Workplace supports for early pregnancy loss: A scoping review of international literature

Abstract

Background

Despite the prevalence and impacts of pregnancy loss, there is a lack of statutory or workplace-based supports for workers experiencing pregnancy loss, especially before the point of viability. As reproductive and working ages overlap, workplaces can play a significant role in pregnancy loss experiences.

Objective

The aim of this study is to map the available literature on workplace supports for pregnancy loss before viability.

Methods

We conducted a scoping review following JBI Guidance and a pre-registered protocol. We searched eight academic databases/platforms, grey literature sources, and reference lists for eligible documents (2012–2022).

Results

Following title and abstract screening and full-text review, 48 records were included for analysis: 18 reports, 15 journal articles, 6 guides/codes of practice, 3 theses, 2 book/book chapters, and 4 other narrative records. Secondary research was the most common methodology employed (n = 16) followed by primary research (n = 14). Reports mainly originated from South-East Asia, while all empirical studies took place in high-income, English-speaking countries. Leave from work was the most discussed/important form of workplace support. Helpful organisational measures were also identified.

Conclusions

Our review found a lack of empirical research on workplace supports and experiences of pregnancy loss. Further research is needed to understand experiences and develop and implement appropriate supports.

Introduction

Between one in four and one in five pregnancies end in miscarriage, stillbirth or neonatal death. Impacts–physical, psychological, and economic–can be significant, for individuals who experience pregnancy loss and societies.^1,2 As reproductive years significantly overlap with working years, workplace environments play an important role in experiences of pregnancy loss.

While many countries offer mandatory workplace leave for people who experience the loss of a pregnancy from the point of ‘viability’ (i.e., a stillbirth), similar provisions often do not extend to earlier pregnancy losses, in the form of first and second trimester miscarriage, ectopic pregnancy, molar pregnancy, or termination of pregnancy/abortion. Approximately one in ten women will experience one miscarriage in their lifetime, ² while globally the rate of abortions is 39 per 1000 women aged 15–49 years. ³ Though many first trimester miscarriages resolve without treatment, sometimes medical or surgical management is required to remove fetal tissue, which can result in days of bleeding, pelvic pain, and admission to hospital, amongst other side effects.^2,4,5 Similar is observed for termination of pregnancy given the overlapping medical management strategies.

In recent years, a number of countries have recognised the impacts of such earlier pregnancy losses, and the need for greater supports within the workplace. In 2021, New Zealand introduced three days paid bereavement leave for women and their partners who have experienced a miscarriage, but not a termination of pregnancy. ⁶ Later that year, the Australian Government passed an amendment to the Fair Work Act 2009 which provides for two days of compassionate leave for those experiencing a pregnancy loss under 20 weeks’ gestation. ⁷ Countries such as the Republic of Ireland^8,9 and the United Kingdom ¹⁰ are also exploring such leave provisions.

A scoping review of the scientific literature on the experiences of workers coping with perinatal loss and the resulting bereavement by Meunier and colleagues ¹¹ found qualitative research describing the experiences of returning to work following a perinatal loss, but it primarily included participants experiencing late perinatal loss (20 weeks’ gestation or more). Some studies have since been published which report experiences of miscarriage in the workplace and associated supports.^12–14 These note that support can often be informally received from colleagues and managers, rather than formally provided through the organisation. ¹³ In addition, people report taking leave around the time of miscarriage (a median of seven days reported in an Australian study), with many using paid sick or annual leave for this. ¹³ Barriers to taking leave include inadequate resources, poor support from managers, or stigma; professional consequences; and personal feelings associated with taking leave, such as guilt and shame. ¹² Additional organisational supports can include referral to Employee Assistance Programmes or counselling, and flexible working arrangements. ¹⁴

To inform discussions relating to the types of supports needed within workplaces for people who experience earlier pregnancy loss (i.e., before the point of viability and/or stillbirth, where mandatory leave may be provided), a review of existing literature is warranted, one which adopts a systematic approach to identifying and describing literature that meets the inclusion criteria. Specifically, this review needs to address the following research questions, to examine the scope of the available evidence and any gaps:

1. Which workplace supports (e.g., legislative, policy, psychological, social) are, or should be, available for people who experience pregnancy loss before viability?

2. What are people's experiences of workplace supports for pregnancy loss before viability?

We use the term ‘pregnancy loss before viability’ to be as specific as possible about our area of focus. It is not ideal, and not without critique. ¹⁵ We are particularly interested in pregnancies that end before this period, and which are not classified as ‘stillbirth’. Internationally, definitions of miscarriage, stillbirth and viability vary, by gestational age and/or fetal weight. ² Miscarriage is generally defined as the loss of pregnancy before viability – this can range from 20 to 28 weeks of gestation, depending on geographical region. ¹⁶ For the purpose of this review, a pregnancy loss is defined by any form of pregnancy loss (e.g., miscarriage, termination of pregnancy), before the point at which it would be considered a stillbirth in the country it occurred in. In Ireland, a pregnancy loss is considered a stillbirth at 24 weeks gestation and/or with a fetal weight of 500 grammes or more. ¹⁶

Methods

Protocol and registration

We conducted a scoping review according to a pre-registered protocol ¹⁷ following JBI guidance.^18–21 A scoping review ‘addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field’ [ ²² :1292–1294] and thus was appropriate to address our aim and research questions. We followed the five stages as per this guidance: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarising and reporting the results. We report our scoping review in line with the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines; ²³ see Supplementary File A. This study, as a scoping review of literature, did not require ethical approval.

Knowledge user engagement

This work was conducted as part of the PLACES (Pregnancy Loss in Workplaces: Informing policymakers on support mechanisms) Project which was commissioned and funded by the Department of Children, Equality, Disability, Integration and Youth in the Republic of Ireland. ⁹ Decision-makers from the Department, in addition to people with lived experience, were involved in discussions which informed the conduct and reporting of this scoping review. In addition, members of the research team (KOD, DN) are involved in the care of people–including workers–who experience pregnancy loss. The team engaged in reflexivity throughout the study, individually and during group discussions. This included reflecting on their positionality and assumptions and how they might affect the research process.

Eligibility criteria

Our inclusion and exclusion criteria are detailed in our protocol. ¹⁷ In brief, included documents addressed pregnancy loss before viability in the context of paid employment/work, in terms of experiences and/or supports. The search covered the publication period from 2012 to 2022, given the increasing attention on this issue in recent years. We did not restrict by study design, language or geographical location.

Information sources

We searched the following databases/platforms in December 2022 to identify potentially relevant records: EMBASE (Elsevier), CINAHL Plus with Full Text (EBSCOhost), Business Source Complete (EBSCOhost), MEDLINE (Ovid), SCOPUS (Elsevier), Academic Search Complete (EBSCOhost), ProQuest Dissertations and Theses (Clarivate), PsycINFO (APA), and Web of Science (Clarivate). We also searched for grey literature via Google Scholar and relevant organisational websites encompassing Human Resources/Occupational Health (n = 11), Miscarriage/Early Pregnancy Loss (n = 8) and General (n = 2) (detailed in Protocol ¹⁷ ). Finally, we conducted backward and forward citation searches (via hand searches of citation lists and Google Scholar, respectively) on all included documents.

Search strategy

We developed our search strategy using the PCC (population, concept, and context) framework. ¹⁹ Search terms were informed by previous reviews.^11,24 We developed the search strategy in EMBASE and adapted it for each included information source. We adapted searches for each organisational website, depending on the functionality of the website. Full search strategies for each source are available in Supplementary File B.

