Development of a pregnancy loss pocket guide for health professionals supporting women and their partners during miscarriage in hospital settings

Development of a pregnancy loss pocket guide for health professionals supporting women and their partners during miscarriage in hospital settings | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development of a pregnancy loss pocket guide for health professionals supporting women and their partners during miscarriage in hospital settings Martina Galeotti, Eric Spikol, Martin Robinson, Áine Aventin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6830161/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Miscarriage is a common gestational complication with significant emotional and psychological consequences for those affected. Despite the crucial role healthcare professionals (HCPs) play in supporting women and their partners through pregnancy loss, existing research highlights a persistent lack of training and guidance in this area. The Miscarriage and Mental Health Study identified gaps in the emotional support provided to women experiencing miscarriage in hospital settings in Northern Ireland, underscoring the need for targeted educational interventions. Methodology This study details the development and implementation of a Pocket Guide (PG) designed to equip HCPs with evidence-based guidance on best practices for providing compassionate care. The PG was informed by qualitative and quantitative data from women who had experienced miscarriage, alongside insights from HCPs. It was structured around key themes identified in the research, including communication, management of miscarriage, hospital environments, and follow-up care. The guide was designed for accessibility in clinical settings, available in both printed and digital formats. Conclusion By addressing gaps in professional training and fostering improved communication, the Pocket Guide aims to enhance the quality of care provided to women experiencing pregnancy loss. This study contributes to the ongoing discourse on improving miscarriage care, emphasising the necessity of structured educational resources to better support both patients and HCPs. It sets the foundation for future research to explore the impact of such interventions on clinical practice and patient experiences and outcomes. Miscarriage pregnancy loss pocket guide health care professionals maternal health women’s health women’s wellbeing healthcare inequality health and wellbeing Figures Figure 1 Figure 2 Background Miscarriage is the loss of a pregnancy and is the most common gestational complication, affecting approximately 15.3% of all pregnancies [1]. While the legal definition of miscarriage varies between countries [2], in the United Kingdom (UK) it is defined as a pregnancy loss occurring before the 24th week of the total gestational period [3]. Miscarriage can be sporadic or recurrent, with legal definitions of recurrent miscarriage also varying around the world. In the USA, recurrent loss is defined as two or more failed clinical pregnancies [4], while in the UK, it is three or more consecutive losses[3]. For many people, miscarriage can be a traumatic event [5, 6]. The development of emotional distress post-miscarriage and emotional adjustment may be influenced by social support, a culture of ‘respect and understanding’ [7], by adequate provision of information [8] and emotional support [9]. Healthcare professionals (HCPs) play an important role in supporting women during pregnancy loss in hospital settings [10, 11], giving them an integral role in women’s experiences. Despite the positive potential for HCPs to help reduce negative impacts for parents, some have reported feeling inadequately prepared to deal with perinatal loss in their practice [12, 13]. Lack of training and guidance may contribute to a lack of understanding of the complexity of miscarriage and its emotional and physical implications for women’s wellbeing, which can further impact on overall care [14]. HCPs in training generally have limited exposure to perinatal death [15] and as a result, they may feel anxious when encountering pregnancy loss in practice [12]. Adequate training on how to communicate during a loss has the potential to improve practice [16], especially in terms of using respectful and compassionate language [17]. Previous studies have evaluated the effectiveness of interventions targeting HCPs to improve experience of pregnancy loss in hospital, specifically focusing on the delivery of the news [18, 19], while others have focused on training university students on pregnancy loss [13]. This study aims to develop and evaluate an educational resource to better equip health care professionals who care for parents who experience miscarriage in practice. Specifically, the study aims to create a pocket guide to provide evidence-based written information easily available to health professionals. Foundational Research- The Miscarriage and Mental Health Study Background There is a lack of research exploring women’s experiences of miscarriage in hospital settings in Northern Ireland (NI), specifically, their perceptions of the experience, factors contributing to their psychological/emotional health and wellbeing, and care/support made available to them. The Miscarriage and Mental Health Study was undertaken from January 2020 till April 2023 to investigate these perceptions [20]; and it aimed to explore the emotional needs of women and the views of HCPs on providing emotional support and care. Methods The research study adopted a sequential mixed-methods design. This study was guided by the 2008 Medical Research Council (MRC) Framework for the development and evaluation of complex interventions, and it was informed by the Intervention Mapping Framework (IM) [21]. This study involved development of a needs assessment (Step 1 of the IM process) involving a scoping review of international literature [9], an online cross-sectional survey of n =723 women, semi-structured interviews with n =20 women, written narrative accounts provided by n =8 women and n =24 HCPs. A summary of Step 1 can be found in Table 1. Table 1. Intervention Mapping Step 1 Needs assessment 1. Establish an advisory group 2. Conduct a scoping review 3. Online survey of women’s needs 4. Interviews with women on their experience of miscarriage in hospital settings 5. Narrative accounts with women on their experience of miscarriage in hospital settings 6. Narrative accounts with health professionals on their experience of caring for women who had a miscarriage Summary of findings The Miscarriage and Mental Health study results highlighted women’s needs when experiencing miscarriage [20]. In exploring emotional support provided to women during their time in hospital for treatment of miscarriage, participants reported a lack of compassion in some HCPs professional attitudes and interactions with them. Specifically, participants recounted that their worries and fears when initially presenting with symptoms of miscarriage were not always addressed, and that they experienced inadequate provision of information to suitably prepare them for the impact/aftermath of the miscarriage. Participants also reported that they needed time, support, and privacy to process the diagnosis of miscarriage before moving on to a discussion of care options and ultimately to a management decision. Further, they expressed dissatisfaction with emotional support from HCPs impacted on their levels of distress both during and after the miscarriage. Results from the cross-sectional survey showed that unmet emotional needs were associated with increased adverse impact of miscarriage and increased distress [22]. In exploring the attitudes and experiences of HCPs, they reported that they did not always feel sufficiently trained and/or comfortable caring for women experiencing miscarriage. These findings indicated a clear need for educational support aimed at HCPs pertaining to pregnancy loss, including the perceived emotional needs of parents throughout the management process. This led the research team to proceed to Stage 2 of the IM Process and develop an educational resource to guide health professionals to care for parents who experience a miscarriage. Methodology