British Journal Of Midwifery - Parents' experiences of clinical care during second trimester miscarriage

The Royal College of Obstetricians and Gynaecologists (2010) define second trimester miscarriage as pregnancy loss after 12 weeks and before 24 weeks' gestation. A study conducted in a large Dublin maternity hospital reported a rate of second trimester pregnancy loss of 0.8% (Cullen et al, 2017a). The admission to hospital has been identified as a critical part of the women's experience of miscarriage and can greatly influence the women's recovery after a pregnancy loss (Stratton and Lloyd, 2008; Siassakos et al, 2018).

While there is limited research specifically examining parents' experience of hospital care during second trimester miscarriage, there is a body of evidence examining parents' experiences of hospital care before, during and after perinatal loss (Lee, 2012; Downe et al, 2013; Basile and Thorsteinsson, 2015; O'Connell et al, 2016; Siassakos et al, 2018), which helps to inform the discourse on these issues for parents following a second trimester miscarriage. The majority of parents were positive about the quality of care they received from medical staff (Lasker and Toedter, 1994; Lee, 2012; Downe et al, 2013; Basile and Thorsteinsson, 2015; O'Connell et al, 2016; Siassakos et al, 2018) but did report that their distress following miscarriage could be intensified by dissatisfaction with aspects of care (Stratton and Lloyd, 2008). The literature highlights the importance of adequate pain relief, the clinical area in which the women is cared for, memory-making, and follow-up for bereaved parents. This study will explore whether these needs are similar for parents with second trimester miscarriage.

Study aim

The overall aim of the study was to explore mothers' and fathers' experiences of second trimester miscarriage. In particular, this article will report on mothers' and fathers' views on the clinical care received in the hospital from the time of diagnosis of the second trimester miscarriage through to follow-up care.

Methods

Ethnography provides a holistic view of a particular culture with historical roots in anthropology (Polit and Beck, 2011). According to Holloway and Todres (2006), when aiming to gain an ‘insider view’ of patient's experience, ethnography is a suitable method to consider. The main features of the ethnographic approach are the use of thick description, data collection from observation and interviews, selection of key informants and settings and an emphasis on culture. A focused ethnographic approach is problem-centred and provides a better understanding of specific aspects of individuals' ways of life, producing findings that are generally meaningful and applicable to practice (Cruz and Higginbottom, 2013). Miscarriage is often not openly discussed, which can compel bereaved parents to remain silent about their experience, and may prevent them from seeking support (Mander, 2006). This study set out to learn from bereaved parents in order to better understand their views of hospital care during a second trimester miscarriage. The cultural aspect of pregnancy loss greatly influenced the decision to take a focused ethnographic approach. Lincoln and Guba's (1985) principles of credibility, dependability, confirmability and transferability to ensure rigour were adhered to throughout the study.

Participants

The population for this study was women and their partners who experienced a second trimester miscarriage at a large Dublin maternity hospital. Parents were contacted 6–24 months after a second trimester miscarriage, a time frame that would allow participants to recall events, but would also give sufficient time for recovery. Purposive sampling was used, with a list of inclusion and exclusion criteria drawn up after consultation with the bereavement team in the hospital. The bereavement midwives acted as gatekeepers and wrote to potential participants, explaining the study and including a consent form to allow their contact details to be released to the researcher. Once the signed consent form was received, parents were contacted by the researcher to discuss the study further and arrange an interview. A total of 14 parents (nine mothers and five fathers) participated in the study and parents were recruited until data saturation was achieved. All fathers participated with their partner.

Data collection and analysis

A series of semi-structured interviews were completed with nine mothers and five fathers. Each parent took part in one interview. Most parents were interviewed separately but one couple were interviewed together at their request. Interviews were audio recorded and transcribed verbatim. Thematic network data analysis (Attride-Sterling, 2001) was used to systematically extract basic themes (the simplest themes found in the data), organising themes (categories of basic themes grouped into more abstract principles) and global themes (superordinate themes summarising the main principles in the data overall) (Attride-Stirling, 2001). Two global themes were identified in the study: ‘relational and social experiences of miscarriage’ and ‘clinical care needs’.The second theme has been previously discussed by Cullen et al (2017b), and so the central focus of this paper is the second global theme (Figure 1).

