‘It’s not just a pap-smear’: Women speak of their experiences of hospital treatment after miscarriage

Abstract

This exploratory study sought to investigate how a small sample of self-selected women attending hospital for a miscarriage in the first 20 weeks of pregnancy experienced the treatment they received. Six women who had a miscarriage between June 2006 and December 2007, and sought treatment at six Melbourne metropolitan hospitals, participated in semi-structured interviews during August–September 2008. Thematic analysis revealed that participants perceived hospital responses to miscarriage to be inadequate. Findings suggested that there was no consistent response, there was little compassion or acknowledgement of the miscarriage and that information provision was largely absent; social workers were rarely involved. Participants indicated that they wanted a more consistent and specialized hospital response, with timely access to diagnostic testing equipment as necessary, the offer of social work, information provision and staff to be compassionate in their care and to acknowledge their pregnancy loss.

Keywords

Hospital social work hospital treatment miscarriage women’s health

Introduction

In recent years the Australian media has highlighted inadequate responses to women attending hospital emergency departments for miscarriage diagnosis and treatment, particularly noting an apparent lack of compassion or regard for the emotional needs of those women (see AAP, 2009; ABC News, 2009; Cresswell and Clayfield, 2009; Smith, 2007). In two cases in New South Wales (NSW), and a more recent case in Victoria, it was reported that the women were left waiting in the hospital emergency department while their pleas of impending miscarriage were ignored by hospital staff, resulting in those women eventually ‘passing’ their dead babies into the hospital’s public toilet (ABC News, 2009, 2011).

It is estimated that approximately one in four pregnancies end in miscarriage (Hurley, 2001), with most of these occurring before the twelfth week of gestation. Approximately fifty thousand Australian women experience a miscarriage every year (Evans et al., 2002) and miscarriage could be described as a normal outcome of reproductive attempts (Herbert et al., 2009). Despite the frequency of the experience, miscarriage is often overlooked, both by the community and health professionals (Cote-Arsenault et al., 2001 in Stratton and Lloyd, 2008) and even amongst women themselves. In the current study, miscarriage was defined, as it is most commonly in recent literature (Armstrong, 2004; Brier, 1999; Kluger-Bell, 2000; Stratton and Lloyd, 2008), as an unintended loss or interruption of pregnancy in the first 20 weeks. This definition is also shaped by the legal requirement in the state of Victoria, Australia, that all births/deaths over 20 weeks’ gestation be registered (Births, Deaths and Marriages Registration Act, 1996).

Despite its apparent absence in the cases described above, social work has a long established role in health care, particularly in hospitals. In this environment, social work has a dual focus: attending to the emotional and social context of patients and acting as a conduit, both of information and to the community (Beder, 2006). Social workers bring specific and necessary skills to hospitals. They create safe spaces within busy wards for patients to talk, they communicate, network and advocate with other medical and allied health staff (Gibbons and Plath, 2009; Stevenson and Unwin, 1990), and bring a multi-dimensional framework to presenting problems. Given that miscarriage is not merely a medical condition or event, but is an emotional experience, with consequences stretching beyond the hospital stay, social work would seem well placed to serve the best interests of patients.

The impact of miscarriage

There are few studies which focus on women’s experience of miscarriage; Australian research is particularly sparse. Much of what is available is of a medical nature and focuses on risk factors or on treatment for miscarriage once it has occurred. Indeed, Gerber-Epstein et al. (2009) advise that it is only in the past two decades that broad social science research has focused on this area of need.

Some have argued that it is the very frequency of miscarriage that detracts attention from examining its emotional consequences (Bloch and Singh, 2004; Goldsworthy, 2005). At the time of writing, there were no consistent findings about the impact of miscarriage upon grief and loss. Almost two decades ago, Cuisinier et al. (1993) reported similarities with other experiences such as stillbirth and recommended acknowledgement and response by hospital services. Broader examination of the issue by Mander (2006), however, showed less consistent findings. What is evident is that with ‘no … public way in which a … miscarried baby can be marked, no consoling rituals … no commonly accepted ways of coming to terms with bereavement’ (Layne, 2003 in Frost et al., 2007: 1018), the grief of miscarriage differs from other types of grief.

