Table 2.

Summary of studies included in the review

Author	Country	Study design	Setting	Population	Study aim	Summary of findings
Baird et al., 2018 [48]	USA	Qualitative- interviews	Emergency Department	Women N = 10 Early pregnancy loss (< 13 weeks) Age range 20–41 Participant’s ethnicity Black or Afro-American 4 Hispanic 3 Other 2 White 0	To better understand why women present to Emergency Departments for early pregnancy loss and their overall experience during and after their visit.	The study identified multiple areas for improvement in quality of care, including more complete and empathetic communication, additional information, and follow up care planning. Providers in primary care and ER settings can work together to provide improved patient-centered care to women experiencing Early Pregnancy Loss.
Bellhouse at al., 2019 [5]	Australia	Qualitative- Interviews	Hospital setting -not specified	Women N = 15 (18–50) who experienced miscarriage 3 months to 10 years prior to interview. Age range 33–43 years old Participants’ ethnicity not disclosed in the paper	To explore women’s healthcare support experiences and how these experiences impacted women’s psychological distress following miscarriage.	Women experienced both positive and negative interactions with healthcare providers throughout their miscarriage journeys. All women interviewed expressed their increased distress following negative experiences with healthcare providers. Women commonly expressed concerns with the lack of causative information provided, a lack of follow-up from healthcare professionals, insensitive comments and terminology relating to their miscarriage, dismissive or insensitive attitudes, and a general lack of emotional support from a variety of healthcare professionals. Positive interactions with healthcare professionals included those in which women were provided with emotional support, the offer of follow-up or further testing and opportunities to express their grief through memorial services. While almost all women had some positive experiences in their interactions with healthcare professionals, most women’s stories involved significant negative experiences with healthcare providers, which caused them further distress.
Chaloumsuk, 2013 [23]	Thailand	Qualitative- Interviews with women and focus group with medical staff.	Hospital setting -not specified	Women who experienced miscarriage N = 11 Age range 20–30 years old Doctors N = 10 and nurse-midwives N = 11 Ethnicity: Thai 11	To gain an understanding of experiences of miscarriage and termination of pregnancy for foetal anomaly among a group of Thai women	Women need more in-depth knowledge and empathetic care from health professionals. Involving family members to support women in the labour unit can reduce the feelings of loneliness and insecurity.
Cullen et al., 2017 [49]	Republic of Ireland	Qualitative	Maternity Hospital	Women N = 9 and their partners N = 5, who experienced second semester miscarriage (15–19 weeks). Age range 30–42 years old Women’s ethnicity Irish 8 Asian 1 Men’s ethnicity Irish 4 Asian 1	To explore parents’ experiences of second trimester miscarriage and clinical care received in the hospital from the time of diagnosis through to follow-up.	Overall, the participants were very positive about how they were cared for during an extremely difficult time. However, a number of parents described negative experiences owing to insensitivity on the part of some staff, which added to their distress. Empathy and sensitivity were described by parents as ways that hospital staff recognised and helped to alleviate their suffering following a second-trimester miscarriage.
Cullen et al., 2018 [50]	Republic of Ireland	Qualitative	Maternity Hospital	Women N = 9 and their partners N = 5 who experienced second semester miscarriage (15–19 weeks). Age range 30–42 years old Women’s ethnicity Irish 8 Asian 1 Men’s ethnicity Irish 4 Asian 1	To explore parents’ experiences of second trimester miscarriage and clinical care received in the hospital from the time of diagnosis through to follow-up.	Overall, parents were satisfied with the medical treatment they received; however, some parents highlighted issues in relation to medical treatment. A number of parents commented on how busy the casualty department was and described long waits to see a doctor. Five of the women talked about difficulties in taking bloods and reported numerous attempts by staff before blood was taken successfully. The local hospital policy when a second trimester miscarriage is diagnosed is to administer mifepristone and allow the mother to go home for 48 h. Five of the women experienced this care pathway. Parents described this period of time as very difficult, but it was also acknowledged that the time allowed the parents the opportunity to begin to adjust to the loss. Being separate from pregnant women appeared to be very important to bereaved parents during outpatient appointments, casualty visits and when admitted to the hospital. Parents discussed the importance of honest and open communication with medical staff. Some parents highlighted the negative impact when communication with hospital staff was not clear.