Study Design The research design was informed by: Intervention Mapping involving evidence synthesis and primary research with local stakeholders to guide the adaptation process [21]. This framework was chosen because it offered guidelines for a systematic process for the construction of a Logic Model of the Problem which can be used to design intervention; and A participatory approach to research [23] involving consultation with an advisory group, to provide guidance on the development of the PG. The advisory group ensured that the information within the PG was appropriate for the Northern Irish clinical context, used suitable language, and was relevant to healthcare professionals. Intervention Mapping Step 2: the development of the educational resource Logic model of the problem The needs assessment conducted as part of the Miscarriage and Meatal Health Study guided the description of a health problem that has an impact on women’s quality of life [20]. The Logic Model of the Problem systematically identify behaviours and environmental factors likely responsible for the development of the health problem. Furthermore, this helped to identify different personal determinants that influence behavioural and environmental factors that cause the health problem and impact on quality of life. Once the needs assessment was conducted [20], a diagram of a logic model of the problem (PRECEDE) was developed and this helped to visually illustrate the casual pathway for the different identified factors influencing the health problem. The Logic Model of the Problem was subsequentially used to structure the PG. A summary of the logic model of the problem can be seen in Figure 1. Participatory approach An advisory group was convened, comprising eight voluntary members: two nurses, three midwives, one gynaecologist, one bereavement specialist, and two women with lived experience of miscarriage. The research team organised two online meetings, one at the start of the project and another during the design phase PG. During the first meeting, the aims and objectives of the project were explained to the group, and members were consulted on the content of the PG. In the second meeting, they were invited to provide feedback on the graphic design and structure. Finally, once the PG was finalised, a copy was emailed to all members to request any final comments or feedback. Pocket guide graphics The graphic design of the PG focused on using appropriate graphics with a muted colour scheme befitting the seriousness of the subject matter. Graphics were taken from domain free/public use libraries on the Canva graphic design platform (https://www.canva.com/) and graphics depicting HPCs and service users were rendered in a simple style with no facial features which could distract from/dilute the overall messaging. Text and font sizes were chosen to ensure that the PG content could be read quickly in an emergency healthcare setting. Graphic design and layout were based on a UK A6 size to enable HCPs to carry the PG on their person in a lab coat or scrubs pocket. The pocket guide is available for consultation at https://tinyurl.com/2s4xpf47. Pocket guide content The PG was divided into sequential sections describing main themes of experiences as a woman and their partner progressed through the journey through hospital settings (Figure 2). Further, these sections are reflective of the findings of the Logic Model of the Problem (Figure 1). Five themes were generated from the Miscarriage and Mental Health Study , based on qualitative data from open-ended survey items, semi-structured interview and narrative account transcripts describing women’s lived experiences [20]. Each theme covered areas where participants felt that their support needs had not been met and that this had a significant negative impact on their mental/emotional health and wellbeing. Each theme has been summarised and used to populate PG sections supported by anonymised quotation. Interactions with health professionals : This section covers positive practice on how parents experiencing a miscarriage in a hospital setting perceive interactions with health professionals and includes ‘best practice’ advice to guide these interactions. This focuses on acknowledging the significant impact of the miscarriage on parents, allowing empathy to inform interactions, prioritising women in their own care, acknowledging partners, respecting religious, societal, cultural, and personal mourning practices, and understanding the importance of memory-making for parents. The guide includes quotes which are representative of women’s experiences of interactions with health professionals: “As I said, they’re as real as [my child] is, so I like having physical things to remember. You know, what has happened and remember that they were part of my life and that they exist for me” (Yasmine) “I have the little scan picture of my baby’s heartbeat and […] I was happy” (Grace) Communication : This section covers the importance of communication with parents during their time in hospital, specifically the use of compassionate language in conversation, clear and definite terms when describing the diagnosis and management options, parents’ need for time to emotionally and cognitively adjust to the reality of the miscarriage before making management decisions. This section includes helpful communication tips for meeting these support needs while also providing clear information and “make eye contact and remember that your words will have impact”; avoid using phrases such as “ at least you know you can get pregnant ” or “ products of conception ”. These tips were supported by some quotes such as the following: “The midwife at the 12 th week scan failed to explain that she thought I was having a missed miscarriage” (Hina) Management of miscarriage : This section covers parents’ support needs around management of miscarriage options and in making health-informed decisions of care based on those options. It includes a QR code linking to NICE guidelines on management of miscarriage and ectopic pregnancy [24]. Recommendations such as women should not be advised “ to come back in 10 days ”, without providing adequate information to support the rationale behind this decision is included. Further, this section emphasises that women should be given a full explanation of what to expect depending on the proposed miscarriage management option offers, with practical advice and all the information required to make an informed care decision. The following quote is testimony of a women’s experience: “I delivered the baby in the toilet. If I didn’t have a specimen pot, what was I meant to do? Flush it away like a goldfish?” (Sofia) Hospital environments : This section covers the importance of a hospital environment where women’s privacy and dignity were considered from diagnosis communication to miscarriage management; and the detrimental impact of long waiting times/intervals between management steps without clear communication or continuity of care. Additionally, the guide indicates that treating women in settings around other pregnant women and their babies can be highly traumatising and was distressing to the participants who reported this experience. The following quotes are used to support the content of the theme: “ The doctor said it to me in the waiting room with people beside me who I didn’t know, they didn’t know me and there was no privacy. He didn’t call me over to one side or anything to tell me that, he just said it like it was a matter of fact and I just started to cry ” (Zahra) “I wouldn’t have a clue who I was chatting to. And then the next time it will be somebody else, it was like I don’t know who I am chatting to. That was the hard thing, not having a face to fae , that everything was impersonal” (Ruoxi) Follow-up and emotional support : The final section covers the importance of providing clear information on any post-miscarriage investigations/tests and follow-up appointments, and the adverse impact that miscarriage can have on a woman’s sense of loneliness and isolation. The guide indicates that highlighting and signposting options for emotional support, either provided through the trust or with a charity organisation can help parents to