Selection of sources of evidence

Identified records were downloaded to Endnote X9 and duplicates automatically identified and removed before being imported into Rayyan software. ²⁵ Two reviewers (RKH and MH) independently screened the titles and abstracts of 25 randomly selected records against the inclusion criteria; 96% agreement was reached and conflicts were resolved through discussion. The remaining titles and abstracts were then screened by the first author, in line with the review protocol. Full texts were subsequently retrieved and independently screened by two reviewers (RKH and MH); conflicts were resolved through discussion with a third reviewer (SL), where necessary.

Data extraction/charting process

Information was extracted and documented from included records in a data extraction table, including specific details about the participants, concept, context, study methods, and key findings relevant to the review questions. Initially two reviewers (RKH and MH) independently extracted data from 10% of included records and met to determine whether approach to data extraction was consistent with the research question and purpose, and captured the data appropriately. One reviewer (RKH) then extracted the remaining data, and these were independently checked by a second reviewer (MH).

Critical appraisal of sources of evidence

In line with guidance on scoping review conduct, we did not appraise the methodological quality or risk of bias of included articles. ¹⁹

Collating, summarising, and reporting the results

For quantitative data, descriptives of concepts, populations, or locations, and other data categories were created and are presented within tables, accompanied by narrative summaries. Selected characteristics of included records are presented in graphs and maps, using Excel. For qualitative results, conventional content analysis ²⁶ was used across studies to identify key characteristics.

Results

We identified 26,013 records following database/platform and website searches. Following title and abstract screening (n = 10,938), and subsequent full text review (n = 95), we included 46 records in our review. We identified a further five records following backward and forward citation searches, two of which were included, resulting in the final inclusion of 48 records. Full details are available in the PRISMA flow diagram in Supplementary File C. Excluded records are detailed in Supplementary File D.

Table 1 provides an overview of the characteristics of included records, by year of publication, country of publication, focus/aim, and methodology, while Table 2 displays the population, concept, and context details of included records.

Table 1.

Characteristics of included records.

