Childbirth is considered a major highlight in human life (Bennett et al, 2008), but early pregnancy loss occurs more frequently than many realise. The loss of a pregnancy before 13 completed weeks is referred to as ‘early pregnancy loss’, ‘miscarriage’ or ‘spontaneous abortion’ (American College of Obstetricians and Gynaecologists, 2015). Early pregnancy loss accounts for over 50 000 annual hospital admissions in the UK and 15-20% of confirmed pregnancies are reported to end spontaneously in the first trimester, according to the National Institute for Health and Care Exellence (NICE) (2012). In Ireland, there is a reported early pregnancy loss rate of 20%, with approximately 14 000 women affected annually (The Miscarriage Association of Ireland, 2010). In maternity hospitals in Ireland, as in other parts of Europe, midwives are the main caregivers for women experiencing a miscarriage. There are limited evidence-based practice recommendations to guide the care of women experiencing early pregnancy loss, and very little is known of the experience of midwives as care providers for those who are bereaved (Gergett and Gillen, 2014). When health professionals experience difficulties supporting or connecting with women or couples, this can sometimes result in focusing on what is strictly necessary in terms of technical care (Camarneiro et al, 2015), potentially detracting from the care, compassion and empathy that people in their care need.
Background
Most pregnancies begin as a very positive and exciting experience, full of anticipation and joy. However, miscarriage may be the most painful form of bereavement for women because it is commonly unexpected, likely to be unexplained and may never be forgotten (Bacidore et et al, 2009; Evans, 2012). The physical symptoms signify the reality of miscarriage and even if the pregnancy is unwanted, these symptoms can be difficult to cope with (Maker and Ogden, 2003). Murphy and Philpin (2010) discuss the tension between women's actual physical experience of miscarrying—including passing blood clots, fragments of tissue and, in some cases, intact fetuses—and their conceptualisation of their pregnancy. For example, some women associate miscarriage with blood and the concept of failure, and may seek to depersonalise their loss by referring to the fetus as ‘it’, and using technical terms such as ‘fetus’ and ‘embryo’ as opposed to terms such as ‘baby’ and ‘child’ (Murphy and Philpin, 2010). In addition, many have unanswered questions after miscarriage (Olesen et al, 2015). An online survey of 305 women who had experienced a miscarriage confirmed that it was challenging, and that women desired extra support (Séjourné et al, 2010). Many women may feel forgotten and alone in busy clinical areas, and nurses and midwives need to be proactive to meet these women's needs holistically (Murphy and Merrell, 2009).
Guidelines have been developed by the Royal College of Obstetricians and Gynaecologists (RCOG) (2006), NICE (2012) and voluntary organisations (The Miscarriage Association, 2015) to inform policy and improve practice. In the UK, it is common for early pregnancy loss (under 18 weeks) care to be provided within gynaecological services. While dedicated early pregnancy units exist across the UK, this is not always the case for other countries, such as Ireland, where women presenting with early pregnancy loss are cared for in maternity services. In an obstetric setting, therefore, midwives are often the key caregivers when dealing with miscarriage and are required to support women and their partners through complex decision-making (Baxter and Baron, 2011) while also providing psychological support. Women recognise the fact that the healthcare team considers their physical safety, rather than psychological care, a priority at this time, particularly in the initial stages (Murphy and Merrell, 2009; Murphy and Philpin, 2010; Zavotsky et al, 2013; Gergett and Gillen, 2014); however, a woman-centred, holistic approach that addresses emotional, psychological and physical needs is required for women who have experienced a miscarriage. A holistic perspective needs to consider how family and health professionals influence a woman's response to her loss (Rowlands and Lee, 2010).
Caring for women experiencing any form of pregnancy loss is an essential component of the work that midwives do. Wallbank and Robertson (2013) note that midwives must endure varying levels of loss in their clinical practice and can be expected to witness the products of pregnancy, support parents experiencing distress, and initiate discussions about funeral and disposal arrangements—all while performing routine administrative duties in a busy unit (Gold, 2007). The frequency of miscarriage means that some midwives are exposed to dealing with many losses during their working day (Murphy and Philpin, 2010). Providing quality care to women experiencing miscarriage in the maternity setting is challenging, given the complexity and sensitivity associated with this care (Wallbank and Robertson, 2013). There is an expectation that nurses and midwives engage emotionally with women and remain empathetic to enable healthy grieving processes for the family (Sands, 2018), regardless of whether they feel adequately prepared or personally inclined to do so (Cox and Briggs, 2004). Opportunities for midwives to discuss the personal effects of their repeated exposure to loss in early pregnancy are recommended (Wallbank and Robertson, 2008) but are not often provided, despite maternity staff experiencing significant subjective stress when caring for bereaved couples (Wallbank and Robertson, 2008).
