Primary healthcare midwives' experiences of caring for parents who have suffered an involuntary pregnancy loss: a phenomenological hermeneutic study.

OBJECTIVE: To illuminate the experiences of primary healthcare midwives who care for parents who have suffered an involuntary pregnancy loss. DESIGN: The phenomenological hermeneutic approach developed by Lindseth and Norberg was used to carry out narrative interviews. SETTING AND PARTICIPANTS: A purposive sample of 11 public primary healthcare midwives from a municipality in northern Spain, was selected. The participants' ages ranged between 26 and 62 years, and they were all women. FINDINGS: Four main themes were identified: (1) handling adversity, (2) finding a motive to get involved, (3) providing care from the rear, and (4) avoiding emotional connections with the parents. For the midwives, caring for parents who had suffered an involuntary pregnancy loss meant leaving their own comfort zone and handling adversity. They described acting in different ways such as going beyond task-focused care, following their intuition or avoiding encounters with the parents. CONCLUSIONS: More knowledge and preparation in terms of communication skills and bereavement is crucial for midwives in order to meet the needs of parents who have suffered an involuntary pregnancy loss. A caring organizational culture and supportive leadership will facilitate care continuity between specialized and primary healthcare and promote the welfare of midwives.

Involuntary Pregnancy Loss and Nursing Care: A Meta-Ethnography.

Healthcare professionals find the care of parents following an involuntary pregnancy loss stressful and challenging. They also feel unprepared to support bereaved parents. The challenging nature of this support may have a personal impact on health professionals and the care provided to parents. The aim of this meta-ethnography is to synthesise nurses' and midwives' experiences of caring for parents following an involuntary pregnancy loss. A meta-ethnography of ten studies from five countries was carried out. GRADE CERQual was assessed to show the degree of confidence in the review findings. An overarching metaphor, caring in darkness, accompanied by five major themes provided interpretive explanations about the experiences of nurses and midwives in caring for involuntary pregnancy losses: (1) Forces that turn off the light, (2) strength to go into darkness, (3) avoiding stumbling, (4) groping in darkness, and (5) wounded after dealing with darkness. Nursing staff dealt with organizational difficulties, which encouraged task-focused care and avoidance of encounters and emotional connection with parents. However, nurses and midwives might go beyond in their care when they had competencies, support, and a strong value base, despite the personal cost involved.

Women's Experiences of Miscarriage in the Emergency Department.

INTRODUCTION: Miscarriage is a common event, usually managed in the emergency department. Although studies have examined the impact of miscarriage on women's mental health and the effects of their dissatisfaction with health care received, little is known about the characteristics of the miscarriage experience in the emergency department. The objective of this study was to identify characteristics of care management that may have contributed to the difficulties experienced by women presenting with miscarriage in the emergency department. METHODS: Forty-eight women treated at 4 emergency departments in different regions of Quebec, Canada, were interviewed for 60 to 90 minutes. A thematic qualitative analysis of these interviews was performed. RESULTS: Analyses revealed that participants' experiences were characterized particularly by a lack of information at 3 critical junctures of the miscarriage experience: the announcement of the miscarriage, the course of the miscarriage, and the ED discharge. The topics on which the women lacked information were categorized into 7 subthemes within these junctures. DISCUSSION: Lack of information throughout the care management of miscarriage exacerbated the already-difficult nature of this event for the participants. Training emergency nurses to give adequate and complete information enables the delivery of compassionate care, potentially making a difficult situation less traumatic.

Exploring the needs of parents who experience miscarriage in the emergency department: A qualitative study with parents and nurses.

AIMS AND OBJECTIVES: To understand how parents experienced miscarriage in an emergency department setting. Objectives were to identify parents' needs, isolate factors that influenced their experience, and provide recommendations to improve care from the perspective of women, their partners, nurses and nurse managers. BACKGROUND: Miscarriage is the most prevalent complication encountered during pregnancy. It subjects parents to a multitude of emotions and may have significant consequences on mental health. Emergency department visits are frequently the only opportunity for parents to receive formal support during a miscarriage; it is thus crucial to understand the experiences of parents in this setting. DESIGN: The study employed a descriptive, exploratory, qualitative approach with semi-structured interviews. METHODS: The study was founded on the W.K. Kellogg Foundation's Logic Model Development Guide (2004) and Meleis' Transitions Theory (2015). A total of 26 participants were interviewed (17 parents, 7 emergency department nurses and 2 emergency department nurse managers). Consolidated criteria for reporting qualitative research was used to report results. RESULTS: Three categories of needs were identified: physical health, cognitive and emotional. For instance, parents expressed a need to receive more information during their visit to the emergency department (i.e., a cognitive need), whether about the diagnostic test results or how to ensure a better recovery. Parents also reported a desire for professionals to address their emotional concerns. Nurses were aware of the emotional impact of miscarriage but felt that they were not adequately trained in providing optimal care to parents in this situation. CONCLUSIONS: Parents who visited the emergency department for miscarriage reported several unfulfilled needs that generated dissatisfaction with care. Emergency department organisational constraints hindered optimal nursing care practices. RELEVANCE TO CLINICAL PRACTICE: Nurses have an important role to play in improving parents' experience. They can do so by understanding the needs of parents and by being involved in developing new guidelines.