Author/Year [Source]	Title	Country/Countries of Origin	Focus/Aim	Methodology
Reports
Addati et al. (2014) 27	Maternity and paternity at work: Law and practice across the world	International	Review national law and practice on both maternity and paternity at work across the world- including leave, benefits, employment protection, health protection, breastfeeding arrangements at work and childcare; statistical coverage in law and in practice of paid maternity leave; as well as statutory provision of paternity, parental and adoption leaves	Secondary research: Analysis of data from ILO Working Conditions Laws Database – Maternity Protection; Review national legislative provisions on maternity protection at work in 185 countries and territories
Bober et al. (2022) 42	Social Dialogue Report 2022: Collective bargaining for an inclusive, sustainable and resilient recovery	International	Analyse collective agreements across sectors and countries which were in force during 2020–2021 and examine their contribution to an inclusive, effective, and sustainable social and economic recovery from the Covid 19 pandemic	Primary and secondary research: Analysis of national legislation (N = 125); gathering data on regulatory coverage of collective agreements (98 countries); examination of 512 collective agreements; in-depth country studies (case studies); interviews with key informants in 21 countries; secondary data
Chung (2021) 43	Reforms of the employment insurance system of the Republic of Korea to cope with the COVID-19 crisis	Korea	Describe the scope and reform of the employment insurance system of the Republic of Korea, including adaptations made to cope with the Covid-19 crisis	Secondary research: Desk research (narrative)
Fuller et al. (2018) 30	Death before birth: Understanding, informing and supporting choices made by people who have experienced miscarriage, termination and still birth	UK	Examine the law surrounding the disposal of the remains of pregnancy and the ways in which it is interpreted, and to examine the narratives of women and those who support them, focusing on metaphor as a commonly-used resource for expressing the inexpressible	Primary research: Qualitative interviews (N = 51): Workers in: bereavement care in NHS hospitals in England, funeral industry, and bereavement charities; women who experienced stillbirth, miscarriage, termination following diagnosis of fetal anomaly; their partners and friends. 4 focus groups: Women who experienced miscarriage and stillbirth; partners of women who experienced stillbirth.
Goulding (2013) 44	Gender dimensions of national employment policies: A 24 country study	International	Review and document the gender dimensions of various national employment policies and strategies	Secondary research: Policy analysis
Infante Villarroel & Tar (2021) 45	Assessment of drivers and constraints for occupational safety and health in the construction global supply chain in Myanmar	Myanmar	Assess occupational safety and health (OSH) drivers and constraints in the construction global supply chain in Myanmar, to help identify potential interventions models that can help address OSH deficits in the sector	Primary and secondary research: Desk research/scoping; value chain analysis (including online consultation; online focus group discussions); workplace observation (interviews with construction site managers, and site visits (n = 11))
ILO (2016) 33	Study on maternity protection insurance in Sri Lanka	Sri Lanka, Singapore, Malaysia, Hong Kong, Japan, Philippines, Thailand, Vietnam	Review maternity protection in Sri Lanka and other countries in the region, and make recommendations for Sri Lanka	Secondary research: Documentary analysis
Maffii et al. (2012) 59	Action-oriented research on gender equality and the working and living conditions of garment factory workers in Cambodia	Cambodia	Increase understanding on gender equality and discrimination in Cambodia's garment industry with a view to improve the economic and social well-being of its mostly female workforce and inform the further development of a responsible corporate model of garment production	Primary and secondary research: Desk research; focus group discussions (N = 90) with owners, managers, workplace union leaders, representatives of the government, employers’ and workers’ organisations; interviews (N = 240) with female and male workers in Cambodia's garment factories
Miller & Suff (2022b) 60	Workplace support for employees experiencing pregnancy or baby loss: Survey report	UK	Explore support in UK workplaces for employees experiencing pregnancy or baby loss	Primary research: Online surveys. (N = 295 employees; N = 2023 senior HR professionals & decision-makers)
Olivier (2018) 27	Social protection for migrant workers in ASEAN: Developments, challenges, and prospects	Southeast Asia	Provide overview of policies & regulations of social protection for migrant workers within ASEAN, with particular reference to certain relevant developments, challenges, and prospects	Secondary research: Documentary analysis
Ramírez López et al. (2021) 46	Adapting social insurance to women's life courses: A gender impact assessment of Viet Nam	Viet Nam	Analysis of the gender dimensions of the social insurance system – focusing on benefits for old-age, survivors, maternity & sickness, regulated by the Social Insurance Law, as amended in 2014	Secondary research: Documentary analysis
Scheil-Adlung (2014) 47	Can productivity in SMEs be increased by investing in workers health? Taking stock of findings on health protection of workers in small and medium-sized enterprises and their impacts on productivity	International	Understand whether, and how, effective social protection policies in small and medium-sized enterprises (SMEs) with between 50 and 250 employees can generate positive outcomes for firms as well as for the broader economy	Secondary research: Literature review
Srivastava (2013) 53	A social protection floor for India	India	Examine the innovations, opportunities, challenges and trends in the area of social protection and recommend measures for progressively extending social protection to all workers in the informal economy, particularly those who are most disadvantaged	Primary and secondary research: Documentary analysis; survey (N = ∼150 informal workers in Delhi, Uttar Pradesh (Allahabad), and Maharashtra (Nanded, Beed, Pandarpur, Pune, Aurangabad)-primarily waste pickers, headloaders and domestic and construction workers)
Tsuruga et al. (2021) 49	Policy design for unemployment benefits in Myanmar: The social security law, 2012, and social security rules, 2014	Myanmar	Illustrate the policy design of unemployment protections in Myanmar	Secondary research: Review of existing legal provisions and information and data from official and primary references
Tsuruga & Moo (2021) 50	Employment termination in Myanmar: Rules and payments on separation	Myanmar	Create knowledge base for advanced studies and policy dialogue on employees’ rights and employers’ liabilities on employment termination	Secondary research: Desk research – Reviewing legal provisions and data from official and primary sources on employment termination rules
Theile et al. (2017) 40	Summary report: Assessment-based national dialogue on social protection Lao People's Democratic Republic	Lao	Assess existing social protection programmes and to develop appropriate recommendations regarding the extension of a social protection floor, providing basic income security for all, especially the poor and vulnerable	Secondary research: Documentary analysis, along with a series of consultative meetings and national dialogue workshops (participatory methods)
Tommy's (2022) 67	Pregnancy and parenting at work survey findings June 2022	UK	Describe experiences of pregnancy and pregnancy/baby loss, and supports, in the workplace	Primary research: Mixed methods survey [432 responses in 2022, 1000 responses in 2021]
UN Women (2021) 41	Country gender equality profile: Viet Nam 2021	Viet Nam	Provide a snapshot of gender equality progress against key socio-economic indicators, and to offer analysis and recommendations for addressing barriers to progress and closing gender gaps	Secondary research: Documentary analysis [Review of reports, legislation, datasets, thematic literature, budgets, and statistical reports. Follow ups with content specialists. Aid from an External Technical Advisory Group]
Journal articles
Behari (2016) 28	Daddy's home: The promotion of paternity leave and family responsibilities in the South African workplace	South Africa	Analyse South African paternity leave and its influence on child-rearing culture	Narrative
Boncori & Smith (2019) 63	I lost my baby today: Embodied writing and learning in organisations	UK	Miscarriage and the sharing of intimate experiences as an example of alternative writing that can be used to challenge and resist dominant masculine discourse in academia [Describes the author's own experience of a very early miscarriage while at a work conference]	Primary research: Multi-voice-autoethnography/Embodied narrative
Breen et al. (2022) 54	Grief literacy: A call to action for compassionate communities	International	Theorise how grief could be better conceptualised and operationalised in society	Narrative [Literature review of grief literacy and development of vignettes]
Castillo-Angeles et al. (2022) 64	Pregnancy during surgical training: Are residency programs truly supporting their trainees?	USA	Describe residency programmes and colleague support of trainees for pregnancy related needs	Primary research: Quantitative survey; (N = 258 female surgical residents and fellows).
Fisk (2022) 29	The complexity and embeddedness of grief at work: A social-ecological model	Canada	Provide an integrated and multi-layered view of the grief and bereavement literature as it relates to work and organizations	Secondary research: Literature review/Narrative
Goonetilleke (2016) 55	Maternity legislation in Sri Lanka: Are women equal, special or different?	Sri Lanka	Study and critically analyse the laws governing maternity benefits in Sri Lanka – including maternity and paternity leave and pay, nursing intervals, job security, health and safety of mother and child, creche facilities	Secondary research: Documentary analysis
Keep et al. (2021) 13	Experiences of Australian women on returning to work after miscarriage	Australia	Examine experiences of women returning to work after early pregnancy loss	Primary research: Quantitative/qualitative survey (N = 607)
Meunier et al. (2021) 11	Workplace experiences of parents coping with perinatal loss: A scoping review	Canada/International	Scope the extent of scientific literature on the experiences of workers coping with perinatal loss	Secondary research: Scoping review
Modgil (2021) 36	Surrogate mothers in Indian maternity benefit law: A blind spot or a blind eye?	India	Focus on the rights of gestational surrogates which have been ignored under Indian law, make a case for extending maternity leave to surrogates and to understand the possible rationale of the Government in having ignored their inclusion in the 2020 code	Narrative
Musodza et al. (2021) 70	Experiences of maternity healthcare professionals returning to work following a personal perinatal loss: A scoping review of the literature	Australia/International	Scope the extent of literature on the experiences of midwives/maternity professionals when they return to work following a personal pregnancy loss/neonatal death	Secondary research: Scoping review
Obst et al. (2022) 14	Australian men's experiences of leave provisions and workplace support following pregnancy loss or neonatal death	Australia	Explore the types of workplace leave offered to men following pregnancy/baby loss, and how men perceive leave and support provided by their employers	Primary research: Quantitative/qualitative survey (N = 220)
Porschitz & Siler (2017) 65	Miscarriage in the workplace: An autoethnography	USA	Describe and analyse miscarriage as it relates to the workplace	Primary research: Autoethnography (N = 2)
Rahayuningsih (2016) 38	Analysis on psychological impacts due to violation of the rights of women workers	Indonesia	Investigate the violations of the labour rights of women, and the psychological impacts these violations have	Primary and secondary research: Collective case study – qualitative interviews; observation; documentary analysis. Involved 16 companies
Rose & Oxlad (2022) 39	LGBTQ + people's experience of workplace leave and support following pregnancy loss	Australia	Explore workplace leave and support experiences following pregnancy losses of LGBTQ + people as gestational or non-gestational parents	Primary research: Qualitative interviews (N = 12)
Watson & Jewell (2018) 71	Journey interrupted: A phenomenological exploration of miscarriage	USA	Investigate the impact of miscarriage on relationships, perceptions of motherhood and the meaning of occupation	Primary research: Qualitative interviews (N = 4)
Guides and Codes of Practice
CIPD (2022a) 61	Workplace support for employees experiencing pregnancy or baby loss: A guide for managers	UK	Guide for managers on developing capabilities in behavioural areas to support their employees	N/A: Guide [Drawing on their previous research of management behaviours and competencies, and pregnancy loss research by Tommy's and Miscarriage Association]
ILO (2013) 98	Practical guidelines for employers for promoting equality and preventing discrimination at work in Indonesia: Equality in company practices	Indonesia	Practical guidelines for employers for promoting equality and preventing discrimination at work in Indonesia	N/A: Guide and code of practice
ILO (2020b) 58	Introduction to Myanmar labour law 2020	Myanmar	Guide to Myanmar's labour laws	N/A: Guide
ILO (2022) 57	Safety and health in construction: ILO code of practice	International	Practical guidance for those who have rights and responsibilities regarding safety and health in construction	N/A: Code of practice
Miller & Suff (2022a) 62	Workplace support for employees experiencing pregnancy or baby loss: A guide for people professionals	UK	Guide for HR professionals on developing organisational support for pregnancy loss in the workplace	N/A: Guide
Thompson et al. (2019) 48	Voluntary labour compliance assessment for Myanmar Garment Manufacturers Association	Myanmar	Describe the Voluntary Labour Compliance Assessment (VLCA) tool, how to use it and its contribution to the development of the garment sector	N/A: Guide
Theses [Doctoral]
Light (2022) 68	Labour pains: the multiple and conflicting roles of academic mothers	USA	Investigate the lived experiences of tenure-line academic mothers	Primary research: Qualitative interviews: 12 tenured academic mothers at 5 midwestern higher education institutions
McNiven (2014) 69	(Re)collections: engaging feminist geography with embodied and relational experiences of pregnancy losses	UK	Explore lived experiences of pregnancy losses, and the ways in which spaces and places are intimately involved	Primary research: Qualitative interviews (N = 24): 21 women, 1 male partner and 2 siblings (1 male, 1 female)
Silverman (2020) 66	Women's return to work experience post miscarriage	USA	Explore experiences going back to work after miscarriage	Primary research: Qualitative interviews (N = 12)
Books/book chapters
Hackney et al. (2020) 56	Invisible grief: an examination of miscarriage in the workplace	USA	Insight into the impact of miscarriage on women in the workplace	Secondary research: Literature Review
Ministry of Employment and Labor (2013) 35	2013 employment and labour policy in Korea	Korea	Describe the major achievements of Korea's employment and labour policies	N/A – Narrative
Case studies
CIPD (2022b) 51	Workplace support for employees experiencing pregnancy or baby loss: Case study – The Co-operative Group	UK	Co-op's dedicated policy to support employees who have been affected by pregnancy and baby loss, including its development, outcomes and next steps	N/A: Case Study – Narrative
CIPD (2022c) 52	Workplace support for employees experiencing pregnancy or baby loss: Case study – Vodafone UK (Vodafone)	UK	Vodafone UK's new policy new policy to provide support to people who experience pregnancy loss at any stage, under a ‘compassionate leave’ policy,	N/A: Case Study – Narrative
Note
ILO (2020a) 97	Short-term policy responses to COVID-19 in the world of work	India	Recommend possible actions to be considered during the COVID-19 crisis to protect workers & workplaces with a focus on vulnerable groups	N/A: Note
Training module
ILO (2015) 32	Rural road maintenance training modules for contractors. Module-8: Occupational health & safety, environmental issues and decent work	India	For management staff and contractors, with guidelines for management of road maintenance works	N/A: Training module