‘There is an expectation that nurses and midwives engage emotionally with women and remain empathetic to enable healthy grieving processes for the family, regardless of whether they feel adequately prepared or personally inclined to do so’
There are few evidence-based recommendations to guide the care of women experiencing early pregnancy loss, or the psychological and physiological suffering associated with this loss. In addition, very little literature is available on the experience of midwives who care for those who are bereaved (Gergett and Gillen, 2014), despite the likelihood of this care affecting midwives' wellbeing and the care that bereaved women and their families receive as a result. Consequently, this study sought to explore the experiences of midwives caring for women who have experienced early pregnancy loss.
Method
Design
A qualitative descriptive design was used to provide a rich description (Neergaard et al, 2009) of midwives' experiences of caring for women with early pregnancy loss. Qualitative descriptive studies allow the researcher to stay closer to the verbatim data and to the surface of words and events than during grounded theory, phenomenological, ethnographic, or narrative studies (Sandelowski, 2000). The study design allowed for in-depth exploration of midwives' accounts of caring for women with early pregnancy loss and how these experiences affected them as individuals.
Sample and recruitment
The study took place in Ireland in a busy regional maternity hospital. The hospital research ethics committee granted ethical approval to conduct the study.
A purposive sample of eight midwives with experience of caring for women with early pregnancy loss was recruited via poster advertisement. Purposive sampling ensures that participants are best placed to provide the information that is needed to understand the personal meanings of health-related events (Polgar and Thomas, 2008). Midwives with a minimum of 12 months' experience, working in the maternity hospital at the time of data collection, with experience of caring for women with early pregnancy loss were included in the study. The participants worked in theatre, labour ward, antenatal ward and in the maternity emergency unit, which encompasses the early pregnancy assessment unit. As the first author was a midwife working in the maternity emergency unit, steps were put in place to ensure that contact was initiated by potential participants and all participants provided written consent. A first interview was used as a pilot study where data were not included, and eight interviews were subsequently conducted. A midwife counsellor was available for the participants, if they so wished, due to the sensitive nature of the subject.
Data collection
Face-to-face interviews were conducted between December 2015 and March 2016 following informed written consent of participants. The interviews were semi-structured, an approach that combines the probing of views and opinions with flexibility in the way and order in which questions were asked, allowing the interview to flow more freely and naturally (Newell and Burnard, 2011). The interviews were guided by questions (Box 1) that were informed by the literature. The use of open-ended questions ensured that the participants remained close to their experiences (Holloway and Fulbrook, 2001). The interviews were conducted outside of work time in the education room in the hospital—a quiet space, free of distractions—in order to maintain confidentiality and privacy for the participant. The length of time for the interviews varied, but all were completed within 1 hour. Participants were encouraged to talk openly about their experiences and to be aware that there was no right or wrong answers to the questions asked (Doody and Noonan, 2013).
Data analysis
Braun and Clarke's (2006) framework for thematic analysis was used to analyse the interview data. Thematic analysis is a poorly delineated, yet widely used, method of qualitative analysis (Roulston, 2001). To analyse the data, the first author familiarised herself with the data through verbatim transcription. Initial codes were generated after re-reading the transcripts, with words and phrases highlighted in the margins. Some examples of codes were ‘taking it home’, ‘coping’, ‘conveyor belt care’, and ‘personal impact’. Some examples of emerging themes were ‘impact’; ‘environmental issues’; ‘resources’; and ‘what midwives found difficult’. The themes were then reviewed with the second researcher and an audit trail was maintained of how findings emerged.