Patient perspectives of pregnancy loss in the emergency department.

OBJECTIVES: While threats to pregnancy such as vaginal bleeding are common, half will miscarry. The ED environment is not always conducive to the emotional and psychological needs of women grieving the loss of a pregnancy. Healthcare providers have a great impact on the women's experience of pregnancy loss. This study describes the perspectives of women experiencing a pregnancy loss in the ED. METHODS: The study used a qualitative descriptive research design interviewing women diagnosed with a pregnancy loss in the ED. Data analysis consisted of descriptive statistics of the sample and content analysis of interviews. RESULTS: Eight participant interviews generated five themes related to the ED as part of the crossroads of motherhood and pregnancy loss. The themes were (a) Decisions to get help, (b) The environment of emergency care, (c) Not knowing, (d) Finally knowing and moving on, (e) Assisting with the grieving process. CONCLUSIONS FOR PRACTICE: Understanding the needs of women diagnosed with pregnancy loss allows emergency nurses and providers to provide more holistic, compassionate care. Knowledge of pregnancy loss experiences will assist in the improvement of future patient care, and may positively impact recovery and transition to normalcy.

Educating Emergency Department Nurses About Miscarriage.

Miscarriage is the unwanted ending of a pregnancy before 20 weeks gestation. Women experiencing miscarriage require specialized care from nurses and other healthcare professionals. Many women are dissatisfied with emergency care related to miscarriage and desire honest communication, validation of urgency, and more robust information at discharge. Perinatal bereavement education offers an opportunity for emergency department nurses to acquire specific knowledge and communication skills that assist with understanding the individualized experience of early pregnancy loss. For many women, a miscarriage is devastating, whereas for some, a part of life. Therefore, assessing the meaning of miscarriage is an essential step to providing sensitive, supportive care. Education was offered to emergency department nurses based on a 4-hour Resolve Through Sharing curriculum. Education focused on knowledge of policy and practice, medical aspects of pregnancy loss, information on how to assess the meaning of the miscarriage, respectful handling and disposition of the remains, and communication strategies to initiate and sustain a meaningful relationship with the woman and her family, within the barriers to care that are exclusive to the emergency department. Participants embraced the information and actively participated in dialogue of an evaluation process to identify needed revisions in current policies and practices for caring for this patient population. Recommendations and guidance for emergency room nurses who care for women experiencing miscarriage are offered.

Respectful Disposition After Miscarriage: Clinical Practice Recommendations.

Compassionate clinical practice guidelines for healthcare providers for respectful disposition after miscarriage are presented. When woven into the whole of a clinician's practice, these guidelines provide the framework for giving women and their families the care they want and deserve when experiencing miscarriage. Relying on theoretical concepts of personhood, place, and protection, care providers can assess the unique meaning a woman assigns to her early pregnancy loss and offer interventions that embrace the concept of respectful disposition. Respectful methods of disposition involve a continuum of care that shows respect for remains and relies on person-, family-, and culture-centered nursing care. Policies, practices, and perspectives that flow from respectful disposition have women and families at their core and flexibility to cocreate care. This involves courage and competence. Several states have enacted fetal disposition laws, but these mandates are of questionable benefit because the expertise of healthcare leaders, nurses, physicians, chaplains, and other stakeholders must be involved in this sensitive and important area of care. Compassionate care cannot be legislated. We offer a practical approach to respectful disposition, including how to handle and prepare remains and examples of burial and memorial services, which will give clinicians the ability to respond empathetically and respectfully to the heart-rending plea of a woman who asks, "Where is my baby?"

Health Professionals' Practices and Attitudes About Miscarriage.

