Antenatal care is fundamental to prevent, detect and treat risks as early as possible during pregnancy (Aji et al, 2019; Saime et al, 2022). A partner’s involvement in pregnancy, from the antenatal period through to childbirth is highly encouraged to provide women with psychosocial support (Kashaija et al, 2020). However, some couples may experience pregnancy loss, such as through miscarriage or stillbirth, which results in the experience of grief.
Women experiencing pregnancy loss may opt to undergo the physiological process of loss at home or seek help at a healthcare facility. Some women may self-refer to a facilities (Saime et al, 2022), while others may be influenced by advice from families and friends (Aji et al, 2019; Muhammad Wafiuddin Wa’ie et al, 2020). Women experiencing a first loss may be more anxious and experience growing fear of the unknown than those who have previously experienced pregnancy loss (Lothian, 2016; Leach et al, 2017), meaning it is more likely that these women attend healthcare facilities. These facilities may include antenatal clinics at maternal and child healthcare facilities at primary health centres or hospitals (Saime et al, 2022), emergency departments, outpatient departments or gynaecological wards. Nurse-midwives, midwives and maternity nurses working at these facilities are on the front line in encounters with women experiencing a pregnancy loss and provide care accordingly.
Women may be accompanied by a partner or close family member when attending a healthcare centre for pregnancy loss (Aji et al, 2019), but some may prefer to experience the loss alone. It has been found that women may feel that a pregnancy loss signifies that they failed to successfully progress with their pregnancy (Fernández-Basanta et al, 2021), or that they failed their partners (Randolph et al, 2021). These feelings can lead women to decide to experience the loss alone (Meredith et al, 2017). Ultimately, a couple’s experience of pregnancy loss may be influenced by the healthcare system’s organisation and the sociocultural context of the country where they live (Abdul-Mumin, 2016).
While not all women experiencing a loss will have a partner, this article specifically discusses the provision of pregnancy loss care to couples, and the challenges and considerations that this process includes. It is important that pregnancy loss care that is provided to couples meets the needs of both the individual and the couple together.
The complexity of pregnancy loss
A couple’s experience of pregnancy loss, how they cope and their role in supporting and caring for each other during the loss may be complex and difficult to understand. Childbirth generally, whether low- or high-risk, is dependent on sociocultural perspectives that can differ by country (Hillier, 2013). A couple’s experience of pregnancy is complex as care must be given to three different units: the woman, her partner and both of them as a couple.
The experience of pregnancy loss is equally multifaceted and highly individual (Obst et al, 2020). Studies have demonstrated that women’s emotional response to loss is immediate, involving heightened emotions and feeling severely affected by the loss (Batool and Azam, 2016). Conversely, a woman’s partner may attempt to delay or set aside their own response in order to prioritise their role in caring for their partner, which affects their own experience (Story Chavez et al, 2019;Williams et al, 2020). However, both a woman and her partner have similar needs for empathy, encouragement and support after a loss.
Studies show that men need as much support as women after pregnancy loss (Obst et al, 2020), despite a common perception of the prescribed male as strong and calm (Williams et al, 2020). Healthcare professionals may unintentionally neglect or isolate men after a loss, potentially believing the woman to be experiencing greater trauma because of a lack of emotional behaviour from a man, resulting from the outdated social perspective than men should not be emotional, when in fact they are in need of support (Story Chavez et al, 2019). Women and their partners can support one another through the emotional experience of a loss, which can be intense (Figueredo-Borda et al, 2022). The complexity of the situation poses challenges that require midwives and maternity nurses to provide care that is individualised to women and their partners yet holistic to them as a couple.
Support for couples throughout pregnancy loss
Support is crucial for every woman and their partner throughout the process of pregnancy loss (Jensen et al, 2019). Informal support or support from other sources than healthcare professionals, which is common following a loss, may significantly contribute to a couple’s psychological health (Meaney et al, 2017). A primary source of informal support for a woman can be her partner, which can help with emotional pain and provide comfort not only for the woman but also her partner (Freidenfelds, 2020). Women can benefit from their partner’s support during a loss as much as they do during pregnancy or the birth of a live baby (Kashaija et al, 2020). Women may view their partner as their best source of support, as they are often the closest person to them, whom they turn to when they first find they are pregnant (Jensen et al, 2019).
