital-based follow-up support services should entail, and how these can be implemented and integrated into current care provision to meet the needs of women who experience EPL. This service evaluation (SE) reports on an Early Pregnancy Loss Support Clinic (EPLSC) in an inner-city Hospital Trust.

Methods

This SE gathered both quantitative and qualitative feedback from women to assess the value of a locally implemented Early Pregnancy Loss Support Clinic (EPLSC). Quantitative feedback was collected using the Short Assessment of Patient Satisfaction (SAPS) questionnaire and the Visual Anxiety Scale (VAS-A), both administered to women attending the EPLSC. Qualitative feedback was collected through semi-structured interviews and focused on four pre-determined themes based on EPL literature - physical health, mental health, role of the bereavement midwife and overall service user experience. Quantitative feedback was summarised using descriptive statistics, while qualitative feedback was analysed using framework analysis.

Results

A total of 127 women were invited to the EPLSC, with 110 (87%) attending, and 17 (13%) not attending their appointment. SAPS scores ranged from 21 to 28, indicating that women were either satisfied or very satisfied with the care they received at the EPLSC. Results from VAS-A scores showed that 76 (69%) women reported a decrease in anxiety immediately after attending the EPLSC, compared to 8 (7%) who reported no change or a small increase in anxiety. Qualitative findings highlighted women’s concerns around future fertility, the importance of emotional support and the value of connecting with the bereavement midwife.

Conclusion

An EPLSC that focuses on providing emotional support and reassurance, particularly regarding future fertility, is important to women. Further rigorous evaluation of national disparities in EPL follow-up is urgently needed to assess the gaps in clinical care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11750-1.

Introduction

Early pregnancy loss (EPL) is defined as a diagnosis of miscarriage or ectopic pregnancy before 14 weeks of gestation [1, 2]. An estimated 1 in 5 pregnancies end in miscarriage, and approximately 1 in 90 pregnancies are diagnosed as an ectopic [3, 4], with ectopic pregnancy being the leading cause of maternal morbidity and unexpected death worldwide [5].

EPL can have profound implications for both physical and psychological health [6–9]. Physical complications following early pregnancy loss may include infection, pain and heavy bleeding [6, 7]. Furthermore, recurrent miscarriage is a sentinel risk marker for obstetric complications in future pregnancies, including preterm birth, fetal growth restriction, placental abruption, and stillbirth [7].

Psychological morbidity is also common after EPL, particularly within the first six months [7, 10]. A significant proportion of women experience psychological sequalae such as depression, anxiety, and Post Traumatic Stress Disorder (PTSD) [7–11]. Qualitative studies have highlighted that many women experience grief and guilt after EPL, with the ‘silence that surrounds miscarriage’ leading to feelings of loneliness and isolation [12, 13]. Anxiety concerning future pregnancies and fertility are also commonplace, the latter especially so for women with surgically managed ectopic pregnancies [14, 15]. Importantly, there are no differences between gestational age at pregnancy loss and adverse psychological outcomes [16].

A review conducted in 2014, on support available for loss during early and late pregnancy, found that of 300 women surveyed, nearly four out of five (79%) received no aftercare [4]. Nearly a decade later, it appears very little has changed. EPL is often unexpected and can be devastating for women and their families [13]. Variations in care, access to treatment options, support networks and follow-up care can significantly impact women’s physical and psychological recovery [7, 12, 13, 17].

A recurring theme in the literature relates to experiences of EPL care [12, 13, 18], and that interactions with healthcare professionals shape experiences of miscarriage and can influence their emotional wellbeing [19, 20]. One Systematic Review reported that women who had experienced EPL valued empathy, sympathy and reassurance provided by healthcare professionals. Effective communication has been cited as crucial in several studies, particularly regarding the provision of knowledge and information [19]. The failure to receive appropriate and timely information relating to EPL led to women feeling disempowered, and experiencing emotions such as loss of control, fear and confusion [20]. Additionally, discussion at the time of miscarriage and support at discharge were identified as important [20].

Sadly, all too often women report feeling like ‘part of a conveyor belt’ system, with their loss inadequately acknowledged by clinical care teams [12, 13]. Additionally, the lack of bereavement care and follow-up support after EPL has been described as unacceptable by women [4, 13, 18]. This paucity has been highlighted in the Pregnancy Loss Review (2023), which recommends that NICE guidance on pre-24-week pregnancy loss should be updated and embedded into clinical care pathways so that all women are offered mental health support, investigation, and consistency in standards of care [21]. Further recommendations include establishing pregnancy-after-loss clinics in hospitals offering maternity care, staffed by specialist gynaecology nurses and/or midwives and led by a consultant [21].

