Service Evaluation of an Early Pregnancy Loss Support Clinic in a London EPU

Service Evaluation of an Early Pregnancy Loss Support Clinic in a London EPU | 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 Service Evaluation of an Early Pregnancy Loss Support Clinic in a London EPU Michelle Anderson, Gemma Gluckman, Tara Ajith, Emma Kirk, Maria Memtsa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3963399/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Nov, 2024 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Early pregnancy loss (EPL) can have profound implications for physical and psychological health. In the UK, huge variation in service provision exists for women affected by EPL. There is very little guidance on what hospital-based follow-up support services should look like, and how these can be implemented and embedded into current care provision to meet the needs of women who experience EPL. This service evaluation (SE) reports on a newly implemented Early Pregnancy Loss Support Clinic (EPLSC) in an inner-city Hospital Trust. Methods: This SE gathered both quantitative and qualitative data to assess the value of a locally implemented Early Pregnancy Loss Support Clinic (EPLSC). Quantitative data were collected using the Short Assessment of Patient Satisfaction (SAPS) questionnaire and the Visual Anxiety Scale (VAS-A), both were administered to women attending the EPLSC. Qualitative data were collected through semi-structured interviews and consisted of four pre-determined themes based on EPL literature - physical health, mental health, role of the bereavement midwife and overall service user experience. Quantitative data was summarised using descriptive statistics and qualitative data was analysed deductively using Framework analysis. Results: A total of 127 women were invited to the EPLSC, with 110 (87%) attending, and 17 (13%) not attending their appointment. SAPS scores ranged between 21-28 demonstrating that women were either satisfied or very satisfied with the care they received in the EPLSC. Results from VAS-A scores found that 76 (69%) of women reported a decrease in anxiety immediately after attending the EPLSC, compared to 8 (7%) who reported no change or a small increase in anxiety. Qualitative results revealed women’s concerns around future fertility, the importance of emotional support and the value of connecting with the bereavement midwife. Conclusion: An EPLSC which focuses on providing emotional support and reassurance, especially in relation to future fertility, is important to women. Further rigorous evaluation on national disparities in EPL follow-up is urgently needed to assess the gaps in clinical care delivery. Early pregnancy loss miscarriage ectopic pregnancy bereavement Figures Figure 1 Introduction Early pregnancy loss (EPL) is defined as a diagnosis of miscarriage or an ectopic pregnancy diagnosis before 14 weeks of gestation [ 1 ][ 2 ]. An estimated 1 in 5 pregnancies end in miscarriage, and approximately 1 in 90 pregnancies are diagnosed as an ectopic [ 3 ][ 4 ][ 1 ][ 2 ], with ectopic pregnancy being the leading cause of maternal morbidity and unexpected death worldwide [ 5 ]. EPL can have profound implications for physical and psychological health [ 6 ][ 7 ][ 8 ][ 9 ]. Complications following an early pregnancy loss include infection, pain and heavy bleeding [ 6 ][ 7 ]. Furthermore, recurrent miscarriage is a sentinel risk marker for obstetric complications in future pregnancies, including preterm birth, fetal growth restriction, placental abruption, and stillbirth [ 7 ]. Psychological morbidity is common after EPL, especially within the first six months [ 7 ][ 10 ]. A significant proportion of women experience psychological sequalae such as depression, anxiety, and Post Traumatic Stress Disorder (PTSD) [ 8 ][ 7 ][ 9 ][ 11 ][ 10 ]. Qualitative work has highlighted that many women experience grief and guilt after EPL, and that the ‘silence that surrounds miscarriage’ can lead to feelings of loneliness and isolation [ 12 ][ 13 ]. Anxiety around future pregnancies and fertility are also commonplace, the latter especially so for women with surgically managed ectopic pregnancies [ 14 ][ 15 ][ 13 ]. Importantly, there are no differences between gestational age at pregnancy loss and adverse psychological outcomes [ 16 ]. A review of support available for loss in early and late pregnancy conducted in 2014, found that out of 300 women surveyed, nearly four out of five (79%) received no aftercare [ 4 ]. Nearly 10 years on, it would appear very little has changed. EPL is often unexpected and can be devastating for women and their families [ 13 ]. Variations in care, access to treatment options, support networks and follow-up care can adversely impact women’s physical and psychological recovery [ 7 ][ 17 ][ 13 ][ 12 ]. A recurring theme in the literature relates to experiences of EPL care [ 18 ] [ 13 ][ 12 ]. Sadly, all too often women report that they feel ‘part of a conveyor belt’ system and that their loss is not appropriately acknowledged by clinical care teams [ 13 ][ 12 ]. Additionally, lack in bereavement care and follow-up after EPL has been identified as unacceptable to women [ 18 ][ 4 ][ 13 ]. This paucity has been highlighted in the Pregnancy Loss Review (2023) which recommends that NICE guidance on pre-24-week pregnancy loss should be updated and embedded into clinical care pathways so that all women are offered mental health support, investigation, and consistency in standards of care [ 19 ]. Further recommendations include establishing pregnancy-after-loss clinics in hospitals offering maternity care, staffed by specialist gynaecology nurses and/or midwives and led by a consultant [ 19 ]. Need for research In the UK, huge variation in service provision exists for women affected by EPL [ 3 ]. Many hospitals do not have standardised EPL care pathways with most services signposting to outside organisations for counselling and support [ 3 ]. There is very little guidance on what hospital-based follow-up support services should look like, and how these can be implemented and embedded into current care provision to meet the needs of women who experience EPL. The delivery of EPL care is considered important but has not been rigorously evaluated [ 19 ]. This service evaluation (SE) gathered both quantitative and qualitative data to assess the value of a locally implemented Early Pregnancy Loss Support Clinic (EPLSC). The aim of this SE was to assess if an EPLSC was important to women and to identify potential areas for improvement [ 20 ]. Service evaluation Initiated and led by a consultant specialising in early pregnancy care, this project took place for one year from February 2023 to February 2024 and involved the evaluation of a newly implemented EPLSC in an inner-city Hospital Trust. A patient feedback questionnaire, anxiety scoring and semi-structured interviews to explore the experiences of women attending the EPLSC were used as evaluation tools. Areas of specific focus included physical health, mental health, role of the bereavement midwife and the overall service user experience. Key project objectives aim to- Determine the number of women who attended the EPLSC between February 2023 to February 2024. Identify sociodemographic characteristics of the women accessing the EPLSC as well as the type of EPL. Identify the number of post miscarriage/ectopic complications diagnosed through the EPLSC. Assess if the EPLSC provides early intervention for post miscarriage/ectopic complications by addressing physical and mental health issues. Evaluate the importance of the EPLSC for supporting women in physical and psychological wellbeing. Authorisation process Authorisation for the project was sought from the Clinical Leadership Team and approved by the Business Unit Governance Team. As this is a service evaluation, the project did not require ethics approval. Handling of data complied with the requirements of the Data Protection Act 2018 with regards to the collection, storage and processing and disclosure of personal information. All women who took part in the SE received information about the project and verbal or written informed consent was given by all women. Methods Quantitative data were collected using the Short Assessment of Patient Satisfaction (SAPS) questionnaire [ 21 ] and the Visual Anxiety Scale (VAS-A) [ 22 ], both were administered to women attending the EPLSC, and scores were stored securely on an anonymised Excel spreadsheet, along with baseline data collected from Electronic Patient Records. It should be noted that the response rate for SAPS was initially low because women experienced problems accessing the QR code, this was subsequently changed to paper copies which improved response rates. Qualitative data were collected through semi-structured interviews and consisted of four pre-determined themes based on EPL literature [ 1 ][ 2 ][ 6 ][ 7 ][ 8 ][ 19 ] - physical health, mental health, role of the bereavement midwife and overall service user experience. Five women took part in interviews either online or face-to-face. Due to the sensitive nature of the topic, a bereavement midwife telephoned the women 24 hours after interview to check on psychological wellbeing. Analysis Quantitative data was summarised using descriptive statistics and qualitative data was analysed deductively using Framework analysis. The