Some of the reported consequences of miscarriage for women include: feelings of emptiness, helplessness, self-blame, low self-esteem, and anger (Stratton and Lloyd, 2008); insomnia, withdrawal, guilt and marital strain (Bloch and Singh, 2004). Consequently, Brier (1999) argued that women’s relationships with treating staff are vital; these relationships have been shown to have a significant impact on shaping women’s experiences (Rowlands and Lee, 2010). Similarly Boyce et al. (2002) and Séjourné et al. (2010) have suggested that a comprehensive style of managing miscarriage should be introduced to provide holistic support to mothers, incorporating psychological and medical support. Such management would also provide screening opportunities and education for women who appear to be at risk of abnormal grief (Frost and Condon, 1996 in Wong et al., 2003). Recent research has also shown a negative emotional impact, albeit short-term, on fathers experiencing miscarriage (Kong, Chung et al., 2010); it is beyond the scope of this article, however, to discuss this further.

The hospital experience for women

Simmons et al.’s (2006) exploration of 172 women’s experience of miscarriage in the UK identified five key findings, with two of these focusing specifically on the treatment women receive at the hospital. Participants reported that interactions with hospital staff played an important role in how their miscarriage experience was shaped, and specifically, that more compassion, sympathy, acknowledgement and offers of support were needed from hospital staff. That women feel ‘unsupported’ by healthcare professionals has been echoed in other research (Cuisinier et al., 1993; Evans et al., 2002). This has resulted from a perceived lack of attention (Wong et al., 2003), feeling disempowered, receiving inadequate information (Harvey et al., 2001; Rowlands and Lee, 2010; Séjourné et al., 2010), or feeling that their loss is not acknowledged (Cecil, 1994 cited in Brier, 1999).

As a result of the medicalization of women’s health, miscarriage tends to be seen as a brief event that may or may not need intervention, depending on the clinical diagnosis. Frost et al. (2007) argued that this medicalization detracts from a situation of complexity which, as already reported above, can have far-reaching psychological, social, emotional and practical consequences, beyond the cessation of ‘medical’ needs. In their investigation of women’s experiences after miscarriage, Wong et al. (2003) found that women reported communication difficulties with staff which resulted in them leaving hospital poorly informed, and further that the type of care they received depended on the individual staff they encountered. Stratton and Lloyd (2008) and Simmons et al. (2006) identified similar concerns about this lack of information provision and insensitivity of health professionals deeply affecting women’s experiences. A meta-analysis by Brier (1999) and a small qualitative study by Rowlands and Lee (2010) both reported that many women judge their treatment by doctors as inadequate and insensitive, and indicated that they had no opportunity to talk about their loss.

Frost et al.’s (2007: 1019) study of 79 UK women who had miscarried recommended that all medical and nursing staff be ‘encouraged to talk through’ miscarriages with women to help normalize the process, and that printed information be freely available within hospitals. Harvey et al. (2001) similarly recommended the introduction of holistic care and of a primary care nurse, the offer of counselling within the hospital environment, and that women are offered printed information about what to expect following a miscarriage. Importantly, they asserted that nurses should be educated to improve their therapeutic communications, particularly on how best to navigate the often brief stays of their patients. Interestingly, the recent findings of Séjourné et al.’s (2010) French study of the self-identified support needs of 305 women who had experienced miscarriage vary somewhat. Although almost one-half of the respondents did not want printed information, and fewer wanted counselling, they did identify the need for immediate support at the time of diagnosis, suggesting a role for hospital social workers. The findings of Kong, Lok et al. (2010) in Hong Kong, also support the need for greater attention by hospital practitioners to psychological care. To date, little research has focused on how women perceive treatment responses by hospital staff within an Australian, or specifically Melbourne context, and what treatment needs they identify.

In Australia, women who seek hospital medical treatment for miscarriage generally attend the hospital’s Emergency Department (ED), which involves being assessed initially by nursing staff, having to wait in the general area and potentially being treated by a doctor with minimal gynaecological experience. This treatment process has been reported as unsatisfactory for many women (e.g. see Stratton and Lloyd, 2008). In response, Condous (2008) argued that Australian hospitals should embrace a new mode of treatment originating in the UK – Early Pregnancy Units (EPUs). EPUs are dedicated units that operate within a flexible woman-centred model and act as a central point for the medical, diagnostic and counselling needs of women. While this approach has been adopted by at least one Melbourne hospital (RWH, 2007), it has not followed the UK model of 24-hour opening. While advocates of EPUs (Alkatib, 2006; Condous, 2008) have reported on the success of EPUs in the UK, unsurprisingly, little research, evaluation or costing of EPUs has been undertaken in Australia.

