Spiritual Support to Improve Women's Mental Health after Miscarriage and Stillbirth: A Qualitative Study in Japan.

PROBLEM: Miscarriage and stillbirth can severely impact maternal mental well-being. BACKGROUND: In Japan, local municipalities must prepare systems to provide mental and social-spiritual support to women after miscarriage or stillbirth. OBJECTIVE: To elucidate what spiritually supports the mental health of women who have experienced miscarriages and stillbirths. METHODS: This analysis included 25 women who had experienced miscarriage or stillbirth at least one month previously and participated in self-help group meetings at least twice. Data were collected from March 2020 to March 2021 using two narrative interviews and questionnaires. FINDINGS: The mothers led their lives "together" with their children. They derived spiritual support from others, such as "the presence of someone who is living now after having experienced anguish" and "others who acknowledge the presence of my child and me as a mother. " Further elements of the support included "resigning myself to face my grief" and "strong links to deceased children. " While facing their grief by accepting that this anguish cannot be replaced [with anything else] and resigning themselves to reality, their bond to their child is strengthened. CONCLUSION: What women perceive as support after a miscarriage or stillbirth will be an important clue to care.

Women's experiences of early pregnancy loss services during the pandemic: A qualitative investigation.

PROBLEM: Early pregnancy losses [EPL] are common, varied, and require different courses of management and care. BACKGROUND: In the UK, women who suspect or suffer a pregnancy loss are usually provided specialist care in early pregnancy assessment units [EPAUs]. Their configuration has recently been evaluated, but recommendations for change in-line with best practice for optimum outcomes were unable to be implemented due to the COVID-19 pandemic health system shock. AIM: To compare women's experiences of EPAUs during the pandemic to themes previously found in qualitative work undertaken with women who utilised EPAUs before the pandemic. METHODS: We conducted semi-structured virtual interviews, with women (N = 32) who suffered an early pregnancy loss during the pandemic; analysing transcripts using Template Analysis, based on findings about women's (pre-pandemic) experiences of EPAU from The VESPA Study. FINDINGS: We report on seven key themes: Barriers to Accessing Services; Communication & Information; Retention of Relational Care; Involvement in Care Decisions; Staffs' Attitude or Approach; Efficiency of Service Delivery; Sensitive Patient Management. DISCUSSION: Sensitive patient management and woman-staff interactions in EPAU settings remain a fundamental issue. Women also reported their experiences of EPAUs were comparatively worse during the pandemic. CONCLUSIONS: Women valued the care provided by EPAUs and found services to be efficient, despite pandemic-related restrictions. However, psychological recognition surrounding EPL and appropriate, sensitive, relational care and support continue to be areas in need of improvement. Our recommendation is to implement the improvements suggested by VESPA as a priority to ameliorate present sub-optimal experiences and prevent further deterioration.

Improving access, understanding, and dignity during miscarriage recovery in British Columbia, Canada: A patient-oriented research study.

BACKGROUND: Approximately 15%-25% of clinical pregnancies end in miscarriage, with more than 15,000 miscarriages occurring annually in British Columbia, Canada. Despite the significant rates of loss, research and health care services for pregnancy loss remain scarce in British Columbia. OBJECTIVES: This study aimed to (1) aid miscarriage recovery through the identification and sharing of equitable pregnancy loss care practices and supports and (2) present policy recommendations to improve prenatal care guidelines and employment standards for pregnancy loss. DESIGN: This research took a patient-oriented methodological approach alongside people with lived/living experience(s) of miscarriage recovery in British Columbia to evaluate access to health care during pregnancy loss, societal understanding of miscarriage, and treatment options that foreground dignity. METHODS: The mixed-methods design of this research included policy research on prenatal care guidelines, policy research on provincial and territorial employment legislation for bereavement leave, semi-structured interviews (n = 27), and a discovery action dialogue (n = 4). RESULTS: The findings of this research demonstrate the need for improved prenatal care guidelines for early pregnancy loss, follow-up care after a miscarriage, mental health screening and supports, and bereavement leave legislation. CONCLUSION: This article includes recommendations to improve equitable access to pregnancy loss care, bereavement leave legislation, and future research in this area.

