Individualized Supportive Care for Patients with Recurrent Pregnancy Loss: A Prospective Survey Study Addressing Preferences and Providing Personalized Support

Individualized Supportive Care for Patients with Recurrent Pregnancy Loss: A Prospective Survey Study Addressing Preferences and Providing Personalized Support | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 9 January 2025 V1 Latest version Share on Individualized Supportive Care for Patients with Recurrent Pregnancy Loss: A Prospective Survey Study Addressing Preferences and Providing Personalized Support Authors : S. Chiba , R. Athurupana 0000-0002-7796-6781 , T. Yang , S. Liu , A. Yokomizo , and M. Nakatsuka [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.173640884.45658289/v1 254 views 132 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To understand the specific contents of supportive care (SC) preferred by patients with recurrent pregnancy loss (RPL) and their satisfaction level with what they have experienced. Design : A Prospective Survey Study Setting and Population : Patients with RPL who visited the outpatient clinics located at two hospitals in Hiroshima and Okayama, Japan from June to September 2019. Method: Awareness of SC, preferences, experience, and the level of satisfaction regarding 26 SC options, the number of doctors consulted and the frequency of ultrasound examinations were assessed. Main Outcome Measures : Self-reported experience of care around the time of pregnancy loss. Results: Responses from 142 participants were analyzed, and less than 10.0% of them were aware of SC. Patients with RPL preferred their partners (99.3%) and mothers (44.8%) as their primary sources of support. The majority preferred to consult with one doctor (43%) and have a weekly ultrasound examination (54.9%). Doctors (85.9%) and nurses (82.4%) were the preferred medical staff. Six categories of supportive care were identified, with preference rates of 60.0% or higher, but the experience rates were 47.0% or lower. Conclusion: The study emphasizes the importance of tailor-made care, addressing the specific needs and desires of each patient rather than providing routine care specifically in the early stages of their subsequent pregnancies. 1 Introduction Pregnancy loss refers to the spontaneous demise of a pregnancy before viability and affects approximately 15 to 25% of clinically recognized pregnancies [1,2]. Recurrent pregnancy loss (RPL) is defined as the spontaneous loss of two or more pregnancies [3]. Abnormal metabolic and endocrine disorders, inherited thrombophilias, immune factors, anatomical factors and chromosomal abnormalities are considered the major causes of RPL. However, more than 50% of patients with RPL have no identified etiology, and effective medical treatment is currently lacking [2,4,5]. It is known that patients who have miscarriages or stillbirths are more likely to have heightened anger along with grief and guilt, leading to anxiety and/or depression [2,6]. Consequently, providing mental support is crucial to alleviate anxiety and fear related to future pregnancies. Supportive care (SC), occasionally referred to as ‘tender loving care’ is being implemented in RPL treatments to address these needs [7]. The word SC is used throughout the article to maintain consistency. SC involves providing sympathetic treatments and psychological support to patients experiencing RPL. According to the ASRM guidelines [2], SC defines as a combination of weekly medical and ultrasonographic examinations, along with instructions to avoid heavy work, travel, and sexual activity. The effectiveness of SC in improving pregnancy outcomes has been reported in studies by Stray-Pedersen and Stray-Pedersen and Liddell et al., showing significantly higher birth rates in the SC group (86%) compared to those who did not receive SC (33%) [8,9]. Clifford et al. also found a higher pregnancy continuation rate of 73.8% in patients with unexplained RPL who underwent medical examinations until the 12th week of pregnancy at a specialized clinic for early pregnancy care [10]. Despite its effectiveness on pregnancy continuation not being fully proven, several societies, including RCOG and ESHRE, recommend provision of SC for patients with RPL as it important for maternal heath, to address rising rates of anxiety and depression, and for maternal bonding with future or current children [5,1]. SC for patients with RPL lacks a defined concept and treatment protocol. The specific preferences of patients with RPL for such care are still unclear, emphasizing the need for research and patient-centered approaches. This study aimed to investigate the preferences, experiences, and satisfaction levels of patients with RPL regarding SC, including the number of doctors consulted and the frequency of ultrasound examinations. 