The social work response

Whilst most of the studies previously conducted have not specifically examined the role of social work in the context of miscarriage, findings have pointed to the need for staff with social work skills to assist with the provision of care to women who miscarry (e.g. see Abboud and Liamputtong, 2003; Stratton and Lloyd, 2008). Only two social work-authored articles were located on this topic: a literature review investigating the existence of evidence-based, hospital-provided interventions for miscarriage (Stratton and Lloyd, 2008) and a qualitative study by Abboud and Liamputtong (2003), examining the meaning of pregnancy loss for six women and their partners and practice implications for social work. The latter reported findings which indicate that women’s physical and emotional pain must be acknowledged, that, similar to Séjourné et al. (2010) women need immediate support services ‘to facilitate recovery’ (Abboud and Liamputtong, 2003: 58) and that social workers should be mindful of the unique perceptions and experiences of those involved, offering individualized support. The effectiveness of such simultaneous medical and psychological support has been noted in previous research.

Women who miscarry can be affected by more than just the physical loss, with research suggesting that such consequences can be minimized with responsive hospital treatment. Whilst social work is ideally placed to take a leading role in both the provision of and research into such services, to date the profession has not done so. This study therefore aims to establish localized knowledge from a social work perspective of women’s experiences of hospital treatment after miscarriage.

Methodology

This study sought to investigate how women attending a hospital for a miscarriage in the first 20 weeks of pregnancy experienced the treatment they received. This is an important area given that previous research has indicated that the hospital experience is a key factor in women’s psychological and emotional reactions to their miscarriage.

This study was exploratory in nature and investigated how women felt their range of needs were addressed when seeking treatment or advice in a hospital setting. Generating ‘initial insights into the nature of an issue and [developing] questions to be investigated by more extensive studies’ is a key function of exploratory research (Marlow and Boone, 2005: 334). As described in the literature review, little is known about how Australian women experience their hospital treatment, especially from a social work perspective. This study sought to provide new directions for research by identifying themes which may promote more active investigation into this area of women’s health.

Important to the development of a responsive methodology, the authors’ review of previous research indicated that this had relied for the main part on quantitative data which, by its nature, can ‘hide’ the voices of participants. In comparison, this study utilized a feminist informed methodology and sought to gather qualitative data solely from women about their views and experiences of their miscarriage treatment. Qualitative methods are also appropriate for topics which are supported by little extant research because they produce rich data by being able to view the whole person within her environment (Rubin and Babbie, 2008). The chosen approach allowed the researchers to pursue topics presented by the participants, thereby ensuring appropriate attention to both knowledge building and the establishment of a more collaborative relationship with participants (Cosgrove and McHugh, 2000). A critique of previous research also indicated that the most effective and sensitive – given the topic – way of collecting qualitative data was through face-to-face semi-structured interviews (Marlow and Boone, 2005). It was important that the participants be able to express their own subjective experiences without stringent limits placed upon them, whilst in an environment which was supportive and which could respond appropriately to any distress experienced.

Ethical approval was obtained from the then Monash University Standing Committee on Ethics in Research involving Humans (SCERH).

Participants

Data was gathered during August–September 2008 and was confined to the Melbourne metropolitan area. Melbourne is the capital city of Victoria, Australia, with a population of approximately four million. To be eligible for participation in this study, women must have sought treatment at any hospital (public or private¹) in the defined area for a miscarriage with a gestation of 20 weeks or less, which had occurred between June 2006 and December 2007. The time-frame was to ensure that participants were able to provide data about contemporaneous experiences, but would not be discussing very recent, possibly upsetting, issues. Participants were recruited via a combination of availability and snowball sampling (Rubin and Babbie, 2008). The sensitive and hidden nature of the research problem, as well as the study’s exploratory aims, indicated these methods to be the most appropriate to source participants. An advertisement was placed on an online parenting forum – essentialbaby.com.au – as the largest available forum in Australia; an email containing an identical advertisement was also circulated to the first author’s network of colleagues; the latter then forwarded this onto their networks. A total of 12 women made contact with the primary researcher expressing interest in the study, with six women ultimately fitting the criteria and agreeing to participate. Whilst no incentives were offered, all interviews were conducted in locations convenient to participant’s homes and refreshments were provided during the interviews.