Figure 1. Themes and sub-themes that emerged during data analysis

Ethical considerations

The researchers adhered to the ethical principles of autonomy and informed consent; beneficence and non-maleficence; justice and respect; confidentiality; veracity; and fidelity at all times in the research process (Nursing and Midwifery Board of Ireland, 2007). Ethical approval for this study was granted by both the hospital and university's ethics committee. Consent was sought at multiple stages throughout the research process, with participants given the option to withdraw at any stage without consequences to their care. The potential of emotional distress for participants due to the sensitive issues being discussed was managed using a detailed protocol. Following interviews, parents were given contact details for the bereavement team in the hospital and support agencies relating to pregnancy loss.

Findings

The findings reported in this paper are from the second global theme, ‘clinical care needs’ (Figure 1). A total of 14 parents (9 mothers and 5 fathers) participated in this study. The mothers' ages ranged from 30–40 years (the fathers ages were not recorded) the mean gestational age at the time of the miscarriage was 16.88 weeks (SD=1.36). Participant information is contained in Table 1. In order to maintain confidentiality, all parents were allocated a pseudonym and have been referred to by their pseudonym throughout the study.

Table 1. Description of the participants

	Mothers (n=9)	Fathers (n=5)
Age	30–42 years
Gestational age	15–19 weeks	16–19 weeks
Ethnicity
Irish	8	4
Asian	1	1
Mother's obstetric history
First pregnancy	3
Previous miscarriage	5
One or more children	5
Length of time following miscarriage	7–23 months

Medical care

The organising theme of ‘medical care’ highlights parents' experiences in relation to various aspects of the care that they received during second trimester miscarriage, discussed under five basic themes: ‘medical treatment received during the miscarriage’, ‘pain relief’, ‘length of hospital stay’, ‘going home to prepare for the delivery’ and ‘the follow-up appointment’.

Medical treatment

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.

‘I can't recall exactly how long I was waiting but it was certainly about an hour or two … it is a very busy area and nobody is really paying too much attention to you because they are all so busy.’

(Emily, 19/40).

Five of the women talked about difficulties in taking bloods and reported numerous attempts by staff before blood was taken successfully.

‘That was the thing I found hardest for a long time afterwards, seeing all the bruises … so every time I looked for weeks after … a physical scar to remind you of what you had gone through.’

(Deirdre, 16/40).

Pain relief

The majority of mothers described the process of labour and delivery as ‘severe’ or ‘horrible’ pain, ‘strong’ and ‘extremely painful’. Three of the women who delivered in the hospital were happy with the pain relief they received and trusted their midwife's advice regarding pain relief, saying, for example:

‘The pethidine was fine and I felt reassured, the midwife said it would be enough; it is not the same as full labour. I trusted her then and she went with pethidine and it was fine.’

(Deirdre, 16/40).

Two women and their partners described severe pain during attempts to deliver the placenta when they were admitted to the hospital, and felt they didn't receive enough analgesia during this time.

‘I was in serious pain … I know I was shouting a lot.’

(Ciara, 16/40)

Length of hospital stay

Almost all of the parents interviewed were happy with the length of hospital stay. Most women stayed in hospital less than 24 hours and were happy to go home. One mother would have liked the option of staying another night, but the majority of parents described wanting to go home as soon as possible.

‘We literally got out as soon as … we just wanted to get out. It was very traumatic.’

(Michelle, 19/40)

Going home to prepare for delivery

The local hospital policy when a second trimester miscarriage is diagnosed is to administer mifepristone and allow the mother to go home for 48 hours. 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.

‘It is just horrendous, you are left for two days knowing your baby is … but equally I found that period of time you needed to process what was going on.’

(Emily, 19/40)

The mothers had different opinions about the support needed from the hospital during that time, with some parents saying that they would have liked more contact:

‘A house visit or something might have been good … you are just processing, and then life is going on around you … So I think a house visit would have helped.’

(Emily, 19/40)

‘I suppose they had said to phone at any time, but it was from my family I felt very supported.’

(Orla, 17/40)

Follow-up care

The majority of parents were satisfied with their medical follow-up, and all but one mother had a follow-up appointment after the miscarriage. Some parents explained that discussing the circumstances of the miscarriage gave them some closure and helped them to move on.