Framework method is generated towards policy and practice orientated findings and commonly used for the thematic analysis of semi-structured interview transcripts [ 23 ][ 24 ]. Data was analysed from the four pre-defined themes and followed five steps of data management: familiarisation, constructing an initial thematic framework, indexing, and sorting, reviewing data extracts and data summary and display, followed by interpretation [ 24 ][ 25 ]. The findings were discussed among the SE team at each stage of analysis and there were several iterations of this process before the final categories were developed and agreed by all authors. Findings Quantitative A total of 127 women were invited to the EPLSC between February 2023 and February 2024, with 110 (87%) attending, and 17 (13%) not attending their appointment. Table 1 summarises the characteristics of the women who attended the EPLSC. Table 1 Characteristics of women who attended the EPLSC Characteristics of Women who Attended the EPLSC N = 110 (%) Age (years) 35 62 (56%) Ethnicity Black (British, Caribbean, African) 7 (6%) Asian (British, South, Indian, Other) 19 (17%) White (British, Other) 48 (44%) Mixed (White & Black Caribbean, White & Black African) 4 (4%) Any Other Group (Other/ not Stated) 32 (29%) Previous Pregnancy Losses < 14 weeks 0 54 (49%) 1 23 (21%) 2 16 (15%) 3 6 (5%) 4 or more 11 (10%) Type of Loss Miscarriage 71 (65%) Ectopic 39 (35%) Management Miscarriage Surgical 26 (37%) Medical 12 (17%) Expectant 33 (46%) Management Ectopic Surgical 27 (70%) Medical 6 (15%) Expectant 6 (15%) Post EPL Complications > 3 miscarriages 5 (5%) Gynae issues (fibroids, adenomyosis, endometrial polyps) 40 (36%) Cesarean scar niche 4 (4%) Mental health (anxiety, struggling with emotions) 7 (6%) Other (HCG levels high, medical issues) 8 (7%) No complications 46 (42%) The Short Assessment of Patient Satisfaction (SAPS) questionnaire was completed by 56 (51%) of women who attended the EPLSC. Scores ranged between 21–28 demonstrating that women were either satisfied or very satisfied with the care they received in the EPLSC. The Visual Anxiety Scale (VAS-A) was completed by 84 women (76%) pre and post EPLSC appointment. 76 (69%) of women reported a decrease in anxiety immediately after attending the EPLSC, compared to 8 (7%) who reported no change or a small increase in anxiety. Table 2 shows the overall VAS-A scores for pre (319.9) and post (151) EPLSC clinic attendance highlighting a 47% decrease in anxiety scores. Qualitative Five women who attended the EPLSC consented to interview, two face-to-face, and three via Microsoft Teams. Three women experienced miscarriage between 11–13 weeks of pregnancy, and two-women, ectopic pregnancy. Three categories pertaining to women’s experiences of attending the EPLSC were identified as fundamentally important- Future Fertility Emotional Support Bereavement Midwife Physical health & future fertility Physical health concerns such as recovery following EPL, recurring miscarriage/ectopic pregnancy and future fertility were commonplace in all women interviewed. However, the EPLSC helped to ameliorate some of these worries through discussions on future fertility and being offered an ultrasound scan (USS). All women who attended the EPLSC were offered USS with only 5% declining- ‘I felt very reassured about that [fertility] because before the [EPLSC] appointment I was worried about it taking years to get pregnant again (003)’. [Ectopic]. ‘It [ultrasound scan] was very helpful for two reasons a) confirmation of what’s happened, and b) you also get reassurance that your body is bouncing back, things are as they should be (002)’ [Ectopic]. ‘This [menstrual] cycle in particular was a lot more delayed than I’m used to which caused me to worry a little bit but having that checked and told that everything looked fine, has helped put my mind at rest (001)’ [Miscarriage]. Some women discussed how a lack of involvement from their GP, receiving conflicting information and not knowing how or when their IVF referral would take place created further anxiety- ‘Receiving contradictory information from the GP on what you need to do before your referral can be sent off-it would really help knowing what the next steps are (002)’ [Ectopic]. Mental health & emotional support Women described the emotional burden of EPL as particularly difficult. Variations in mood were linked to different timepoints in the EPL journey. Women reported feeling shocked, scared, and anxious at the point of their EPL diagnosis, while feelings of grief, trauma and isolation were reported in the weeks afterwards- ‘I always felt quite matter of fact [about EPL] but I was off work for a month in the end, just because it felt very difficult (003)’ [Ectopic]. One woman reported her feelings of grief partially attributed to the change in her body after salpingectomy- ‘The grief from that [salpingectomy]… I think actually hit later on. Then I started processing everything and not just the pregnancy loss but the change in my body (002)’ [Ectopic]. The EPLSC was important to women as a safe space to discuss emotions and receive acknowledgement for their loss- ‘It was the first time I was asked how I was feeling and the first time that I thought anybody cared about my miscarriage (004)’ [Miscarriage]. ‘I think with an early miscarriage, people don’t talk about it very much and no one knew you were pregnant really, because you weren’t showing. So, I don’t think I would have had a clue where to turn [if it wasn’t for EPLSC] (005)’ [Miscarriage]. Bereavement Midwife The role of the Bereavement Midwife in relation to EPL care was considered important, especially as an easily accessible point of contact, and for future pregnancy concerns- ‘I do feel like in the future, if I had any worries or concerns, I would probably be more likely to get in touch with her [BM], rather than going to the GP or anybody else because I think I’ll be taken a little bit more seriously (001)’ [Miscarriage]. One woman describes how earlier contact with the BM may have been helpful in the first few weeks following EPL- ‘I think I was given her [BM] details at the four-week follow-up rather than at discharge, but that’s the time [immediately after EPL] that most people would be off work recovering and sitting with their thoughts (002)’ [Ectopic]. Improvement suggestions Improvements proposed by women who were interviewed included more information on fertility care pathways, better links with primary care services, and signposting to appropriate external resources- ‘It would be really helpful knowing what next steps are [fertility] and given more information on the process, because that’s one of the most frustrating things I’ve had to deal with since’ (002) [Ectopic]. Discussing the risks and benefits when signposting women to EPL online resources for support is important because, as one woman explains, some online platforms can be counterproductive, and induce anxiety rather than relieve it- ‘One of the things that was recommended was the Early Pregnancy Trust website, but the forums and the messages that were there may have been counterproductive because, when people are vocal about things and they post things on forums and stuff, it’s almost always worse case scenarios, and experiences rather than support (002)’ [Ectopic]. Providing women with options on how to access the EPLSC, such as offering online or face-to-face appointments, was also felt to be important, depending on the woman’s preference and need- ‘I went to the clinic in person, and I was happy to go in person, but it might be an idea to offer it online if it's not already. Because people experience miscarriages in different ways, and I was fine to go in and I had the support (004)’ [Miscarriage]. Evaluation Outcome This SE assessed the quality of a newly implemented EPLSC in one London Trust. Evaluative feedback was obtained to determine women’s views on a new service. Key components of the EPLSC based on recommendations from the recent Pregnancy Loss Review (2023) focused on physical health, mental health and support from the bereavement midwife [ 19 ]. Characteristics of women who attended the clinic included age, ethnicity, previous pregnancy loss, type of loss and management, and post EPL complications. Around 56% of women who attended the EPLSC were over 35 years old, 49% experienced their first EPL and 56% of women were non-white. This is concurrent with literature highlighting the increased risk of miscarriage in women from ethnic minority groups [ 7 ][ 26 ][ 27 ]. Out of 110 women, 36% (n = 40) were confirmed to a have gynaecological condition in the EPLSC. Confirming gynae pathology during the EPLSC visit can help focus the consultation on pertinent issues that may impact fertility and help to ensure that appropriate referral pathways are initiated. Furthermore, offering women an USS as part of EPL care is a safe, minimally invasive and relatively quick to perform option, which can be useful in confirming issues such as endometriosis, fibroids, and other abnormalities of the uterus [ 28 ][ 29 ]. Psychological sequalae, such as post-traumatic stress, anxiety and depression, are commonplace following EPL [ 30 ][ 19 ] with significant variation in emotional care follow-up [ 19 ]. Standardising follow-up EPL care may be important for supporting women emotionally and reducing the mental health burden