The sample size and location were limited due to the study’s practical constraints: data collection was limited to an eight week period, ceasing in September 2008. The study was also indirectly restricted to women from an English speaking background who had access to a computer, an email address and the ability to use the internet and interweb forums because of the chosen recruitment strategy. The authors acknowledge the limited nature of this study. Whilst a commonality of themes was evident in the data set, direct and broad application of these findings was not an aim of this study; rather it was to establish a basis for more extensive, locally informed research.

Data analysis

All interviews were conducted, audio-taped and fully transcribed by the first author; this author also coded and analysed all data. The second author engaged in peer review of the data and themes presented. To further ensure trustworthiness of the findings, all participants reviewed their transcripts and were provided with an overview of the themes identified by analysis. Thematic analysis was the chosen analytic method, due both to the exploratory nature of the study and the assumption that while some ‘general issues’ (Ezzy, 2002: 88) may already be suspected based on previous research findings, more specific themes would emerge during the analysis itself.

Results

Six women, ranging in age from 31–41 years, participated in this study; they are referred to by pseudonyms throughout this article. Each woman sought treatment at a different hospital. All reported experiencing at least one live birth; in all but one case this occurred prior to miscarriage. Four of the six participants experienced more than one miscarriage in the study time-frame. In these circumstances, the participants described both of these experiences and reflected on any differences they perceived in treatment they received; all four women returned to their original treating hospital on the second occasion. The differing experiences are denoted numerically after the participant’s name (e.g. Anna [1]).

The hospital experience

It was a lot of time just sort of laying there waiting. (Fran)

… you just see them all [various staff]; you don’t stay with one [staff member] the whole way through, and the way that it is structured, you can’t. (Debra)

To accurately map the interactions and treatments that participants received, pertinent information is presented in Table 1. As shown, there appears to be little consistent treatment response to miscarriage, except that eventually all women saw medical staff, either an obstetrician or ED doctor, as part of their hospital experience. Nurses were the most frequently encountered professionals, whilst social workers and midwives were the least. Of concern are the participants who reported contact with staff who did not identify themselves or their role.

Table 1.

Staff encountered by participants during their hospital experience.

Staff	Hospital type	ED Doctor	Obstetrician	Nurse	Midwife	Anaesthetist	Social Worker	Ultrasonographer	Unsure, not disclosed
Participant	Hospital type	ED Doctor	Obstetrician	Nurse	Midwife	Anaesthetist	Social Worker	Ultrasonographer	Unsure, not disclosed
Anna [1]	Public maternity	X	X	X	X
Anna [2]	Public maternity	X	X	X	X	X
Bettina [1]	Private maternity	X	X	X	X
Bettina [2]	Private maternity	X	X	X
Carla [1]	Private maternity	X	X	X
Carla [2]	Private maternity	X	X	X
Debra	Public	X	X	X	X
Elaine [1]	Public maternity	X	X	X	X
Elaine [2]	Public maternity	X	X	X
Fran	Public maternity	X	X	X	X	X¹

Fran reported having interactions with two separate staff members who failed to introduce themselves.

Staff contact

As indicated in Table 1, participants interacted with various staff during their contact with the hospital. Every participant saw either an ED doctor or an obstetrician; the latter largely dependent on attending a hospital with maternity facilities or being a private patient with their own obstetrician. Anna, the only woman to have had contact with an EPU during her hospital treatment, was the only participant to have seen a midwife during her experience. Likewise, she was also the only person who had contact with a social worker. The three participants who saw anaesthetists (Anna, Bettina, Carla) did so as part of the surgical management of their miscarriage. While every participant had an ultrasound in the process of their diagnosis, these were not always conducted by specialist ultrasonographers. Interestingly, four of the participants (Anna, Debra, Elaine, Fran) reported contact with staff who failed to disclose their role to them, with the latter two participants reporting that this occurred on two separate occasions. The following excerpt from the interview with Fran illustrates the unhelpfulness of this contact, which did not respond to her needs:

There was one woman who came in, and I only sort of vaguely remember this, because I think she was a mess, and she came in and she was comforting me, and all I remember her saying was ‘I know how you feel, I know how you feel’ and that’s all she said over and over again. When she left I said ‘what did she mean she knows how I feel?’