Interpretative Phenomenology of Grief following Reproductive Loss: A Narrative Review and Considerations on Improving Support.

The loss of pregnancy through miscarriage or stillbirth is typically an unexpected and highly distressing event for parents. While death in any form may be overwhelming to those bereaved, pregnancy and newborn loss are unique in several ways because they involve the added loss of parental identity and the idealized baby and family. In this study, the authors performed a narrative review of the literature regarding the phenomenon of grief following reproductive loss in bereaved parents, focusing on heteronormative mothers and fathers and on nontraditional families. One of the main highlighted aspects is the disenfranchisement of grief, which refers to a loss that is not or cannot be acknowledged, publicly mourned, or socially supported. This feeling is elicited by family, society, and healthcare providers. Although the literature has consistently documented the negative impact of this type of experience on parents and families, it is still largely unrecognized by healthcare providers. As most studies demonstrate, there are significant gaps in the psychosocial components of miscarriage and stillbirth care, including a lack of clarity in communication about the loss and subsequent steps, a lack of empathy, an invalidation of grief, and a failure to attend to emotional needs. Since healthcare providers are most often the first point of contact as they experience the loss, it is imperative to act so that patients' needs are more adequately met. To this purpose, the authors propose a set of measures aimed at improving the quality of care and support.

Impacto psicológico inicial e incidencia de trastorno mental en torno a las interrupciones voluntarias del embarazo (IVE): un estudio piloto en población general / Initial psychological impact and incidence of mental disorders Around voluntary terminations of pregnancy (vtp): a pilot Study in the general population

Introducción/Antecedentes: Existe todavía una insuficiente evidencia científica sobre los efectos psicológicos/psicopatológicos y emocionales de las interrupciones voluntarias del embarazo (IVE), especialmente en nuestro entorno. Los estudios previos sobre el tema se caracterizan por 1) ofrecer resultados dispares, 2) estudiar depresión, ansiedad, trastorno por estrés postraumático y abuso de sustancias, pero al mismo tiempo 3) existen cuestiones metodológicas que limitan la generalización de los resultados. Objetivos: Describir una muestra de mujeres de población general que realizaron una IVE en un servicio público de Atención a la Sexual y Reproductiva (ASSIR) de Catalunya. Métodos: Estudio piloto de pacientes provenientes de población general y atendidas en nuestras consultas de Ginecología del Servicio de Atención a la Salud Sexual y Reproductiva (ASSIR) de Osona a Vic (Barcelona). Las pacientes fueron evaluadas siguiendo escalas estandarizadas, incluyendo la MINI (Mini Psychiatric Interview) y la Escala de Depresión de Hamilton. El seguimiento fue durante cuatro meses. Se realizó una estadística descriptiva. Resultados: Hasta 23 mujeres fueron incluidas en la muestra piloto. La edad media era joven (31.4 años). La mayoría (62.5%) estaban activas laboralmente y tenías estudios equivalentes al bachillerato o superiores (52.2%). El 26.1% habían tenido IVE previas. La IVE actual fue mayoritariamente farmacológica (73.9%). El principal motivo fue su voluntad (86.9%). Tres mujeres puntuaron más de 7 puntos en la Escala de Depresión de Hamilton. La entrevista diagnóstica MINI identificó diez mujeres con criterios para enfermedad mental en ese momento. De estas diez mujeres, seis no tenían antecedentes familiares ni personales de enfermedad mental, mientras que cuatro ya tenían antecedentes personales de alguna patología mental y ya habían consultado anteriormente en alguna ocasión al Servicio de Psiquiatría...(AU)