2 Material and Methods 2.1. Participants The survey involved all the patients (n=146) who received RPL treatment at 2 outpatient clinics in Okayama and Hiroshima prefectures, Japan, during June-September 2019. All of them have a history of pregnancy loss and 79/142 (55.6%) were pregnant during the study period. 2.2. Survey design A self-administered questionnaire was distributed to all the patients (n=146) who visited the studied clinics during the above-mentioned period. Filled questionnaires posted in the collection box were considered as consent. 2.3. Data collection through questionnaires The questionnaire, based on previous publications [11,12] and developed by the authors, comprised three sections. The first section includes basic information [age, marital status, pregnancy status (past and present pregnancies, number of miscarriages, cause of miscarriage, stillbirths and live births), past and present treatments, preferred person to get support during treatment (family members and medical staff)]. The cause of miscarriage was further divided into anti-phospholipid antibody (APA)-positive (lupus anticoagulant, anti-cardiolipin antibodies IgG and IgM, anti-cardiolipin β2 glycoprotein I IgG as aCLβ2GPI, and anti-phosphatidylethanolamine and anti-phosphatidylserine as an optional measurement), blood coagulation abnormality (including protein S deficiency), thyroid abnormality, uterine abnormality, chromosomal abnormality, under examination and unexplained. The second section assessed the preferred number of consulted doctors (1/2/3 or more) and satisfaction level, as well as the preferred frequency of ultrasound examinations (once per; 1-3 days/a week/2 weeks/4 weeks, during pregnancy check-up and symptom-based) and the satisfaction level. The third part of the questionnaire assessed 26 supportive care options in 6 categories, focusing on the perspectives and preferences of patients with RPL. Participants were asked about their experiences and satisfaction level with the medical facility environment and staff. Answers were further divided into ‘necessary? (yes/no), experienced? (yes/no), and the level of satisfaction (satisfied/somewhat satisfied/somewhat dissatisfied/dissatisfied)’. Additionally, an open-ended question allowed participants to express their likes, dislikes, and expectations regarding the medical facility and staff. 2.4. Statistical analysis The chi-squared test was performed using SPSS Ver. 23, and a P value the case of a comparison between groups, nonresponses were excluded. 3 Results 3.1. Background of the subjects From distributed questionnaires, 144 were returned, giving a collection rate of 98.6% (144/146). Of these, 142 questionnaires were included in the analysis (valid response rate 98.6%) after excluding those with incomplete responses. The age of the subjects was 35.8 ± 5.0 [24-46] (mean ± S.D. [range]) (Table 1). The number of miscarriages/stillbirths in the past was 3.0 ± 1.7 [1-12] times, and the length of hospital visits for RPL treatments was 22.6 ± 25.6 [0-144] months. Among the study group, the main causes of RPL were ”APA positive” (37.3%), ”blood coagulation abnormality including protein factors” (27.5%), ”under examination” (24.6%), ”unexplained” (21.1%), ”thyroid abnormality” (12.0%), uterine abnormality (4.2%) and chromosomal abnormality (3.5%). 3.2. Preferred person to receive support during the next pregnancy The majority of patients [(99.3%, (135/136)] preferred their partners as their primary source of support during RPL treatment. Mothers and elder sisters were also preferred by a significant number of patients (44.8% and 18.2%, respectively). Medical staff preferences were highest for doctors (85.9%) and nurses (82.4%), followed by psychologists (49.2%) and midwives (35.2%). 3.3 Awareness of SC Only 2.8% of respondents were aware of the content of ”supportive care or tender-loving care,” while 5.6% had heard about it. The majority (83.1%) were not familiar with the term, and 8.5% did not answer. 3.4. Number of doctors consulted in early pregnancy The majority of patients with RPL (43.0%) preferred to consult with one doctor during the early stages of pregnancy (Table 2). Additionally, 28.9% preferred two doctors, and 5.6% preferred three or more doctors. However, during their recent treatments, 40.1% of patients were consulted by one doctor, 26.8% by two doctors, and 26.1% by three or more doctors. Regarding satisfaction levels, 77.5% of patients with RPL expressed satisfaction or partial satisfaction with the number of doctors consulted during the early stage of their latest pregnancy. A higher percentage of patients were fully or partially satisfied with one doctor (86.0%) than with two doctors (84.2%) or three or more doctors (78.3%). Significant difference in satisfaction levels was observed between the group consulted by a single doctor and those consulted by two, three or more doctors (for participants who preferred one doctor, P <0.05). Additionally, significant difference was noted between the group consulted by two doctors and the group consulted by more than three doctors (for participants who preferred two doctors, P <0.05). 