The sociocultural perception that men must be strong and require less or no support can lead men to neglect their own grief (Due et al, 2017), which is potentially exacerbated if this perception is shared by family, friends or healthcare professionals (Jensen et al, 2019). However, men are just as likely as women to view their partner as a principal source of support (Campbell-Jackson et al, 2014). Prioritising their partner after a loss may cause a man to privately experience or even neglect their emotions (Story Chavez et al, 2019), and they may prefer to grieve in isolation (Obst et al, 2020). Consequently, a man may develop a sense of helplessness or powerlessness because of the perceived responsibility to care for their partner (Obst et al, 2020) or children (if any) (Williams et al, 2020) after a loss, as well as because of the sociocultural obligations and norms related to pregnancy loss (Ullah and Ahmad Kumpoh, 2019); in Asian cultures in particular, these obligations can include receiving visits from friends and family (Hemle Jerntorp et al, 2021).
Research has led to varied findings on the emotional impact of pregnancy loss (Meaney et al, 2017; Coomarasamy et al, 2021a, b). In some situations, pregnancy loss can bring a woman and her partner closer together, as well as bring them closer to the people around them, allowing them a strong support system (Batool and Azam, 2016; Quenby et al, 2021). However, a loss can also cause irreversible relationship problems (Bellhouse et al, 2019), including feelings of failure to become parents (Obst et al, 2020) or accept the loss (Meredith et al, 2017) and blame.
Family, friends and the community are important sources of support throughout the experience of pregnancy loss (Alqassim et al, 2022). A woman and her partner may have different preferences for support, including for example the preference for a close person of the same gender to be there, or for priority to be given to approaching family first, then friends (Obst et al, 2020). Despite these differences, support from family and friends are often invaluable in helping a couple cope with loss, especially for men who may prefer not to receive formal support from healthcare professionals (Wilson et al, 2015).
A couple may feel anxiety over facing the community following a pregnancy loss, which can be the result of sociocultural stigma surrounding pregnancy loss against the expectations of a successful pregnancy, the birth of a live baby and a parent’s role (Figueredo-Borda et al, 2022). Studies have shown that men may find it more challenging to talk about their experience with others but are often more at ease talking to other men (Obst et al, 2020). Men and women have both been found to find communications via social media groups to be helpful, where they do not necessarily know with whom they are communicating or sharing with (Story Chavez et al, 2019; Alqassim et al, 2022).
The dilemma for healthcare professionals
Giving birth can be a traumatising event (Campbell-Jackson et al, 2014), even when that baby is alive and healthy. Many studies have indicated that a couple’s needs and expectations after pregnancy loss may not be fully met, in cases where the care provided was perceived as not in-depth, which eventually led to further distress (Jensen et al, 2019). Care provision has been depicted as lacking completeness because of a lack of holistic cohesiveness, causing fragmentation and lack of continuity (Coomarasamy et al, 2021a, b; Quenby et al, 2021). Worldwide reform of care after a pregnancy loss was advocated in the Lancet (2021).
Studies focusing on midwives or maternity nurses in care after a pregnancy loss are scarce. In spite of the couple’s needs and expectations of pregnancy loss care, midwives and maternity nurses may not be trained in providing this care, leading them to feel unprepared (Bellhouse et al, 2019). A systematic review of research in the UK and USA (n=14), Asia (n=9), Ireland (n=3), Australia (n=2), Africa (n=2) and Spain (n=2) confirmed that healthcare professionals, including midwives, are psychologically and physically affected by pregnancy loss and lack training and education in this area; they require social support in coping with providing care to couples experiencing perinatal loss (Shorey et al, 2017). Additionally, nurses and midwives providing care for women experiencing pregnancy loss may be affected psychologically if they have themselves experienced a pregnancy loss.
Healthcare professionals, including midwives and maternity nurses, have acknowledged inadequacy of care and strive to improve this situation, despite experiencing burnout and neglecting their own needs for psychological health (Figueredo-Borda et al, 2022). While the needs of couples experiencing a loss should ideally be fulfilled, healthcare professionals should also be equipped with the required skills to cope with providing care in this context. The healthcare system should be organised to allow the provision of structured, cohesive, continuous and holistic pregnancy loss care.
Implications for midwifery
Initial care at first point of contact
Women may experience signs and symptoms of pregnancy loss, such as vaginal bleeding during a miscarriage, abdominal cramp in an ectopic pregnancy or the sudden absence of fetal movement for intrauterine fetal death. They may decide to remain home in these circumstances, but some will present at healthcare facilities (Batool and Azam, 2016), particularly if they are not aware of the cause of the symptom.