Introduction/Background: There is still insufficient scientific evidence on the psychological/psychopathological and emotional effects of voluntary terminations of pregnancy (V.T.P.), especially in our setting. Previous studies on the subject are characterized by 1) mixed results, 2) studying depression, anxiety, post-traumatic stress disorder and substance abuse, but at the same time 3) there are methodological issues that limit the generalizability of the results. Objectives: To describe a sample of women from the general population who underwent an abortion in a public center of the Sexual and Reproductive Assistance Network (ASSIR) of Catalonia. Methodology: Pilot study of patients from the general population attended in our Sexual and Reproductive Health outpatient clinics at the ASSIR of Osona (Vic, Barcelona). Patients were assessed using standardized scales, including the MINI (Mini Psychiatric Interview) and the Hamilton Depression Scale. Follow-up was for four months. Descriptive statistics were performed. Results: Up to 23 women were included in the pilot sample. The average age was young (31.4 years). The majority (62.5%) were active in the labour market and had a high school education or higher (52.2%). 26.1% had had a previous VTP. The current abortion was mostly pharmacological (73.9%). The main reason was willingness (86.9%). Three women scored more than 7 points on the Hamilton Depression Scale. The MINI diagnostic interview identified ten women with criteria for mental illness at that time. Of these ten women, six had no family or personal history of mental illness, while four had a personal history of mental illness and had previously consulted the psychiatric service. After the abortion, during the following four months, only one patient consulted the psychology service and was subsequently discharged...(AU)

Lived experience of recurrent miscarriage: women and their partners' experience of subsequent pregnancy and support within an NHS specialist clinic - a qualitative study.

OBJECTIVE: This study aims to describe the lived experiences of couples with a history of recurrent miscarriage in subsequent pregnancies and their perception of clinic support and cytogenetic investigations. DESIGN: A qualitative interview study with a phenomenological approach. Semistructured interviews were conducted using video conferencing software. Two researchers coded the transcripts and developed themes. SETTING: A National Health Service (NHS) hospital in central England between May 2021 and July 2021, during the COVID-19 pandemic. PARTICIPANTS: Patients attending a specialist recurrent miscarriage clinic and their partners. This clinic accepts referrals from all over the UK for couples who have suffered two or more miscarriages. RESULTS: Seventeen participants were interviewed: 14 women and 3 male partners. Six main themes were identified from the data. Three related to the women's lived experience of recurrent miscarriage (emotions in pregnancy, confidence in their bodies, expectations and coping strategies) and three related to the clinical support offered by the NHS service (impact of early pregnancy scanning, effect of the COVID-19 pandemic and cytogenetic investigations). CONCLUSIONS: Pregnancy following recurrent miscarriage is extremely difficult. Recurrent miscarriage specialist services can provide couples with support and access to early pregnancy scanning, which can make the first trimester of pregnancy manageable. Partners should not be excluded from the clinic as it can result in a feeling of disconnect. Cytogenetic testing of pregnancy tissue can offer couples with recurrent miscarriage closure after pregnancy loss and is a desired investigation.

Utility of early, short psychological care for women who experience early miscarriage: protocol for the randomized, controlled MisTher trial.

BACKGROUND: Around one in ten women will have a miscarriage in their lifetime. Miscarriage is often considered a trivial event by caregivers, but it is associated with a high burden of psychological morbidity, especially during the first 6 months. There is no validated psychological management strategy for women who have had a miscarriage. The MisTher study aims to evaluate the utility of early, short psychological care for women who have had early miscarriage, in terms of anxiety, depression and post-traumatic stress disorder. METHODS: This is a prospective, multicenter, randomized, controlled, superiority study. In total, 932 women who have experienced early miscarriage (spontaneous interruption of pregnancy prior to 14 weeks of gestation) will be randomly assigned to either the intervention or the control group. The intervention consists of 4 teleconsultations of 45 min with a psychologist. All women, regardless of their allocated group, will be encouraged to seek an early consultation with a general practitioner or midwife. The primary endpoint will be anxiety at 3 months after randomization evaluated using State Trait Anxiety Inventory. The secondary endpoints will be anxiety at 6 months evaluated using State Trait Anxiety Inventory, depression at 3 and 6 months evaluated with the Beck Depression Inventory, and post-traumatic stress disorder at 3 and 6 months, evaluated using the Posttraumatic stress disorder Checklist Scale. DISCUSSION: This project will validate the importance of early psychological management, based on primary care and accessible to most women, via teleconsultation, in reducing the frequency of psychological disorders after early miscarriage. Our results should provide a basis for new recommendations for the management of women who have experienced miscarriage, notably by recommending the involvement of trained psychologists in the management pathway for these women. TRIAL REGISTRATION: The trial is registered with ClinicalTrials.gov: NCT05653414. December 15th, 2022.