associated with this event. A decrease in self- reported anxiety was found for 85% of women who attended the EPLSC and a further 8% disclosed struggling with their mental health. Identifying difficulties with mental health in women following EPL means that early intervention can be offered to help provide psychological support. However, further evaluation is needed in this area to fully understand the mental health needs of women following-EPL. The bereavement midwife role was considered important to women especially as an easily accessible point of contact and for future concerns in subsequent pregnancies. However, women raised concerns about the lack of involvement from their GP. Therefore, involving primary care services may be a crucial next step in developing integrated clinical care pathways, especially as, navigating EPL pathways can be confusing for women [ 19 ]. Recommendations Key findings from this SE have highlighted the importance of EPLSC. Recommendations for improvements and factors to consider when an implementing EPLSC include- Provide information about EPL care at the time of loss, including EPLSC follow-up and contact details for bereavement midwife. Offer a follow-up EPLSC appointment 3–4 weeks after the first negative pregnancy test. Offer ultrasound to all women to detect possible complications following post EPL or undiagnosed gynaecological conditions. Provide information on future fertility and next steps (if required). Develop services to include pathways for mental health referrals/support and GP involvement. Signpost to appropriate outside agencies or/and online resources for further information/support. Consider the needs of the local population groups to develop culturally sensitive EPL services. Offer EPLSC appointments either face-to-face or online, depending on the women’s preference. Conclusion An EPLSC which focuses on providing emotional support and reassurance, especially in relation to future fertility, is important to women. Further rigorous evaluation on national disparities in EPL follow-up is urgently needed to assess the gaps in clinical care delivery. Only then can standardised care pathways and further EPLSC implementation work be developed to address the physical and mental health needs of women following EPL. Abbreviations EPU Early Pregnancy Unit EPL Early Pregnancy Loss SE Service Evaluation EPLSC Early Pregnancy Loss Support Clinic SAPS Short Assessment of Patient Satisfaction VAS-A Visual Anxiety Scale PTSD Post Traumatic Stress Disorder UK United Kingdom NICE National Institute for Health & Care Excellence QR Code Quick Response Code USS Ultrasound Scan GP General Practitioner Declarations Ethics approval and consent to participate: Authorisation for the project was sought from the Clinical Leadership Team and approved by the Business Unit Governance Team. Ethical approval was not required since participants are those who use the service and were therefore involved to help evaluate the service provided. Consent for publication: Written consent was given by all women interviewed for their data to be used anonymously for publication. Availability of data and materials: The datasets used and/or analysed during this SE are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: No funding received for this service evaluation. Authors' contributions: MA-Contribution to the design of service evaluation, qualitative data collection and analysis, and authorship. GG-Contribution to the design of the service evaluation and quantitative data collection and analysis. TA-Contribution to the quantitative data collection. EK-Contribution to the design of the service evaluation. MM-Substantial contribution to the conception and design of the service evaluation, and approved the submitted version, previous and modified versions of this paper. All authors contributed to the interpretation of findings and reviewed previous drafts and approved current version. Acknowledgements: We would like to thank the women who attended the clinic and freely agreed to volunteer their time to complete the questionnaires and interviews. We would also like to thank the staff in the Early Pregnancy and Emergency Gynaecology Unit at the Royal Free Hospital for their support. References Elson C, Salim J, Potdar R, Chetty N, Ross M, Kirk JA, E., J on behalf of the Royal College of Obstetricians and Gynaecologists. (2016) Diagnosis and management of ectopic pregnancy. BJOG 2016 RCOG Diagnosis and Management of Ectopic Pregnancy. Green-top Guideline No. 21. https://www.nice.org.uk/guidance/ng126/resources/ectopic-pregnancy-and-miscarriage-diagnosis-and-initial-management-pdf-66141662244037 . [Accessed: December 2023]. NICE. Ectopic pregnancy and miscarriage: diagnosis and initial management, NG 126. 2019 [Last updated: August 2023]. https://www.nice.org.uk/guidance/ng126 . [Accessed: December 2023]. Department of Health & Social Care. Government response to the independent Pregnancy Loss Review: care and support when baby loss occurs before 24 weeks' gestation. 2023. https://www.gov.uk/government/publications/government-response-to-the-independent-pregnancy-loss-review/government-response-to-the-independent-pregnancy-loss-review-care-and-support-when-baby-loss-occurs-before-24-weeks-gestation . [Accessed: December 2023]. Improving Quality. A review of support available for loss in early and late pregnancy. 2014. https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Available-Support-for-Pregnancy-Loss.pdf . [Accessed: December 2023]. Zhang S, Liu J, Yang L, Li J, Tang J, Hong L. Global burden and trends of ectopic pregnancy: An observational trend study from 1990 to 2019. Plos One. 2023. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0291316 . [Accessed: December 2023]. Morin A, Sideris M, Platts S, Palamrchuk T, Odejinmi F. To Fight or to Flee? A Systematic Review of Ectopic Pregnancy Management and Complications During the Covid-19 Pandemic. In vivo. 2022. 10.21873/invivo.12867 . [Accessed: December 2023]. Quenby S, Gallos D, Dhillon-Smith I, Podesk RK, Stephenson M, Fisher MD, Brosens J. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet. 2021. 10.1016/S0140-6736(21)00682-6 . [Accessed: December 2023]. Farren J, Mitchell-Jones N et al. The Psychological Impact of Early Pregnancy Loss. Human Reproduction Update. 2018. https://spiral.imperial.ac.uk/handle/10044/1/62886 . [Accessed; December 2023]. Ho L, Hernandez A, Robb J, Zeszutek M, Luong S, Okada S, Kumar E. K Spontaneous Miscarr Manage Experience: Syst Rev Cureus. 2022. 10.7759/cureus.24269 . [Accessed: December 2023]. Barbe C, Boiteaux-Chabrier M, Charillon E, Bouazzi L, Maheas C, Merabet F et al. Utility of early, short psychological care for women who experience early miscarriage: protocol for the randomized, controlled MisTher trial. BMC Psychology. 2023. https://doi.org/10.1186/s40359-023-01421-x . [Accessed: December 2023]. Cuenca D. Pregnancy loss: Consequences for mental health. Frontiers in Women’s Global Health. 2022. 10.3389/fgwh.2022.1032212 . [Accessed: December 2023]. Bellhouse C, Temple-Smith M, Bilardi J. J, E. It’s just one of those things people don’t seem to talk about.. women’s experiences of social support following miscarriage: a qualitative study. BMC Women’s Health. 2018. https://doi.org/10.1186/s12905-018-0672-3 . [Accessed: December 2023]. Spillane N, Meaney S, O’Donoghue K. Irish women’s experience of Ectopic pregnancy. Sexual & Reproductive Healthcare. 2018. https://doi.org/10.1016/j.srhc.2018.04.002 . [Accessed: December 2023]. McCarthy F, Moss-Morris P, Khashan R, North AS, Baker RA, Dekker PN, Poston G. Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy. BJOG. 2015. 10.1111/1471-0528.13233 . [Accessed: December 2023]. Schliep K, Mitchell C, Mumford EM, Radin SL, Zarek RG, Sjaarda SM. Schisterman, E, F. Trying to Conceive After an Early Pregnancy Loss: An Assessment on How Long Couples Should Wait. Obstet Gynecol. 2016. 10.1097/AOG.0000000000001159 . [Accessed: December 2023]. Campillo I, Meaney SL, McNamara S, O’Donoghue K. Psychological and support interventions to reduce levels of stress, anxiety or depression on women’s subsequent pregnancy with a history of miscarriage: an empty systematic review. BMJ Open. 2017. 10.1136/bmjopen-2017-017802 . [Accessed: December 2023]. Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, et al. Saving Lives, Improving Mothers’ Care Core report: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2022. [Accessed: December 2023]. Smith L, Frost F, Levitas J, Bradley R, Garcia H. Women’s experiences of three early miscarriage management options a qualitative study. Br J Gen Pract. 2006;56(524):198–205. Clark-Coates Z, Collinge S. The Independent Pregnancy Loss Review - Care and support when baby loss occurs before 24 weeks gestation. 2023. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1172354/Pregnancy-Loss-Review-print-ready.pdf . [Accessed: December 2023]. Best Practice in the Ethics and Governance of Service Evaluation. Guidelines for evaluators and commissioners of evaluation in health and social care. https://arc-w.nihr.ac.uk/Wordpress/wp-content/uploads/2021/02/Full-ethics-guidelines-revised-Nov-2020.pdf . [Accessed: December 2023]. Hawthorne G, Sansoni, Hayes L, Marosszeky N, Sansoni E. Measuring patient satisfaction with health care treatment using the Short Assessment of Patient Satisfaction measure delivered superior and robust satisfaction estimates. J Clin Epidemiol. 