Table 2.

Population, concept, and context details of included records.

Author/Year [Source]	Population	Definition of pregnancy loss used	Concept	Context
Addati et al. (2014) 27	Women – miscarriage	None provided	Special periods of leave for miscarriage, stillbirth, death, or other complications arising from childbirth.	Global workforce
Behari (2016) 28	Women – miscarriage	None provided	Provision of maternity leave for incidents of miscarriage	South Africa's workforce
Bober et al. (2022) 42	Women – miscarriage and abortion	None provided	Some collective agreements provide for paid maternity leave in case of miscarriage (or abortion) [4 For example, sectoral level (CBA-India#498, CBA-Uganda#311), and enterprise level (CBA-Australia#197, CBA-Brazil#162, CBA-Colombia#87, CBA-Indonesia#417, CBA-Uganda#183). Some of these also specify using leave in the case of abortion]	International workforces
Boncori & Smith (2019) 63	Woman – Miscarriage	None provided. Early loss (shortly after positive pregnancy test)	Author's experience of miscarriage at work	Academic workplace
Breen et al. (2022) 54	Men – Miscarriage	None provided	Legal and workplace support for miscarriages	International workforce
Castillo-Angeles et al. (2022) 64	Women – miscarriage	Under 20 weeks gestation	Leave taken and support experiences of those who had a miscarriage	UK – Surgical residency programmes
Chung (2021) 43	Women – miscarriage	None provided	Employment insurance in South Korea provides maternity leave in cases of miscarriage (Insured labour providers and artists specified)	Workforce in South Korea
CIPD (2022a) 61	Women and partners – pregnancy and baby loss	Term ‘pregnancy or baby loss’ refers to many different types of loss	Impact of pregnancy loss on employees, why and how managers need to support them through these experiences in the workplace	Workplaces in UK
CIPD (2022b) 51	Parents (men and women; baby's surrogate) and family members who experience pregnancy loss, embryo transfer loss	Miscarriage, stillbirth, ectopic pregnancy, molar pregnancy, neonatal loss, embryo transfer loss and termination of pregnancy (for any reason).	Workplace support policy for pregnancy and baby loss – leave; time off; adjustments; access to counselling and support; access to GP; signposting to relevant organisations. Policy implementation supported by manager's guide, leadership, communication and advocacy. Includes narrative regarding people's views/experiences of workplace supports	The Co-operative Group, UK
CIPD (2022c) 52	All parents/expected parents, including adopters, foster parents, and guardians/parents of a child born to a surrogate, who experience pregnancy loss at any stage	Pregnancy loss at any stage	Parents are granted paid compassionate leave for pregnancy or child loss (two weeks). Additional supports: 24/7 remote GP, counselling, peer support networks with practical help, policy signposting, wellbeing support, buddying opportunities. Policy implementation supported by leadership, communication, mandated manager training. Includes people's views/experiences of workplace supports.	Vodafone UK
Fisk (2022) 29	People who experience miscarriage	None provided	Different types of grief including miscarriage can impact work and require workplace and legislative support. Policies that extend duration of leave, acknowledge a wider range of grief experiences, and account for the unique needs of some individuals and groups could over time shape collective attitudes toward and behavioural norms around grief	International workforce
Fuller et al. (2018) 30	Women, partners, and professionals who support them – miscarriage, termination, stillbirth	None provided	Experiences of workplace leave following miscarriage or termination	England – workplaces
Goonetilleke (2016) 55	Women – miscarriage	Before 28 weeks gestation	Laws governing leave entitlement for miscarriage and the lack of these entitlements.	Sri Lanka workforce
Goulding (2013) 44	Women – miscarriage and stillbirth	None provided	The Employment Insurance system provides childcare leave benefits including miscarriage or stillbirth leave/benefits	Workforce in Korea
Hackney et al. (2020) 56	Women – miscarriage	<20 weeks of pregnancy	Miscarriage is relevant to the workplace and work can impact employees’ experience of their miscarriage and vice versa	Workplaces
ILO (2013) 98	Women – miscarriage	None provided	Women who suffer a miscarriage are entitled to 1.5 months paid leave under article 82 of the Manpower Act	Workforce in Indonesia
ILO (2015) 32	Women workers – miscarriage	None provided	Legal entitlements to leave and benefits in case of miscarriage	Workforce in India
ILO (2016) 33	Women – miscarriage	None provided	(In the Philippines) women's leave entitlements for miscarriage	Workforce in Sri Lanka and neighbouring countries
ILO (2020a) 97	Women – miscarriages and abortions	None provided	During Covid-19, counselling is essential, including for managing abortions, and on miscarriages.	Workforce in India, with special focus on state level and informal sector
ILO (2020b) 58	Women workers – miscarriage	None provided	Entitlements to maternity leave for miscarriage	Workforce in Myanmar
ILO (2022) 57	Women in construction sector – miscarriage	None provided	Compliance with national laws/regulations on miscarriage leave	Construction sector
Infante Villarroel & Tar (2021) 45	Insured workers – miscarriage	None provided	Insured workers are entitled to miscarriage cash benefits	Myanmar workforce
Keep et al. (2021) 13	Women – miscarriage	Spontaneous loss before 20 weeks	Workplace support following pregnancy loss	Australia – workplaces
Light (2022) 68	Woman – miscarriage	None provided	Workplace culture towards pregnancy and loss	Academic workplaces in USA
Maffii et al. (2012) 59	Woman – miscarriage	None provided	The difficulty of obtaining sick/miscarriage leave from employers	Garment and footwear factories in Cambodia
McNiven (2014) 69	Women, partners and siblings – all pregnancy losses	Chemical, early, ectopic, anembryonic, missed and/or late miscarriages (<24 weeks); terminations (early and elective, and late following positive prenatal diagnosis); pre-partum stillbirth (>24 weeks, officially/legally recognised as deaths) and early neonatal death (<one week after birth).	Workplace experiences following pregnancy loss	UK – Workplaces
Meunier et al. (2021) 11	Women, men – Perinatal loss	Death of a child during pregnancy, childbirth, or first 28 days of life	Workplace experiences of people coping with perinatal loss	Global – workplaces
Miller & Suff (2022a) 62	Women and partners – pregnancy or baby loss	Miscarriage (the loss of a baby during the first 24 weeks), stillbirth (the loss of a baby after 24 weeks), termination for any reason, ectopic pregnancy, molar pregnancy, chemical pregnancy, embryo transfer loss, and neonatal loss	Impact of pregnancy loss and need for workplace support, guide on creating supportive workplaces/policies	Workplaces in UK
Miller & Suff (2022b) 60	Women and partners – pregnancy and baby loss	Miscarriage: loss of a baby during the first 24 weeks; ectopic pregnancy: a fertilised egg attaches itself somewhere outside the uterus. Molar pregnancy: a foetus doesn’t form properly in the womb. Termination for medical reasons. Stillbirth: a baby dies before or during labour after 24 completed weeks of pregnancy.	Employees’ and employers’ experiences of pregnancy loss in the workplace and supports	Workplaces in UK
Ministry of Employment and Labor (2013) 35	Women – miscarriage and stillbirth	None provided	Women are granted maternity leave for miscarriage or stillbirth	Workforce in Korea
Modgil (2021) 36	Women undergoing miscarriage or medical termination of pregnancy	None provided	Women who have a miscarriage or medical termination of pregnancy are entitled to maternity benefits	Workplaces in India
Musodza et al. (2021) 70	Women – Perinatal Loss	Miscarriage: pregnancy losses before 20 weeks’ gestation; stillbirths: foetal deaths at and beyond 20 weeks’ gestation; neonatal deaths: deaths of babies within 28 days of birth	Experiences of returning to work and support received following perinatal loss	Maternity-related workplaces – international
Obst et al. (2022) 14	Men – Pregnancy Loss or Neonatal Death	Ectopic pregnancy, miscarriage (<20 weeks of gestation), termination of pregnancy for nonviable foetal anomaly (any stage of gestation), stillbirth. Neonatal death: death of a baby within 28 days of birth.	Workplace leave and other support experienced by men following a pregnancy loss	Workplaces in Australia
Olivier (2018) 37	Migrant workers – women – miscarriage	None provided	Migrant workers are entitled to social security benefits including miscarriage benefit	Workforce in Lao
Porschitz & Siler (2017) 65	Women – miscarriage	First trimester miscarriage	Documenting their experiences of first-trimester miscarriage while employed as academics	University (workplaces) in USA
Rahayuningsih (2016) 38	Women – miscarriage	None provided	Women's statutory right to miscarriage leave	Workplaces in Indonesia
Ramírez López et al. (2021) 46	Women – Pregnancy loss	Miscarriage, abortion, stillbirth, pathological abortion	Women's statutory entitlement to maternity leave for pregnancy loss	Workplaces in Vietnam
Rose & Oxlad (2022) 39	LGBTQ + people who are gestational or non-gestational parents – Pregnancy Loss	Ectopic pregnancy, miscarriage, stillbirth, surrogacy	Employees’ experiences of workplace leave and supports following pregnancy loss	Workplaces in Australia
Scheil-Adlung (2014) 47	Women – miscarriage or medical termination of pregnancy	None provided	Women's statutory entitlement to maternity leave for miscarriage/medical termination of pregnancy	Workforce in India
Silverman (2020) 66	Women – miscarriage	Before 20 weeks of pregnancy	Women's experiences returning to work following a miscarriage	Workplaces in USA
Srivastava (2013) 53	Construction workers – miscarriage/abortion	None provided	Assistance for abortion/miscarriage	Construction industry in the Tamil Nadu state in India
Theile et al. (2017) 40	Women – miscarriage	None provided	Women's statutory right to maternity leave in the event of a miscarriage	Workforce in Lao People's Democratic Republic
Thompson et al. (2019) 48	Women insured with Social Security Board – miscarriage	None provided	Insured women are eligible to receive miscarriage benefits	Workforce in Myanmar
Tommy's (2022) 67	Employees – pregnancy and baby loss	None provided	Experiences of workplace policies and support following pregnancy and baby loss	Workplaces in UK
Tsuruga et al. (2021) 49	Insured female workers – miscarriage	None provided	Insured workers entitlements to miscarriage leave	Workforce in Myanmar
Tsuruga & Moo (2021) 50	Women – miscarriage	None provided	Paid leave entitlements for miscarriage	Workforce in Myanmar
UN Women (2021) 41	Women – miscarriage, abortion and stillbirth	None provided	Leave entitlements in cases of miscarriage, abortion and stillbirth	Workforce in Viet Nam
Watson & Jewell (2018) 71	Women – Miscarriage	Under 20 weeks of pregnancy	The impact of working after/around the time of miscarriage, on their experience of miscarriage	Workplaces in USA