Navigating miscarriage in Jordan: understanding emotional responses and coping strategies.

BACKGROUND: Miscarriages account for 20% of clinically confirmed pregnancies and up to 50% of all pregnancies and is considered one of the most heartbreaking events experienced by women. The current study aimed to explore participants' perceptions and practices and how they link with the negative emotions of miscarriage. METHODS: In this cross-sectional study a web-based questionnaire was used to gather data from 355 women living in Jordan who had experienced a previous miscarriage. The questionnaire consisted of four sections, including socio-demographic information, experience with miscarriage, emotions after the experience, and self-care practices. Participants were recruited through social media platforms from April to August 2022. Data were analyzed using SPSS, and descriptive statistics, chi-square test, and binomial regression were performed to examine the results. RESULTS: The results show that the majority of participants were in the age group of 22-34 years and a larger percentage of participants hold a Bachelor's degree and were employed. All participants had experienced a previous miscarriage with 53.8% having one, 27.0% having two, and 19.2% having three or more miscarriages. In addition, most miscarriages did not have an explanation for their cause (77.5%), but vaginal bleeding was the most reported symptom (55.2%) and surgical management was predominant (48.7%). Most participants reported adequate emotional support from partners and family (63.7% and 62.3%, respectively). Almost half (48.7%) of the respondents felt like they had lost a child and those who did not receive any social support had a higher association with the same feeling (p = 0.005). Of the participating women, 40.3% decided to postpone another pregnancy while 20.0% planned for a subsequent pregnancy. The feeling of shame regarding the miscarriage was the main driver for women to get pregnant again (Odd ration [OR] 2.98; 95% confidence interval (CI) 1.31-6.82; p = 0.01). CONCLUSIONS: The findings highlight the emotional impact of miscarriage on women and the need for proper support and self-care practices.

The Process Model of Stigmatized Loss: Identity-Threatened Experiences of Bereaved Mothers.

Despite almost one-third of women suffering from the loss of a baby through miscarriage, stillbirth, or infant loss, it is surprising how little research examines how such loss affects the identity and stigmas experienced by these individuals. Through in-depth, semi-structured interviews with bereaved mothers (in particular, mothers who lost a baby during pregnancy or within one year after birth), this research sheds light on the bereaved mother's experiences after loss. Specifically, this research applies the identity-threat model of stigma to showcase the process of stigmatized loss. Based on our findings, we also introduce the process model of stigmatized loss that can apply to all types of stigmatized loss. Key themes emerged as we explored stigmatized loss discourses. These include situational cues that trigger stigma, identity-based responses that aim to preserve both a baby's and mother's identity, as well as nonvolitional and volitional responses that help restore control and reconstruct identity. Additionally, other themes revolve around positive and negative outcomes stemming from avoiding stigmatized identity activation and identification of triggers that initiate a recursive process through stigmatized baby loss. Importantly, stigma can be perceived as both an identity threat (negative) and an identity confirmation (positive). Findings inform theory and practice alike.

Psychological impact over time of women with pregnancy loss due to gestational trophoblastic disease compared with miscarriage.