‘So I closed a chapter there…’

(Ciara, 16/40)

Parents talked about the importance of a follow-up appointment to get the results of any investigations and to discuss future pregnancies.

‘It's unlikely that it [second trimester miscarriage] will happen again so that was really good to know.’

(Michelle, 19/40)

The organising theme of ‘medical care’ reports on parents' experiences of various aspects of their medical treatment during second trimester miscarriage. Overall, parents were satisfied with the medical care they received, highlighting the importance of adequate pain relief throughout labour and the value of follow-up care.

Facilities

The organising theme of ‘facilities’ highlights the issues parents faced in relation to the hospital environment. This theme is discussed under three basic themes: ‘being separate’, ‘hospital facilities for mothers’ and ‘hospital facilities for fathers’.

Being separate

The majority of parents discussed the importance of being separated from other pregnant women and babies when experiencing a miscarriage. In total, seven parents (two fathers and five mothers) were cared for on the antenatal ward, while seven (three fathers and four mothers) were cared for on the gynaecology ward. Parents reported distress and upset caused by seeing other pregnant women and hearing babies crying, saying, for example, that after a miscarriage:

‘You are absolutely allergic to any other pregnant woman.’

(Emily, 19/40)

Being separate from pregnant women appeared to be very important to bereaved parents during outpatient appointments, casualty visits and when admitted to the hospital. Emily reported the distress she felt when waiting in a crowed waiting room in the casualty department.

‘I was getting more and more upset … I couldn't really understand why the hospital didn't have a more separated area … It is not something a woman in any miscarriage situation should have to do.’

(Emily, 19/40)

Parents reported distress at being cared for in the same area as women with healthy pregnancies and hearing babies crying. David found it very difficult being surrounded by other pregnant women and the memories of their previous deliveries.

‘We had all these, kind of, pregnant women marching around the place in various stages of labour … that probably wasn't ideal … It's a place where, where most people would associate very happy memories … but not for us on that day.’

(David, 16/40)

Eugene also described the upset that he and his partner felt when they left the room and saw other pregnant women:

‘Going out to the toilet and there was pregnant women sitting right outside your door … you could have some kind of separate part … Because that was literally the hardest thing.’

(Eugene, 19/40)

Hospital facilities for mothers

The majority of mothers were cared for in a single room either in the antenatal or gynaecology ward during their hospital admission. Most parents were satisfied with the overall facilities but had a number of suggestions that could improve the facilities in these single rooms. Mothers reported finding it difficult to leave the room to use the bathroom and felt an en-suite bathroom would have been easier.

‘I would have had to go to the toilet just across the way … it was really really difficult … I suppose there isn't much of a choice but there should be.’

(Michelle, 19/40)

Jack felt that a television in the room and brighter decor would have been helpful.

‘The TV, she had it on and it was scrambled, and I felt really bad, she was lonely, obviously … it is was bit old fashioned … it was very clean … just a bit more brighter it would be less depressing.’

(Jack, 16/40)

Hospital facilities for fathers

Both mothers and fathers highlighted a lack of facilities for bereaved fathers, such as facilities for them to stay overnight and toilets for men. The only male toilet for the hospital is on the ground floor, and a number of fathers discussed this as an issue

‘The men's toilet is diabolical really to be honest.’

(Jack, 16/40)

Mark did not want to go home and leave his wife when she was admitted overnight in the high dependency unit, but reported that there were very limited facilities for him.

‘I literally went lie on a bench. It would have been nice to have somewhere proper to sleep the bench was really narrow.’

(Mark, 17/40)

Parents' experiences of hospital facilities highlighted the importance of separation from other mothers and babies. It was also clear that the facilities provided for bereaved fathers—particularly toilets and for overnight stays—could make a lasting impression on parents.

Information

The third and final organising theme in the global theme of clinical care needs was ‘information’. This theme highlights parents' needs in relation to the information they received from medical professionals during a second trimester miscarriage, and highlights the importance of clear communication.

Clear communication

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.

For example, Kate said that she valued honest communication from her consultant throughout a difficult pregnancy:

‘We were told at 12 weeks. He was very clear about … He was very black and white about things, which I found hard at the time, but I much appreciated later on.’