Need for research

In the UK, there is significant variation in service provision for women affected by EPL [3]. Many hospitals lack standardised follow-up EPL care pathways with most services signposting to outside organisations for counselling and support [3]. Although the Miscarriage, Ectopic Pregnancy and Molar Pregnancy Bereavement Care Pathway was developed to guide healthcare professionals in reducing variability in care provision for families following EPL [22], there is still no widely accepted pathway or consensus on how follow-up care should be integrated and delivered into current care provision. Therefore, while the delivery of EPL care is considered important, it has not been rigorously evaluated [21] and the lack of standardisation highlights the ongoing need for further improvement in this area.

This service evaluation (SE) gathered both quantitative and qualitative service user feedback to assess the value of a locally implemented Early Pregnancy Loss Support Clinic (EPLSC).

Service evaluation

In this hospital, women presenting with pain and bleeding in early pregnancy are cared for in the Early Pregnancy Unit (EPU), a dedicated unit staffed by specialist nurses, sonographers and consultant gynaecologists specialising in early pregnancy care. The EPU provides women access to investigations, such as urine pregnancy tests, blood tests (including, amongst others, serum hCG and progesterone), as well as transvaginal ultrasound. The unit protocols are aligned with national protocols and guidelines (such as RCOG and NICE guidance), ensuring that women with early pregnancy complications are offered expectant, medical and surgical management options. Once an early pregnancy complication has been identified, women continue to receive care within the unit, with specialist input as required, and are given direct access to the unit should they need it. Typically, three weeks after an EPL, women are followed-up via telephone to confirm a negative urine pregnancy test. During this telephone call, women were offered an additional appointment to attend the EPLSC for a face-to-face follow-up three weeks later.

This SE aimed to evaluate women’s experiences of attending an EPLSC for follow-up care after a miscarriage or ectopic pregnancy. Feedback was used to identify areas for improvement locally [23].

Initiated and led by a consultant specialising in early pregnancy care, this project took place over one year, from February 2023 to February 2024 and involved the evaluation of a newly implemented EPLSC in an inner-city Hospital Trust. Evaluation tools included a service user feedback questionnaire, anxiety scoring and semi-structured interviews to explore the experiences of women attending the EPLSC.

Specific areas of focus included physical health, mental health, the role of the bereavement midwife and overall service user experience.

Key project objectives-.

• quantify the number of women who attended the EPLSC between February 2023 to February 2024.

• identify the sociodemographic characteristics of women accessing the EPLSC, as well as the type of EPL (miscarriage, ectopic, PUL).

• assess the number of post miscarriage/ectopic complications diagnosed through the EPLSC.

• explore whether the EPLSC increases overall service-user satisfaction with follow-up EPL care.

• determine if mental health issues relating to EPL are identified during the EPLSC consultation.

• evaluate the role of the bereavement midwife in relation to EPL care.

Authorisation process

Authorisation and approval for the project was sought from the Clinical Leadership Team and registered with the Business Unit Governance Team.

A service evaluation is undertaken to benefit those who use a particular service and is designed and conducted to define or judge current service provision [24, 25]. Our participants were those who used the EPLSC with no change to the standard service being delivered (e.g. no randomisation of service users into different groups). Therefore, ethical approval was not required [23–25] (see further supplementary material for HQIP Ethical Principles Checklist).

Handling of data complied with the requirements of the Data Protection Act 2018 with regards to the collection, storage and processing and disclosure of personal information. All women who took part in the SE to provide feedback received information about the project and verbal or written informed consent was given by all women.

Methods

The NHS Evaluation Toolkit was used as a framework to conduct this service evaluation. The framework followed the evaluation cycle of. ‘Identify and understand, Assess, Plan, Do, Review and act’. The NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board (BNSSG ICB) Clinical Effectiveness Team Short Checklist was used to plan and develop this SE [26].

All women attending the EPLSC were approached by the clinical care team to give feedback. Service users were asked to complete the Short Assessment of Patient Satisfaction (SAPS) questionnaire [27] and the Visual Anxiety Scale (VAS-A) [28]. The VAS-A was completed upon arrival at the EPLSC and repeated at the end of the consultation, along with the SAPS questionnaire. Scores from the SAPS and VAS-A were securely stored on an anonymised Excel spreadsheet, along with baseline data collected from Electronic Patient Records. Initially, the response rate for the SAPS questionnaire was low due to issues with accessing the QR code. To address this, paper copies were provided, which resulted in improved response rates.