3.5. Frequency of ultrasound examination during early pregnancy The majority of patients with RPL preferred (53.5%) and received (55.6%) weekly ultrasound examinations in the early stages of pregnancy (Table 3). Regarding the frequency of ultrasound examinations received, the majority of them (65.4%) were satisfied or somewhat satisfied. When comparing the preferred and received frequencies, satisfaction was significantly higher (56.7%) when they received ultrasound examinations once a week, as preferred, compared to once every two weeks (P80.0%) of patients with RPL (Figure 1). However, emotional support and psychological care had the lowest preference rate (61.7%) and experience rate (16.5%), while all 6 categories had preference rates of 60.0% or higher and an experience rate of 47.0% or less. More than 70.0% of the patients with RPL preferred 14 out of 26 options for SC, while 2 options were not considered necessary by more than half of them (Table S1). The highest satisfaction rates were for options that included ‘an environment for asking questions freely’ and ‘support for the baby’s growth’. From RPL patients, 39.4% considered ’avoid staying with other pregnant patients in the waiting room’ is necessary and 36.6% considered ’hospitalization around the same week of last miscarriage’ is necessary, and the experience rate for these options was relatively low (15.5% and 9.9%, respectively). 3.6.1 Information, education and planning The majority of patients with RPL (>95.0%) preferred explanations about pregnancy, examinations and treatments (Table S1). Approximately 60.0% experienced these care options and expressed satisfaction. Hospitalization around the same week of the last miscarriage was considered necessary by a few (36.6%), with a low experience rate (9.9%), and 71.4% of them were satisfied or somewhat satisfied. 3.6.2 Guidance and advice Most patients with RPL (88.0%) considered ’Lifestyle advice’ necessary, but only 37.3% had experienced it. The highest satisfaction was gained with ’guidance regarding quitting smoking and drinking’ (65.8%, Table S1). 3.6.3 Friendly atmosphere Most patients with RPL preferred ’An environment where you can ask questions freely’ (95.8%) and ’an atmosphere where you feel free to talk about anxiety and worries’ (89.4%, Table S1). However, only 42.3% and 30.3% of them experienced it, satisfaction levels were 57.0% and 58.0% respectively. 3.6.4 Testing The most desired option was ’do sufficient tests to find the cause of RPL’ (97.2%), with an experience rate of 61.3% and a satisfaction rate of 82.3% (Table S1). Testing was the highly preferred (81.9%) and largely experienced (47.0%) category compared to others. 3.6.5 Sensitivity and empathy Only 39.4% of patients with RPL considered avoiding other pregnant patients in the waiting room necessary (Table S1). Few experienced this option (15.5%), but 81.8% of them were satisfied. 3.6.6 Emotional support and psychological care The preferred care option in this category was ’spend time to listen to anxieties and worries’ (81.7%, Table S1). However, the experience rate was low (17.6%), with 64.0% satisfaction. 3.6.7 Preference for SC based on the number of miscarriages/stillbirths Patients with 4 or more miscarriages/stillbirths showed a significantly high preference rate for care options that fall under the categories ‘information, education and planning’, ‘sensitivity and empathy’ and ‘emotional support and psychological care’ (Table S2). They showed a significantly higher preference rate for ‘hospitalization around the same week of the last miscarriage’ (59.4% vs, 26.8% P<0.01), ‘avoid other pregnant patients in the hospital waiting room’ (64.7% vs 30.4%, P<0.01), ‘understanding the situation and feelings of the family (81.8% vs 56.4%, P<0.05) and ’think together about ways to relieve stress and relax’ (82.4% vs 61.8%, P<0.05) compared to the patients with 2 miscarriages/stillbirths. 3.7. Answers to open ended question In addition to the SC options provided in the questionnaire, patients with RPL expressed preferences for other types of SC, which primarily fell under five main concerns. These groups include ultrasound examinations (Access to ultrasound examination whenever the patient feels anxious, clear and visible pictures, show the monitor while examining, a lot of pictures of the baby), information (regarding child’s development and associated risks, pre-mom classes), treatments (lead to a progress without repeating the same treatment), instructions (give clear instruction to follow during an emergency, precautions to take during early stages) and the manner of responding (casually, clearly, gently, slowly, quietly and respond with a smile). 