Second-trimester miscarriage is defined as pregnancy loss after 12 weeks' and before 24 weeks' gestation (Royal College of Obstetricians and Gynaecologists, (RCOG), 2010). An Irish study found the rate of second-trimester miscarriage to be 0.8% of all births (Cullen et al, 2016). Miscarriage is seen by women as sudden, surprising and an upsetting experience (Murphy and Merrell, 2009). In order to give the best possible care for parents who experience a pregnancy loss, health care providers must consider not only the woman's physical needs but also her and her partner's psychological needs (Schott and Henley, 2007).
There is limited research examining parents' expe riences of hospital care during second-trimester miscarriage. The profound psychological impact of pregnancy loss on a woman (and her partner) and the need for sensitive, individualised care has been high lighted in the literature (Lee, 2012; Downe et al, 2013). Interactions with health professionals are vital to women who experience a pregnancy loss (Rowlands and Lee, 2010). Research has highlighted the need for empathetic communication during pregnancy loss and the importance of sensitivity (Paton et al, 1999; Säflund et al, 2004; Fenwick et al, 2007; Murphy and Merrell, 2009; Musters et al, 2013; Mulvihill and Walsh, 2014). Women who experienced a stillbirth valued interactions with health professionals when they took time to sit with them, used eye contact and showed empathy (Kelley and Trinidad, 2012).
Study aims
The aim of this study was to explore women's and their partners' experiences of hospital care during second-trimester miscarriage. In particular, this paper will report on parents' experiences of compassionate care. This study aimed to inform the development of bereavement care services for families experiencing a second-trimester miscarriage.
Method
A focused ethnographic design was adopted for this study. This approach provided a methodology that is problem-focused and is used to enhance our understanding of specific aspects of an individual's way of life; its findings are generally applicable to clinical practice (Cruz and Higginbottom, 2013). This study aims to learn from bereaved parents in order to better understand their views of hospital care during a second-trimester miscarriage. While ethnography has been traditionally used to study whole communities or cultures, Cruz and Higginbottom (2013) explain that it is also widely used to study subcultures. Parents who have experienced a second-trimester miscarriage can be considered as a subculture of bereaved parents.
Participants
The population for this study was parents who had experienced a second-trimester miscarriage and who attended a large maternity hospital in Dublin. Purposive sampling was felt to be the most appropriate method of sampling for this study. The bereavement midwife acted as a gatekeeper and wrote to potential participants explaining the study, and included a consent form to allow their contact details to be released to the researcher. Once the researcher received the signed consent form, the researcher then made contact with the parents to further discuss the study and arrange interview.
Data collection and analysis
A series of semi-structured interviews were completed with 14 bereaved parents (nine mothers and five fathers) in a variety of locations. Interviews took place between October 2015 and February 2016. The data were analysed using thematic network data analysis (Attride-Stirling, 2001).
Ethical considerations
Ethical approval for this study was granted by both the hospital and university's ethics committee. The ethical principles of autonomy and informed consent, beneficence and non-maleficence, justice and respect, confidentiality, veracity and fidelity were all adhered to throughout the research process. Consent was sought at multiple stages during the research process, with participants given the option to withdraw at any stage without consequence.
The researcher was aware of the potential of emotional distress for participants owing to the sensitive issues being discussed in the interviews, and was prepared to pause or terminate the interview at any time should a participant appear distressed or request the interview be stopped.
Follow-up support with the bereavement team in the hospital was offered to all participants; contact details were provided both for the bereavement team and for support agencies relating to pregnancy loss.
Findings
Nine women and five men participated in this study (Table 1). Six of the women had been induced after the diagnosis of fetal demise, and three women had laboured spontaneously. The women's interviews took place between 7–23 months following their miscarriage (mean = 14.44 months, SD = 5.17). In order to maintain confidentiality, all participants were allocated a pseudonym and referred to by their pseudonym throughout the study.
| General | |
| Participants | n = 14 |
| Women | n = 9 |
| Men | n = 5 |
| Age range of women | 30–42 years |
| Gestation | 15–19 weeks |
| Women's obstetric history | |
| First pregnancy | n = 3 |
| Previous miscarriage | n = 5 |
| One or more children | n = 5 |
Two global themes emerged from the data collected from bereaved parents: clinical care needs, and relational and social experiences of miscarriage. A global theme is considered ‘the core, principal metaphor that encapsulates the main point in the text’ (Attride-Stirling, 2001: 393). Each global theme consists of organising themes which have been identified through a series of basic themes that provided the starting point for understanding parents' experiences of hospital care during a second-trimester miscarriage.