PURPOSE: The purposes of the study were to explore relationships between attitudes, beliefs, and practices of healthcare professionals caring for women and families experiencing miscarriage and to identify gaps and barriers in follow-up services and supports for these women and families. STUDY DESIGN AND METHODS: A survey about beliefs, attitudes, and practices regarding women and families experiencing miscarriage and barriers to care was conducted electronically and through distribution in three emergency departments (EDs). There were 174 participants; physicians (n = 50), RNs (n = 63), midwives (n = 38), nurse practitioners (n = 9), and others (n = 4). RESULTS: Participants believed that miscarriage can have high impact on women and families. They provided information to patients about miscarriage and its present and future implications. The most important predictor for mobilization of support by healthcare professionals was confidence. Nurses in EDs reported the least amount of confidence and knowledge to provide women and families with support. Availability and awareness of specific services by professionals and health system issues were identified as barriers to care. CLINICAL IMPLICATIONS: Education of healthcare professionals, particularly of RNs in EDs, is important to address misconceptions about miscarriage, increase confidence in providing support, and promote effective care. Women and families experiencing miscarriage need privacy and timeliness in care. Interventions such as funded midwifery loss care or a routine telephone follow-up call could improve access to care and help healthcare professionals ensure that families obtain the type and amount of support that they need.

Memorial services offered following an early pregnancy loss in Scotland.

Empirical evidence suggests that memorial services and mementoes aid the grieving process for couples following an early pregnancy loss, and reduce the risk of psychological morbidity with its attendant sequelae. Following a telephone questionnaire, the provision of and signposting to memorial services was found to vary across 20 Early Pregnancy Units (EPUs) identified in Scotland, with local media resources employed, rather than personal invitation, and no consistency at which gestational age or when mementoes were offered. These discrepancies need to be resolved. All units were aware of national charities working in this area.

Women's experiences of early miscarriage: implications for nursing care.

AIMS AND OBJECTIVES: To investigate women's experience of early miscarriage (the first 16 weeks of pregnancy) by reviewing the literature since 1990, identifying and exploring critical themes. BACKGROUND: Early miscarriage loss accounts for 50,000 inpatient admissions per year in the UK reported in 2010. It can result in anxiety, depression, guilt, emptiness and other features of bereavement. DESIGN: A structured literature review of qualitative literature was undertaken to explore the evidence of women's experience of early miscarriage, and elicit common themes emerging. METHODS: A systematic electronic database search was conducted using a range of search engines. Nine papers were identified; four from the UK and one paper each from the USA, Australia, Canada, Israel and Sweden. RESULTS: Four predominant themes were identified from the experiences of 211 women in the nine studies: 'What I feel', 'Care for me and communicate with me', 'Me, my baby and others' and 'Help me to cope with the future'. CONCLUSIONS: Early miscarriage is a potentially devastating experience, and the diversity of experiences of women must be reflected in the provision of appropriate and sensitive nursing care. RELEVANCE TO CLINICAL PRACTICE: The study demonstrated a significant training need for nurses and midwives to provide women with individualised care.

My daughter's daughter: the tragedy of late stage miscarriage.

This article sets out my observations of my daughter's difficult pregnancy and late-stage miscarriage. I share this information to raise awareness that the specialist support for women going through this is not always in place and doesn't fully prepare women for this experience. Even though this can be uncomfortable for maternity professionals, the care that women receive, especially during labour and birth, has a massive impact on them and their families. There are many opportunities for midwives to make a positive difference at this difficult time. My granddaughter, Jess, died at five months gestation and was later confirmed to have Turner Syndrome. Turner Syndrome is a chromosomal abnormality that only affects girls and is related to the partial or complete deletion of the X chromosome. Not all affected girls are miscarried and an estimated one in 2000 girls born in the UK has Turner Syndrome.

Sexual health risks and health-seeking behaviours among substance-misusing women.

AIMS: To report on a survey of sexual health service needs among substance-misusing women attending a substance misuse service. BACKGROUND: Substance-misusing women carry a disproportionate burden of sexual ill health, yet the range and frequency of their sexual health risks, morbidities and service engagement are poorly understood. DESIGN: A cross-sectional survey of a convenience sample of substance-misusing women attending a substance misuse service. METHODS: From 4 April 2010-17 September 2010, substance-misusing women in Hastings & Ore, UK, were invited to complete a paper questionnaire addressing: drug use; cervical cytology, sexually transmitted infection and HIV screening history; pregnancy history, perceived pregnancy risk and contraceptive advice and supply; sexual activity and assault. Of 91 respondents, 77 attended local drug treatment services - results comprise analysis of this sub-sample. RESULTS: The study sample was characterized by long-term opioid and crack cocaine use. Of 53% sexually active in the previous 4 weeks, 66% perceived they had experienced sexual intercourse that could lead to pregnancy during that time. Fifty-five per cent had been forced to have sex against their will during their lifetime. High rates of sexually transmitted infections, pregnancy termination, miscarriage and abnormal cervical cytology were reported. CONCLUSIONS: Findings indicate the need to recognize the breadth of elevated sexual health risks and morbidities experienced by substance-misusing women with long-term opioid/crack use, including those not identifying as intravenous drug users. Poor recall of drop-in and appointment times, reluctance to disclose substance misuse and likelihood of previous sexual assault present significant challenges to nurses, who must take a sensitive, opportunistic approach to referral and provision of sexual health interventions to substance-misusing women.