navigate and process their experiences of trauma and grief. This section also includes contact information for NI/UK charity organisations who provide support and assistance to parents who have experienced pregnancy loss (Sands, Cradle, Antenatal Results & Choices, and the Miscarriage Association). The following quotes are provided to represent some women’s experience: “Signposting to support services should be a basic expectation. I benefited greatly from the opportunity to speak about my experience moths down the line”. ( Aoife) “I was given a flyer, you know like that really old font they sued to use back in the 90s and on a piece of paper that would have been clearly photocopied from the original, like 100 times, so the writing isn’t even on the paper”. (Aylin) Distribution The PG is available both as physical printed copies (water-resistant cardstock pages with a single ball-chain loop at the top left corner) and online as a digital download (PDF file) for ease of distribution amongst HCPs. Physical copies were disseminated at the resource launch event and the digital version was uploaded to the Queen’s University Belfast ‘Pregnancy Loss Research at QUB’ webpage. There is no charge associated with either version of the PG. Data collection and future plans Data collection is ongoing. Perceived professional competency will be assessed using the Perinatal Bereavement Care Confidence Scale (PBCCS) [25]. The PBCCS includes 4 subscales: Bereavement Support Knowledge Scale; Bereavement Support Skills Scale; Self-Awareness Scale; and Organisational Support Scale. Scores are collated using a 5-point Likert scale ranging from 1 “strongly disagree” to 5 “strongly agree”. The PBCCS has demonstrated good psychometric properties as reported in the original study on all four subscales. These data will be used to assess changes in confidence in care provision among pocket guide users. Discussion Health professionals may have limited exposure to perinatal loss [ 15 ], which can lead to anxiety when encountering pregnancy loss in practice [ 12 ]. Health professionals play an important role in shaping patients’ experiences. Often, HPs meet patients at their most vulnerable time and often patients might see healthcare providers as those who offer emotional support. Prior studies have noted the correlation between patient-health professional relationships and overall satisfaction with hospital services [ 26 , 27 ]. However, there is a lack of training both at university and organisational level to support health professionals in practice. Pocket guides have been previously used in hospital settings to answer most common questions asked by practitioners [ 28 , 29 ]. Further, others have demonstrated the efficacy of pocket guides to support clinical decisions [ 30 ]. However, to the best of our knowledge this is the first pocket guide created to support health professionals to care for women who experience miscarriage. Previous studies in the field have focused on developing of educational resources to support parents experiencing pregnancy loss [ 31 , 32 ]. While others have developed guidelines to promote the use of sensitive language when interacting with women who have experienced miscarriage [ 33 ]; others have introduced workshops on compassionate communication for obstetric trainees and student midwives [ 34 , 35 ]. However, there remains a general and persistent lack of training on pregnancy loss for HCPs in practice [ 9 , 13 , 20 , 36 ]. Bereavement guidelines are currently implemented in hospital settings and accessible to all healthcare professionals [ 16 , 24 , 37 – 39 ]. However, these guidelines are often extensive and not always readily available. Our pocket guide provides evidence-based information, and it has been specifically designed for ease of access. The printed version can be stored in various clinical environments, and its compact size facilitates convenient consultation. This represents a crucial step in improving clinical confidence and ensuring compassionate care in hospital settings. Strengths and limitations The Pocket Guide is founded on a strong evidence base, having been developed following the completion of a comprehensive doctoral study [ 9 ]. The Miscarriage and Mental Health Study utilised three distinct data collection methods, enhancing the validity and rigour of its findings. To ensure its relevance to clinical practice, the Pocket Guide was reviewed by members of an expert advisory group. It is readily accessible as a digital download and has been widely distributed across various clinical settings where it has been utilised. However, the Pocket Guide has not yet undergone formal evaluation. Data collection is ongoing, and the research team intends to publish the findings in a separate paper. As the Pocket Guide was specifically designed for use in the United Kingdom, certain aspects may not be directly applicable to an international context. Conclusion This article summarised the steps which were undertaken to create a pocket guide to support health professionals in practice to support parents who experience miscarriage. The PG aims to provide useful guidance to HCPs who may not be exposed to perinatal loss on a regular basis or who may not be comfortable in supporting parents. The information contained in the guide is evidence based, ensuring that it aligns with the latest research and best practice in the field. The content of the guide reflects the journey that women may experience when they come to hospital for pregnancy loss. However, it is crucial to understand that pregnancy loss is an individual experience, and now two journeys are the same. Therefore, the suggestions and guidelines presented are meant to serve as general recommendations. Abbreviations HCP- health care professionals IM- Intervention Mapping Framework MRC- Medical Research Council NI- Northern Ireland PBCCS- Perinatal Bereavement Care Confidence Scale PG- pocket guide UK- United Kingdom Declarations Ethical Approval and consent to participate The Miscarriage and Mental Health ethical was conducted in compliance with the Helsinki Declaration and approval was granted by the Queen’s University Belfast Research Ethics Committee (REC) for the faculty of Medicine, Health, and Life Sciences (MHLS 20_99). Informed consent to participate was obtained from all participants. The Pocket Guide Study ethical approval was granted by the Queen’s University Belfast Research Ethics Committee (REC) for the faculty of Medicine, Health, and Life Sciences (#MHLS 24_84). Consent to for publication Authors have consent for publications from participants. All participants have been given a pseudonymous to maintain their confidentiality Availability of data and materials The datasets used and/or analysed during the Mental Health Study are available from the corresponding author on reasonable request. The pocket guide is available at https://tinyurl.com/2s4xpf47 Competing interest The authors declare that they have no competing interests Funding The Miscarriage and Mental Health study was part of doctoral study funded by the Department of Economy and sponsored by Queen’s University Belfast. The Pocket Guide Study was funded by grant from the Economic & Social Research Council (ESRC) Impact Acceleration Account through Queen’s University Belfast. Authors’ contributions ÁA and MG were involved in the conceptualisation and execution of the Miscarriage and Mental Health Study. MG obtained the fundings to produce the pocket guide and acted as Principal Investigator for the study. ÁA and MG conceptualised the Pocket Guide. 