In the authors’ experiences in Brunei, women in these circumstances are most likely to attend an emergency department, where they can receive initial transition care before entering further care pathways of ward admission or being discharged home for self-care. The initial transition care is very important; if women are neglected or feel overloaded with too much information, this can impact the entire experience of pregnancy loss (Quenby et al, 2021). Providing the right information at the right time is important (Coomarasamy et al, 2021b). The woman or couple may be in shock, heightening the traumatising pregnancy loss experience (Jensen et al, 2019). In these circumstances, they may not be able to absorb and process all information they are given (deMontigny et al, 2017). Couples may wish to be informed of all findings, and hesitancy in conveying what is taking place can adversely result in a couple being unsure of what is going on. This may inadvertently affect or delay acceptance of the loss, prolonging the experience (Freidenfelds, 2020).
Admission for further care
While uncomplicated pregnancy loss, such as a miscarriage, may be undergone at home, losses such as ectopic pregnancy, incomplete miscarriages and intrauterine fetal death are likely to require admission to a hospital (Quenby et al, 2021). There may be a need for intervention through an operation for an ectopic pregnancy, dilatation and curettage for an incomplete miscarriage, or induction and augmentation of labouror a caesarean section for intrauterine fetal death, all of which require hospital admission (Dugas and Slane, 2022). Not all women will attend a healthcare facility as soon as a loss occurs; some may use a ‘wait and see’ approach until the loss is confirmed (Coomarasamy et al, 2021b). When arriving at a healthcare facility, emergency care may be needed, especially in the prevention of haemorrhage or infection (World Health Organization, 2022). The experience of pregnancy loss during a stay at a hospital requires tangible care by midwives and maternity nurses (Alqassim et al, 2022), especially in managing the heightened and prolonged emotions that can be caused by a delay in seeking healthcare.
Self-care at home and care after discharge
Women may prefer to experience a loss at home or be discharged home for self-care as part of the care pathway following transition care. In both cases, midwives and maternity nurses have an important role in providing women with advice on self-care and making resources available to address various dimensions of care, encompassing the physical, psychosocial (Sutan and Miskam, 2012), religious and spiritual (Kalu, 2019) aspects of care. Depending on the context, the religious/spiritual aspect may play a more significant role.
Recommendations for midwifery education, practice and research
Pregnancy loss care can be challenging for healthcare professionals, including midwives and maternity nurses (Quenby et al, 2021). This area requires further research to fully understand the limitations experienced by healthcare professionals when providing this care. Midwives and maternity nurses need to be equipped in terms of knowledge and skills to provide pregnancy loss care confidently. This could be achieved through the use of a structured educational programme on pregnancy loss.
Midwives must be sensitive and competent when it comes to psychological, religious and spiritual care (Iwanowicz-Palus et al, 2021). The lack of individualised, holistic and cohesive pregnancy loss care requires guidelines to ensure healthcare professionals are clear on their role. Care should also address a couple’s needs as well as the needs of the two individuals. Pregnancy loss care needs to be organised and systematically structured to ensure continuity and consistency, providing holistic and cohesive care to couples from all inter and multidisciplinary teams (The Lancet, 2021).
Pregnancy loss care must be evidence-based as well as culturally sensitive, appropriate and relevant (Kalu, 2019). While the current evidence is substantial, the relevance of applying research findings to different countries must be examined, taking into account a country’s context. Between countries, organisation of the healthcare system and the cultural context differ (Abdul-Mumin, 2016; Syam et al, 2021). There are many areas of pregnancy loss care that require in-depth research. These areas include initial supportive care during the transition period and midwives’ preparedness and confidence in providing cohesive pregnancy loss care and counselling. There should be a model, framework and guidelines for providing cohesive pregnancy loss care, and instruments to measure midwives’ knowledge, attitudes and practices in providing cohesive pregnancy loss care.
Conclusions
Providing pregnancy loss care for couples is highly complex and may require care to be tailored to both individuals and a couple collectively. Care should be organised in a structured manner, to ensure couples’ needs are met and the care provided is holistic, continuous, consistent and cohesive. Midwives and maternity nurses may face challenges if they are not equipped with the required knowledge and skills to care for a couple experiencing pregnancy loss. Consideration should be given to the needs of the woman, her partner, if she has one, the couple as a unit and the midwives providing care, to ensure that the care provided is high quality.
Key points
- Nurses’ and midwives’ roles in providing supportive care for couples after pregnancy loss are challenging and complex.
- A partner’s ability to care for a woman experiencing a pregnancy loss can be complicated by their own grief.
- Responses to loss may be affected by sociocultural perspectives, and men and women may have different experiences of the same loss event.
- Developing a model, framework and guidelines for providing cohesive pregnancy loss care is recommended.
- Developing instruments to measure knowledge, attitudes and practices in providing pregnancy loss care should be considered.