2014. 10.1016/j.jclinepi.2013.12.010 . [Accessed: December 2023]. Atkin R. C. Measurement of feelings using visual analogue scales. Proceedings of the Royal Society of Medicine. 1969 62 (10) 989 – 93. https://pubmed.ncbi.nlm.nih.gov/4899510/ . [Accessed: December 2023]. Green J, Thorogood N. Qualitative Methods for Heath Research. 4th Edition. Sage. London. 2018. Gale N, Heath K, Cameron G, Rashid E, Redwood S. S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013. 1471–2288 (13) 117. Baldwin S, Bick D. Using framework analysis in health visiting research: Exploring first-time fathers’ mental health and wellbeing. J Health Visiting. 2021. 206–13 (9) 5. The Lancet. Miscarriage: worldwide reform of care is needed. EDITORIAL| VOLUME 397, 10285 ISSUE. P1597. 2021. https://doi.org/10.1016/S0140-6736(21)00954-5 . [Accessed: December 2023]. Mukherjee S, Edwards D, Baird RV. Risk of miscarriage among black women and white women in a U.S. Prospective Cohort Study. Am J Epidemiol. 2013. 10.1093/aje/kws393 . [Accessed: December 2023]. Bean E, Chagger P, Thanatsis N, Dooley W, Bottomley C, Jurkovic D. Intra- and interobserver reproducibility of pelvic ultrasound for the detection and measurement of endometriotic lesions. Hum Reprod Open. 2020. 10.1093/hropen/hoaa001 . [Accessed: December 2023]. NICE. (2022) Fibroids. Clinical Knowledge Summaries. https://cks.nice.org.uk/topics/fibroids/NHS [Accessed: December 2023]. Farren J, Jalmbrant M, Falconieri N et al. (2019) Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. AJOG. https://doi.org/10.1016/j.ajog.2019.10.102 . [Accessed: December 2023]. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Nov, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 12 Mar, 2024 Submission checks completed at journal 12 Mar, 2024 Editor assigned by journal 12 Mar, 2024 First submitted to journal 17 Feb, 2024 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-3963399","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":278772027,"identity":"29cdf3f8-e490-46fe-b84f-a310fd62641f","order_by":0,"name":"Michelle Anderson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIie2PMUvDQBTHHwTO5UrWVw6STyBcCFwN9MPkcI2l4OIUA4V0CbhG8ENk0kXw5CAuFteMgpCpgy7SIYNnRRCbxtXhfsPjDe/H//0BLJb/iAMEYH603XE7fa2cvxWOPxQk8ZdC9ko7CuWDyuHSaZ9fOXpwsLpv3m5Tb8KK95d5BzPXz3oVockkKDmGQGfHUdnqMLpa3YSXOZyO8/4UoSlhlKPMIBGMKiUrdXLNRhnIqh5QOo7nmbsWrFOpUZKW0Q7k3ZBi6seAJgWUI6smMbnEpOypb7qIccExyHEdRoXSIX+sBRvlKMs67leedIubs6nvuknQbFTq8YfF52NTebFQ/THf/P4Ch88tFovFMsgHlfxU0rnTFhIAAAAASUVORK5CYII=","orcid":"","institution":"Royal Free London NHS Foundation Trust, Royal Free Hospital","correspondingAuthor":true,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Anderson","suffix":""},{"id":278772032,"identity":"fbfab1cf-0882-48b7-b162-7715640c9cd9","order_by":1,"name":"Gemma Gluckman","email":"","orcid":"","institution":"Royal Free London NHS Foundation Trust, Royal Free Hospital","correspondingAuthor":false,"prefix":"","firstName":"Gemma","middleName":"","lastName":"Gluckman","suffix":""},{"id":278772034,"identity":"2a6b0446-220b-4202-af60-f6b06bbe0222","order_by":2,"name":"Tara Ajith","email":"","orcid":"","institution":"Royal Free London NHS Foundation Trust, Royal Free Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tara","middleName":"","lastName":"Ajith","suffix":""},{"id":278772035,"identity":"0e55f609-19d1-4483-9abd-00b0ec966e6f","order_by":3,"name":"Emma Kirk","email":"","orcid":"","institution":"Royal Free London NHS Foundation Trust, Royal Free Hospital","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Kirk","suffix":""},{"id":278772037,"identity":"bca2d694-b3d0-47ac-83ba-0208af8af611","order_by":4,"name":"Maria Memtsa","email":"","orcid":"","institution":"Royal Free London NHS Foundation Trust, Royal Free Hospital","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Memtsa","suffix":""}],"badges":[],"createdAt":"2024-02-17 07:22:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3963399/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3963399/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-11750-1","type":"published","date":"2024-11-01T16:22:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":52712240,"identity":"ae18d375-27af-472b-9e31-dc64180f1118","added_by":"auto","created_at":"2024-03-14 20:07:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":9686,"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-3963399/v1/7cf74043e162458c08af36d6.png"},{"id":68207444,"identity":"6409d5bd-a10d-4f1e-b6b7-c2a5ab1c1228","added_by":"auto","created_at":"2024-11-04 16:37:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":525449,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3963399/v1/48bf8769-97ea-4ba5-afd8-e06a84d2e3ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Service Evaluation of an Early Pregnancy Loss Support Clinic in a London EPU","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEarly pregnancy loss (EPL) is defined as a diagnosis of miscarriage or an ectopic pregnancy diagnosis before 14 weeks of gestation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. An estimated 1 in 5 pregnancies end in miscarriage, and approximately 1 in 90 pregnancies are diagnosed as an ectopic [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], with ectopic pregnancy being the leading cause of maternal morbidity and unexpected death worldwide [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEPL can have profound implications for physical and psychological health [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Complications following an early pregnancy loss include infection, pain and heavy bleeding [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, recurrent miscarriage is a sentinel risk marker for obstetric complications in future pregnancies, including preterm birth, fetal growth restriction, placental abruption, and stillbirth [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological morbidity is common after EPL, especially within the first six months [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A significant proportion of women experience psychological sequalae such as depression, anxiety, and Post Traumatic Stress Disorder (PTSD) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Qualitative work has highlighted that many women experience grief and guilt after EPL, and that the \u0026lsquo;silence that surrounds miscarriage\u0026rsquo; can lead to feelings of loneliness and isolation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Anxiety around future pregnancies and fertility are also commonplace, the latter especially so for women with surgically managed ectopic pregnancies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Importantly, there are no differences between gestational age at pregnancy loss and adverse psychological outcomes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA review of support available for loss in early and late pregnancy conducted in 2014, found that out of 300 women surveyed, nearly four out of five (79%) received no aftercare [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Nearly 10 years on, it would appear very little has changed. EPL is often unexpected and can be devastating for women and their families [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Variations in care, access to treatment options, support networks and follow-up care can adversely impact women\u0026rsquo;s physical and psychological recovery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA recurring theme in the literature relates to experiences of EPL care [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Sadly, all too often women report that they feel \u0026lsquo;part of a conveyor belt\u0026rsquo; system and that their loss is not appropriately acknowledged by clinical care teams [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, lack in bereavement care and follow-up after EPL has been identified as unacceptable to women [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This paucity has been highlighted in the Pregnancy Loss Review (2023) which recommends that NICE guidance on pre-24-week pregnancy loss should be updated and embedded into clinical care pathways so that all women are offered mental health support, investigation, and consistency in standards of care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Further recommendations include establishing pregnancy-after-loss clinics in hospitals offering maternity care, staffed by specialist gynaecology nurses and/or midwives and led by a consultant [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eNeed for research\u003c/h2\u003e \u003cp\u003eIn the UK, huge variation in service provision exists for women affected by EPL [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Many hospitals do not have standardised EPL care pathways with most services signposting to outside organisations for counselling and support [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There is very little guidance on what hospital-based follow-up support services should look like, and how these can be implemented and embedded into current care provision to meet the needs of women who experience EPL. The delivery of EPL care is considered important but has not been rigorously evaluated [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis service evaluation (SE) gathered both quantitative and qualitative data to assess the value of a locally implemented Early Pregnancy Loss Support Clinic (EPLSC). The aim of this SE was to assess if an EPLSC was important to women and to identify potential areas for improvement [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eService evaluation\u003c/h2\u003e \u003cp\u003eInitiated and led by a consultant specialising in early pregnancy care, this project took place for one year from February 2023 to February 2024 and involved the evaluation of a newly implemented EPLSC in an inner-city Hospital Trust. A patient feedback questionnaire, anxiety scoring and semi-structured interviews to explore the experiences of women attending the EPLSC were used as evaluation tools.