Domingos et al., 2011 [47]	Brazil	Qualitative	Hospital setting (not specified)	Women (N = 13) who experienced spontaneous abortion (weeks not specified). Nurses (N = 7) who assisted women in the situations. Age range 18–38 Participants’ ethnicity not disclosed in the paper	To explore what is the meaning of miscarriage is for women and what they expect from HPs who care for them. To establish if there is a difference in type of care provided between public and private health care institutions. To explore how nurses feel when caring for women who experience miscarriage.	Women acknowledge that when experiencing miscarriage they require attention, support and information from the professionals. Regardless of whether they have health insurance or not, women should be treated with respect, dignity and have the right to health and citizenship guaranteed.
Edwards et al., 2018 [45]	Australia	Qualitative- interviews	Emergency Department	Women N = 3 and their partners N = 2 who presented to ED with first trimester bleeding. Nurses N = 6 Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To examine approaches to care provided to women who present to non-metropolitan EDS with first trimester bleeding.	The process of providing optimal care relies on the provision of nursing care that incorporates the experiences and expectation of the women and their partners as well as those nursing staff in this context.
Emond et al., 2019 [46]	Canada	Qualitative	Emergency Department	Parents who have presented to the ED with miscarriage (N = 14, Women = 3). ED nurses (N = 7) and nurse managers (N = 2). Average age 32.6 years old Participants’ ethnicity not disclosed in the paper	To identify the needs of parents, factors influencing their experience of care when attending ED due to miscarriage.	Parents who visit the ED during a miscarriage report multiple physical, cognitive and emotional needs. Physical health needs include a desire to undergo diagnostic testing as rapidly as possible to determine the viability of the pregnancy and to be referred for a follow-up appointment with a healthcare professional. Parents’ cognitive needs consisted of a desire to receive a detailed explanation at thetime of diagnosis, information to assist recovery, and written materials regarding the miscarriage experience and available resources and services. Finally, the emotional needs of parents include care centred on emotional health, a more private space in the ED, and, for the women experiencing miscarriage, their partner’s support.
Iwanovicz-Pakus et al., 2014 [44]	Poland	Quantitative- survey	Hospital setting (not specified)	Women who experienced miscarriage N = 303 Age < 20 and > 30 noted in the paper Participants’ ethnicity not disclosed in the paper	To recognise the care options for women after miscarriage in relation to support and assistance from medical staff providing care during hospitalisation.	28.71% of the women in this study admitted that they did not receive sufficient psychological support from physicians and the 22.44% definitely did not obtain such support. 41.58% of respondents reported that after miscarriage midwives showed adequate skills, and provided them with necessary informative support. Statistical analysis showed that respondents who could freely express their emotions during hospitalization evaluated physicians and midwives more positively (p < 0.001). Respondents who evaluated their psychological status after miscarriage as severe, expressed better evaluation of assistance and support provided by physicians (p < 0.001) and midwives (p < 0.01), compared to those who evaluated their status as moderate or light (p < 0.001). More than a half of the respondents needed peace and quiet during hospitalisation (58.09%), half required understanding (50.50%), nearly one-third expected seclusion (31.68%) and the same number wanted conversation (31.68%). Based on statistical analysis, the mean evaluation of the respondents’ needs during hospitalization was 15.22 ± 3.21 (5–20 scores). Respondents who evaluated their psychological status after miscarriage as severe had more intensified needs during hospitalization than the respondents who evaluated their psychological status as light or moderate (p < 0.0001). Respondents who at the time of pregnancy loss were married had significantly more intensified needs compare to those who were single (p < 0.01). The results of this study showed a significant correlation between the level of intensity of needs during hospitalisation and evaluation of physicians (R = 0.23; p = 0.00005) and midwives (R = 0.23; p = 0.02). The higher the intensity of patients’ needs, the more positive the evaluations of physicians and midwives providing them with care. Statistical analysis showed that the respondents who received complete and sufficient instructions from the medical staff concerning follow-up assistance after the loss of a baby evaluated both physicians and midwives in more positive terms, compared to those who had insufficient information or did not obtain any information at all (p < 0.0001).