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INTERDISCIPLINARY GUIDELINES FOR CARE OF WOMEN PRESENTING TO THE EMERGENCY DEPARTMENT WITH PREGNANCY LOSS...Reprinted with permission by the National Perinatal Association, 2017. Copyright National Perinatal Association, 2017. MCN Am J Matern Child Nurs. 2018;43:13–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6830161","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":481388005,"identity":"6511f17b-7834-4c74-9eca-6ce648d57639","order_by":0,"name":"Martina Galeotti","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYLCCByCCmfkAA2MDmM9MWEsCA4MEDzNbAqlaGHgMiNOi28B+8UNChU2dPTvPx9u8Oxjk+Rt4jA3waTE7wFMskXAmDegw3s3WvGcYDGcc4DFOIKAlQSKx7TBIyzZp3jYGxg0MPMYHCGhJ/pH4D6SF5xlIiz0RWtiPSSQ2gLWwgbQkgrTgd9hhHjaLhGNpkj2H2Ywt556RSJ5xmK0Yv/ePtz++8aHGhp+9//DDG2932Nj2tzdvlsCnhYGZB2GkBBgRjkj2B8haRsEoGAWjYBRgAgBEDT9r03/ZGAAAAABJRU5ErkJggg==","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":true,"prefix":"","firstName":"Martina","middleName":"","lastName":"Galeotti","suffix":""},{"id":481388006,"identity":"50b25592-2b2c-4b0e-bb88-bb778c1bd653","order_by":1,"name":"Eric Spikol","email":"","orcid":"","institution":"University of Ulster","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"","lastName":"Spikol","suffix":""},{"id":481388007,"identity":"090f378b-60a5-4d7e-8682-67b639fd0e6a","order_by":2,"name":"Martin Robinson","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Robinson","suffix":""},{"id":481388008,"identity":"0ee27853-3b79-4e24-b756-c476271843d6","order_by":3,"name":"Áine Aventin","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Áine","middleName":"","lastName":"Aventin","suffix":""}],"badges":[],"createdAt":"2025-06-05 14:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6830161/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6830161/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86328731,"identity":"a26587b4-57e7-4ac0-9449-bf334bcc91d5","added_by":"auto","created_at":"2025-07-09 11:36:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":243475,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6830161/v1/a2833b65a8393d59fbe908e6.png"},{"id":86328733,"identity":"55c02a26-fbd5-4b31-aaf8-1d116dbe20f5","added_by":"auto","created_at":"2025-07-09 11:36:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46258,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNarrative framework for the hospital ‘journey’\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6830161/v1/743eb588e72416b4f81ffa7e.png"},{"id":108601109,"identity":"0a501d88-945e-422c-bd22-0ce512a769ae","added_by":"auto","created_at":"2026-05-06 11:28:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":585232,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6830161/v1/b6bd455f-3ea5-4ba1-a604-4c35107c79e8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of a pregnancy loss pocket guide for health professionals supporting women and their partners during miscarriage in hospital settings","fulltext":[{"header":"Background","content":"\u003cp\u003eMiscarriage is the loss of a pregnancy and is the most common gestational complication, affecting approximately 15.3% of all pregnancies [1]. While the legal definition of miscarriage varies between countries [2], in the United Kingdom (UK) it is defined as a pregnancy loss occurring before the 24th week of the total gestational period [3]. Miscarriage can be sporadic or recurrent, with legal definitions of recurrent miscarriage also varying around the world. In the USA, recurrent loss is defined as two or more failed clinical pregnancies [4], while in the UK, it is three or more consecutive losses[3].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor many people, miscarriage can be a traumatic event [5, 6]. The development of emotional distress post-miscarriage and emotional adjustment may be influenced by social support, a culture of \u0026lsquo;respect and understanding\u0026rsquo; [7], by adequate provision of information [8] and emotional support [9]. Healthcare professionals (HCPs) play an important role in supporting women during pregnancy loss in hospital settings [10, 11], giving them an integral role in women\u0026rsquo;s experiences. Despite the positive potential for HCPs to help reduce negative impacts for parents, some have reported feeling inadequately prepared to deal with perinatal loss in their practice [12, 13]. Lack of training and guidance may contribute to a lack of understanding of the complexity of miscarriage and its emotional and physical implications for women\u0026rsquo;s wellbeing, which can further impact on overall care [14].\u003c/p\u003e\n\u003cp\u003eHCPs in training generally have limited exposure to perinatal death [15] and as a result, they may feel anxious when encountering pregnancy loss in practice [12]. Adequate training on how to communicate during a loss has the potential to improve practice [16], especially in terms of using respectful and compassionate language [17]. \u0026nbsp; Previous studies have evaluated the effectiveness of interventions targeting HCPs to improve experience of pregnancy loss in hospital, specifically focusing on the delivery of the news [18, 19], while others have focused on training university students on pregnancy loss [13].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study aims to develop and evaluate an educational resource to better equip health care professionals who care for parents who experience miscarriage in practice. Specifically, the study aims to create a pocket guide to provide evidence-based written information easily available to health professionals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFoundational Research- The Miscarriage and Mental Health Study\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eBackground\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere is a lack of research exploring women\u0026rsquo;s experiences of miscarriage in hospital settings in Northern Ireland (NI), specifically, their perceptions of the experience, factors contributing to their psychological/emotional health and wellbeing, and care/support made available to them. The \u003cem\u003eMiscarriage and Mental Health Study\u0026nbsp;\u003c/em\u003ewas undertaken from January 2020 till April 2023 to investigate these perceptions [20]; and it aimed to explore the emotional needs of women and the views of HCPs on providing emotional support and care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eMethods\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe research study adopted a sequential mixed-methods design. This study was guided by the 2008 Medical Research Council (MRC) Framework for the development and evaluation of complex interventions, and it was informed by the Intervention Mapping Framework (IM) [21]. This study involved development of a needs assessment (Step 1 of the IM process) involving a scoping review of international literature [9], an online cross-sectional survey of \u003cem\u003en\u003c/em\u003e=723 women, semi-structured interviews with \u003cem\u003en\u003c/em\u003e=20 women, written narrative accounts provided by \u003cem\u003en\u003c/em\u003e=8 women and \u003cem\u003en\u003c/em\u003e=24 HCPs. A summary of Step 1 can be found in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1. Intervention Mapping Step 1\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eNeeds assessment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e1. Establish an advisory group\u003c/p\u003e\n \u003cp\u003e2. Conduct a scoping review\u003c/p\u003e\n \u003cp\u003e3. Online survey of women\u0026rsquo;s needs\u003c/p\u003e\n \u003cp\u003e4. Interviews with women on their experience of miscarriage in hospital settings\u003c/p\u003e\n \u003cp\u003e5. Narrative accounts with women on their experience of miscarriage in hospital settings\u003c/p\u003e\n \u003cp\u003e6. Narrative accounts with health professionals on their experience of caring for women who had a miscarriage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eSummary of findings\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Miscarriage and Mental Health study results highlighted women\u0026rsquo;s needs when experiencing miscarriage [20]. In exploring emotional support provided to women during their time in hospital for treatment of miscarriage, participants reported a lack of compassion in some HCPs professional attitudes and interactions with them. Specifically, participants recounted that their worries and fears when initially presenting with symptoms of miscarriage were not always addressed, and that they experienced inadequate provision of information to suitably prepare them for the impact/aftermath of the miscarriage. Participants also reported that they needed time, support, and privacy to process the diagnosis of miscarriage before moving on to a discussion of care options and ultimately to a management decision. Further, they expressed dissatisfaction with emotional support from HCPs impacted on their levels of distress both during and after the miscarriage. Results from the cross-sectional survey showed that unmet emotional needs were associated with increased adverse impact of miscarriage and increased distress [22]. In exploring the attitudes and experiences of HCPs, they reported that they did not always feel sufficiently trained and/or comfortable caring for women experiencing miscarriage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings indicated a clear need for educational support aimed at HCPs pertaining to pregnancy loss, including the perceived emotional needs of parents throughout the management process. This led the research team to proceed to Stage 2 of the IM Process and develop an educational resource to guide health professionals to care for parents who experience a miscarriage.