OBJECTIVES: Pregnancy loss, occurring after miscarriage or after gestational trophoblastic disease, has a psychological impact. Besides pregnancy loss, women diagnosed with gestational trophoblastic disease have to deal with a prolonged period of follow-up and potential advice to postpone a future pregnancy. We studied the severity and course of the psychological impact after gestational trophoblastic disease and miscarriage, to identify whether women with gestational trophoblastic disease need different psychological care. METHODS: A prospective multicenter study using online questionnaires was performed. Women diagnosed with gestational trophoblastic disease or miscarriage received the following questionnaires directly after diagnosis, and after 6, 6, and 12 months: a self-report questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale, and the Reproductive Concerns Scale. RESULTS: 74 women with gestational trophoblastic disease and 76 women with miscarriage were included. At baseline, the proportion of women scoring above the cut-off level for the anxiety subscale of the HADS and for the Impact of Event Scale was significantly higher for women with gestational trophoblastic disease than for women after miscarriage (43.2% vs 28.9%, p=0.02 and 87.8% vs 78.9%, p=0.03, respectively). During follow-up, the differences between both groups vanished and only the Impact of Event Scale after 12 months remained significantly different between women with gestational trophoblastic disease and women after miscarriage (62.7% vs 37.3%, p=0.005). All outcomes, except the Reproductive Concerns Scale, showed a significant decline. However, in women who scored above the cut-off level on the HADS-total or Impact of Event Scale at baseline, and women with psychological or psychiatric history, significant higher scores persisted. CONCLUSION: Although women with gestational trophoblastic disease at baseline had more anxiety and distress than women after miscarriage, no significant differences were seen using the HADS-total after 12 months. Using the HADS or Impact of Event Scale directly after pregnancy loss is helpful to identify women at risk of remaining psychological symptoms to provide them with extra psychological support.

Knight by force and wounded, protecting without a shield: A meta-ethnography of men's experiences after an involuntary pregnancy loss.

OBJECTIVE: To synthesize the available body of qualitative research regarding the experiences of men after an involuntary pregnancy loss. DESIGN: Noblit and Hare's interpretive meta-ethnography of 13 original qualitative articles was carried out. RESULTS: After reciprocal and refutational translations, the lines of argument synthesis were developed, together with the metaphor "Knight by force and wounded, protecting without a shield." This metaphor symbolizes the experience of men after an involuntary pregnancy loss. CERQual assessment showed that the results are a (highly) reasonable representation of the phenomenon of interest. CONCLUSIONS: The men attempted to cope with the loss of fatherhood and suffering, while managing the lack of social recognition and social expectations of masculinity in terms of their behaviour and expression of suffering. They tended to be strong, although they did not always have the necessary support or knowledge. IMPLICATIONS FOR PRACTICE: Comprehensive and individualized care that includes the man is required. This requires the theoretical-practical training of nurses and midwives, and the provision of tools that help the emotional management of emotionally demanding care.

"Technically an abortion": Understanding perceptions and definitions of abortion in the United States.

Anti-abortion legislation in the United States exploits misinformation and ignores medical definitions to curtail access to essential healthcare. Little is known about how individuals most likely to need this care define abortion, in general or as distinct from miscarriage, and how this might impact access to, utilization of, and experiences of care. Using mixed-method card sort and vignette data from cognitive interviews (n = 64) and a national online survey (n = 2009), we examined individuals' understandings of pregnancy outcomes including abortion and miscarriage. Our findings show that people hold varying ideas of what constitutes an abortion. Many respondents considered 'intent' when classifying pregnancy outcomes and focused on intervention to distinguish between miscarriages and abortions. Particularly, medical intervention was found as a defining feature of abortion. Lack of knowledge regarding pregnancy experiences and ambiguity surrounding early stages of pregnancy also influenced respondents' understanding of abortion. We find that abortion and miscarriage definitions are socially constructed and multi-layered. Advancing our understanding of abortion and miscarriage definitions improves reproductive health research by elucidating potential areas of confusion that may lead to misreporting of reproductive experiences as well as highlighting ways that blurred definitions may be exploited by abortion opponents.

Pregnancy loss following miscarriage and termination of pregnancy for medical reasons during the COVID-19 pandemic: a thematic analysis of women's experiences of healthcare on the island of Ireland.