Johnson et al., 2015 [42]	USA	RCT	Obs-Gyne Clinic and ED	40 women who experienced miscarriage between 8/40 and 20/40 weeks and attended the emergency room Age range 18–42 years old Participants’ ethnicity: Hispanic/Latino 10 African American 5 White 4 Other 1	To build an intervention to ease the potential negative consequences of grieving. The intervention was delivered in the emergency department at the time miscarriage occurred.	Findings from the study indicated that women who received the bereavement protocol reported lesser levels of overall grieving.
Klein et al., 2012 [43]	United Kingdom	Quantitative	EPAU	67 women and their partners miscarriage before 24th week of gestation IG (N = 33 reduced to N = 19 post- randomization) CG (N = 34 increased to N = 48 post-randomization) Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To establish the feasibility of undertaking a large multicentre trial using a modified PRPP design to evaluate the effectiveness of a web-based intervention in promoting the mental wellbeing of women and partners after miscarriage.	Results indicated that the IG group was significantly less anxious and depressed at the 3-month follow-up (HADS anxiety, P = 0.01; HADS depression, P = 0.02). IG group reported significantly higher levels of emotional wellbeing (SF-36 vitality, P = 0.018; SF-36 emotional role, P = 0.005; SF-36 mental health, P = 0.008; and SF-36 MCS score, P = 0.005).
Kong et al., 2013 [41]	China	RCT	Hospital setting (not specified)	180 women suffering miscarriage managed by either surgical, medical and expectant Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To investigate the clinical and psychological outcomes of surgical, medical and expectant management of first trimester miscarriage	In terms of satisfaction with the mode of treatment, there was no significant difference in the satisfaction scores between groups. Significantly more women who received either surgical or medical evacuation expressed worries of weakening or even damage to their bodies as a result of the treatment. Significantly more women with successful treatment scored higher on CSQ-8 compared with women having unsuccessful treatment. Fewer women with successful treatment expressed worries about the treatment damaging their bodies. There were no significant differences in psychological outcomes measured in terms of psychological well-being (GHQ-12), depression (BDI), anxiety (STAI) and fatigue symptoms (FS) at the time of treatment and four weeks after treatment among three treatment modalities. There was no significant correlation between randomised treatment modalities on the psychological outcome measures. Women with active intervention (both surgical and medical evacuation) had a significantly higher CIES-R score at the time of treatment when compared with women in the expectant management group. The traumatic psychological impact lessened in the subsequent follow-up at Day 28.
Kong et al., 2014 [40]	China	RCT	Hospital setting (not specified)	N = 280 women who were admitted to hospital with a diagnosis of miscarriage Counselling group (N = 140, 8 withdrawn after randomization N = 132). Control group N = 140, 4 withdrawn after randomization N = 136). Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To assess the effectiveness of supportive counselling after miscarriage.	A session of supportive counselling with a trained nurse counsellor, delivered immediately and at 2 weeks after diagnosis for miscarriage, did not show a statistically significant effect in reducing psychological distress of women after miscarriage. It also failed to show any additional effect. 30% reduction in the proportion of women with high GHQ-12 scores (indicative of definitive psychological distress) was evident by 3 months post miscarriage in the counselling compared with the standard care group, suggesting a potential clinical beneficial effect, albeit not a statistically significant one. Among the subset of women who had high baseline scores on the GHQ-12 and BDI questionnaires, there was a statistically significant difference was observed between counselling group and standard care groups, in terms of lower scores and reduced proportions of women scoring highly at 6 weeks in the counselling group. This suggests that a ‘selective’ counselling programme aimed at women with high baseline levels of psychological distress might be beneficial for improving emotional wellbeing in this group in the first weeks after miscarriage.