\u0026nbsp;\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe research design was informed by:\u0026nbsp;\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eIntervention Mapping involving evidence synthesis and primary research with local stakeholders to guide the adaptation process [21]. This framework was chosen because it offered guidelines for a systematic process for the construction of a Logic Model of the Problem which can be used to design intervention; and\u003c/li\u003e\n \u003cli\u003eA participatory approach to research [23] involving consultation with an advisory group, to provide guidance on the development of the PG. The advisory group ensured that the information within the PG was appropriate for the Northern Irish clinical context, used suitable language, and was relevant to healthcare professionals.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cu\u003eIntervention Mapping Step 2: the development of the educational resource\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLogic model of the problem\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe needs assessment conducted as part of the \u003cem\u003eMiscarriage and Meatal Health Study\u003c/em\u003e guided the description of a health problem that has an impact on women\u0026rsquo;s quality of life [20]. The Logic Model of the Problem systematically identify behaviours and environmental factors likely responsible for the development of the health problem. Furthermore, this helped to identify different personal determinants that influence behavioural and environmental factors that cause the health problem and impact on quality of life. Once the needs assessment was conducted [20], a diagram of a logic model of the problem (PRECEDE) was developed and this helped to visually illustrate the casual pathway for the different identified factors influencing the health problem. The Logic Model of the Problem was subsequentially used to structure the PG. \u0026nbsp;A summary of the logic model of the problem can be seen in Figure 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eParticipatory approach\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAn advisory group was convened, comprising eight voluntary members: two nurses, three midwives, one gynaecologist, one bereavement specialist, and two women with lived experience of miscarriage. The research team organised two online meetings, one at the start of the project and another during the design phase PG.\u003c/p\u003e\n\u003cp\u003eDuring the first meeting, the aims and objectives of the project were explained to the group, and members were consulted on the content of the PG. In the second meeting, they were invited to provide feedback on the graphic design and structure. Finally, once the PG was finalised, a copy was emailed to all members to request any final comments or feedback.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePocket guide graphics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe graphic design of the PG focused on using appropriate graphics with a muted colour scheme befitting the seriousness of the subject matter. Graphics were taken from domain free/public use libraries on the Canva graphic design platform (https://www.canva.com/) and graphics depicting HPCs and service users were rendered in a simple style with no facial features which could distract from/dilute the overall messaging. Text and font sizes were chosen to ensure that the PG content could be read quickly in an emergency healthcare setting. Graphic design and layout were based on a UK A6 size to enable HCPs to carry the PG on their person in a lab coat or scrubs pocket. The pocket guide is available for consultation at https://tinyurl.com/2s4xpf47.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePocket guide content\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe PG was divided into sequential sections describing main themes of experiences as a woman and their partner progressed through the journey through hospital settings (Figure 2). Further, these sections are reflective of the findings of the Logic Model of the Problem (Figure 1).\u003c/p\u003e\n\u003cp\u003eFive themes were generated from the \u003cem\u003eMiscarriage and Mental Health Study\u003c/em\u003e, based on qualitative data from open-ended survey items, semi-structured interview and narrative account transcripts describing women\u0026rsquo;s lived experiences [20]. Each theme covered areas where participants felt that their support needs had not been met and that this had a significant negative impact on their mental/emotional health and wellbeing. Each theme has been summarised and used to populate PG sections supported by anonymised quotation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInteractions with health professionals\u003c/em\u003e\u003c/strong\u003e: This section covers positive practice on how parents experiencing a miscarriage in a hospital setting perceive interactions with health professionals and includes \u0026lsquo;best practice\u0026rsquo; advice to guide these interactions. This focuses on acknowledging the significant impact of the miscarriage on parents, allowing empathy to inform interactions, prioritising women in their own care, acknowledging partners, respecting religious, societal, cultural, and personal mourning practices, and understanding the importance of memory-making for parents. The guide includes quotes which are representative of women\u0026rsquo;s experiences of interactions with health professionals:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;As I said, they\u0026rsquo;re as real as [my child] is, so I like having physical things to remember. You know, what has happened and remember that they were part of my life and that they exist for me\u0026rdquo; (Yasmine)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have the little scan picture of my baby\u0026rsquo;s heartbeat and [\u0026hellip;] I was happy\u0026rdquo; (Grace)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommunication\u003c/em\u003e\u003c/strong\u003e: This section covers the importance of communication with parents during their time in hospital, specifically the use of compassionate language in conversation, clear and definite terms when describing the diagnosis and management options, parents\u0026rsquo; need for time to emotionally and cognitively adjust to the reality of the miscarriage before making management decisions. This section includes helpful communication tips for meeting these support needs while also providing clear information and \u0026ldquo;make eye contact and remember that your words will have impact\u0026rdquo;; avoid using phrases such as \u0026ldquo;\u003cem\u003eat least you know you can get pregnant\u003c/em\u003e\u0026rdquo; or \u0026ldquo;\u003cem\u003eproducts of conception\u003c/em\u003e\u0026rdquo;. These tips were supported by some quotes such as the following:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The midwife at the 12\u003csup\u003eth\u003c/sup\u003e week scan failed to explain that she thought I was having a missed miscarriage\u0026rdquo; (Hina)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eManagement of miscarriage\u003c/em\u003e\u003c/strong\u003e: This section covers parents\u0026rsquo; support needs around management of miscarriage options and in making health-informed decisions of care based on those options. It includes a QR code linking to NICE guidelines on management of miscarriage and ectopic pregnancy [24]. Recommendations such as women should not be advised \u0026ldquo;\u003cem\u003eto come back in 10 days\u003c/em\u003e\u0026rdquo;, without providing adequate information to support the rationale behind this decision is included. Further, this section emphasises that women should be given a full explanation of what to expect depending on the proposed miscarriage management option offers, with practical advice and all the information required to make an informed care decision. The following quote is testimony of a women\u0026rsquo;s experience: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I delivered the baby in the toilet. If I didn\u0026rsquo;t have a specimen pot, what was I meant to do? Flush it away like a goldfish?