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‘Minimised and often dismissed’: Calls for reforms to miscarriage care


Evelyn Lewin


6/05/2021 2:55:21 PM

This comes on the heels of a new paper that has found approximately 20% of women experience PTSD nine months after miscarriage.

Distressed woman sitting on of the floor
New estimates show miscarriage occurs in 15% of pregnancies, equating to approximately 23 million a year around the world.

‘For too long, miscarriage has been minimised and often dismissed. The lack of medical progress should be shocking. Instead, there is a pervasive acceptance.
 
‘Not all miscarriages could be avoided, but the insidious implication that miscarriage, like other women’s reproductive health issues, including menstrual pain and menopause, should be managed with minimal medical intervention is ideological, not evidence based.’
 
That is an excerpt of an editorial published in The Lancet alongside a new report on miscarriage.
 
In the three-page original report, experts call for comprehensive global reform of miscarriage care and treatment. They say new estimates show miscarriage occurs in 15% of pregnancies, equating to approximately 23 million miscarriages a year worldwide.
 
Yet existing care for sporadic or recurrent miscarriage is inconsistent and poorly organised worldwide.
 
Co-lead author of the report, Professor Arri Coomarasamy, is concerned about the psychological aspect of miscarriage.
 
‘Recurrent miscarriage is a devastating experience for most women, but the mental health impact is rarely acknowledged or addressed in medical care,’ he said.
 
‘Women can experience trauma and bereavement, which may have no obvious signs and can go unrecognised.
 
‘In our study we found that miscarriage was associated with anxiety, depression, and post-traumatic stress disorder [PTSD], with approximately 20% of women experiencing PTSD nine months after miscarriage.
 
‘As a result, we recommend screening and offering mental health support to every woman who needs it. Services should prioritise both physical and psychological support.’
 
Another co-lead author of the report, Professor Siobhan Quenby from the University of Warwick, says many women have concerns over the ‘unsympathetic care’ they receive following a miscarriage.
 
She says some are not offered any explanation for their miscarriage, and the only advice they receive is to ‘try again’.
 
‘This is not good enough, and we must ensure women are properly supported,’ Professor Quenby said.
 
She says a ‘significant’ portion of the population requires treatment and support for a miscarriage.
 
‘Yet silence around miscarriage remains not only for women who experience miscarriage but also among healthcare providers, policy-makers, and research funders,’ Professor Quenby said.
 
Dr Nicole Highet, founder and executive director of the Centre of Perinatal Excellence (COPE),  does not believe miscarriage is managed well in Australia.
 
She told newsGP patients are often managed with a clinical focus, with little thought to the emotional impact associated with pregnancy loss.
 
‘People talk about “This is what’s happening; it’s the body’s way of doing this”,’ Dr Highet said.
 
‘But there’s no real understanding or sensitivity around what the couple or individual might be going through.’
 
She believes this is part of a wider issue in society, where as a community ‘we’re not always that comfortable in managing conversations’ around miscarriage.
 
‘Women tell us all the time that they felt like their experiences were really negated by comments like, “It was probably for the best,” which doesn’t really give them time to acknowledge or receive support,’ Dr Highet said.
 
‘It’s brushed off because it might be an uncomfortable conversation, either from a health professional, or family or friend.’
 
She says the fact it is common for women to keep a pregnancy largely secret in the early stages means they are likely to feel unsupported if they miscarry.
 
‘Because they haven’t told anyone, people describe it as a very silent journey,’ Dr Highet said.
 
‘So this is where GPs … play a really important role in acknowledging the person’s loss and letting people know there’s good quality help and supports out there.’
 
Dr Wendy Burton, Chair of RACGP Specific Interests Antenatal and Postnatal Care, told newsGP there is a wide variety in how miscarriage is managed in Australia.
 
‘It’s hit and miss,’ she said.
 
Dr Burton agrees that women are too often not supported as well as they should be, and says the new paper is a reminder for clinicians to ‘be on our game and not overlook the simple things because it’s common’.
 
She stresses the importance of being kind, listening to patients and ensuring adequate follow-up, but says it also helps to remember that miscarriage affects women differently.
 
‘It hits some women harder than others,’ Dr Burton said.
 
‘It’s one of those things [where] I’ll never assume how a woman will feel. Some will want to talk about it, some won’t want to talk about it.
 
‘Some don’t want to talk about it now, but may want to talk about it later so [you need to] leave that door open.’

Wendy-Burton-Hero.jpg
Dr Wendy Burton says this paper acts as a reminder not to overlook simple issues just because they are common.

Dr Burton says GPs can let women know there is assistance available in the form of Medicare-funded item numbers for psychological support, which does not need a mental healthcare plan. It can help to be aware of local resources including online options that can offer further support.
 
Dr Highet agrees, saying patients can be referred to the COPE website to find information on miscarriage, including links to practitioners and other organisations specialising in this area, including the Pink Elephants Support Network and Sands.
 
Along with offering support, Dr Burton believes the issue lies in addressing modifiable risk factors associated with miscarriage, which include:

  • smoking
  • alcohol consumption
  • air pollution
  • pesticides
  • persistent stress
  • working night shifts
  • having a body-mass index (BMI) less than 18.5 kg/m2, or greater than 24.9 kg/m2.
However, in addressing these issues, Dr Burton says it is important to avoid ‘making it seem like you’re judging [women] or blaming them for having had the miscarriage’.
 
‘You don’t want to suggest to a woman that the reason she miscarried was because she’s a night shift worker,’ she said.
 
‘But if that’s statistically associated with miscarriage, that’s an option that she [may be able to] modify.
 
‘So it’s complicated.’
 
To improve management of miscarriage, the authors are calling for accurate diagnosis through high-quality ultrasound services and say women should also be offered guidance on how to manage their miscarriage.
 
After a first miscarriage, the authors recommend women are provided with information about miscarriage and physical and mental health needs, as well as health guidance to support future pregnancy.
 
This could be via patient groups, online self-help, lifestyle services, and mental health screening.
 
Following a second miscarriage, the authors say women should be offered an appointment at a miscarriage clinic for full blood count and thyroid function tests, as well as a discussion of their risk factors.
 
If any test results are abnormal or women have chronic physical or mental health problems, they should be referred for specialist care.
 
Women who have had two miscarriages should be offered extra support with early scans for reassurance in subsequent pregnancies.
 
After three miscarriages, additional tests and treatments should be offered under the care of a medical consultant.
 
Genetic testing of pregnancy tissue should also be offered, as well as pelvic ultrasound and, if necessary, parental genetic testing.
 
The authors say women should be screened and offered care for mental health issues, as well as for obstetric risks in future pregnancies.
 
‘We know from our research that people who do go on to become pregnant with a second pregnancy often describe having particularly high levels of anxiety through that pregnancy as well,’ Dr Highet said.
 
‘Their fear is that it’s going to happen again.’
 
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