The clinical care team also invited women to offer more in-depth feedback via an interview. Five women participated in semi-structured interviews which were conducted either online or face-to-face. The interview Topic Guide consisted of four pre-determined themes based on EPL literature [1, 2, 6–8] - physical health, mental health, role of the bereavement midwife and overall service user experience.

Due to the sensitive nature of the topic, a bereavement midwife telephoned the women 24 hours after interview to check on psychological wellbeing.

Analysis

Quantitative feedback was summarised using descriptive statistics and qualitative feedback was analysed deductively using Framework analysis. The Framework method is generated towards policy and practice orientated findings and commonly used for the thematic analysis of semi-structured interview transcripts [29, 30].

Interview feedback was analysed from the four pre-defined themes and followed five steps of data management: familiarisation, constructing an initial thematic framework, indexing, and sorting, reviewing data extracts and data summary and display, followed by interpretation [30, 31]. Findings were discussed among the project team at each stage of analysis and there were several iterations of this process before the final categories were developed and agreed by all authors.

Findings

Quantitative

A total of 127 women were offered an appointment to attend the EPLSC as part of follow-up care between February 2023 and February 2024. Of these, 110 (87%) attended, and 17 (13%) did not. Table 1 summarises the characteristics of the women who attended the EPLSC.

Table 1.

Characteristics of women who attended the EPLSC

Characteristics of Women who Attended the EPLSC	N = 110 (%)
Age (years)
< 35	48 (44%)
> 35	62 (56%)
Ethnicity
Black (British, Caribbean, African)	7 (6%)
Asian (British, South, Indian, Other)	19 (17%)
White (British, Other)	48 (44%)
Mixed (White & Black Caribbean, White & Black African)	4 (4%)
Any Other Group (Other/ not Stated)	32 (29%)
Previous Pregnancy Losses < 14 weeks
0	54 (49%)
1	23 (21%)
2	16 (15%)
3	6 (5%)
4 or more	11 (10%)
Type of Loss
Miscarriage	71 (65%)
Ectopic	39 (35%)
Management Miscarriage
Surgical	26 (37%)
Medical	12 (17%)
Expectant	33 (46%)
Management Ectopic
Surgical	27 (70%)
Medical	6 (15%)
Expectant	6 (15%)
Post EPL Complications
> 3 miscarriages	5 (5%)
Gynae issues (fibroids, adenomyosis, endometrial polyps)	40 (36%)
Cesarean scar niche	4 (4%)
Mental health (anxiety, struggling with emotions)	7 (6%)
Other (high hCG levels, medical issues)	8 (7%)
No complications	46 (42%)

The Short Assessment of Patient Satisfaction (SAPS) questionnaire was completed by 56 (51%) women who attended the EPLSC. Scores ranged between 21 and 28, indicating that women were either satisfied or very satisfied with the care they received at the EPLSC.

The Visual Anxiety Scale (VAS-A) was completed by 84 women (76%) before and after their EPLSC appointment. Of the women who completed the VAS-A, 76 (69%) reported a decrease in anxiety at the end of their EPLSC appointment, compared to 8 (7%) who reported no change or a small increase in anxiety.

Figure 1 shows the overall VAS-A scores for women pre (319.9) and post (151) EPLSC attendance, highlighting a 47% decrease in anxiety scores immediately after their appointment.

Fig. 1.

Pre and post VAS-A scores

Qualitative

Five women who attended the EPLSC consented to be interviewed, two face-to-face, and three via Microsoft Teams. Three women experienced miscarriage between 11 and 13 weeks of pregnancy, while two had experienced ectopic pregnancy.

Three key categories pertaining to women’s experiences of attending the EPLSC were identified as fundamentally important-.

1. Future Fertility.

2. Emotional Support.

3. Bereavement Midwife.

Physical health & future fertility

Physical health concerns such as recovery following EPL, recurring miscarriage/ectopic pregnancy and future fertility were commonplace among the five women interviewed. However, the EPLSC helped to ameliorate some of these worries through discussions about future fertility and the offer of an ultrasound scan (USS). All women who attended the EPLSC were offered USS with only 5% declining-.