Results
There were three main themes identified in the data analysis. These were: midwives coping with the experience of early pregnancy loss; resourcing compassionate for women; and what midwives find difficult. The themes and the related subthemes are shown in Table 1.
| Themes | Subthemes |
|---|---|
| Coping with the experience of early pregnancy loss | Midwives' exposure to early pregnancy loss |
| Distancing yourself | |
| Support from colleagues | |
| ‘Taking it home’ | |
| Compassionate care for women and midwives | Information for women |
| Counselling support | |
| Midwives' educational needs | |
| What midwives find difficult | Emotional effect on midwives |
| What to say | |
| Going from happy to sad | |
| Staffing levels | |
| Hospital system |
Coping with early pregnancy loss
This theme described how midwives coped with caring for women experiencing early pregnancy loss and included references to their frequent exposure to such loss. Most participants spoke of their experience in dealing with pregnancy loss in conjunction with their personal coping mechanisms.
Midwives' exposure to early pregnancy loss
Participants were asked how often they saw womn undergo early pregnancy loss.
‘I work on the antenatal ward and I suppose in our everyday work we would deal with a lot of women having lost babies in early pregnancies.’
‘Working in the emergency unit we come across it daily … quite frequently.’
Participants reported having differing levels of experience in caring for bereaved women:
‘I didn't know a lot about it before I came here. You learn about it in college but you don't really know the reality of it until you come across the women every day.’
One participant reported that they had experienced early pregnancy loss themselves:
‘I had a personal experience of miscarriage so I kind of know more about it and what they are going through.’
Distancing yourself
Participants spoke of how they dealt with the situation and the coping mechanisms they employed to prevent themselves feeling overwhelmed.
‘You have to learn to distance yourself because otherwise if you take it too much on board you just fall apart.’
‘In this environment you have to be like, … “OK, I dealt with that now … That situation is over and now I have to approach somebody new, this is somebody else's experience.” And you have to be there to support them too. You have to switch off, no matter who is in the unit.’
One participant found that working long term in the emergency unit meant that they found it easier to distance themselves:
‘That's why the longer I'm there, the easier it is to do, to completely switch off from your job.’
Support from colleagues
Most participants mentioned colleagues as a source of support and comfort.
‘Coping skills are with my colleagues more so than with my social circle … I rely on my colleagues a lot. There isn't a whole pile of supports available to me in the hospital, just get on with it.’
‘You know, from time to time it's important to trash out [sic] different things and if you're feeling particularly upset over a certain situation, it's good to talk to your line manager and I have done, in one particular case.’
‘Taking it home’
Most participants spoke about talking through their exposure to loss at home with family and friends in order to help them cope.
‘Sometimes you find yourself talking to the people at home about it just to go over it or, you know, it might be troubling you, it might be something keeping you awake at night but you know you do take your work home with you and that's for sure.’
‘It does impact your life. You carry it home.’
One participant, however, was adamant that they would not bring their work home with them:
‘I wouldn't bring it home. Definitely not bring it home. Well, I suppose it affects my mood at home maybe if I was in here all day but I wouldn't discuss it with them at home.’
One participant spoke of personal coping mechanisms developed by doing a counselling course. This was sourced personally outside of the work environment in order to assist with midwifery care.
‘I did a counselling course myself, more for my personal development, but it helps me process my day without taking too much home; there are days you take it home anyway but it can be hard.’
Compassionate care for women and midwives
The second theme identified was the resources and educational needs that midwives identified as necessary to care for women experiencing a miscarriage. Most midwives interviewed mentioned miscarriage booklets and counselling as important resources.
Information for women
All participants drew attention to the miscarriage booklets when asked about resources they relied on for women experiencing a miscarriage. However, there were mixed feelings on their value:
‘This booklet can help direct them to places that they can go to, even online to support networks.’
‘I don't think handing out leaflets is really going to make them go home and sit down and go, “I just lost my baby and had an ERPC [evacuation of retained products of conception] but I'll read this book because it's going to make everything better.”’
Midwives did recognise that written information alone was not enough:
‘You can't just give them a booklet and walk away.’
Counselling support
All participants talked about the hospital bereavement counsellor as a resource that they could refer women to:
‘That is a really valuable service—I think she really makes a difference to people and people come back and tell us.’
‘I would say to women that they don't have to talk to someone now (counsellor) but may need somebody in the future.’
Midwives' educational needs
Participants viewed training and education as very important for them when caring for women experiencing early pregnancy loss. There was a sense that participants learnt on the job and that experience helped them to communicate with women experiencing loss. Most participants considered that there was little education or training available for them and accessing relevant study days was often not possible due to service needs.
‘A study day would give us some good support and some good advice to know how best to look after people who are having early pregnancy loss.’