Characteristics of included records

Records included were published between 2012 and 2022, with an increase in publications in the past three years; 2012–2015 (n = 9); 2016–2019 (n = 11); 2020–2023 (n = 28) (see Figure 1). The majority of records were published in and/or focused on the UK (n = 9), North America (n = 8) and Southeast Asia (n = 13) (Figure 2). Publication types included reports (n = 18), journal articles (n = 15), codes of practice or guides (n = 6), books/book chapters (n = 2), theses (n = 3), and other: case study, note, and training module (n = 4) (see Table 1). Secondary research, including scoping reviews, literature reviews, documentary analysis, and other methods, was the most common type of methodology employed (n = 16). Primary research (n = 13) included qualitative interview studies, quantitative surveys, mixed method surveys, and autoethnographies. Some records (n = 5) employed both primary and secondary research methods, such as desk research and focus groups, or case studies with interviews. The remaining records (n = 14) did not utilise scientific research methods and included narratives, guides, codes of practice, a note and a training module.

Figure 1.

Publication dates of included records (N = 48).

Figure 2.

Country of origin of included records (N = 48).

Note: Nine records included multiple countries/continents and are therefore not represented in this map.

Context

As seen in Table 1 and Figure 2, records spanned most continents, with a concentration of research in Asia (n = 20), North America (n = 7) and Europe (n = 9). Primary research was mainly conducted in high-income countries, while most reports focused on middle-and-lower income countries. As per this review's inclusion criteria, all records included workplace contexts. These included international, national, or industry workforces; workplaces within a particular country, and specific industry workplaces including academia (n = 3), healthcare (n = 2), garment and footwear factories (n = 1), and construction (n = 2) (see Table 2).

Population

Miscarriage was the form of pregnancy loss most commonly discussed in included records (n = 29), though miscarriage was only defined within six records. Among these, ‘less than 20 weeks of pregnancy’ was the most common definition used (n = 5), and one record defined miscarriage as ‘the loss of a pregnancy before 28 weeks gestation’. Some records included all types of pregnancy loss, i.e., losses before and after viability (n = 19). Most records included women experiencing pregnancy loss (n = 33); a minority focused on and/or included men (n = 2). The remainder either included both (n = 9) or did not specify (n = 4).

Concept

Many reports stated or discussed legal rights to time off work or cash benefits following a miscarriage or other pregnancy loss (n = 24). Other records discussed the impact of workplace experiences on pregnancy loss and the need for support and policies (n = 6) or supports for pregnancy loss in specific workforces or workplaces (n = 3). Most records utilising primary research methods, and both scoping reviews, explored participants’ experiences of workplaces and workplace supports following a pregnancy loss (n = 15).

Addressing our research questions

In this review, we first aimed to map the literature with regards to publication characteristics. Secondly, we wanted to examine the literature in relation to two specific issues – workplace supports and experiences of these supports. The results below are presented according to the findings for each research question.

Research question 1: Which workplace supports (e.g., legislative, policy, psychological, social) are, or should be, available to people experiencing pregnancy loss?