\u003c/p\u003e \u003cp\u003eAreas of specific focus included physical health, mental health, role of the bereavement midwife and the overall service user experience.\u003c/p\u003e \u003cp\u003eKey project objectives aim to-\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDetermine the number of women who attended the EPLSC between February 2023 to February 2024.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIdentify sociodemographic characteristics of the women accessing the EPLSC as well as the type of EPL.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIdentify the number of post miscarriage/ectopic complications diagnosed through the EPLSC.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAssess if the EPLSC provides early intervention for post miscarriage/ectopic complications by addressing physical and mental health issues.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEvaluate the importance of the EPLSC for supporting women in physical and psychological wellbeing.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAuthorisation process\u003c/h2\u003e \u003cp\u003e Authorisation for the project was sought from the Clinical Leadership Team and approved by the Business Unit Governance Team. As this is a service evaluation, the project did not require ethics approval.\u003c/p\u003e \u003cp\u003eHandling of data complied with the requirements of the Data Protection Act 2018 with regards to the collection, storage and processing and disclosure of personal information. All women who took part in the SE received information about the project and verbal or written informed consent was given by all women.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eQuantitative data were collected using the Short Assessment of Patient Satisfaction (SAPS) questionnaire [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and the Visual Anxiety Scale (VAS-A) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], both were administered to women attending the EPLSC, and scores were stored securely on an anonymised Excel spreadsheet, along with baseline data collected from Electronic Patient Records. It should be noted that the response rate for SAPS was initially low because women experienced problems accessing the QR code, this was subsequently changed to paper copies which improved response rates.\u003c/p\u003e \u003cp\u003eQualitative data were collected through semi-structured interviews and consisted of four pre-determined themes based on EPL literature [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] - physical health, mental health, role of the bereavement midwife and overall service user experience. Five women took part in interviews either online or face-to-face. Due to the sensitive nature of the topic, a bereavement midwife telephoned the women 24 hours after interview to check on psychological wellbeing.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eQuantitative data was summarised using descriptive statistics and qualitative data was analysed deductively using Framework analysis. The Framework method is generated towards policy and practice orientated findings and commonly used for the thematic analysis of semi-structured interview transcripts [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e][\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData was analysed from the four pre-defined themes and followed five steps of data management: familiarisation, constructing an initial thematic framework, indexing, and sorting, reviewing data extracts and data summary and display, followed by interpretation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e][\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The findings were discussed among the SE team at each stage of analysis and there were several iterations of this process before the final categories were developed and agreed by all authors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFindings\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative\u003c/h2\u003e \u003cp\u003eA total of 127 women were invited to the EPLSC between February 2023 and February 2024, with 110 (87%) attending, and 17 (13%) not attending their appointment. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the characteristics of the women who attended the EPLSC.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eCharacteristics of women who attended the EPLSC\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics of Women who Attended the EPLSC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;110 (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (44%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack (British, Caribbean, African)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian (British, South, Indian, Other)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite (British, Other)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (44%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed (White \u0026amp; Black Caribbean, White \u0026amp; Black African)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny Other Group (Other/ not Stated)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious Pregnancy Losses\u0026thinsp;\u0026lt;\u0026thinsp;14 weeks\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (49%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of Loss\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiscarriage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (65%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEctopic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eManagement Miscarriage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpectant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eManagement Ectopic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (70%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpectant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (15%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost EPL Complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 miscarriages\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGynae issues (fibroids, adenomyosis, endometrial polyps)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean scar niche\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental health (anxiety, struggling with emotions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (HCG levels high, medical issues)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Short Assessment of Patient Satisfaction (SAPS) questionnaire was completed by 56 (51%) of women who attended the EPLSC. Scores ranged between 21\u0026ndash;28 demonstrating that women were either satisfied or very satisfied with the care they received in the EPLSC.\u003c/p\u003e \u003cp\u003eThe Visual Anxiety Scale (VAS-A) was completed by 84 women (76%) pre and post EPLSC appointment. 76 (69%) of women reported a decrease in anxiety immediately after attending the EPLSC, compared to 8 (7%) who reported no change or a small increase in anxiety.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;2 shows the overall VAS-A scores for pre (319.9) and post (151) EPLSC clinic attendance highlighting a 47% decrease in anxiety scores.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eQualitative\u003c/h2\u003e \u003cp\u003e Five women who attended the EPLSC consented to interview, two face-to-face, and three via Microsoft Teams. Three women experienced miscarriage between 11\u0026ndash;13 weeks of pregnancy, and two-women, ectopic pregnancy.\u003c/p\u003e \u003cp\u003eThree categories pertaining to women\u0026rsquo;s experiences of attending the EPLSC were identified as fundamentally important-\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFuture Fertility\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEmotional Support\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBereavement Midwife\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003ePhysical health \u0026amp; future fertility\u003c/h2\u003e \u003cp\u003ePhysical health concerns such as recovery following EPL, recurring miscarriage/ectopic pregnancy and future fertility were commonplace in all women interviewed. However, the EPLSC helped to ameliorate some of these worries through discussions on future fertility and being offered an ultrasound scan (USS). All women who attended the EPLSC were offered USS with only 5% declining-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I felt very reassured about that [fertility] because before the [EPLSC] appointment I was worried about it taking years to get pregnant again (003)\u0026rsquo;. [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;It [ultrasound scan] was very helpful for two reasons a) confirmation of what\u0026rsquo;s happened, and b) you also get reassurance that your body is bouncing back, things are as they should be (002)\u0026rsquo; [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;This [menstrual] cycle in particular was a lot more delayed than I\u0026rsquo;m used to which caused me to worry a little bit but having that checked and told that everything looked fine, has helped put my mind at rest (001)\u0026rsquo; [Miscarriage].