‘Not even structured days but just to kind of put out new information; just to inform us of new policies and things that have changed and new fertility treatments.’
Most participants spoke of the frightening experience of dealing with early pregnancy loss for the first time as a newly qualified midwife, and how training might have made it an easier, less daunting experience.
‘I just threw myself in and learnt as I went along but nobody ever said, “This is what you do.”’
‘Training would be great. When I first qualified, I knew nothing about it and as a student you're kind of taken away from things like that; you're not exposed to it, not as much as you should be.’
‘It's very sink or swim when you first qualify and it's with experience you learn. It's not fair when you start out because you do get it wrong and say the wrong thing.’
What midwives find difficult
It was evident there were many aspects of caring for women with early pregnancy loss that the midwives found difficult. Some of these were of a professional nature and some were of a personal nature. At times in the interviews, the boundaries between personal and professional challenges merged.
Emotional effect on midwives
Providing care for women who had suffered a loss in early pregnancy had affected the majority of the midwives interviewed. Some participants referred to different emotions they felt especially when caring for women who have had multiple pregnancy losses.
‘You'd have to be made of stone for it not to impact you.’
‘It's very intense for the midwife looking after these people. There have been days when I've gone home and cried over different situations from here.’
‘There was days when I cried before I even left the hospital, cried all the way home and cried when I got home.’
One participant felt that support at work was only available if the pregnancy loss was in the later stages.
‘It depends on the stage of their pregnancy loss. If it's a mid-trimester or like a 24-week stillbirth, there is a lot more support; people will actually ask you, “Are you ok?’”
Some midwives referred to how dealing with early pregnancy loss affected how they felt about other women accessing maternity services:
‘People have unwanted pregnancies or children who are neglected and these other people are so desperate for a baby, I find that difficult.’
What to say
Some participants expressed difficulty in knowing what to say to women who experienced early pregnancy loss and that, for women who had experienced recurrent losses, it was particularly difficult.
‘It's always hard. I always find it really hard to know what to say to them.’
‘You say, “Maybe better circumstances the next time.” And they say, “You said that the last time,” and then you're like, “Oh no, back here again.”’
‘It is very sensitive and quite, I suppose, gruesome in the way we explain it. A lot of them would grimace at even words like ‘products of conception’ and you'd try not even say those words, because it just sounds like ‘products’ [like] they aren't a pregnancy so you try even avoid that terminology.’
Switching roles
Most participants struggled with the challenge of switching to care for women in the differing contexts of childbirth.
‘You have to be a bit of a machine: switch it on and switch it off. You get a bit insincere … like, I think you get a bit immune … I never thought I would say it, but you do, after a while.’
‘You have to kind of turn it on and turn it off, to be honest. You're turning on and off your emotions and your reactions; you've to go with the woman's.’
Staffing concerns
Some midwives drew attention to the effect that staff deficits could have on the care provision of women who have experienced loss in early pregnancy
‘We cannot give them the care they deserve because we just don't have the time, and we could have another eight or nine women to look after.’
‘Your kind of saying the same thing:“Sorry to meet you under these circumstances, here's your gemeprost, here's your tea and toast, have a wee and go home.” You know, it's very kind of routine, very much like a conveyer belt.’
Hospital system
Most participants were frustrated by the physical layout of the hospital in some areas where women with early pregnancy loss had to be in close proximity to pregnant and labouring women.
‘If we could get the early pregnancy unit completely separate I think it would be so much kinder to the women.’
‘You're watching people with an ongoing pregnancy and they are dealing with this and probably sometimes unfortunately hearing fetal hearts.’
Many participants found the hospital system difficult to work in, including examples of when initial booking visits were completed before the woman received confirmation of a viable fetus.
‘“Oh sorry, you've had a miscarriage so everything we just talked about is null and void.”’
Some midwives questioned the suitability of having women undergo ERPC in a maternity hospital and how hard it was on the women.
‘Going home at all hours because they can't bear to be here anymore because it's a hospital full of babies.’
‘I think it's very traumatic coming into a maternity hospital. They've had a pregnancy, I know, but then they have to see women going around with bumps and they are always going to think, “That could have been me.”’
Discussion
Midwives' experiences of coping with early pregnancy loss
This study aimed to explore midwives' experiences of caring for women facing early pregnancy loss, and found that midwives must overcome personal and professional challenges in order to provide compassionate care. Midwives developed strategies to cope with repeated exposure to early pregnancy loss, including the support of colleagues, distancing themselves from the situation at times, and offloading to family and friends. Participants in this study found it easier to cope the more experience they had, and the more they distanced themselves from the grief, which is similar to the findings of Wallbank and Robertson's (2013) study.