The diagnostic pathway

Participants’ diagnostic pathways varied greatly, even though the majority of women (Anna, Debra, Elaine, Fran) presented at ED departments of public hospitals, with what they described as ‘spotting’. Elaine, during her second miscarriage, spent between four and six hours in a public hospital ED waiting room before being seen, yet Debra and Fran were seen almost immediately. While Anna [1] initially attended an EPU for treatment for her miscarriage, due to the limited operating hours of the EPU, she ultimately presented at ED to receive the final diagnosis of miscarriage. A flow chart of her journey to diagnosis is given below, illustrating her contact with a range of staff over a period of days and the information with which she was provided.

As Figure 1 displays, there was considerable delay in Anna’s diagnosis. From her initial presentation it took ten days and four individual attendances at hospital to get a final diagnosis of miscarriage. In comparison, Bettina and Carla, with both of their miscarriages, were diagnosed by their respective private obstetricians and the trajectory of diagnosis was uncomplicated; they encountered few other treatment providers.

Figure 1.

Anna’s [1] journey to diagnosis.

Anna’s story is not uncommon among the participants. Although different ‘types’ of miscarriage exist (including for example, threatened miscarriages and ectopic pregnancies) indicating the need for different, and individually responsive, treatment approaches, participants in the current study clearly reported inconsistent responses to identical symptoms. These appeared to be shaped by both systemic and individual staff factors.

Does social work play a role in miscarriage treatment?

As indicated in Table 1, for the majority of participants social work intervention was not a standard feature of the hospital care they received, nor had they been offered a referral. Debra advised she had been offered ‘Nothing. That would have been great … just to be offered some information’. Elaine advised that she was similarly advised to ‘just go and see your GP’. Only one participant, Anna, had social work involvement. Unfortunately, Anna perceived this service negatively, as she saw that it had been imposed upon her rather than being responsive to her needs. She described waking up crying and emotional after a surgical procedure to treat her second miscarriage. She reported being told by nursing staff that she was ‘not allowed’ to go home until she spoke to a social worker. This left her confused and upset, with the feeling that staff could not cope with her emotional output.

That’s crazy – why can’t I be upset? (Anna)

Participant views on the hospital response

There’s not a personal side to it. (Carla)

Medical management

For some, the medical management of their miscarriage was a positive aspect of their experience. This was especially true of participants Bettina and Carla, reflecting the relationships they had developed with their private obstetricians prior to their miscarriages and the continuity of care they received. With her first miscarriage, Bettina praised her obstetrician and recalled that he hugged her and said ‘Look, I’m really sorry. I thought it was going to work out’. She also described a positive experience with the same obstetrician during her second miscarriage, in which he gave her the opportunity to make decisions about her treatment as well as ‘squeezing’ her in first on his operation list for the following day. This meant that ‘it was all very quick, I think I was home by eleven o’clock in the morning’. However, not all participants viewed their medical management so positively. Anna described her doctor’s ten attempts to use a speculum and his ultimate inability to locate her cervix as ‘pure incompetence’. Elaine [2] recalled asking her doctor for a medical certificate and was shocked to find, after being discharged, that the doctor had filled in ‘vaginal bleeding’ as the reason for her absence, instead of the more usual ‘medical condition’. Fran also recalled having an internal in which ‘they had just pulled out some stuff’, with no explanation.

Compassion

Analysis of participant data indicated that ‘compassionate’ treatment had three key elements: being seen promptly, being given clear information and having the miscarriage and the loss of a baby acknowledged. Staff providing such care were singled out for praise by participants:

The midwives were great. They were very good, compassionate [and] understanding. I think it’s very difficult if you haven’t been through it … But they showed as much compassion, as much understanding as they could, given their own experiences. (Anna [1])

Even the receptionist, she came in and got me some tissues and gave me some comfort, and explained the procedures of what would have to happen … and … also cancelled all of my bookings for, like, future scans and for my hospital stay and all that, so I actually thought the treatment was very caring. (Bettina [1])

A general lack of acknowledgement and compassion from all levels of staff was, however, more commonly expressed by participants. In relation to her first miscarriage, Anna described her obstetrician as ‘cold’. Similarly, Carla described being ‘treated like you’re having your wisdom teeth out or something’. The need for acknowledgement by the women related not only to the miscarriage experience. Most participants (Anna, Debra, Elaine, Fran) also felt more generally that their knowledge or experience of their own bodies was discounted by hospital staff.