Larivière-Bastien et al., 2019 [38]	Canada	Qualitative – Interviews	Emergency Department	Women (N = 48) who experienced miscarriage (20 weeks or less) in the past 4 years and had consulted one of the 4 ED where the study took place. Age range 22–41 years old Participants’ ethnicity not disclosed in the paper	To identify characteristics of care management that may have contributed to the difficulties experienced by women presenting with miscarriage in the emergency department.	Analysis of the data revealed the experience of women who miscarried in the emergency department was characterized by lack of information at 3 critical junctures: announcement of the miscarriage, course of the miscarriage, and ED discharge. Respondents identified lack of information throughout the process as a recurrent factor that exacerbated the already difficult nature of this event. Although lack of information negatively influenced participants’ experiences in different ways, they shared the belief that having more information would have alleviated their difficulties. The majority of participants reported feeling unprepared emotionally and physically at the time of discharge, with long-term effects on their psychological well-being.
Linnet Olesen et al., 2015 [30]	Denmark	Qualitative- Interview	Hospital setting (not specified)	Women who experienced miscarriage and chose and completed either medical, surgical or expectant management of miscarriage. Age range 30–41 years old Participants’ ethnicity not disclosed in the paper	To gain insight into the decision-making process for the treatment of miscarriage and the circumstances that may affect it.	Unspoken emotional considerations dominated women’s reasons for choosing a specific treatment, despite pre-treatment counselling that provided detailed information about the different treatments’ efficacy and risk of side effects. Sometimes, these reasons were grounded in unrealistic beliefs about the course of the treatment. Women kept their reasons to themselves, and the HCPs did not explore them.
MacWilliams et al., 2016 [39]	Canada	Qualitative- Interview	Emergency Department	Women (N = 8) who had sought treatment in ED while actively miscarrying and subsequently experienced a completed miscarriage. Gestation at time of the loss 5–14 weeks. Age range 21–36 years old Participants’ ethnicity not disclosed in the paper	To explore the experience of women who attended the ED while experiencing miscarriage	Participants reported feeling isolated during discharge and after leaving the emergency department because of the lack of support and acknowledgment from HCPs, family, and friends. Having a miscarriage and receiving treatment for a miscarriage in the emergency department was a traumatic experience that had a lasting emotional impact on all the women in this study.
McLean and Flynn, 2013 [37]	Australia	Qualitative	Hospital setting (not specified)	Women (N = 6) who attended a hospital for a miscarriage in the first 20 weeks of pregnancy Age ranged 31–41 years old Participants’ ethnicity not disclosed in the paper	To establish a localised knowledge from a social work perspective of women’s experiences of hospital treatment after miscarriage	This study revealed that the medicalisation of miscarriage has excluded likely emotional and psychological effects from consideration. Women subsequently experience a lack of acknowledgement and compassion from the attending hospital staff, who treat them in an inconsistent, ad hoc fashion.
Meaney et al. 2017 [35]	Republic of Ireland	Qualitative	Maternity Hospital	Women (N = 10) and Men (N = 6) who experienced miscarriage (5–16 gestational weeks) Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To explore the experiences of women and men of miscarriage diagnosis and management	Analysis of the data indicated six themes in relation to the participant’s experience of miscarriage: acknowledgement of miscarriage as a valid loss, misperceptions of miscarriage, the hospital environment, management of miscarriage, support and coping, reproductive history and implications for future pregnancies.
Miller et al., 2019 [34]	USA	Mixed-methods	Emergency Department/Ambulatory settings	Women (N = 54) who had an ultrasound diagnosis of anembryonic gestation or embryonic or foetal demise in the first trimester (5–12 completed weeks of gestation). 1st group 25 attended the ED for miscarriage- within this group 20 completed an interview 2nd group 29 an ambulatory setting- within this group 25 completed an interview Age < 30 and > 30 noted in the paper Participants’ ethnicity Hispanic 2 Non-Hispanic 52	Sought to characterise the timeline from presentation to resolution in patients with miscarriage attending ED and ambulatory settings, as well as patient satisfaction with miscarriage management among these two groups.	The ED patient experience was qualitatively associated with greater patient confusion and less satisfaction, similar to other qualitative studies of miscarriage care in the ED where patients reported poor communication, unfriendly environment, and a lack of emotional support. Participants who sought care in the ED had longer time to miscarriage resolution and a greater number of care teams involved in the miscarriage diagnosis and management.