\u0026rdquo; (Sofia)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHospital environments\u003c/em\u003e\u003c/strong\u003e: This section covers the importance of a hospital environment where women\u0026rsquo;s privacy and dignity were considered from diagnosis communication to miscarriage management; and the detrimental impact of long waiting times/intervals between management steps without clear communication or continuity of care. Additionally, the guide indicates that treating women in settings around other pregnant women and their babies can be highly traumatising and was distressing to the participants who reported this experience. The following quotes are used to support the content of the theme: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe doctor said it to me in the waiting room with people beside me who I didn\u0026rsquo;t know, they didn\u0026rsquo;t know me and there was no privacy. He didn\u0026rsquo;t call me over to one side or anything to tell me that, he just said it like it was a matter of fact and I just started to cry\u003c/em\u003e\u0026rdquo; (Zahra)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I wouldn\u0026rsquo;t have a clue who I was chatting to. And then the next time it will be somebody else, it was like I don\u0026rsquo;t know who I am chatting to. That was the hard thing, not having a face to fae , that everything was impersonal\u0026rdquo; (Ruoxi)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFollow-up and emotional support\u003c/em\u003e\u003c/strong\u003e: The final section covers the importance of providing clear information on any post-miscarriage investigations/tests and follow-up appointments, and the adverse impact that miscarriage can have on a woman\u0026rsquo;s sense of loneliness and isolation. The guide indicates that highlighting and signposting options for emotional support, either provided through the trust or with a charity organisation can help parents to navigate and process their experiences of trauma and grief. This section also includes contact information for NI/UK charity organisations who provide support and assistance to parents who have experienced pregnancy loss (Sands, Cradle, Antenatal Results \u0026amp; Choices, and the Miscarriage Association). The following quotes are provided to represent some women\u0026rsquo;s experience: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Signposting to support services should be a basic expectation. I benefited greatly from the opportunity to speak about my experience moths down the line\u0026rdquo;. ( Aoife)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was given a flyer, you know like that really old font they sued to use back in the 90s and on a piece of paper that would have been clearly photocopied from the original, like 100 times, so the writing isn\u0026rsquo;t even on the paper\u0026rdquo;. (Aylin)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDistribution\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe PG is available both as physical printed copies (water-resistant cardstock pages with a single ball-chain loop at the top left corner) and online as a digital download (PDF file) for ease of distribution amongst HCPs. Physical copies were disseminated at the resource launch event and the digital version was uploaded to the Queen\u0026rsquo;s University Belfast \u0026lsquo;Pregnancy Loss Research at QUB\u0026rsquo; webpage. There is no charge associated with either version of the PG. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection and future plans\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection is ongoing. Perceived professional competency will be assessed using the Perinatal Bereavement Care Confidence Scale (PBCCS) [25]. \u0026nbsp; The PBCCS includes 4 subscales: Bereavement Support Knowledge Scale; Bereavement Support Skills Scale; Self-Awareness Scale; and Organisational Support Scale. \u0026nbsp;Scores are collated using a 5-point Likert scale ranging from 1 \u0026ldquo;strongly disagree\u0026rdquo; to 5 \u0026ldquo;strongly agree\u0026rdquo;. \u0026nbsp;The PBCCS has demonstrated good psychometric properties as reported in the original study on all four subscales. These data will be used to assess changes in confidence in care provision among pocket guide users.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHealth professionals may have limited exposure to perinatal loss [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which can lead to anxiety when encountering pregnancy loss in practice [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Health professionals play an important role in shaping patients\u0026rsquo; experiences. Often, HPs meet patients at their most vulnerable time and often patients might see healthcare providers as those who offer emotional support. Prior studies have noted the correlation between patient-health professional relationships and overall satisfaction with hospital services [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, there is a lack of training both at university and organisational level to support health professionals in practice.\u003c/p\u003e\u003cp\u003ePocket guides have been previously used in hospital settings to answer most common questions asked by practitioners [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Further, others have demonstrated the efficacy of pocket guides to support clinical decisions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, to the best of our knowledge this is the first pocket guide created to support health professionals to care for women who experience miscarriage. Previous studies in the field have focused on developing of educational resources to support parents experiencing pregnancy loss [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. While others have developed guidelines to promote the use of sensitive language when interacting with women who have experienced miscarriage [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]; others have introduced workshops on compassionate communication for obstetric trainees and student midwives [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, there remains a general and persistent lack of training on pregnancy loss for HCPs in practice [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBereavement guidelines are currently implemented in hospital settings and accessible to all healthcare professionals [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, these guidelines are often extensive and not always readily available. Our pocket guide provides evidence-based information, and it has been specifically designed for ease of access. The printed version can be stored in various clinical environments, and its compact size facilitates convenient consultation. This represents a crucial step in improving clinical confidence and ensuring compassionate care in hospital settings.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThe Pocket Guide is founded on a strong evidence base, having been developed following the completion of a comprehensive doctoral study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The Miscarriage and Mental Health Study utilised three distinct data collection methods, enhancing the validity and rigour of its findings. To ensure its relevance to clinical practice, the Pocket Guide was reviewed by members of an expert advisory group. It is readily accessible as a digital download and has been widely distributed across various clinical settings where it has been utilised. However, the Pocket Guide has not yet undergone formal evaluation. Data collection is ongoing, and the research team intends to publish the findings in a separate paper. As the Pocket Guide was specifically designed for use in the United Kingdom, certain aspects may not be directly applicable to an international context.