‘I felt very reassured about that [fertility] because before the [EPLSC] appointment I was worried about it taking years to get pregnant again (003)’. [Ectopic].

‘It [ultrasound scan] was very helpful for two reasons a) confirmation of what’s happened, and b) you also get reassurance that your body is bouncing back, things are as they should be (002)’ [Ectopic].

‘This [menstrual] cycle in particular was a lot more delayed than I’m used to which caused me to worry a little bit but having that checked and told that everything looked fine, has helped put my mind at rest (001)’ [Miscarriage].

Some women discussed how a lack of involvement from their GP, receiving conflicting information and uncertainty about when their IVF referral would occur created further anxiety-.

‘Receiving contradictory information from the GP on what you need to do before your referral can be sent off-it would really help knowing what the next steps are (002)’ [Ectopic].

Mental health & emotional support

The emotional burden of EPL was described as particularly challenging. Variations in mood were linked to different timepoints in the EPL journey. Women reported feeling shocked, scared, and anxious at the time of diagnosis, while feelings of grief, trauma and isolation were common in the weeks that followed-.

‘I always felt quite matter of fact [about EPL] but I was off work for a month in the end, just because it felt very difficult (003)’ [Ectopic].

One woman reported her feelings of grief being partly attributed to changes in her body following a salpingectomy-.

‘The grief from that [salpingectomy]… I think actually hit later on. Then I started processing everything and not just the pregnancy loss but the change in my body (002)’ [Ectopic].

The EPLSC was valued as a safe space for women to discuss their emotions and receive acknowledgement of their loss-.

‘It was the first time I was asked how I was feeling and the first time that I thought anybody cared about my miscarriage (004)’ [Miscarriage].

‘I think with an early miscarriage, people don’t talk about it very much and no one knew you were pregnant really, because you weren’t showing. So, I don’t think I would have had a clue where to turn [if it wasn’t for the EPLSC] (005)’ [Miscarriage].

Bereavement midwife

The role of the Bereavement Midwife (BM) in EPL care was considered significant, particularly as an easily accessible point of contact, and as a source of support for future pregnancy concerns-.

‘I do feel like in the future, if I had any worries or concerns, I would probably be more likely to get in touch with her [BM], rather than going to the GP or anybody else because I think I’ll be taken a little bit more seriously (001)’ [Miscarriage].

One woman expressed that earlier contact with the BM may have been helpful during the initial weeks following EPL-.

‘I think I was given her [BM] details at the four-week follow-up rather than at discharge, but that’s the time [immediately after EPL] that most people would be off work recovering and sitting with their thoughts (002)’ [Ectopic].

Improvement suggestions

Suggestions for improvement from the women interviewed included providing more information on fertility care pathways, strengthening links with primary care services, and signposting to appropriate external resources-.

‘It would be really helpful knowing what next steps are [fertility] and given more information on the process, because that’s one of the most frustrating things I’ve had to deal with since’ (002) [Ectopic].

Discussing the risks and benefits of signposting women to EPL online resources was considered important, as one woman highlighted that some platforms can be counterproductive and induce anxiety-.

‘One of the things that was recommended was the Ectopic Pregnancy Trust website, but the forums and the messages that were there may have been counterproductive because, when people are vocal about things and they post things on forums and stuff, it’s almost always worse case scenarios, and experiences rather than support (002)’ [Ectopic].

Offering women options for accessing the EPLSC, such as online or face-to-face appointments, depending on their preference, was also deemed important-.

‘I went to the clinic in person, and I was happy to go in person, but it might be an idea to offer it online if it’s not already. Because people experience miscarriages in different ways, and I was fine to go in and I had the support (004)’ [Miscarriage].

Evaluation discussion

This SE assessed the quality of a local EPLSC within one London Trust. Evaluative feedback was gathered to capture women’s perspectives on the service. The key components of the EPLSC were aligned with recommendations from the recent Pregnancy Loss Review (2023), focusing on physical health, mental health and support provided by the bereavement midwife [19].

The characteristics of women attending the clinic included age, ethnicity, previous pregnancy loss, type of loss and management, and post EPL complications. Approximately 56% of women were over the age of 35, 49% were experiencing their first EPL and around 56% identified as non-White or belonging to Any Other Group. This is concurrent with existing literature that highlights the increased risk of miscarriage among women from ethnic minority backgrounds, particularly Black women, who experience a 43% higher risk of miscarriage compared to their White counterparts [32, 33].