Miller et al. 2019 [36]	Australia	Qualitative	Hospital setting (not specified)	Men (N = 10) who’s partner experienced miscarriage Age range 29–49 years old Participants’ ethnicity not disclosed in the paper	To explore miscarriage from a male partner perspective, and men’s needs for additional support.	Men commonly reported a lack of emotional support from healthcare and social networks at the time of miscarriage. Men may have even less support around them at the time of miscarriage, with many stating that healthcare providers, and family and friends directed their acknowledgement and support toward their partners rather than themselves at the time of their loss. Support services and information were also largely targeted at women, leaving men feeling very isolated and alone at the time of miscarriage, and consequently they turned to online forums for support and to share their experiences of miscarriage.
Murphy and Merrell, 2009 [33]	United Kingdom	Qualitative	Gynaecological Unit	Women (N = 8 who had an early miscarriage Health professionals (N = 16) Age range 30–59 years old Participants’ ethnicity not disclosed in the paper	To explore women’s experience of having an early miscarriage in a hospital gynaecological unit.	The hospital settings emerged as highly influential in shaping the care that was given to women and influencing their experiences. Three clear phases emerged in women’s experience of miscarriage: first signs and confirmation of miscarriage, losing the baby and aftermath.
Murphy and Philpin, 2010 [6]	United Kingdom	Qualitative	Early Pregnancy Assessment Unit	Women who had an early miscarriage Health professionals (N = 16) Age range 30–59 years old Participants’ ethnicity not disclosed in the paper	To explore women’s experience of having an early miscarriage in a hospital gynaecological unit.	The findings presented here focused on the woman’s experience of their miscarriage with the physical symptoms of pain and blood loss being very important. There was a tension between the idea of early miscarriage as losing a baby and the actual reality of their physical experience.
Nash et al., 2018 [31]	Republic of Ireland	Qualitative	Maternity Hospital	Midwives (N = 8) caring for women with early pregnancy loss Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To explore the perception of midwives caring for women experiencing early pregnancy loss.	There were three main themes identified in the data analysis. These were: midwives coping with the experience of early pregnancy loss; resourcing compassionate for women; and what midwives found difficult. This study reported that exposure to early pregnancy loss can have a profound emotional effect on midwives, with a potential for this to influence the care provided to women.
Norton and Lynn, 2018 [32]	United Kingdom	Qualitative	Early Pregnancy Assessment Unit	Women (N = 10), who experienced miscarriage within the first 12 weeks of gestational period and had not experienced a previous miscarriage Age range 21–44 years old Participants’ ethnicity Asian 2 White 8	To explore how women experience care within an early pregnancy assessment unit and how they are helped to understand, reconcile and make sense of their loss and make informed decisions about how they care will be managed following first trimester miscarriage.	Findings from this study have some important implications for managing the care of women and their partners from the point of seeking initial help from their midwife or GP through to the provision of care in the EPAU. Individualised care is required to ensure that women and their partners do not feel ‘dehumanised’ in a system that they do not understand. The provision of individualised care, respect for women’s opinions and appropriate clinical information is imperative to those experiencing miscarriage. This is important because women respond to miscarriage differently. Furthermore, staff need to give equal consideration to women’s emotional needs as well as their physical needs to help them relieve their level of distress which in turn may help their recovery after miscarriage.
Punches et al., 2019 [29]	USA	Qualitative	Emergency Department	Women had to be between 18 and 45 years old who had experienced a pregnancy loss and were discharged home to self-care from ED department. Age range 21–34 years old Participants’ ethnicity African American 4 Caucasian 4	To describe the contemporary perspectives of women experiencing a pregnancy loss in the ED.	Women perceived that healthcare workers are withholding information and that the providers do not understand their experience. Additionally, the participants described methods of assisting with the grieving process that were beneficial, as well as some that were disconcerting.