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis article summarised the steps which were undertaken to create a pocket guide to support health professionals in practice to support parents who experience miscarriage. The PG aims to provide useful guidance to HCPs who may not be exposed to perinatal loss on a regular basis or who may not be comfortable in supporting parents. The information contained in the guide is evidence based, ensuring that it aligns with the latest research and best practice in the field. The content of the guide reflects the journey that women may experience when they come to hospital for pregnancy loss. However, it is crucial to understand that pregnancy loss is an individual experience, and now two journeys are the same. Therefore, the suggestions and guidelines presented are meant to serve as general recommendations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHCP- health care professionals\u003c/p\u003e\n\u003cp\u003eIM- Intervention Mapping Framework\u003c/p\u003e\n\u003cp\u003eMRC- Medical Research Council\u003c/p\u003e\n\u003cp\u003eNI- Northern Ireland\u003c/p\u003e\n\u003cp\u003ePBCCS- Perinatal Bereavement Care Confidence Scale\u003c/p\u003e\n\u003cp\u003ePG- pocket guide\u003c/p\u003e\n\u003cp\u003eUK- United Kingdom\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthical Approval\u003c/em\u003e \u003cem\u003eand consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Miscarriage and Mental Health ethical was conducted in compliance with the Helsinki Declaration and approval was granted by the Queen\u0026rsquo;s University Belfast Research Ethics Committee (REC) for the faculty of Medicine, Health, and Life Sciences (MHLS 20_99). Informed consent to participate was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Pocket Guide Study ethical approval was granted by the Queen\u0026rsquo;s University Belfast Research Ethics Committee (REC) for the faculty of Medicine, Health, and Life Sciences (#MHLS 24_84).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to for publication\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have consent for publications from participants. All participants have been given a pseudonymous to maintain their confidentiality\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during \u003cem\u003ethe Mental Health Study\u003c/em\u003e are available from the corresponding author on reasonable request. The pocket guide is available at https://tinyurl.com/2s4xpf47\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interest\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe Miscarriage and Mental Health study was part of doctoral study funded by the Department of Economy and sponsored by Queen\u0026rsquo;s University Belfast. The Pocket Guide Study was funded by grant from the Economic \u0026amp; Social Research Council (ESRC) Impact Acceleration Account through Queen\u0026rsquo;s University Belfast.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026Aacute;A and MG were involved in the conceptualisation and execution of the Miscarriage and Mental Health Study. MG obtained the fundings to produce the pocket guide and acted as Principal Investigator for the study. \u0026nbsp;\u0026Aacute;A and MG conceptualised the Pocket Guide. EP designed the Pocket Guide graphics, with support from \u0026Aacute;A, MG, and MR.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgments\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge all the study participants and the advisory group members who made these projects possible.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eQuenby S, Gallos ID, Dhillon-Smith RK, Podesek M, Stephenson MD, Fisher J, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. The Lancet. 2021;397:1658\u0026ndash;67.\u003c/li\u003e\n\u003cli\u003eKerstin A, Wanger B. Complicated grief after perinatal loss. Dialogues Clin Neurosci. 2012;14:187\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eRcOG. The Investigation and Treatment of Couples with Recurrent First-trimester and Second-trimester Miscarriage. RCOG Green-top Guideline No. 17. 2011;:1\u0026ndash;18. http://www.ncbi.nlm.nih.gov/pubmed/21037217%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1757074\u0026amp;tool=pmcentrez\u0026amp;rendertype=abstract%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/14654599%5Cnhttp://dx.doi.org/10.1016/j.fertnstert.2012.06.048%5Cnhtt. Accessed 7 Mar 2020.\u003c/li\u003e\n\u003cli\u003eCommittee of the American Society for Reproductive Medicine P. Definitions of infertility and recurrent pregnancy loss: A committee opinion. Fertil Steril. 2013;99:63.\u003c/li\u003e\n\u003cli\u003eKukulskienė M, Žemaitienė N. Postnatal Depression and Post-Traumatic Stress Risk Following Miscarriage. Int J Environ Res Public Health. 2022;19.\u003c/li\u003e\n\u003cli\u003eFarren J, Mitchell-Jones N, Verbakel JY, Timmerman D, Jalmbrant M, Bourne T. The psychological impact of early pregnancy loss. Hum Reprod Update. 2018;24:731\u0026ndash;49.\u003c/li\u003e\n\u003cli\u003eRowlands I, Lee C. Adjustment after miscarriage: Predicting positive mental health trajectories among young Australian women. Psychol Health Med. 2010;15:34\u0026ndash;49.\u003c/li\u003e\n\u003cli\u003eLarivi\u0026egrave;re-Bastien D, deMontigny F, Verdon C. Women\u0026rsquo;s Experiences of Miscarriage in the Emergency Department. J Emerg Nurs. 2019;45:670\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGaleotti M, Mitchell G, Tomlinson M, Aventin \u0026Aacute;. Factors affecting the emotional wellbeing of women and men who experience miscarriage in hospital settings: a scoping review. BMC Pregnancy and Childbirth 2022 22:1. 2022;22:1\u0026ndash;24.\u003c/li\u003e\n\u003cli\u003eBellhouse C, Temple-Smith M, Watson S, Bilardi J. \u0026ldquo;The loss was traumatic\u0026hellip; some healthcare providers added to that\u0026rdquo;: Women\u0026rsquo;s experiences of miscarriage. Women and Birth. 2019;32:137\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eJensen KLB, Temple-Smith MJ, Bilardi JE. Health professionals\u0026rsquo; roles and practices in supporting women experiencing miscarriage: A qualitative study. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2019;59:508\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eShen Q, Liang J, Gao Y. Experience of undergraduate midwifery students faced with perinatal death in clinical practice: A qualitative study. Nurse Educ Today. 2022;108.\u003c/li\u003e\n\u003cli\u003eGaleotti M, Heaney S, Robinson M, Aventin \u0026Aacute;. Evaluation of a pregnancy loss education intervention for undergraduate nursing students in Northern Ireland: A pre- and post-test study. BMC Nurs. 2023;22:1\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eNash M, Barry M, Bradshaw C. Midwives\u0026rsquo; experiences of caring for women with early pregnancy loss in an Irish maternity hospital. 2018.\u003c/li\u003e\n\u003cli\u003eZwerling B, Rousseau J, Ward KM, Olshansky E, Lo A, Thiel de Bocanegra H, et al. \u0026ldquo;It\u0026rsquo;s a horrible assignment\u0026rdquo;: A qualitative study of labor and delivery nurses\u0026rsquo; experience caring for patients undergoing labor induction for fetal anomalies or fetal demise. Contraception. 2021;104:301\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eBoyle FM, Horey D, Middleton PF, Flenady V. Clinical practice guidelines for perinatal bereavement care \u0026mdash; An overview. Women \u0026amp; Birth. 2020;33:107\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eQian J, Cai W, Sun S, Wang M, Yu X. Influencing factors of perinatal bereavement care confidence in nurses and midwives: A cross-sectional study. Nurse Educ Today. 2022;117.\u003c/li\u003e\n\u003cli\u003eBrann M, Bute JJ, Scott SF. Qualitative Assessment of Bad News Delivery Practices during Miscarriage Diagnosis. Qual Health Res. 2020;30:258\u0026ndash;67.