Our first research question was addressed by most included records, either through describing or noting existing supports, or illustrating the need for workplace supports to be introduced. Most leave and benefits discussed were a statutory entitlement (n = 15)^27–41 while some were achieved through collective agreements (negotiated agreements between trade unions and employers) (n = 2)^11,42 and others are available through social insurance and/or only available to insured workers (n = 8).^43–50 Certain sectors or workplaces created/implemented their own pregnancy loss supports, as discussed by three records.^51–53

The most common types of supports discussed were leave from work (n = 30)^{11,27–33,35–38,40–44,46,47,49–52,54–60} and benefits or cash benefits (n = 9).^{32,36,37,44,45,47–49,57} Many records stated the provision of leave entitlements or benefits in the case of miscarriage with no further detail; where provided, specific information provided is summarised in Table 3 (n = 12 records).

Table 3.

Leave entitlements for pregnancy loss documented in records (n = 12).

Source	Country/Organisation	Details of entitlement
Addati et al. (2014) 27	Nicaragua and Panama Mauritius Indonesia	In accordance with the woman's needs. Two weeks. One and a half months.
CIPD (2022b) 51	The Co-operative Group	Flexible paid leave and time off to attend appointments or support partner
CIPD (2022c) 52	Vodafone	Two weeks paid compassionate leave – can be taken as one block or as two separate periods of one week
ILO (2013) 98	Indonesia	1.5 months paid leave after a miscarriage
ILO (2016) 33	Philippines	Maternity leave of 4 weeks after miscarriage
Ministry of Employment and Labour (2013) 35	South Korea	Workers are granted 5–90 days of miscarriage or stillbirth leave depending on their pregnancy period and given miscarriage or stillbirth leave benefits
Rahayuningsih (2016) 38	Indonesia	Rest of 1.5 [months] or in accordance with a medical certificate or midwife [not contract employees]
Ramírez López et al. (2021) 46	Vietnam	10 days (pregnancy <5 weeks); 20 days (5–13 weeks); 40 days (13–25 weeks); 50 days (25 + weeks)
Rose & Oxlad (2022) 39	Australia	Two days of paid leave for women and partners following miscarriage before 20 weeks gestation
Scheil-Adlung (2014) 47	India	6 weeks leave with average pay for miscarriage or medical termination of pregnancy
Theile et al. (2017) 40	Lao	In the event of a miscarriage, the duration of maternity leave is determined by a doctor.
Tsuruga et al. (2021) 49	Myanmar	70% of average wage during the leave period for up to six weeks after miscarriage
Tsuruga & Moo (2021) 50	Myanmar	Six weeks paid maternity leave for miscarriage

Records which discussed workplace policies or collective agreements identified organisational supports such as gradual return to work (n = 2),^11,60 flexibility and reasonable adjustments (n = 2),^51,60 and training for managers (n = 4).^32,51,61,62 Emotional/psychological supports such as counselling, referral to GP, or signposting to peer support groups or relevant organisations were identified by five records.^{51,52,60,61,62} A minority of records noted or described the need for unspecified supports, provisions, or assistance (n = 3).^29,53,55

Research question 2: What are people's views and experiences of workplace supports for pregnancy loss before viability?

A number of included records utilised primary research methods including–but not limited to–surveys, interviews, and focus groups with people who had lived experience of pregnancy loss (n = 14). These studies examined people's experiences of workplace supports (or lack thereof) for pregnancy loss, and views on these supports. Records utilising secondary research methods including scoping reviews, literature reviews, and case studies (n = 5) also included results or discussion pertaining to experiences of support. The most common themes addressed in the literature, drawing on qualitative and/or quantitative data, are described below and findings from individual records are summarised in Table 4.

Table 4.

People's experiences of workplace support for pregnancy loss, by theme.