All of the women described receiving inadequate or unhelpful information from hospital staff; this included a lack of basic information about what they could expect to experience physically, to staff using technical medical language in their explanations to women, a lack of detail on possible emotional consequences of a miscarriage or a failure to offer any written information or brochures about miscarriage. While one-half of the participants were offered printed information (Anna, Bettina, Debra), all thought it should be routinely distributed. Anna particularly commented that at her first miscarriage she would have preferred ‘more literature about dealing with miscarriage’. Participants reported leaving hospital with poorly informed expectations. Having been confused by unexplained technical terms Fran advised, ‘Dr. Google is wonderful! When I got home I worked it all out’. Debra also recalled lacking basic, yet important, information when she was sent home from hospital:

I had the sac … come away … I actually saw all the cells and fibrous materials … and it was such a shock … [They] didn’t tell me that was going to happen, I thought my womb was coming away … I was petrified. I didn’t dare move off the toilet. I was like ‘what the hell is this?’ It was awful.

Future hospital responses

It’s not about giving hope when there is no hope … people just want to know whether they are losing their baby … or whether everything is ok. (Elaine)

Medical management: A consistent and specialized response

Participants expressed a need for treatment to be more consistent and specialized. Fran identified the need to have ‘people who know what they’re doing, that specialize’ from the outset. Participants expressed awareness of the other pressing medical emergencies presenting to ED, and understood the triage system, but felt responses to miscarriage should be dealt with via a different process. Anna had experienced treatment in an EPU and along with Elaine felt that this service should be operating ‘twenty-four hours [a day]’, as should ultrasound. She further noted that:

They really need to have the equipment available … to bring somebody in and then say ‘well, you have to go home and come back tomorrow’ … it’s just terrible.

Participants were, however, realistic in their suggestions. Anna recognized that medically the hospital was limited in its response to her, that no one could reverse miscarriage symptoms or stop a miscarriage from occurring. However, she felt that the hospital could respond with ‘understanding and compassion’ by offering timely diagnostic tests and treatments. Furthermore, most participants wanted clear printed information about what to expect during or as a result of miscarriage, including medical and emotional impacts, and details of local support groups or services which could provide assistance to them if necessary (e.g. telephone counselling). Bettina reflected: ‘they are very good groups … to put that knowledge out there to women would be very helpful’. Carla recommended that ‘part of the admission process … have someone ask how you’re feeling, just to give the person the opportunity to talk a little bit about it and definitely getting the leaflets and information afterwards, just … yeah … acknowledgement of it’.

Information and support: The opportunity for social work involvement

Social workers were largely absent from participants’ hospital experiences. Yet when asked whether social work had a place in hospital care for miscarriage, participants responded positively. Responses typically indicated the need for such services to be both available:

If there was a social worker there or a volunteer there … They were great when [my husband] was ill, they helped me; particularly the social workers. (Debra)

and offered to women

Women should be offered the choice of having their involvement. (Anna)

Give them an opportunity to talk about it … a social worker … or a counsellor … even in post-op, a visit from a hospital social worker. (Carla)

Offering a social worker would be brilliant. (Elaine)

The authors acknowledge it is possible that being asked this question directly by a student of social work may have influenced participants’ responses; in particular they may have offered positive responses through a desire to be polite or to satisfy what they thought were the interviewer’s expectations. Participants were also not asked specifically about the perceived value of other forms of ‘socially oriented’ help, such as counsellors or self-help groups. This is clearly a limitation of the study and an area which requires consideration in future studies.

Discussion

This study, based on the experiences of six, self-selected women in Melbourne, has described hospital responses to miscarriage which are largely inconsistent and lack a holistic framework. Participants’ evaluation of treatment they received indicates gaps in timely responses, information provision and acknowledgement of women’s emotional needs and responses; lack of referral to or offering of social work services was also noted. Some differences are apparent in treatments provided by public versus private hospitals. The latter are seen to perform better in terms of timeliness and in responding to women’s medical and emotional needs; continuity of relationships between women and staff appear to be important in this process.