Rowlands and Lee, 2010 [28]	Australia	Qualitative	Hospital setting (not specified)	Women (N = 9) who had experienced miscarriage in the previous 2 years Age range 35–42 years old Participant’s ethnicity European 6 Asian 2 Australian 2	To identify how to support Australian women after miscarriage.	Findings suggest that this lack of empathy and recognition can have a profound effect on the woman’s grieving process. Acknowledging the loss has been identified as an important part of coping with miscarriage. Two women in this study found that formal and informal ceremonies provided them with some closure and provided a meaningful way to acknowledge the loss. Acknowledging the loss was identified as an important part of coping with miscarriage. Two women in the study also found that formal and informal ceremonies provided them with some closure and provided a meaningful way to acknowledge the loss.
Schreiber et al. 2016 [27]	USA	Mixed-methods	Emergency Department	Women (55 participants in total for quantitative part 15 interviewed) who experienced miscarriage. A patient was eligible to participate if she was 1) 18 and over, 2) had an ultrasound diagnosis of an anembryonic gestation or embryonic or foetal demise in the first trimester (5–12 completed weeks of pregnancy) confirmed by 2 clinicians, neither of whom were the investigator of record, 3) willing to provide informed consent, and was 4) English speaking Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To understand patient and physician factors that might impact treatment choice and ultimate satisfaction with the goal of informing improvements in patient-centered care miscarriage care	Results suggested that women new to pregnancy rely more heavily on their clinician for guidance, and that they might benefit most substantively from care from providers with expertise in miscarriage management experiences and outcomes. Women reported the importance of having control and self-determination in concluding their miscarriage in a timely manner. Satisfaction with management is driven by the experience with the care received, rather than one specific therapeutic option over another. Satisfaction was mainly driven by efficiency of care, confidence in quality of care, sensitive providers, and effective two-way communication. Both the physician and patient-level data show alignment in considering the individual needs of the patient as well as her external demands when choosing a course of treatment.
Sejourne et al., 2010 [26]	France	Quantitative	Semi-private clinics	Women who had undergone DC or VA for the uncomplicated and anticipated loss of a pregnancy 134 women included in the study 66 assigned to one group 68 assigned to second group Age range 22–43 years old Participants’ ethnicity not disclosed in the paper	To verify if a single-session intervention based on CBT techniques including psychoeducation along with empathetic emotional support would be beneficial for women dealing with miscarriage. If CBT can be applied to preventing the psychological distress associated with a miscarriage	At 3 weeks post-miscarriage, the women in the control group had higher scores on anxiety. There were no significant differences at either 10 weeks or 6 months post-miscarriage with regards to symptom intensity. At 10 weeks, more women in the control group showed elevated scores on depression.
Smith et al. 2020 [25]	United Kingdom	Qualitative	Hospital setting (not specified)	Parents who had a miscarriage between 20 to 24th weeks of gestation. 38 parents (10 parent pairs; 18 mothers) Age of participants not disclosed in the paper Participants’ ethnicity not disclosed in the paper	To explore the healthcare experience of parents whose baby died either before, during or shortly after birth between 20 and 20th weeks of gestation in order to identify practical weys to improve healthcare provision	The key overarching theme to emerge from the interviews with parents was the importance of terminology used to refer to the death of their baby. Parents who were told they were “losing a baby” rather than “having a miscarriage” were more prepared for the realities of labour, birth experience and for making decisions around seeing and holding their baby. Appropriate terminology validated their loss, and impacted on parent’s health and wellbeing immediately following bereavement and in the long term.
Verhaeghe et al., 2020 [24]	France	Quantitative	Emergency Department	Women (N = 72) who had a confirmed diagnosis of first trimester pregnancy loss. Intervention group 45 consultation before the training Control group 27 consultation after the training Age range 28–36 years old Participants’ ethnicity not disclosed in the paper	To address the impact of a simulation training program for residents for the disclosure of diagnosis on the psychological experience of couples following a first trimester pregnancy loss.	Significant improvement in the couples’ personal experience and a significant decrease in the psychological morbidity associated with the disclosure following training. Attitude of the physician announcing the pregnancy loss was significantly improved, and the global perinatal grief score was significantly lower after training. Information provided was more complete and easier to understand, with fewer patients requiring an additional consultation to address uncovered issues. Overall, the study showed an objective improvement in the patients’ psychological morbidity following simulation training of the residents announcing the diagnosis, thus demonstrating a direct benefit of simulation training for patients.