The findings reported in this paper are from the second global theme: relational and social experiences of miscarriage (Figure 1). This paper will focus on the organising theme of compassionate care, which draws on the basic themes of empathy and sensitivity. The authors hope to publish the findings from the first global theme separately in the near future.
Compassionate care
Parents' experiences highlight the need for compassionate care during and after a second-trimester miscarriage. Parents described the experience of miscarriage as a very difficult time, but the majority described the positive impact of compassion from hospital staff. One woman, who had experienced a miscarriage at 16 weeks in her first pregnancy, reported that she was very grateful for the care and compassion she received:
‘It made such a difference to how I felt about everything because I kept coming back to how kind everyone was…’ (Sally, 16/40, P3)
Compassionate care is described drawing from two basic themes: empathy and sensitivity.
Empathy
The majority of parents described sympathetic and empathetic care from all staff in the hospital including nurses, midwives, doctors and non-medical staff. Kate felt that the majority of staff she met showed empathy towards her and her partner during her hospital admission:
‘Everyone from the cleaner to the head consultant cares.’ (Kate, 17/40, P7)
Participants reported that hospital staff showed them genuine empathy during their experience of miscarriage. Parents appeared to greatly appreciate this and often discussed the positive impact that hospital staff had on their experience. Orla described her experience with midwives on the antenatal ward:
‘Their manner was lovely… they were genuinely supportive and sympathetic, they were very good.’ (Orla, 17/40, P9)
Participants discussed the importance of staff acknowledging the loss of their baby. Michelle described the gratitude she felt to the doctor that cared for her during her admission, and valued his empathy and that he acknowl edged their loss:
‘He was the first person that said, “Now you're parents”… mentioned her as a baby rather than just as a miscarriage…’ (Michelle, 19/40, P1)
Emmett felt it was important that staff offered condolences when they met him and his partner for the first time:
‘A new nurse came in and said, “Very sorry to hear of your loss.” That makes a difference as well.’ (Emmett, 16/40, P14)
One mother reported a lack of empathy from a midwife who cared for her during her labour and delivery. She mentioned this a number of times during her interview. This lack of empathy from one member of staff appeared to have a negative impact on her overall experience during her hospital admission:
‘I felt it was that she was overworked, overtired and that wasn't very good… I did feel that even though she was a nice person that she lacked more empathy… even though she was still professional, I'm sorry, but she did definitely lack a bit of empathy there…’ (Kate, 17/40, P7)
It is clear from discussions with these bereaved parents that empathy shown by staff had a notable impact on their experience of miscarriage.
Sensitivity
Both mothers and fathers highlighted the need for sensitivity on the part of health professionals during their experience of miscarriage. Emmett explained that the sensitivity shown by staff had a positive impact on him and his partner:
‘It was dealt with such good sensitivity that it made us feel a lot more comfortable… with that care, that made a bad situation that bit more bearable…’ (Emmett, 16/40, P14)
All participants felt that hospital staff knew about their loss; none reported that they had to explain what had happened to them while they were in the hospital:
‘I was comforted by that, I wanted people to know…’ (Orla, 17/40, P9)
‘I didn't have to explain…’ (Kelly, 17/40, P5)
The hospital routinely uses the bereavement symbol developed by the Hospice Friendly Hospitals Programme (Irish Hospice Foundation, 2017). This symbol is placed on the door of the room when a woman has experienced a bereavement. Some parents noticed that this sign was used, and felt it helped ensure staff knew about their loss:
‘They know what is going on… they put a sign… they won't bother disturbing you and things like that, so that was nice.’ (Jack, 16/40, P12)
‘They started putting a thing up on my door… so people know not to come in, that they know what happened to you…’ (Emily, 19/40, P8)
Participants also discussed the importance of sensitivity in relation to the care of the baby after the delivery. They reported that midwifery staff showed sensitivity in relation to their wishes to see their baby, and supported them in this. Emmett felt that midwifery and nursing staff dealt with his baby very sensitively, and was happy with the care he and his partner received in the immediate period after delivery:
‘I think the way that was dealt with was brilliant, done with the right amount of sensitivity… was no time frame once they brought the baby up…’ (Emmett, 16/40, P14)
Emily was also happy with the sensitivity and under-standing she was shown by the midwife following the delivery of her baby:
‘I wasn't able to spend any time with the baby or anything, and she was very kind and understanding…’ (Emily, 19/40, P8)
Some parents mentioned insensitive terminology used by health professionals. Michelle's labour was induced following the diagnosis of a miscarriage at 19 weeks. She was given medication to induce labour. She explained that staff referred to this as ‘the abortion pill’, which she felt was inappropriate:
‘I think they used the term “the termination” or “the abortion pill” on the first day. And I really didn't think that was appropriate…’ (Michelle, 19/40, P1)
Sally explained that a nurse or midwife discussed putting her baby ‘in the fridge’; she found this upsetting and insensitive:
‘She asked about putting the baby in the fridge, and it was just really unpleasant…’ (Sally, 16/40, P3)
Both mothers and fathers discussed the importance of sensitivity when experiencing a second-trimester miscarriage. 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.