This study both confirms the findings of previous research which indicate that hospital responses do not meet the needs of participants in a timely way, particularly their emotional or psychological needs (e.g. see Cuisinier et al., 1993; Séjourné et al., 2010), and further indicates that needs are attended to inconsistently. This research also contributes by drawing on participant experiences in six different hospitals, albeit in small numbers, supplementing previous research which has typically been restricted to one hospital setting (e.g. see Evans et al., 2002; Wong, 2003). Examining current hospital practices more widely, this research avoids the contamination of its results by factors contingent on individual hospital culture or policy, thus allowing the results to begin to build a broader picture of women’s experiences. To further develop this knowledge, and to understand the extent to which the poor care evident in this study is common, now requires accurate mapping of the hospital services (in both public and private settings) provided to women who experience miscarriage. Such descriptive research will need to examine the specific intervention/s provided and by which staff, the rationale for such treatments, as well as the timeliness of responses.

Participants themselves made a number of recommendations for improved hospital responses, some of which concur with those made previously; those indicated by Condous (2008), for example, who argued for a more coordinated and specialized response to miscarriage within Australian hospitals by the introduction of EPUs. The principles of this model were suggested by all participants, notably, a central point of contact and consistent procedures. The need for specialization echoed Boyce et al.’s (2002) findings; this incorporated ultrasound testing and obstetric care as well as attention to participants’ emotional needs. Previous research findings have similarly indicated the need for a holistic response (Cuisiner et al., 1993; Harvey et al., 2001; Simmons et al., 2006), informed by a bio-psychosocial framework. Furthermore, the women wanted a broadly compassionate response and acknowledgement of their experience. Such recommendations have been made in previous studies (Brier, 1999; Cuisiner et al., 1993; Frost et al., 2007; Simmons et al., 2006). To investigate the outcomes of a more holistic model of hospital care for women who have miscarried requires research attention to be turned to an evaluation of the current EPU model, as well as any alternative models being offered by hospitals.

The need for social work input, which was largely absent, to be offered along with the provision of information featured in participant recommendations. As previously discussed, little or no research has investigated the role of social work in hospital responses to miscarriage. Social work skills have, however, been argued as necessary to improving the treatment of miscarriage in hospitals (Abboud and Liamputtong, 2003; Condous, 2008; Harvey et al., 2001; Stratton and Lloyd, 2008); bringing compassion, attention to the individual, communication skills, a multi-dimensional view and a commitment to holistic care, and as well as an understanding of the emotional and psychological reactions to loss and grief.

Incorporating social work involvement as a core element of a standardized and consistent response to miscarriage has the capacity to provide a multi-dimensional approach to treatment, highlighted as necessary in much preceding research. A clear social work role would address the identified gap in attending with immediacy to women’s emotional needs and ensure that acknowledgement of their loss is on the treatment agenda. As conduits of information, skilled in single-session work, hospital social workers could provide timely and relevant written and verbal information to women as well as providing choice about linkages to community-based services. Many hospital Social Work departments operate on an ‘on-call’ basis, which would enable timely follow-up either during the inpatient stay or shortly thereafter.

As members of a multi-disciplinary team, there is also a clear educative and advocacy role for social workers to play about the needs of women presenting at hospitals for miscarriage. Comprehensive research documenting and examining the current role/s played by hospital social workers in providing care to women who have miscarried is vital.

Conclusion

This aim of this study was to begin to build a localized understanding of how hospitals in Melbourne respond to miscarriage. The study has a number of limitations, as discussed throughout the article, specifically its small sample size and restrictions in the variation within the sample. Despite this, this study has identified several key findings about the way women experience hospital treatment after miscarriage. The findings indicate participants did not receive the care or treatments that they required, in ways that concur with the findings of previous studies. Such work has revealed that the medicalization of miscarriage has excluded from consideration its likely emotional and psychological effects. Women subsequently experience a lack of acknowledgement and compassion from the attending hospital staff, who treat them in an inconsistent, ad hoc fashion. Furthermore, although this study is limited by the factors outlined, it provides a uniquely Australian contribution to the limited body of research in this field. This study has yielded multiple directions for further and more extensive research, about current hospital policies and processes for treating miscarriage, the role of social work, and the impact of existing EPU models on women’s experiences. This will hopefully continue to develop our understanding and treatment of this often ignored and hidden aspect of women’s health.

Footnotes

Acknowledgements

Thank you to Stillbirth and Neonatal Death Support (SANDS) and Bonnie Babes (VIC), along with Sandra Hayman at Essential Baby () for practical support throughout the research process.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Note

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