Measuring the meaning of miscarriage: revision of the Impact of Miscarriage Scale.

BACKGROUND AND PURPOSE: The purpose of this study was to determine a factor structure for the Impact of Miscarriage Scale (IMS). The 24 items comprising the IMS were originally derived from a phenomenological study of miscarriage in women. Initial psychometric properties were established based on a sample of 188 women (Swanson, 1999a). METHOD: Data from 341 couples were subjected to confirmatory factor analysis (CFA) and exploratory factor analysis (EFA). RESULTS: CFA did not confirm the original structure. EFA explained 57% of the variance through an 18-item, 4-factor structure: isolation and guilt, loss of baby, devastating event, and adjustment. Except for the Adjustment subscale, Cronbach's alpha coefficients were > or = .78. CONCLUSION: Although a 3-factor solution is most defensible, with further refinement and additional items, the 4th factor (adjustment) may warrant retention.

A comparison of the nurse work environment between perinatal and non-perinatal hospice providers.

BACKGROUND: Hospice nurses have a unique role in providing perinatal care, yet little is known about the work environment in which nurses provide care for families and infants at the end of life. OBJECTIVE: To compare the nurse work environment between perinatal and non-perinatal hospices. METHODS: Data from the 2007 US National Home and Hospice Care Survey was used. The sample included 526 US hospice agencies. Comparisons were calculated using the Pearson chi-square and Wald tests. RESULTS: A majority of hospices provided perinatal care (60%). Compared with non-perinatal hospices, the perinatal nurse work environment had a significantly higher proportion of registered nurses (mean 0.87 vs mean 0.79), along with clinical nurse specialists and nurse practitioners to support them (95.6% vs 84.9%). Nurses within perinatal care providers worked in a climate of significantly greater safety (95.6% vs 84.9%) and technology (63.7% vs 47.1%). CONCLUSIONS: Understanding the unique perinatal hospice nurse work environment may be essential for advancing knowledge and compassion for mothers and babies at the end of life.

Health promotion: healing through loss.

For many women, miscarriage constitutes an often sudden, unexpected physically as well as psychologically traumatic event. A large percentage of women having miscarriage must present to an outpatient setting, primarily the emergency department, for care during this time. Studies indicate that health care professionals are failing to meet the needs of women and their families during and after miscarriage and that greater emphasis should be placed on psychosocial and interpersonal skills. The problem has been identified as how to assist or prepare emergency nurses to better care for the physical and psychological needs of women having early, unanticipated loss of pregnancy. At 1 rural Midwest medical center, it was the women's health staff who took the initiative to address this problem. They recognized the need for a holistic approach to care for women experiencing pregnancy loss. This would be accomplished through bridging the gap between outpatient services and primary care. This resulted in creating a support group called Ended Beginnings, which was organized to help women convalesce through the physical, emotional, and spiritual hardships associated with pregnancy and infant loss. Positive feedback has been received from both patients and staff with regard to the extent to which collaborative services provide a positive impact for both the patient and staff assisting the patient during a time of sudden, unanticipated loss.

Tackling perinatal loss, a participatory action research approach: research protocol.

AIM: The aim of this study was to promote changes to improve the care provided to parents who have experienced a perinatal loss through participatory action research. BACKGROUND: The birth of a child is a joyful event for most families, however, unfortunately some pregnancies end in loss. Perinatal loss creates a heavy emotional impact not only on parents but also on health professionals, where in most cases there is an evident lack of skills, strategies and resources to cope with these kinds of situations. DESIGN: Participatory action research is the methodology proposed to achieve the purpose of this study. METHODS: Participatory action research consists of five stages: outreach and awareness, induction, interaction, implementation and systematization. The working group will include professionals from the Mother and Child Unit for patients at a tertiary level public hospital in Spain. The duration of the study will be 3 years since the approval of the protocol in January 2011. The qualitative techniques used will include group dynamics such as the SWOT analysis the nominal group technique, focus groups and brainstorming, among others that will be recorded and transcribed, generating reports throughout the evolution of the group sessions and about the consensus reached. Content analysis will be conducted on the field diaries kept by the participants and researchers. This project has been funded by the Andalusian Regional Ministry of Health. DISCUSSION: Participatory action research is a methodological strategy that allows changes in clinical practice to conduct a comprehensive transformative action in the care process for perinatal loss.