BACKGROUND: Losing a baby during pregnancy can be a devastating experience for expectant parents. Many report dedicated, compassionate healthcare provision as a facilitator of positive mental health outcomes, however, healthcare services have been severely impacted during the COVID-19 pandemic. AIM: To explore women's experiences of healthcare service provision for miscarriage and termination of pregnancy for medical reasons (TFMR) on the island of Ireland during the COVID-19 pandemic. METHODS: Findings combine data from elements of two separate studies. Study 1 used a mixed methods approach with women who experienced miscarriage and attended a hospital in Northern Ireland. Study 2 was qualitative and examined experiences of TFMR in Northern Ireland and Ireland. Data analysed for this paper includes open-ended responses from 145 women to one survey question from Study 1, and semi-structured interview data with 12 women from Study 2. Data were analysed separately using Thematic Analysis and combined for presentation in this paper. RESULTS: Combined analysis of results indicated three themes, (1) Lonely and anxiety-provoking experiences; (2) Waiting for inadequate healthcare; and (3) The comfort of compassionate healthcare professionals. CONCLUSIONS: Women's experiences of healthcare provision were negatively impacted by COVID-19, with the exclusion of their partner in hospital, and delayed services highlighted as particularly distressing. Limited in-person interactions with health professionals appeared to compound difficulties. The lived experience of service users will be helpful in developing policies, guidelines, and training that balance both the need to minimise the risk of infection spread, with the emotional, psychological, and physical needs and wishes of parents. Further research is needed to explore the long-term impact of pregnancy loss during a pandemic on both parents and health professionals delivering care.

Women's desires for mental health support following a pregnancy loss, termination of pregnancy for medical reasons, or abortion: A report from the STRONG Women Study.

OBJECTIVE: We report on women's mental health care desires following a miscarriage, medical termination, or abortion. METHOD: 689 women completed a questionnaire on reproductive history, health care following miscarriage/medical termination/abortion, and current mental health. Descriptive statistics and logistic regression analyses examined: miscarriage/termination/abortion incidence, desires for mental health support following miscarriages/terminations/abortions, and current mental health. RESULTS: Of 365 women with a pregnancy history, 37% reported ≥1 miscarriage, 9% ≥1 medical termination, 16% ≥1 abortion, and 3% endorsed all three. Current mental health did not differ between women with a history of miscarriage/termination/abortion and those with only live births (p = 0.82). Following miscarriage, 68% of women discussed options for the medical management of pregnancy loss with their provider, 32% discussed grief/loss, and 25% received mental health care recommendations. Engagement in mental health services was reported by 16% of women with a history of miscarriage, 38% after medical termination, and 19% following an abortion. Of women who became pregnant after their most recent miscarriage/termination/abortion and did not receive mental health care, 55% wished they had received services during the subsequent pregnancy. CONCLUSIONS: Women desire mental health care after miscarriages, medical terminations, or abortions, warranting improved access to mental health care for these individuals.

Symptoms of anxiety and depression in women with gestational trophoblastic disease compared to women who had a miscarriage: a cross-sectional study.

This study was conducted between March 2020 and February 2021 to analyze anxiety and depression symptoms in 64 women with gestational trophoblastic disease (GTD) and 99 women who had miscarried. The Hospital Anxiety and Depression Scale (HADS) was applied by telephone three months after pregnancy loss. Multivariate analysis was performed using hierarchical logistic regression to evaluate associations between variables. Probable anxiety (HADS-A ≥ 8) and depression (HADS-D ≥ 8) were found in 53.1% and 43.8% of the GTD group and 49.5% and 39.4% of the miscarriage group, with no difference between the groups. Severe symptoms of anxiety (HADS-A 15-21) and depression (HADS-D 15-21) were found, respectively, in 12.5% and 4.7% of the GTD group and in 9.1% and 4.0% of the miscarriage group, also with no difference between the groups. Lack of partner support proved a risk factor for anxiety and depression, while poor education increased the risk of depression symptoms 3.43-fold following pregnancy loss. In conclusion, three months after pregnancy loss the frequency of anxiety and depression symptoms was similarly high in both groups, with poor education and lack of partner support being significant risk factors for the subsequent development of psychiatric morbidity.

Parents experiences of pregnancy following perinatal loss: An integrative review.