(Kate, 17/40)

Parents explained the importance of information regarding the process of labour and birth. Mark felt everything was explained very well to both him and his partner.

‘She was explaining everything, the pros and cons, and just making sure you know the dangers if she hadn't delivered, and those issues and complications.’

(Mark, 17/40)

Some parents felt they should have received more information about the analgesia given during their hospital admission, such as Jack, who said:

‘They gave her some gas as well for the pain but for me they didn't really explain to her how to use it properly … maybe if they had told her how to use it properly it might have helped a little bit.’

(Jack, 16/40)

Why did this happen?

The majority of parents discussed a desire to find out why they had experienced a miscarriage. Both mothers and fathers discussed the importance of receiving a clear explanation of the results of investigations, and said that finding out what happened helped support them to move forward after the loss.

‘That doctor was very good and he told us the information and everything … It gave it a little bit of closure to it.’

(Jack, 16/40)

The organising theme of ‘information’ highlights parents' desire for clear communication from health professionals, and that finding out why their miscarriage occurred was also of great significance.

Discussion

‘Medical care’ emerged as a significant theme in this study. Although the majority of mothers were satisfied with their overall care, some parents highlighted areas that could be improved. Physical pain is experienced by the majority of women following a miscarriage (Adolfsson, 2010; Séjourné et al, 2010) and although adequate pain management during miscarriage has been discussed (Gold et al, 2007; Cullen et al, 2017a), there is little evidence in the literature on what constitutes effective analgesia and on women's preferences during miscarriage. This study adds to this discourse by highlighting issues on pain management in labour for women who give birth during the second trimester.

There is a lack of research examining parents' experiences of returning home to prepare for a second trimester miscarriage. A number of studies examining the experiences of mothers waiting for induction following an interuterine death (Malm et al, 2011; Erlandsson et al, 2011) reported women being left with unanswered questions (Malm et al, 2011) and that waiting added further stress and psychological trauma (Erlandsson et al, 2011). These findings concur with previous studies, where parents described the waiting time as difficult, but also adds that parents also valued the time to come to terms with their loss and to make practical preparations for their hospital stay and the birth.

Bereaved parents' desire to know the reasons for miscarriage can make the experience more difficult—particularly if there is no reported cause. The importance of clear communication from health professionals is highlighted in the literature (Nikcevic et al, 1998; Simmons et al, 2006; Mulvihill and Walsh, 2013), which shows that when a cause is identified, women are reassured. If not, many couples may blame themselves or their lifestyle choices (Simmons et al, 2006; Jansson and Adolfsson, 2010). Parents in this study reported that discussing the cause of their miscarriage gave them a sense of closure.

Almost all parents in this study discussed ‘being separate from other pregnant women and babies’ as very important, concurring with previous studies (Gold et al, 2007; Mulvihill and Walsh, 2013; Peters et al, 2016). The most suitable place of care for women who experience a second trimester loss remains unclear; however, the emerging evidence from this study and the literature, is that parents valued being cared for in an area away from other pregnant women and the sounds of babies crying.

This was a qualitative study conducted with participants from one hospital in Ireland and some caution is needed. There is some variation in the care that parents received during second trimester miscarriage, and some findings may not be transferable to other hospital settings. The researcher's experience in caring for bereaved parents in both clinical areas and as part of the bereavement team may have influenced the analysis of the data for this study, although a reflective diary was used by the researcher to reduce bias, and the research process was described in depth. Notwithstanding its limitations, this study provides valuable information on the care needs of a vulnerable group of parents.

Conclusion and recommendations

Second trimester miscarriage is a significant life event for parents. Effective, compassionate clinical care, individualised to meet the needs of bereaved parents, has the potential to impact positively on their experience. Areas for further research include pain relief options, and parents' experiences of going home after the diagnosis of a second trimester miscarriage.

Key points

Second trimester miscarriage (pregnancy loss from 12-24 weeks' gestation) is a very difficult experience for parents

Parents highlight the need for effective medical care, appropriate facilities and information provided in a clear and sensitive manner.

Parents expressed a desire to be cared for in an area away from other mothers and babies.

Clear communication and finding a cause for their miscarriage was also very important for parents.