Discussion
The literature provides numerous definitions of compassion and compassionate care. Dewar and Nolan (2013) define compassion as the need to recognise and support human vulnerability. Kearsley and Youngson (2012) describe the fundamental principles of compassion as the ability to appreciate the suffering of another and to develop strategies to help alleviate that suffering. Compassionate care has been highlighted as a priority in maternity care, particularly when caring for bereaved parents. Ireland's National Standards for Bereavement Care Following Pregnancy Loss and Perinatal Death highlight the need for compassion, empathy and sensitivity for all bereaved parents (Health Service Executive, 2016). Empathy and sensitivity were described by parents as ways that hospital staff recognised and helped to alleviate their suffering following a second-trimester miscarriage.
There are a number of barriers to providing compassionate care to bereaved parents. Caring for bereaved parents can be challenging even for experienced staff and may lead to health professionals feeling overwhelmed and emotionally burned out, which can have a negative impact on care and on their own psychological wellbeing (Moon Fai and Gordon Arthur, 2009; Nuzum et al, 2016). Support and supervision for staff working with bereaved parents is required, to promote staff wellbeing and improve the care they provide to bereaved parents (RCOG, 2010; Youngson, 2011; Wallbank and Robertson, 2013).
Research has highlighted the importance of empathy from health professionals caring for bereaved parents (Paton et al, 1999; Säflund et al, 2004; Fenwick et al, 2007; Murphy and Merrell, 2009; Rowlands and Lee, 2010; Musters et al, 2013; Mulvihill and Walsh, 2014). Rowlands and Lee (2010) reported that a lack of empathy from health professionals has a profound negative impact on a woman's experience of miscarriage (Rowlands and Lee, 2010). While one mother in the current study did discuss a lack of empathy, the other participants described receiving empathy from health professionals during their hospital admission. This empathy shown to parents appeared to positively impact on the parents' overall experience of miscarriage.
Findings from numerous studies demonstrate the need for sensitivity when caring for bereaved parents (Lasker and Toedter, 1994; Simmons et al, 2006; Gold et al, 2007; McCreight, 2008; Rowlands and Lee, 2010; Mulvihill and Walsh, 2014). The majority of parents in this study praised staff for the sensitivity that was shown to them during their hospital admission. Both mothers and fathers discussed the positive impact of this sensitivity on their experience of miscarriage. The literature tells us that staff sensitivity makes a lasting impression on bereaved parents (Lasker and Toedter, 1994; Kong et al, 2010). The findings of this study echo this and demonstrate the positive impact of sensitivity shown by staff. Some parents in this study reported a lack of sensitivity from some hospital staff and this appeared to cause further upset and had a negative impact on their overall experience. A number of studies have found that insensitive comments from health professionals cause anger and distress among parents who have experienced pregnancy loss (Simmons et al, 2006; McCreight, 2008; Rowlands and Lee, 2010; Kelley and Trinidad, 2012; Downe et al, 2013, Mulvihill and Walsh, 2014). Some parents in this study mentioned insensitive comments from staff, which they found very upsetting. The use of words such as ‘the abortion pill’ or referring to putting a baby ‘in the fridge’ caused anger and distress for some of the bereaved parents. Research conducted in the UK by Simmons et al (2006) and McCreight (2008) mirror these findings; mothers in both studies reported dissatisfaction when health professionals used the term ‘abortion’ when discussing their miscarriage. A need for further education for staff caring for bereaved parents in maternity hospitals has been highlighted in the literature (Moon Fai and Gordon Arthur,, 2009; Nuzum et al, 2016). Lack of adequate training for staff can act as a barrier to compassionate care (Williams et al, 2008). A number of parents in this study reported a lack of sensitivity from staff and the use of insensitive language. Further education for health professionals in relation to sensitivity may be of benefit.
Conclusion and recommendations
Effective clinical care delivered in a compassionate manner following second-trimester miscarriage, which is individualised to meet the needs of bereaved parents, has the potential to have a positive impact on their experience. Education programmes are needed for health professionals working in maternity care, in relation to sensitive and empathetic care for bereaved parents. Areas for further research include: barriers to providing compassionate care for bereaved parents in the maternity setting and strategies to overcome these barriers; and health professionals' educational needs in relation to providing care to bereaved parents in the maternity setting.