Most participants spoke of their reliance on colleagues for support to talk through upsetting events related to early pregnancy loss. Support provided by colleagues when health professionals experience death in perinatal settings is a consistent theme in the literature (Roehrs et al, 2008; Jonas-Simpson et al, 2010; Gergett and Gillen, 2014). Participants described distancing themselves in order to help them to cope with the grief of the women experiencing early pregnancy loss, and Evans (2012) suggests that this distancing helps midwives to practise in a professional manner. Previous studies (McCreight, 2005; Murphy and Philpin, 2010) had also had findings that highlighted that the repetitive exposure to early pregnancy loss could have a negative effect on midwives. Some participants referred to ‘being a machine’ and ‘being immune’, perhaps in an effort to continue to function. Little is known from the literature about the effect of repetitive exposure to early pregnancy loss on midwives and their personal lives. Many participants ‘brought their work home with them’ and talked through their experiences with family or friends. Mollart et al (2013) considered factors that might affect work-related stress and burnout among midwives and found that participants reported frustration and stress after repeated disclosures, and experienced intrusive thoughts, which affected their private and family lives. Allowing midwives time to reflect and to process their emotions after the event by debriefing at work could be beneficial to their emotional and physical wellbeing. The Health Services Executive (HSE) (2016) identifies a range of support options for staff involved in the care of women, including supervision, individual debriefing, timeout, peer group support and access to a professional counsellor.
‘You have to be a bit of a machine: switch it on and switch it off. You get a bit insincere … like, I think you get a bit immune … I never thought I would say it, but you do’
Compassionate care for women and midwives
This theme highlighted the need for individualised care, information, bereavement counselling, and the importance of midwives' own educational needs. Information booklets, while considered useful, needed to be provided in the context of individualised care, a finding supported by Gergett and Gillen's (2014) study. These booklets were considered particularly valuable for women who wanted information on how to prevent future early pregnancy losses (Warner et al, 2012), but are never a substitute for verbal communication. The availability of bereavement counselling was a welcome resource, and follow-up care for women was seen as very important, reflecting the National Standards for Bereavement Care following Pregnancy Loss and Perinatal Death (HSE, 2016). Evans (2012) suggests that health professionals may rely on their own experience to compensate for inadequate training in dealing with women experiencing miscarriage. Participants identified the need for continuing education on bereavement care techniques and counselling skills, and stressed the importance of debriefing sessions for caregivers. Gergett and Gillen (2014) suggested that a lack of skills and confidence in bereavement care might prevent health professionals from engaging with families following a miscarriage. Nurses and midwives play a central role in the provision of care to parents and families affected by traumatic events in a situation that is stressful for all involved (Black and Tufnell, 2006).
What midwives find difficult
In this study, participants referred to a woman's history of multiple miscarriages as a factor that affected the care they provided to women, requiring greater emotional input and perhaps draining further their own emotional resilience. Many nurses and midwives have their own personal experience of early pregnancy loss and caring for these women can also mean addressing or resurrecting their own private grief (McCreight, 2005). Health professionals in Gergett and Gillens' (2014) study felt more sympathetic towards a woman who experienced a loss when the woman had no children or a history of infertility. Psychological distress experienced by midwives caring for families experiencing miscarriages remains high, particularly with cumulative exposure (Pezaro, 2016) as midwives continue to provide emotionally intense and deeply empathetic care (Wallbank and Robertson, 2008). This may be further exacerbated by the high risk of psychological distress associated with the nature of midwives' work and their working cultures generally (Pezaro, 2016).
Midwives expressed difficulty in knowing what to say, especially when first qualified. The challenge of providing effective care in the context of perinatal bereavement and loss, given the non-linear nature of grief, has also been highlighted by Barry et al (2017). Similarly, Gergett and Gillen (2014) found that a lack of confidence, exacerbated by a lack of training in counselling and a fear of saying the wrong thing, were additional factors in failing to encourage women to discuss feelings. Rowlands and Lee (2010) suggested that barriers to effective care, such as a lack of time and privacy, were not insurmountable, and recommended that training and education specifically focused on communicating with women and families during pregnancy loss might be beneficial.