Among the 110 women who attended, 36% (n = 40) were confirmed to have a gynaecological condition during their EPLSC consultation. Confirmation of gynae pathology in the EPLSC can help focus the consultation on pertinent issues that may affect fertility, ensuring that appropriate referral pathways are initiated in a timely manner. Additionally, offering women an USS as part of EPL care is a safe, minimally invasive and relatively quick to perform option, for confirming conditions such as endometriosis, fibroids, and other abnormalities of the uterus [34, 35].

Psychological sequalae, including post-traumatic stress, anxiety and depression, are common following EPL [36]. Standardising follow-up care for EPL may be important for supporting women emotionally and reducing the mental health burden associated with this event. In this evaluation, 69% of women reported a decrease in anxiety after attending the EPLSC, while 6% disclosed ongoing struggles with mental health. Early identification of mental health difficulties in women following EPL allows for appropriate signposting and timely psychological interventions to provide emotional support. However, further research is required to fully understand the mental health needs of women following-EPL.

The role of the bereavement midwife was considered important by women, particularly as an easily accessible point of contact for emotional and practical support, both during and after EPL, and as a resource in subsequent pregnancies. This is especially pertinent, as interactions with healthcare professionals are known to influence emotional wellbeing following EPL. Therefore, the quality of support provided during this time, may contribute to improved mental health outcomes for women who have experienced EPL. However, a recurring concern raised by women was the perceived lack of involvement from their GP. Therefore, involving primary care services may be a crucial next step in developing integrated clinical care pathways, given that navigating current EPL pathways can be challenging and confusing for women.

Follow-up care for EPL should be standardised at the point of offer, while being individualised at the point of delivery to ensure that all women receive the care most appropriate to their specific needs [37]. This approach can be facilitated by providing women with choices during their follow-up appointments, such as transvaginal ultrasounds, fertility discussions, or mental health support. Collaborating closely with women, actively listening to their concerns, and addressing their emotional needs through an EPLSC might be an effective way of improving the quality of EPL follow-up care.

Recommendations

Key findings from this SE highlight the importance of EPL follow-care. Recommendations for improvements, and considerations for the implementation of an EPLSC, include-.

• Provide information about EPL care at the time of loss, including scheduling of EPLSC follow-up and contact details for the bereavement midwife.

• Offer a follow-up EPLSC appointment 3 weeks after the first negative pregnancy test.

• Offer ultrasound to all women to detect possible complications following post EPL or undiagnosed gynaecological conditions.

• Offer information regarding future fertility and next steps (if applicable).

• Develop services that incorporate pathways for mental health referrals/support and GP involvement.

• Signpost to appropriate external agencies or/and online resources for additional information and support.

• Consider the needs of local population groups to develop culturally sensitive EPL services.

• Offer EPLSC appointments either face-to-face or online, depending on the women’s preference.

Conclusion

An EPLSC which prioritises emotional support and reassurance, particularly regarding future fertility, is highly valued by women. There is an urgent need for a rigorous evaluation of national disparities in EPL follow-up care to identify gaps in clinical service provision. Such evaluations are essential for developing and implementing standardised care pathways that address both the physical and mental health needs of women following EPL.

Abbreviations

EPU

Early Pregnancy Unit

EPL

Early Pregnancy Loss

SE

Service Evaluation

EPLSC

Early Pregnancy Loss Support Clinic

SAPS

Short Assessment of Patient Satisfaction

VAS-A

Visual Anxiety Scale

PTSD

Post Traumatic Stress Disorder

UK

United Kingdom

NICE

National Institute for Health & Care Excellence

QR Code

Quick Response Code

USS

Ultrasound Scan

GP

General Practitioner

Authors’ contributions

MA-Contribution to the design of service evaluation, qualitative data collection and analysis, and authorship. GG-Contribution to the design of the service evaluation and quantitative data collection and analysis. TA-Contribution to the quantitative data collection.EK-Contribution to the design of the service evaluation.MM-Substantial contribution to the conception and design of the service evaluation, and approved the submitted version, previous and modified versions of this paper. All authors contributed to the interpretation of findings and reviewed previous drafts and approved current version.

Funding

No funding received for this service evaluation.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Authorisation and approval for the project was sought from the Clinical Leadership Team and registered with the Business Unit Governance Team. Ethical approval was not required since participants are those who use the service and were therefore involved to help evaluate the service provided.

Consent for publication

NA.

Competing interests

The authors declare no competing interests.