\u003c/li\u003e\n\u003cli\u003eVerhaeghe C, Gicquel M, Bouet PE, Corroenne R, Descamps P, Legendre G. Positive impact of simulation training of residents on the patients\u0026rsquo; psychological experience following pregnancy loss. J Gynecol Obstet Hum Reprod. 2020;49:101650.\u003c/li\u003e\n\u003cli\u003eGaleotti M. The emotional needs of women who experience miscarriage in hospital settings: a mixed-methods needs assessment in Northern Ireland. Queen\u0026rsquo;s University Belfast; 2023.\u003c/li\u003e\n\u003cli\u003eBartholomew ELK, Markham CM, Ruiter RAC, Fernandez ME, Kok G, Parcel G. Planning health promotion programs : an intervention mapping approach. 4th edition. USA: Jossey-Bass; 2016.\u003c/li\u003e\n\u003cli\u003eHeaney S, Galeotti M, Aventin \u0026Aacute;. Pregnancy loss following miscarriage and termination of pregnancy for medical reasons during the COVID-19 pandemic: a thematic analysis of women\u0026rsquo;s experiences of healthcare on the island of Ireland. BMC Pregnancy Childbirth. 2023;23:1\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eMcKleroy VS, Galbraith JS, Cummings B, Jones P, Harshbarger C, Collins C, et al. Adapting evidence-based behavioral interventions for new settings and target populations. AIDS Education and Prevention. 2006;18 SUPPL. A:59\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence (NICE). Ectopic pregnancy and miscarriage: diagnosis and initial management | NICE guideline [NG126]. 2019.\u003c/li\u003e\n\u003cli\u003eKalu FA, Larkin P, Coughlan B. Development, validation and reliability testing of \u0026ldquo;Perinatal Bereavement Care Confidence Scale (PBCCS)\u0026rdquo;. Women \u0026amp; Birth. 2020;33:e311\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eMcWilliam CL, Brown JB, Stewart M. Breast cancer patients\u0026rsquo; experiences of patient-doctor communication: a working relationship. Patient Educ Couns. 2000;39:191\u0026ndash;204.\u003c/li\u003e\n\u003cli\u003eStreet RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns. 2009;74:295\u0026ndash;301.\u003c/li\u003e\n\u003cli\u003eSephien A, Arunachalam R, Mhaskar R, San Antonio A, Jordan J. An Electronic Medical Record Pocket Guide for Incoming Internal Medicine Interns: Perceptions and Impact on Patient Information Gathering. South Med J. 2023;116:502\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eBousquet J, Heinzerling L, Bachert C, Papadopoulos NG, Bousquet PJ, Burney PG, et al. Practical guide to skin prick tests in allergy to aeroallergens. Allergy: European Journal of Allergy and Clinical Immunology. 2012;67:18\u0026ndash;24.\u003c/li\u003e\n\u003cli\u003eFesler JR, Belcher AE, Moosa AN, Mays MA, Jehi LE, Pestana Knight EM, et al. The Efficacy and Use of a Pocket Card Algorithm in Status Epilepticus Treatment. Neurol Clin Pract. 2021;11:406\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eVarner C, Leduc L, Pasquale J, Yee M, McLeod S, Morson N, et al. Co-designing a web-based education platform for patients with early pregnancy loss. CJEM. 2022;24:805\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKlein S, Cumming GP, Lee AJ, Alexander DA, Bolsover D. Evaluating the effectiveness of a web-based intervention to promote mental wellbeing in women and partners following miscarriage, using a modified patient preference trial design: An external pilot. BJOG. 2012;119:762\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eJohnson J, Arezina J, Tomlin L, Alt S, Arnold J, Bailey S, et al. UK consensus guidelines for the delivery of unexpected news in obstetric ultrasound: The ASCKS framework. Ultrasound. 2020;28:235\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eDoherty J, Cullen S, Casey B, Lloyd B, Sheehy L, Brosnan M, et al. Bereavement care education and training in clinical practice: Supporting the development of confidence in student midwives. Midwifery. 2018;66:1\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eMcNamara K, Smith A, Shine B, Cregan M, Prihodova L, O\u0026rsquo;Shaughnessy A, et al. Addressing obstetricians\u0026rsquo; awareness of compassion, communication, and self-care when caring for families experiencing stillbirth: Evaluation of a novel educational workshop using applied drama techniques. PLoS One. 2022;17:e0277496.\u003c/li\u003e\n\u003cli\u003ePastor Montero SM, Romero Sanchez JM, Hueso Montoro C, Lillo Crespo M, Vacas Jaen AG, Rodriguez Tirado MB. Experiences with perinatal loss from the health professionals\u0026rsquo; perspective. Rev Lat Am Enfermagem. 2011;19:1405\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eJauniaux E, Farquharson RG, Christiansen OB, Exalto N. Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage. Human Reproduction. 2006;21:2216\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eSchott J, Henley A, Kohner N. Pregnancy loss and the death of a baby: Guidelines for professionals 4 th edition. 2016.\u003c/li\u003e\n\u003cli\u003eCatlin A. INTERDISCIPLINARY GUIDELINES FOR CARE OF WOMEN PRESENTING TO THE EMERGENCY DEPARTMENT WITH PREGNANCY LOSS...Reprinted with permission by the National Perinatal Association, 2017. Copyright National Perinatal Association, 2017. MCN Am J Matern Child Nurs. 2018;43:13\u0026ndash;8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Miscarriage, pregnancy loss, pocket guide, health care professionals, maternal health, women’s health, women’s wellbeing, healthcare inequality, health and wellbeing","lastPublishedDoi":"10.21203/rs.3.rs-6830161/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6830161/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMiscarriage is a common gestational complication with significant emotional and psychological consequences for those affected. Despite the crucial role healthcare professionals (HCPs) play in supporting women and their partners through pregnancy loss, existing research highlights a persistent lack of training and guidance in this area. The Miscarriage and Mental Health Study identified gaps in the emotional support provided to women experiencing miscarriage in hospital settings in Northern Ireland, underscoring the need for targeted educational interventions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethodology\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study details the development and implementation of a Pocket Guide (PG) designed to equip HCPs with evidence-based guidance on best practices for providing compassionate care. The PG was informed by qualitative and quantitative data from women who had experienced miscarriage, alongside insights from HCPs. It was structured around key themes identified in the research, including communication, management of miscarriage, hospital environments, and follow-up care. The guide was designed for accessibility in clinical settings, available in both printed and digital formats.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBy addressing gaps in professional training and fostering improved communication, the Pocket Guide aims to enhance the quality of care provided to women experiencing pregnancy loss. This study contributes to the ongoing discourse on improving miscarriage care, emphasising the necessity of structured educational resources to better support both patients and HCPs. It sets the foundation for future research to explore the impact of such interventions on clinical practice and patient experiences and outcomes.\u003c/p\u003e","manuscriptTitle":"Development of a pregnancy loss pocket guide for health professionals supporting women and their partners during miscarriage in hospital settings","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-09 11:36:20","doi":"10.21203/rs.3.rs-6830161/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81daa5ae-55de-4322-85ff-2522e541b9ee","owner":[],"postedDate":"July 9th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-06T11:21:48+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T11:26:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-09 11:36:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6830161","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6830161","identity":"rs-6830161","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}