Most participants highlighted the difficulty in switching roles, where they engaged with women experiencing loss, while also providing care to women labouring at term. The midwives reported that it was esepcially hard to balance their emotions when exposed to this challenge and were very cognisant of the effect that this had on women too. The compassionate connection between the parents and carer (Papadatou, 2009) is adversely affected by the competing personas that midwives have to present when dealing with grief and joy: all mentioned their mixed emotions when going from celebrating with a labouring woman to consoling a woman experiencing early pregnancy loss. The midwives in theatre found it especially challenging to care for a woman who experienced a miscarriage and then witness a live birth directly after.
Midwives are faced with a multitude of workplace pressures (Pezaro et al, 2016), which shows no sign of alleviating. One source of stress for nurses and midwives is the role itself, which has become multifaceted due to increased patient complexity. Participants in this study spoke of the complications of midwifery practice and their worries about women with early pregnancy loss being high risk, particularly in the context of low staffing levels (Royal College of Midwives, 2011). In addition, stress levels are adversely affected by insufficient resources, suboptimal skill mix, shift work, heavy workloads and a lack of peer support, all of which can contribute to burnout and attrition (Mollart et al, 2013).
Many of the midwives drew attention to the hospital system and environment that resulted in women being cared for in a rushed and impersonal manner. This was particularly challenging considering the psychological needs of these women. As noted by Mulvihill and Walsh (2013), the hospital system and environment were perceived to affect women's experiences and were issues that midwives found most difficult. Hearing crying babies, having no privacy and being left in waiting areas surrounded by pregnant women were highlighted both in this and in the Mulvihill and Walsh (2013) study. An early pregnancy assessment unit helps to streamline patient care by GPs, midwives and gynaecologists (Newbatt et al, 2012) and avoid women experiencing loss in pregnancy being confronted with healthy pregnancies. Outside of the early pregnancy assessment unit, it is difficult for midwives caring for a woman with early pregnancy loss who is haemodynamically stable, as this woman may not be evaluated as a priority for care (Zavotsky, 2013).
Implications for practice
Robinson (2014) recommends that women experiencing early pregnancy loss require practitioners to have the knowledge and skills to provide women with a supportive environment. The HSE (2016) recommends that all hospital staff have access to and are encouraged to participate in education and training to enhance compassionate bereavement care. Robinson (2014) highlights that psychological and emotional support are necessary, but that it is essential that the services provided are what women want and need.
Consideration could be given to the introduction of educational practices that encourage critical reflection, for example the integration of Schwartz rounds as a means of support for midwives and other members of the multidisciplinary team (George, 2016). The aim of Schwartz Rounds is to reinforce the importance of the human connection by providing staff with structured time to reflect on practice. Trained facilitators then encourage staff to reflect on their thoughts and feelings rather than attempting to solve problems (George, 2016). Findings from the case study analysis by George (2016) showed that attendance at Schwartz rounds helped staff to feel less alone in experiencing stress, resulting in increased compassion. In the context of care provision and early pregnancy loss, Schwartz rounds would seem to be very beneficial.
Likewise, the introduction of an educational intervention supporting personal resilience might help support the midwife in practice (McDonald et al, 2012). McDonald et al (2012) designed an intervention where participants were removed from their workplace environment and engaged in critical reflection and experiential learning to increase resilience. Titherly (2017) recommended that management recognise and acknowledge staff contribution to care in the event of pregnancy loss and death of a baby, and the need to support individual staff in times of stress. Further research is required to determine how best to support midwives exposed to repeated early pregnancy loss.
Conclusion
Midwives spoke about how they coped with early pregnancy loss with the support of colleagues or people at home, as well as mechanisms such as distancing themselves or crying. Resources for midwives to provide to women with early pregnancy loss, such as the miscarriage booklet and signposts to counselling, were discussed. Issues that impeded midwives' ability to provide care for women experiencing loss in early pregnancy were staffing levels, hospital systems, education and training. This study contributes to the understanding of the difficulties that midwives face in providing compassionate care for women experiencing early pregnancy loss while also caring for women with healthy pregnancies. It also highlights the importance of education and training specific to the needs of the woman who has experienced loss in early pregnancy. Training could also focus on development of resilience mechanisms for staff. The provision of structured support, such as Schwartz rounds, would be beneficial for all health professionals involved in the care of women experiencing early pregnancy loss.