BACKGROUND: Pregnancy following perinatal loss has a profound effect on parents and may contribute to intense psychological distress including grief, post-traumatic stress disorder, anxiety and depression. The subsequent pregnancy may also be perceived as more stressful due to the fear of recurrent loss. Midwives and other health care professionals need to be sensitive and empathetic to the needs of these parents when providing care in a pregnancy subsequent to a loss. METHODOLOGY: The aim of this integrated literature review was to explore parents' experiences of pregnancy following a previous perinatal loss using a systematic approach. This is presented in a five-stage process that includes problem identification, literature search, data extraction and evaluation, data analysis and presentation of results. A systematic search of seven electronic databases was conducted (Jan 2009 -Jan 2023) to identify relevant primary research which addressed parents' experiences of pregnancy following a previous perinatal loss. Seven papers met the eligibility criteria and were assessed for quality using Crowe's Critical Appraisal Tool (CCAT). Thematic analysis identified two themes. FINDINGS: The key themes identified from the literature were; the psychosocial needs and challenges faced by previously bereaved parents in subsequent pregnancies; and the need for specialist care and support in a subsequent pregnancy. Psychological needs and challenges included continued grief, depression, anxiety, and disparities in the grief process between men and women. The importance of specialist care with an increased level of support from competent, confident and compassionate health care providers was highlighted. CONCLUSION: The experience of pregnancy following a perinatal loss can be a complex emotional experience for parents. The review identifies the need for post pregnancy loss debriefing and counselling and care pathways specific to caring for women and their partners in a pregnancy subsequent to a perinatal loss. Care in pregnancy subsequent to loss should be provided by empathetic, competent health care providers and include additional antenatal clinic appointments, pregnancy monitoring and psychological support in order to meet the needs of these expectant parents.

When Words Fail: "Miscarriage," Referential Ambiguity, and Psychological Harm.

Despite significant efforts to support those bereaved by intrauterine death, they remain susceptible to avoidable psychological harm such as disenfranchised grief, misplaced guilt, and emotional shock. This is in part because the words available to describe intrauterine death-"miscarriage," "spontaneous abortion," and "pregnancy loss"-are referentially ambiguous. Despite appearing to refer to one event, they can refer to two distinct events: the baby's death and his preterm delivery. Disenfranchised grief increases when people understand "miscarriage" as the physical process of preterm delivery alone, for this obscures the baby's death and excludes non-gestational parents, such as the father. Additionally, focusing on the delivery reinforces the mistaken idea that a gestational mother bears responsibility for her baby's death, increasing misplaced guilt. When these terms instead shift the focus to the baby's intrauterine death rather than the preterm delivery, they can obscure the physically difficult and often traumatic experience women have when they deliver their dead children, leaving women shocked by preterm delivery's physical reality. Given their outsized role in framing the bereaved's experiences, and their duty to avoid harming their patients, healthcare practitioners in particular should take special care to discuss intrauterine death and preterm delivery appropriately with patients and their families. Changing language to describe intrauterine death and preterm delivery clearly and precisely helps mitigate disenfranchised grief, misplaced guilt, and shock, while also helping to reframe the social response to intrauterine death, making it more obvious why certain steps, such as allowing bereavement leave following an intrauterine death, promote healing.

Pérdida gestacional y el proceso de su duelo. Lo que comparten las mujeres y sus parejas / Pèrdua gestacional i el procés del dol. El que comparteixen les dones i les seves parelles / Pregnancy loss and the grieving process. What women and their partners share

La interrupción del embarazo,ya sea espontánea como voluntaria, supone un impacto emocional intenso tanto en la mujer como en su pareja que alterasu mundo emocional. El elevado porcentaje de mujeres que sufren una pérdida perinatal y las repercusiones emocionalesque conlleva a corto y largo plazo hace necesario replantear el trabajo de las especialidades que atienden a población pe-rinatal (psicología, pediatría, ginecología, obstetricia, psiquiatría, etc.) para conceder la importancia que tiene un procesode duelo frecuente y especialmente silenciado. Nos centraremos en las pérdidas perinatales que ocurren a lo largo de lagestación, un proceso de duelo con idas y vueltas, con sintomatología propia y que requiere una atención, formación yescucha terapéutica también propia. Desde la reflexión y la práctica clínica abordaremos aspectos relevantes que ocurrendurante este proceso terapéutico. Este acompañamiento profesional, necesario y escaso, tiene como objetivo que la mujery su pareja, en caso de tenerla, puedan elaborar suficientemente el duelo, aliviar la sintomatología actual y, caso de una si-guiente gestación, disminuir el riesgo de desajuste emocional tanto en la madre, como en su pareja y en el futuro bebé, quepuede desembocar en una depresión perinatal en los padres o en problemas de desarrollo emocional en el bebé. (AU)