Source	Leave	Emotional Support	Organisational Supports	Difficulties in Returning to Work	Disclosure	Stigma and Taboo
Primary research
Boncori & Smith (2019) 63	—	—	Lack of organisational and peer support for people who experience perinatal loss results in grief which deeply impacts individuals Distraction in work	—	—	Silencing in professional and organisational contexts as the maternal body remains unwelcome or rejected Individual and collective silencing of perinatal loss in professional spheres
Castillo-Angeles et al. (2022) 64	73% of respondents who reported a miscarriage took no time off	Of those who took time off: 14% disagreed that colleagues were supportive of time away from work 14% disagreed that leadership was supportive	—	—	50% did not disclose their miscarriage to colleagues 43% did not disclose the miscarriage to leadership	—
Fuller et al. (2018) 30	The opportunity to take time away from work was highly valued by bereaved individuals		—	—	—	—
Keep et al. (2021) 13	85% of participants took a median duration of 7(10) days following their miscarriage Paid (sick or annual) leave was the most common type taken Participants wanted formal leave options to be provided by their workplace	Most participants received informal support from colleagues and managers Participants reported wanting acknowledgement by managers, human resources, and colleagues	—	—	Women's reasons for disclosing or keeping private their miscarriage aligned with managing their return-to-work experience and workplace culture	—
Light (2022) 68	—	One participant experienced her pregnancy loss the same day as receiving negative comments from her colleagues and supervisor regarding covering maternity leave	—	—	—	—
McNiven (2014) 69	—	Potential for insensitive and intrusive comments/questions was a concern for some whilst for others the prospect of their experiences being ignored was upsetting Practical support: One participant's colleague offered to drive her to the hospital from the workplace while miscarrying	—	Pressure from employers to return to work Physical exhaustion Worries about reputation and career trajectories, and being seen as ‘incompetent’, ‘overly emotional’ etc. For many, going back to work after pregnancy loss was anxiety-inducing, with uncertainty as to how colleagues would respond	Many found disclosing their reproductive experiences in the workplace incredibly difficult and distressing	—
Miller & Suff (2022b) 60	Paid compassionate or other special leave (in addition to any statutory entitlement such as statutory sick pay) was rated as the most helpful form of support Paid time off to attend appointments was in the top five of other helpful supports	45% of employees felt supported by their employer at work. 31% felt neither supported nor unsupported. No significant difference between how male and female employees felt supported 58% were supported by their line manager; 25% neither supported nor unsupported; 11% felt unsupported Understanding that it can be a challenging time is important	The option to work from home when needed was rated as one of the top five most helpful forms of support other than leave. Support from employer is deemed the most beneficial	Almost a quarter of employees have considered reducing their hours or leaving their job because of their experience at work	53% of participants told their manager; 6% told HR; 17% told both their manager and HR. 24% didn’t tell either The most common reason for not telling was because it was a private matter that they didn’t want to share (65%) 28% were concerned about prying questions; 19% were concerned about the possible impact on their career; 17% felt there's too much stigma	17% of participants did not tell anybody in their workplace about their pregnancy loss as they felt there's too much stigma
Obst et al. (2022) 14	42 of 81 participants whose pregnancy loss was before 20 weeks’ gestation were offered leave Participants with a < 20 week pregnancy loss returned to work sooner than those who experienced stillbirth or neonatal death Appreciation for empathetic employers who provided leave	Some participants described a lack of understanding from employers Others described positive experiences with employers who recognised the significance of their loss Dissatisfaction when employers were ‘not understanding or forgiving for time off’ or made ‘little effort’ to ask them how they were coping Some men experienced avoidance from co-workers	A small number of participants were offered flexibility in work hours/location, or a referral to an Employee Assistance Programme or counselling services Some participants desired flexible hours or reduced workload, or a need for counselling	Returning to work took an emotional toll on men Feeling not their ‘normal self’ or emotionally burnt-out, which led to decreased productivity and difficulty coping with their usual tasks/workload Early return to work resulted in ‘burnout’, ‘breakdown’, and reduced productivity	Those who lost a pregnancy before 20 weeks were the least likely to inform their employer (compared to later losses) Some participants experienced ‘awkward conversations’ when their employers had not informed others of their loss	—
Porschitz & Siler (2017) 65	Emotional/physical impacts of pregnancy loss may be exacerbated by not taking enough time off to rest	—	Some can find benefit in the distraction of work and company and camaraderie found in the workplace	Emotional/psychological and physical impacts can make working after miscarriage difficult	The authors didn’t disclose their losses and mourned alone at work. They believe that isolation contributed to their grief	The authors internalised societal and workplace silences about miscarriage, and suppressed outward signs of their feelings
Rose & Oxlad (2022) 39	Bereavement leave was deducted from participants’ sick leave, so some participants returned to work to conserve their leave for future fertility treatments	Expectations of judgement/shaming increased participants’ distress and internalised shame. Male participants experienced less support, due to a lack of understanding about the impact of pregnancy loss on men Anticipated support from colleagues facilitated positive return to work experiences	Most participants described returning to work as a way to manage their grief – returning to work within 1–7 days of the pregnancy loss Having flexible working hours, being able to delegate emotionally charged tasks, and the presence of employee support programmes was highly valued	—	Most participants were uncomfortable disclosing their pregnancy losses to colleagues Many participants explicitly described their reluctance to disclose due to fear of recrimination or judgement	Most participants returned to work within 1–7 days, partly informed by internalised norms minimising grief following pregnancy loss
Silverman (2020) 66	Financial concerns and conserving paid time off were prominent factors determining how long participants requested off Another prominent cause to return to work before they are ready was to lessen the burden on co-workers and/or to meet their work obligations		Work as a distraction positively influenced some participants’ experiences The option to work from home, modified work obligations/demands positively impacted the return to work experience for some participants	All participants reported that they had emotional, physical, and/or social concerns when returning to work post-miscarriage. E.g.: decreases in work functioning (productivity, concentration, multi-tasking, focus on work); regulating emotions and experiencing triggers (repetitiveness of condolences, pressure to ‘be professional’)	Existing work relationships often impacted their decision to disclose Some participants described feeling nervous to disclose their miscarriage or request time off. Others had positive relationships with their employers and felt comfortable having these conversations	—
Watson & Jewell (2018) 71	—	—	—	Participants described their return to their normal routines as ‘surreal’ Attempts to schedule around the physical and emotional recovery	—	—
Tommy's (2022) 67	63% of participants went to work even if they weren’t feeling ready 79% said they feel like they are letting colleagues down if they needed time off	69% said their manager didn’t know how to support them 54% said nobody at work acknowledged it/asked how they were 56% worried they were being judged. 46% experienced colleagues saying insensitive things Policies need workplaces to be equipped with softer skills and confidence to have open conversations	—	83% of participants felt they had to put on a brave face at work	—	—
Secondary research
Hackney et al. (2020) 56	—	Coworkers and supervisors may provide support to help employees battle the ‘seemingly overwhelming workload’	—	Following a miscarriage, employees are on an emotional and physical rollercoaster which can impact on their job, leading to overwhelm and stress	—	Societal and organisational norms regarding miscarriage (stigma and silence) exacerbate the situation and can contribute to disenfranchised grief.
Meunier et al. (2021) 11	—	—	—	Difficulties associated with returning to work after the loss Considerable effort to maintain normal functioning, while being physically and psychologically affected by the loss	—	Taboo and non-recognition of perinatal grief and bereavement in both organisational practices and interpersonal relationships in the workplace
Musodza et al. (2021) 70	—	Bereaved midwives valued emotional support from colleagues. Insensitive comments from colleagues were distressing Generally received good support from colleagues	Sensitive practical support included being asked where they wanted to work	Midwives found it traumatising or distressing to work with women who worked with patients experiencing loss; working on their due date or anniversary	—	—
Case studies
CIPD (2022b) 51	Some people found returning to work helpful, while others needed more time off to recover physically or mentally	—	Lack of support around pregnancy loss, including explicit advice on where to turn for support	—	—	—
CIPD (2022c) 52	Need to record leave as ‘compassionate leave’	—	Need to enhance supports for pregnancy loss and make clear the policy applies to both partners, and in cases of surrogacy Leaders were quick to see the benefits of the policy and offer full support	—	—	—
Primary and secondary research
Maffii et al. (2012) 59	A trade unionist had to fight for an employee's right to take sick leave after a miscarriage	—	—	—	—	—

Leave from work

Most (n = 13) records explored participants experiences of taking leave from work^{13,14,30,39,51,52,59,60,63–67} (Table 4). There was heterogeneity in how these records collected data on how much leave participants took, due to methodology used (e.g., quantitative/qualitative) and research focus. Therefore, there is no clear view from the literature of how much leave is needed, or an average of how much is taken. Across records, some participants found returning to work helpful, while others needed time away from work to physically or emotionally recover. Participants generally did not have access to appropriate leave entitlements, and many participants took sick leave, unpaid leave, or were unable to take any leave at all. Participants across the research expressed a desire for paid specific leave.

Emotional support in the workplace

Experiences of collegial or managerial support were reported by 11 records.^{13,14,39,56,60,64,66–70} The literature found both positive and negative influences that colleagues, supervisors, managers, and employers, could have on participants’ pregnancy loss experiences (Table 4). Sympathy, understanding, and support with workload was valued, while insensitive comments, judgement, or lack of acknowledgement added to participants’ distress.

Organisational supports

Organisational supports were noted by nine records^{14,39,51,52,56,60,63,66,70} (Table 4). Psychological or medical support through referral to GP, counselling, or Employee Assistance Programmes, were discussed in two records (see Table 4). Records presented available supports, participants’ experiences of these supports, and/or the lack of or need for organisational supports. Generally there is a lack of workplace supports for pregnancy loss, and participants highlighted the need for having the option to work from home, flexibility in hours or workload, and access to counselling.

Difficulties in returning to work

In addition to workplace supports, many studies (n = 10) reported on the difficulties participants faced on returning to work following pregnancy loss.^{11,14,56,60,65–67,69–71} Physical symptoms, emotional impacts, and interactions in the workplace were cited as impacting the return-to-work experience (Table 4). Attempting to act professional and hide emotions relating to the pregnancy loss was a common difficulty experienced.

Disclosure

Among primary research records, the majority (n = 8) examined participants’ experiences of disclosing their pregnancy loss in their workplace, or choosing to not share it.^{13,14,39,60,64–66,69} Factors influencing this decision, and responses to disclosure, were discussed across the literature. Many participants did not tell anybody in their workplace about their pregnancy loss, meaning no-one at work knew what they were experiencing. Reasons for non-disclosure included privacy, fear of impact on career, and stigma. Other participants disclosed their pregnancy loss at work, and often found this experience to be uncomfortable or distressing. Participants were motivated to share to access leave or supports, to counteract stigma, or because they had positive relationships in the workplace.

Stigma and taboo

The prevalence and impact of the silence, stigma, and taboo surrounding pregnancy loss was noted in several records (n = 6).^{11,39,56,60,63,65} Pregnancy loss, especially early pregnancy loss, is often not discussed in society, and particularly not in workplaces. The lack of knowledge, understanding, and conversations surrounding pregnancy loss is posed as a barrier to support across the literature. Included studies show how stigma can enhance difficulties surrounding disclosure, accessing leave, acknowledgement from colleagues, and managing emotions upon return to work.^39,60,63,65

Discussion

The aim of this scoping review was to examine the literature pertaining to workplace supports for pregnancy loss before viability, and to identify gaps in the literature. We found a lack of empirical work on this topic, although there has been a notable increase in primary studies in the past five years. Most included records were reports or narratives, many of which concentrated on South-East Asia. Records utilising primary research methods were mainly from Australia and North America, and thus have particular relevance to high-income countries.