\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome women discussed how a lack of involvement from their GP, receiving conflicting information and not knowing how or when their IVF referral would take place created further anxiety-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;Receiving contradictory information from the GP on what you need to do before your referral can be sent off-it would really help knowing what the next steps are (002)\u0026rsquo; [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMental health \u0026amp; emotional support\u003c/h2\u003e \u003cp\u003eWomen described the emotional burden of EPL as particularly difficult. Variations in mood were linked to different timepoints in the EPL journey. Women reported feeling shocked, scared, and anxious at the point of their EPL diagnosis, while feelings of grief, trauma and isolation were reported in the weeks afterwards-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I always felt quite matter of fact [about EPL] but I was off work for a month in the end, just because it felt very difficult (003)\u0026rsquo; [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOne woman reported her feelings of grief partially attributed to the change in her body after salpingectomy-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;The grief from that [salpingectomy]\u0026hellip; I think actually hit later on. Then I started processing everything and not just the pregnancy loss but the change in my body (002)\u0026rsquo; [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe EPLSC was important to women as a safe space to discuss emotions and receive acknowledgement for their loss-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;It was the first time I was asked how I was feeling and the first time that I thought anybody cared about my miscarriage (004)\u0026rsquo; [Miscarriage].\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I think with an early miscarriage, people don\u0026rsquo;t talk about it very much and no one knew you were pregnant really, because you weren\u0026rsquo;t showing. So, I don\u0026rsquo;t think I would have had a clue where to turn [if it wasn\u0026rsquo;t for EPLSC] (005)\u0026rsquo; [Miscarriage].\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBereavement Midwife\u003c/h2\u003e \u003cp\u003eThe role of the Bereavement Midwife in relation to EPL care was considered important, especially as an easily accessible point of contact, and for future pregnancy concerns-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I do feel like in the future, if I had any worries or concerns, I would probably be more likely to get in touch with her [BM], rather than going to the GP or anybody else because I think I\u0026rsquo;ll be taken a little bit more seriously (001)\u0026rsquo; [Miscarriage].\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOne woman describes how earlier contact with the BM may have been helpful in the first few weeks following EPL-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I think I was given her [BM] details at the four-week follow-up rather than at discharge, but that\u0026rsquo;s the time [immediately after EPL] that most people would be off work recovering and sitting with their thoughts (002)\u0026rsquo; [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImprovement suggestions\u003c/h2\u003e \u003cp\u003eImprovements proposed by women who were interviewed included more information on fertility care pathways, better links with primary care services, and signposting to appropriate external resources-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;It would be really helpful knowing what next steps are [fertility] and given more information on the process, because that\u0026rsquo;s one of the most frustrating things I\u0026rsquo;ve had to deal with since\u0026rsquo; (002) [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDiscussing the risks and benefits when signposting women to EPL online resources for support is important because, as one woman explains, some online platforms can be counterproductive, and induce anxiety rather than relieve it-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;One of the things that was recommended was the Early Pregnancy Trust website, but the forums and the messages that were there may have been counterproductive because, when people are vocal about things and they post things on forums and stuff, it\u0026rsquo;s almost always worse case scenarios, and experiences rather than support (002)\u0026rsquo; [Ectopic].\u003c/em\u003e \u003c/p\u003e \u003cp\u003eProviding women with options on how to access the EPLSC, such as offering online or face-to-face appointments, was also felt to be important, depending on the woman\u0026rsquo;s preference and need-\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I went to the clinic in person, and I was happy to go in person, but it might be an idea to offer it online if it's not already. Because people experience miscarriages in different ways, and I was fine to go in and I had the support (004)\u0026rsquo; [Miscarriage].\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation Outcome\u003c/h2\u003e \u003cp\u003eThis SE assessed the quality of a newly implemented EPLSC in one London Trust. Evaluative feedback was obtained to determine women\u0026rsquo;s views on a new service. Key components of the EPLSC based on recommendations from the recent Pregnancy Loss Review (2023) focused on physical health, mental health and support from the bereavement midwife [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCharacteristics of women who attended the clinic included age, ethnicity, previous pregnancy loss, type of loss and management, and post EPL complications. Around 56% of women who attended the EPLSC were over 35 years old, 49% experienced their first EPL and 56% of women were non-white. This is concurrent with literature highlighting the increased risk of miscarriage in women from ethnic minority groups [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e][\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOut of 110 women, 36% (n\u0026thinsp;=\u0026thinsp;40) were confirmed to a have gynaecological condition in the EPLSC. Confirming gynae pathology during the EPLSC visit can help focus the consultation on pertinent issues that may impact fertility and help to ensure that appropriate referral pathways are initiated. Furthermore, offering women an USS as part of EPL care is a safe, minimally invasive and relatively quick to perform option, which can be useful in confirming issues such as endometriosis, fibroids, and other abnormalities of the uterus [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e][\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological sequalae, such as post-traumatic stress, anxiety and depression, are commonplace following EPL [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e][\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] with significant variation in emotional care follow-up [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Standardising follow-up EPL care may be important for supporting women emotionally and reducing the mental health burden associated with this event. A decrease in self- reported anxiety was found for 85% of women who attended the EPLSC and a further 8% disclosed struggling with their mental health. Identifying difficulties with mental health in women following EPL means that early intervention can be offered to help provide psychological support. However, further evaluation is needed in this area to fully understand the mental health needs of women following-EPL.\u003c/p\u003e \u003cp\u003eThe bereavement midwife role was considered important to women especially as an easily accessible point of contact and for future concerns in subsequent pregnancies. However, women raised concerns about the lack of involvement from their GP. Therefore, involving primary care services may be a crucial next step in developing integrated clinical care pathways, especially as, navigating EPL pathways can be confusing for women [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eKey findings from this SE have highlighted the importance of EPLSC. Recommendations for improvements and factors to consider when an implementing EPLSC include-\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eProvide information about EPL care at the time of loss, including EPLSC follow-up and contact details for bereavement midwife.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOffer a follow-up EPLSC appointment 3\u0026ndash;4 weeks after the first negative pregnancy test.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOffer ultrasound to all women to detect possible complications following post EPL or undiagnosed gynaecological conditions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProvide information on future fertility and next steps (if required).