The termination of pregnancy,whether spontaneous or voluntary, involves an intense emotional impact on both the woman and her partner which al-ters their emotional world. The high percentage of women who suffer a perinatal loss, and the emotional repercussions itentails in both the short and long term, make it necessary to rethink the work of the specialties which attend the perinatalpopulation (psychology, pediatrics, gynecology, obstetrics, psychiatry …) to acknowledge the importance of a frequentyet particularly silenced grieving process. In this article focus will be placed on the perinatal losses which occur duringgestation, a mourning process which ebbs and flows, which has its own symptomatology and one which also requires itsown bespoke attention, training, and therapeutic listening. From reflection and clinical practice, relevant aspects whichoccur during this therapeutic process will be addressed. This professional accompaniment, which is necessary yet scarce,aims to enable the woman and her partner to sufficiently work through their grief, alleviate the current symptomatologyand, in the case of a subsequent pregnancy, reduce the risk of emotional imbalance in the mother, her partner and thefuture baby, which can lead to perinatal depression in the parents or emotional development problems in the baby. (AU)

La interrupció de l’embaràsja sigui espontània o voluntària suposa un impacte emocional intens tant en la dona com en la parella que altera el seumón emocional. L'elevat percentatge de dones que pateixen una pèrdua perinatal i les repercussions emocionals quecomporta a curt i llarg termini fan necessari replantejar el treball de les especialitats que atenen la població perinatal(psicologia, pediatria, ginecologia, obstetrícia, psiquiatria, etc.) per concedir la importància que té a un procés de dolfreqüent i especialment silenciat. Ens centrarem en les pèrdues perinatals que esdevenen al llarg de la gestació, unprocés de dol amb anades i tornades, amb simptomatologia pròpia i que requereix una atenció, formació i escoltaterapèutica també pròpia. Des de la reflexió i la pràctica clínica abordarem aspectes rellevants que tenen lloc durantaquest procés terapèutic. Aquest acompanyament professional, necessari i escàs, té com a objectiu que la dona i laseva parella, en cas de tenir-la, puguin elaborar prou el dol, alleujar la simptomatologia actual i, en cas d'una següentgestació, disminuir el risc de desajust emocional tant en la mare, com en la seva parella i en el futur nadó, que pot des-embocar en una depressió perinatal als pares o en problemes de desenvolupament emocional al nadó.(AU)

Toward Optimal Emotional Care During the Experience of Miscarriage: An Integrative Review of the Perspectives of Women, Partners, and Health Care Providers.

INTRODUCTION: Miscarriage is frequently associated with significant emotional impact, causing psychological distress, trauma, and grief. Unfortunately, women and partners frequently report dissatisfaction with care around miscarriage, and health care providers report feeling ill-prepared and underequipped to provide emotional support. This integrative review synthesizes the individual perspectives of the woman experiencing the miscarriage, the partner, and the different health care provider roles involved in the care to better understand what future research is necessary to improve the experiences of bereaved parents and their health care providers. METHODS: Electronic databases were searched for studies that covered emotional care around miscarriage from the perspective of women, partners, or health care providers. The review included studies published in English between 2015 and 2022, using either quantitative or qualitative methods. Thematic analysis was carried out, and conclusions from these articles were integrated into themes and subthemes. RESULTS: A total of 60 studies met the inclusion criteria. Two main themes were identified for women: (1) a need for more information and (2) a need for acknowledgment of their loss. Two main themes were likewise identified for partners: (1) a need for more information and (2) a need for recognition. Three main themes were identified for health care providers: (1) a need for additional training, (2) components of quality care, and (3) perceived barriers to providing care. DISCUSSION: There is broad overlap in the needs identified by bereaved parents and their health care providers, as well as general agreement regarding the barriers to providing effective care. Five areas of future research priority were identified to understand how best to meet these needs: empirical evaluation of strategies to meet identified needs, investigation of setting-specific needs, integrated consideration of all relevant roles, investigation of the care needs of diverse groups, and an investigation of the predictors of emotional impact.