Research question 1: Which workplace supports (e.g., legislative, policy, psychological, social) are, or should be, available for people who experience pregnancy loss before viability?

Our findings show that more is needed to adequately respond to workers’ needs. Empirical studies included in this review demonstrate the range and extent of concerns that workers face when returning to the workplace following pregnancy loss, including dealing with the physical and emotional impacts of pregnancy loss, navigating conversations and relationships in the workplace, and managing the workload while potentially feeling unwell or distressed. Pregnancy loss affects many workers throughout the world. Women who carry the pregnancy can face ongoing physical effects including cramping and bleeding, ⁷² and further complications if medical or surgical management is required. ⁷³ Additionally, both women and men can experience emotional, psychological, and social impacts of pregnancy loss. It is common to experience a period of grief; ⁷⁴ intense sadness; ⁷⁵ and isolation. ⁷⁶ Pregnancy loss also increases the risk of anxiety, depression, and post-traumatic stress disorder.^1,2,77–79 Because of the prevalence and extent of these impacts, it is important that people are supported by their workplaces at a time of potential physical and/or emotional suffering.

Legislative supports for pregnancy loss, in the form of leave and benefits, are primarily found in middle-and-lower income countries, according to the records included in this review. This is reflective of international legislation, whereby high-income countries such as New Zealand and Australia have recently introduced statutory pregnancy loss leave, while lower-and-middle income countries such as China ⁸⁰ and India ⁸¹ have had miscarriage leave since the 1950s and 1960s. ⁸² Recent years have seen a growing awareness of early pregnancy loss and its impacts, which has resulted in several jurisdictions considering the introduction of pregnancy loss leave; these include Northern Ireland, ⁸³ Alberta, ⁸⁴ Nova Scotia ⁸⁵ and Catalunya. ⁸⁶ As such, further research will be needed to explore the efficacy of newly introduced leave.

Companies and organisations are increasingly investing in workers’ health through workplace adaptation and provision of healthcare, which can save costs through preventing sickness absence, presenteeism, turnover, and loss of creativity. ⁸⁷ In addition to, or in the absence of, statutory supports, individual workplaces can create pregnancy loss policies which include leave entitlements, practical supports and accommodations for employees returning to work, and training and awareness raising for management or staff. Practical supports found in this review include working from home; flexible working hours; being able to change the location where they work/delegate emotionally charged tasks; reduced workload; modified work demands. Psychological supports for pregnancy loss were infrequently found within this literature, but participants expressed a need for counselling or peer support through Employee Assistance Programmes. This is reflective of the psychological impact of pregnancy loss and the increased risk of depression and anxiety. ² Social support from management and colleagues were hampered by a lack of awareness and understanding of early pregnancy loss experiences. The lack of understanding about pregnancy loss faced by workers may be alleviated by joining peer support groups, which some workplaces provide referrals to. ⁵² Taboo and stigma was a factor which reduced the likelihood of disclosure of pregnancy loss, which is often required to access support. Alongside organisational and professional supports, education and awareness-raising in workplaces is essential to support workers’ who are returning to work following a pregnancy loss.

Research question 2: What are people's experiences of workplace supports for pregnancy loss before viability?

While there is a general lack of research in this area, recent primary studies have investigated participants’ experiences of leave provisions or supports in their workplace following a pregnancy loss. Across workplaces and countries, participants’ experiences reported in the publications in this review vary from a total lack of support from their workplace, to a positive return to work. There is variation in the type and length of leave available; the option of working accommodations; and the reactions and support from colleagues and management towards employees who experience pregnancy loss. Recently published and ongoing studies will further inform the growing evidence base in this area.^88,89

In addition to the benefits of support policies and programmes to employees, it is important to highlight the advantages to workplaces of supporting and promoting their workers’ health and wellbeing. Poor physical or mental health can result in presenteeism, loss of productivity, reduced creativity, and increased absence, all of which is costly to companies. Conversely, improving work conditions or offering health initiatives results in productivity gains and sickness absence reduction. ⁸⁷ A meta-analysis of a variety of workplace health promotion programmes found small improvements in outcomes such as sickness absence, work productivity, and work ability. ⁹⁰ The World Health Organisation recognises the strategic advantage to workplaces of promoting and supporting workers’ health, alongside the moral and sometimes legal obligation to do so. ⁹¹ The EU Occupational Safety and Health Association has also found that poor workplace safety and health costs money, and it is worthwhile for companies to invest in their workers’ health. ⁹²

What is the scope of the current evidence and are there any gaps in the research?

While our search strategy yielded over 10,000 results and this review includes 48 records, there is a lack of empirical evidence examining workplace supports for pregnancy loss and people's experiences thereof. Furthermore, of the small number of empirical studies included in this review, 11 included participants who had experienced all types of pregnancy loss, which further limits the extent of evidence available for workplace experiences of pregnancy loss before viability. Many of these studies are very recent (within the past three years), which illustrates the growing awareness and attention on early pregnancy loss worldwide. While many of the reports addressed low-and-middle-income countries, all of the included empirical work was conducted in high-income countries. Furthermore, most reports were examining workers’ rights across all aspects of working life, not focusing specifically on pregnancy loss; as such, the information pertaining to pregnancy loss supports was often vague or brief. Many journal articles included discuss the lack of awareness, discussion, and education surrounding pregnancy loss. The lack of research in this area supports this finding.

In addition to the lack of research in this area, pregnancy loss in the workplace would not appear to be given due attention by organisations which focus on occupational health, given that we did not identify any eligible records from the websites of European Union ⁹³ and United States of America ⁹⁴ occupational health bodies. However, an exception – and example of guidance for workplaces in Canada – describes what a miscarriage is and what workplaces can do to support workers’ experiencing pregnancy loss. ⁹⁵ Following on from new research and legislation, guidance from national and international organisations is needed to promote workplace policies and training.

Future research needs to examine the need for, implementation, and impact of workplace supports such as leave (including the optimum duration of same), practical accommodations, and training and education of managers and colleagues about pregnancy loss experiences.

Strengths and limitations

A strength of this work is the involvement of knowledge users, from inception, in the review; such engagement improves the relevance of the research and will also enhance the dissemination and implementation of research findings. ⁹⁶ Furthermore, we did not restrict by language or geographical location, and included grey literature sources. Our results demonstrate the importance of the latter, given the dearth of empirical work identified. There are some limitations, however. We did not include media reports within our scoping review, in order to keep our review manageable, within the available resources and timelines. We have observed much media reporting of issues relating to pregnancy loss in the workplace in recent years, and this is indeed an area for future research. In addition, we did not conduct general internet searches to identify company policies/supports, or searches of legislative sources; we will examine these separately. ⁹

Conclusion

Our scoping review of literature published in the past 10 years, has identified a lack of research and broader literature internationally on workplace supports and experiences of early pregnancy loss. Most reports included in our review focused on middle-and-lower-income countries. In recent years, there has been an increase in primary research on workplace experiences of pregnancy loss in high-income countries. This highlights various issues that workers face when returning to work following pregnancy loss, including navigating the physical and emotional impacts, workplace conversations and relationships, and workloads. Our review identified measures such as leave, flexible working arrangements, and access to support, which organisations can implement to support their employees experiencing pregnancy loss. Education and awareness-raising initiatives in workplaces are also required to enable supportive cultures. Further qualitative and quantitative primary research is needed to understand workplace experiences of pregnancy loss, to inform the development and implementation of supports, including appropriate legislation and guidance for organisations on the introduction of pregnancy loss supports to the workplace.