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDevelop services to include pathways for mental health referrals/support and GP involvement.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSignpost to appropriate outside agencies or/and online resources for further information/support.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConsider the needs of the local population groups to develop culturally sensitive EPL services.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOffer EPLSC appointments either face-to-face or online, depending on the women\u0026rsquo;s preference.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAn EPLSC which focuses on providing emotional support and reassurance, especially in relation to future fertility, is important to women. Further rigorous evaluation on national disparities in EPL follow-up is urgently needed to assess the gaps in clinical care delivery. Only then can standardised care pathways and further EPLSC implementation work be developed to address the physical and mental health needs of women following EPL.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEPU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly Pregnancy Unit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEPL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly Pregnancy Loss\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService Evaluation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEPLSC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly Pregnancy Loss Support Clinic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSAPS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShort Assessment of Patient Satisfaction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVAS-A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisual Anxiety Scale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePTSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost Traumatic Stress Disorder\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUK\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNICE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNational Institute for Health \u0026amp; Care Excellence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eQR Code\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuick Response Code\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUSS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound Scan\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eAuthorisation for the project was sought from the Clinical Leadership Team and approved by the Business Unit Governance Team. \u0026nbsp;Ethical approval was not required since participants are those who use the service and were therefore involved to help evaluate the service provided.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten consent was given by all women interviewed for their data to be used anonymously for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during this SE are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding received for this service evaluation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMA-Contribution to the design of service evaluation, qualitative data collection and analysis, and authorship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGG-Contribution to the design of the service evaluation and quantitative data collection and analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTA-Contribution to the quantitative data collection.\u003c/p\u003e\n\u003cp\u003eEK-Contribution to the design of the service evaluation.\u003c/p\u003e\n\u003cp\u003eMM-Substantial contribution to the conception and design of the service evaluation, and approved the submitted version, previous and modified versions of this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the interpretation of findings and reviewed previous drafts and approved current version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the women who attended the clinic and freely agreed to volunteer their time to complete the questionnaires and interviews. We would also like to thank the staff in the Early Pregnancy and Emergency Gynaecology Unit at the Royal Free Hospital for their support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eElson C, Salim J, Potdar R, Chetty N, Ross M, Kirk JA, E., J on behalf of the Royal College of Obstetricians and Gynaecologists. (2016) Diagnosis and management of ectopic pregnancy. BJOG 2016 RCOG Diagnosis and Management of Ectopic Pregnancy. Green-top Guideline No. 21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/guidance/ng126/resources/ectopic-pregnancy-and-miscarriage-diagnosis-and-initial-management-pdf-66141662244037\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/guidance/ng126/resources/ectopic-pregnancy-and-miscarriage-diagnosis-and-initial-management-pdf-66141662244037\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE. Ectopic pregnancy and miscarriage: diagnosis and initial management, NG 126. 2019 [Last updated: August 2023]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/guidance/ng126\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/guidance/ng126\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Health \u0026amp; Social Care. Government response to the independent Pregnancy Loss Review: care and support when baby loss occurs before 24 weeks' gestation. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/government/publications/government-response-to-the-independent-pregnancy-loss-review/government-response-to-the-independent-pregnancy-loss-review-care-and-support-when-baby-loss-occurs-before-24-weeks-gestation\u003c/span\u003e\u003cspan address=\"https://www.gov.uk/government/publications/government-response-to-the-independent-pregnancy-loss-review/government-response-to-the-independent-pregnancy-loss-review-care-and-support-when-baby-loss-occurs-before-24-weeks-gestation\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImproving Quality. A review of support available for loss in early and late pregnancy. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Available-Support-for-Pregnancy-Loss.pdf\u003c/span\u003e\u003cspan address=\"https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Available-Support-for-Pregnancy-Loss.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang S, Liu J, Yang L, Li J, Tang J, Hong L. Global burden and trends of ectopic pregnancy: An observational trend study from 1990 to 2019. Plos One. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.plos.org/plosone/article?id=10.1371/journal.pone.0291316\u003c/span\u003e\u003cspan address=\"https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0291316\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorin A, Sideris M, Platts S, Palamrchuk T, Odejinmi F. To Fight or to Flee? A Systematic Review of Ectopic Pregnancy Management and Complications During the Covid-19 Pandemic. In vivo. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21873/invivo.12867\u003c/span\u003e\u003cspan address=\"10.21873/invivo.12867\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuenby S, Gallos D, Dhillon-Smith I, Podesk RK, Stephenson M, Fisher MD, Brosens J. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(21)00682-6\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(21)00682-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarren J, Mitchell-Jones N et al. The Psychological Impact of Early Pregnancy Loss. Human Reproduction Update. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://spiral.imperial.ac.uk/handle/10044/1/62886\u003c/span\u003e\u003cspan address=\"https://spiral.imperial.ac.uk/handle/10044/1/62886\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed; December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo L, Hernandez A, Robb J, Zeszutek M, Luong S, Okada S, Kumar E. K Spontaneous Miscarr Manage Experience: Syst Rev Cureus. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.24269\u003c/span\u003e\u003cspan address=\"10.7759/cureus.24269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarbe C, Boiteaux-Chabrier M, Charillon E, Bouazzi L, Maheas C, Merabet F et al. Utility of early, short psychological care for women who experience early miscarriage: protocol for the randomized, controlled MisTher trial. BMC Psychology. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s40359-023-01421-x\u003c/span\u003e\u003cspan address=\"10.1186/s40359-023-01421-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCuenca D. Pregnancy loss: Consequences for mental health. Frontiers in Women\u0026rsquo;s Global Health. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fgwh.2022.1032212\u003c/span\u003e\u003cspan address=\"10.3389/fgwh.2022.1032212\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBellhouse C, Temple-Smith M, Bilardi J. J, E. It\u0026rsquo;s just one of those things people don\u0026rsquo;t seem to talk about.. women\u0026rsquo;s experiences of social support following miscarriage: a qualitative study. BMC Women\u0026rsquo;s Health. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12905-018-0672-3\u003c/span\u003e\u003cspan address=\"10.1186/s12905-018-0672-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpillane N, Meaney S, O\u0026rsquo;Donoghue K. Irish women\u0026rsquo;s experience of Ectopic pregnancy. Sexual \u0026amp; Reproductive Healthcare. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.srhc.2018.04.002\u003c/span\u003e\u003cspan address=\"10.1016/j.srhc.2018.04.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCarthy F, Moss-Morris P, Khashan R, North AS, Baker RA, Dekker PN, Poston G. Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy. BJOG. 2015. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1471-0528.13233\u003c/span\u003e\u003cspan address=\"10.1111/1471-0528.13233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchliep K, Mitchell C, Mumford EM, Radin SL, Zarek RG, Sjaarda SM. Schisterman, E, F. Trying to Conceive After an Early Pregnancy Loss: An Assessment on How Long Couples Should Wait. Obstet Gynecol. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0000000000001159\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0000000000001159\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampillo I, Meaney SL, McNamara S, O\u0026rsquo;Donoghue K. Psychological and support interventions to reduce levels of stress, anxiety or depression on women\u0026rsquo;s subsequent pregnancy with a history of miscarriage: an empty systematic review. BMJ Open. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2017-017802\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2017-017802\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, et al. Saving Lives, Improving Mothers\u0026rsquo; Care Core report: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2022. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith L, Frost F, Levitas J, Bradley R, Garcia H. Women\u0026rsquo;s experiences of three early miscarriage management options a qualitative study. Br J Gen Pract. 2006;56(524):198\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark-Coates Z, Collinge S. The Independent Pregnancy Loss Review - Care and support when baby loss occurs before 24 weeks gestation. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1172354/Pregnancy-Loss-Review-print-ready.pdf\u003c/span\u003e\u003cspan address=\"https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1172354/Pregnancy-Loss-Review-print-ready.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBest Practice in the Ethics and Governance of Service Evaluation. Guidelines for evaluators and commissioners of evaluation in health and social care. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://arc-w.nihr.ac.uk/Wordpress/wp-content/uploads/2021/02/Full-ethics-guidelines-revised-Nov-2020.pdf\u003c/span\u003e\u003cspan address=\"https://arc-w.nihr.ac.uk/Wordpress/wp-content/uploads/2021/02/Full-ethics-guidelines-revised-Nov-2020.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawthorne G, Sansoni, Hayes L, Marosszeky N, Sansoni E. Measuring patient satisfaction with health care treatment using the Short Assessment of Patient Satisfaction measure delivered superior and robust satisfaction estimates. J Clin Epidemiol. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jclinepi.2013.12.010\u003c/span\u003e\u003cspan address=\"10.1016/j.jclinepi.2013.12.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtkin R. C. Measurement of feelings using visual analogue scales. Proceedings of the Royal Society of Medicine. 1969 62 (10) 989\u0026thinsp;\u0026ndash;\u0026thinsp;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/4899510/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/4899510/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen J, Thorogood N. Qualitative Methods for Heath Research. 4th Edition. Sage. London. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGale N, Heath K, Cameron G, Rashid E, Redwood S. S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013. 1471\u0026ndash;2288 (13) 117.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaldwin S, Bick D. Using framework analysis in health visiting research: Exploring first-time fathers\u0026rsquo; mental health and wellbeing. J Health Visiting. 2021. 206\u0026ndash;13 (9) 5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Lancet. Miscarriage: worldwide reform of care is needed. EDITORIAL| VOLUME 397, 10285 ISSUE. P1597. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(21)00954-5\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(21)00954-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukherjee S, Edwards D, Baird RV. Risk of miscarriage among black women and white women in a U.S. Prospective Cohort Study. Am J Epidemiol. 2013. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/aje/kws393\u003c/span\u003e\u003cspan address=\"10.1093/aje/kws393\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBean E, Chagger P, Thanatsis N, Dooley W, Bottomley C, Jurkovic D. Intra- and interobserver reproducibility of pelvic ultrasound for the detection and measurement of endometriotic lesions. Hum Reprod Open. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/hropen/hoaa001\u003c/span\u003e\u003cspan address=\"10.1093/hropen/hoaa001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE. (2022) Fibroids. Clinical Knowledge Summaries. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cks.nice.org.uk/topics/fibroids/NHS\u003c/span\u003e\u003cspan address=\"https://cks.nice.org.uk/topics/fibroids/NHS\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarren J, Jalmbrant M, Falconieri N et al. (2019) Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. AJOG. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ajog.2019.10.102\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2019.10.102\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. [Accessed: December 2023].\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Early pregnancy loss, miscarriage, ectopic pregnancy, bereavement","lastPublishedDoi":"10.21203/rs.3.rs-3963399/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3963399/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEarly pregnancy loss (EPL) can have profound implications for physical and psychological health. In the UK, huge variation in service provision exists for women affected by EPL. There is very little guidance on what hospital-based follow-up support services should look like, and how these can be implemented and embedded into current care provision to meet the needs of women who experience EPL. \u0026nbsp;This service evaluation (SE) reports on a newly implemented Early Pregnancy Loss Support Clinic (EPLSC) in an inner-city Hospital Trust.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This SE gathered both quantitative and qualitative data to assess the value of a locally implemented Early Pregnancy Loss Support Clinic (EPLSC). Quantitative data were collected using the Short Assessment of Patient Satisfaction (SAPS) questionnaire and the Visual Anxiety Scale (VAS-A), both were administered to women attending the EPLSC. Qualitative data were collected through semi-structured interviews and consisted of four pre-determined themes based on EPL literature - physical health, mental health, role of the bereavement midwife and overall service user experience. Quantitative data was summarised using descriptive statistics and qualitative data was analysed deductively using Framework analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 127 women were invited to the EPLSC, with 110 (87%) attending, and 17 (13%) not attending their appointment. SAPS scores ranged between 21-28 demonstrating that women were either satisfied or very satisfied with the care they received in the EPLSC. Results from VAS-A scores found that 76 (69%) of women reported a decrease in anxiety immediately after attending the EPLSC, compared to 8 (7%) who reported no change or a small increase in anxiety. Qualitative results revealed women’s concerns around future fertility, the importance of emotional support and the value of connecting with the bereavement midwife.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e An EPLSC which focuses on providing emotional support and reassurance, especially in relation to future fertility, is important to women. Further rigorous evaluation on national disparities in EPL follow-up is urgently needed to assess the gaps in clinical care delivery.\u003c/p\u003e","manuscriptTitle":"Service Evaluation of an Early Pregnancy Loss Support Clinic in a London EPU","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-14 20:07:40","doi":"10.21203/rs.3.rs-3963399/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-12T12:23:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-12T08:56:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-12T08:56:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-02-17T07:17:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1fa281ad-382c-435f-bf01-16a99818a709","owner":[],"postedDate":"March 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T16:31:05+00:00","versionOfRecord":{"articleIdentity":"rs-3963399","link":"https://doi.org/10.1186/s12913-024-11750-1","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-11-01 16:22:41","publishedOnDateReadable":"November 1st, 2024"},"versionCreatedAt":"2024-03-14 20:07:40","video":"","vorDoi":"10.1186/s12913-024-11750-1","vorDoiUrl":"https://doi.org/10.1186/s12913-024-11750-1","workflowStages":[]},"version":"v1","identity":"rs-3963399","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3963399","identity":"rs-3963399","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}