Women’s Health Care Following Miscarriage Thesis Presentation By Kelly Joy

1. Women’s Health Care Following Miscarriage Thesis Presentation By Kelly Joy

2. Miscarriage • The unintentional loss of pregnancy before 22 weeks • There is little conclusive evidence as to exactly why it occurred • Rarely life-threatening to the mother • In the majority of cases nothing can prevent a miscarriage • Occurs in approximately 15 % of all conceptions

3. Despite Its Ubiquity… • There is little research into clinical assessments and interventions for women who experience this loss. • There is currently no standard system of follow-up.

4. Not Surprisingly… Many women who have experienced a miscarriage report that they were dissatisfied with the health care they received. *Main Reason: A discrepancy between the patient’s and the provider’s perception of patient needs

5. Patient Concerns • Studies report that 30% of women receive follow-up care after miscarriage despite the fact that it is desired by 90% • Women also desire psychological counseling, however, grief and depression after miscarriage is often unrecognized • Nikcevic et al. 1998

6. Attitudes of Health Care Providers Regarding Miscarriage We were in the emergency room for 8 hrs. It was three hours before a doctor saw me. My husband even went to the desk after and hour and told them my cramping was much worse and so was the bleeding and the response was “There are three people in front of you.” I had gone to the bathroom so many times during my wait and each time more blood and...stuff came out. I was so scared I didn’t know what to do. *Pam *Health care providers generally view miscarriage as a common clinical occurrence for which they have little to offer in terms of treatment (Friedman, 1989).

7. Patient Dissatisfaction with the Quality of Care • Condition is not addressed with appropriate seriousness • Being referred to junior staff • Waiting until the end of routine operating lists for procedures • No consultation in the hospital • Poor advice upon discharge

8. Patient Dissatisfaction with the Quality of Care (cont…) • Hurtful Comments: • “You were only pregnant for 3 mos. It wasn’t even a baby yet.” • “Be sorry for the parents who have lost a child in a car accident or to leukemia” • “You’re better off losing the baby now than later.” • DiMarco et al., 2002 “It’s better than having a retarded baby”

9. Medical Follow-up I could no longer stand the pain and I also couldn’t sit up without losing consciousness. We went to the hospital, where my blood pressure was 60/40, and I was diagnosed with an ectopic pregnancy. I went into surgery immediately. *Susan I was taken to the ER with abdominal pain so intense I could barely walk. I had been bleeding heavily for a week straight after being diagnosed with an incomplete miscarriage. After several hours in the ER I pulled myself off the gurney to go home and saw that it was flooded with my own blood. Flooded until it had spilled over onto the floor. After this experience I was met with pure frustration from my midwife. He had told me previously that everything would be alright and couldn’t understand why I was back in the office for follow-up after my night in the ER. *Kara

10. Emotional Follow-up • Significant level of psychological distress in women following miscarriage (Stritzinger and Robinson, 1989; Beutel et al., 1995) • Depression and anxiety are the most common manifestations (Nikcevic et al., 1998a) • The reaction to the loss is as great with miscarriage as it is with the loss of a neonate (Peppers and Knapp, 1980) • The mean levels of grief related feelings and behaviors post-miscarriage were as great as in people who had lost a close relative (Nikcevic et al., 1998b) • 10% suffer from acute stress disorder and 1 % have post-traumatic stress disorder (Bowles, 2000)

11. Women at High Emotional Risk following Miscarriage • Women who have had a previous miscarriage • Women without children • Women who had not planned the pregnancy • Thapar and Thapar, 1992 • Women under 30 with no children and women over 30 with one child have levels of depression at one year greater than their levels at three months after their loss • Robinson et al., 1994

12. Emotional Follow-up: Cause Identification Long after the [miscarriages] I would wonder if I had done something wrong during the pregnancy. Had I gone up too many steps? Had I carried in too many grocery bags at one time? Had I stayed on my feet too long? There can be these quiet issues that some women may never come to terms with. *Caroline

13. Emotional Follow-up: Evidence-based Counseling and Professional Honesty My doctor…asked about my miscarriage and thought it was strange that the OB/GYN didn’t do a D&C after my first miscarriage leaving me to believe I would have had better luck [with my second pregnancy] had he done a D&C. *Dana (I was instructed to) keep my legs elevated, maybe use a heating pad for pain and if I made it through the night without aborting that would be a good sign. The doctor said he couldn’t predict what was going to happen which lead me to believe there was still hope and something I could do to help save the pregnancy. *Dana One piece of advice (from nurses) was that I would be “most fertile” after having a miscarriage. *Jessica

14. Emotional Follow-up: Bereavement We know where each of our babies were buried and that is a comfort. I also baptized each one in utero- to make sure. On one baby I actually got a baptismal certificate. These things help. Women should be given some certificate or some memento to recognize the little one they lost. *Elaine

15. Conclusions • Educational programs pertaining to miscarriage may help health care providers care for their patients in a more sensitive and psychologically effective manner • Establishing a systematic follow-up for women who have experienced miscarriage • The inclusion of mental health care providers in professional networks • The use of screening tools to identify patients at risk for psychiatric problems

16. Special Thanks: Dr. Debra Nickell Dr. Robert Hadley The Writing Center Guy James Belcher for graphic

17. Any Questions?