4 Discussion 4.1 Main findings The study revealed that while patients with RPL exhibited diverse preferences, they consistently prioritized a friendly environment, open communication for asking questions, addressing individual concerns, and comprehensive testing to identify potential causes. However, there was a notable gap between these preferences and their actual experiences, highlighting unmet needs in patient care. Patients expressed a strong desire for enhanced emotional support, underscoring an opportunity to improve care by acknowledging and addressing individual preferences. Tailoring patient care to focus on these personalized needs could significantly enhance the overall patient experience and satisfaction. 4.2 Strengths and Limitations The study’s strengths include its large sample size and an exceptionally high response rate of 98.6%, ensuring robust data collection and reliability. However, a significant limitation is the absence of a couple-oriented approach, as the questionnaires were exclusively completed by female participants, excluding the perspectives of male partners. Additionally, certain measures in the study may have been influenced by subjectivity, as they relied on self-reported data, which can introduce bias or variability in responses. 4.3 Interpretation Patients with RPL placed high importance on the involvement of their significant other during treatment, emphasizing the partner’s critical role in the process. Joint clinic visits as a couple were recommended, as partners often experience emotional distress or encounter challenges in providing adequate support to their counterparts [13]. Couple-based psychological care emerged as a key factor for promoting emotional adjustment and improving outcomes in future pregnancies [14]. Notably, cultural differences were observed in support preferences. Japanese patients predominantly relied on family members, doctors, and nurses for support, in contrast to Dutch patients, who showed a preference for seeking support from friends and social workers [11]. The findings showed that 83.0% of patients were unaware of supportive care (SC), indicating a significant awareness gap. Educating patients about SC is essential, as it enables them to seek appropriate treatments. Targeted interventions like workshops and seminars, along with raising awareness among medical staff, can improve communication and adoption. Key steps include patient education, clear communication, personalized care plans, outlining benefits and limitations, regular updates, and collaborative decision-making. Most patients preferred consulting 1 to 2 doctors during early pregnancy. Continuity with one doctor supports better follow-up, while a second doctor can provide additional insights. Familiarity with SC is crucial when multiple doctors are involved to ensure consistency. Patient satisfaction can be enhanced by listening to their preferences, understanding their medical history, and conducting exams that align with their goals [15]. Negative experiences with healthcare providers, such as inadequate information, poor follow-up, insensitivity, dismissive attitudes, dishonesty, and carelessness, emphasize the need for compassionate, thorough, and transparent care [16]. The majority of patients with RPL referred weekly ultrasound examinations during early pregnancy, which was linked to high satisfaction. For patients with bleeding or those at high risk for RPL, more frequent ultrasound examinations may be recommended. For asymptomatic patients, reassurance that weekly ultrasounds are sufficient should be provided in a calm, evidence-based manner to build confidence in the approach. If this does not alleviate anxiety, an alternative plan may be considered, such as scheduling counseling sessions to address the patient’s concerns or increasing the frequency of ultrasounds to every 3–4 days for additional reassurance. More than 50% of patients with RPL identified 23 out of 26 care options as necessary, highlighting the diverse and comprehensive needs of this population. However, only four of these options were experienced by over half of the patients, emphasizing the need to better address individual preferences. Emotional support, psychological care, and sensitivity in patient interactions are crucial. It is important to recognize that not all patients with RPL want the same level or type of care. This variability calls for customized treatment plans that align with individual preferences, improving both the effectiveness and satisfaction of SC. Patients with a history of four or more miscarriages often prefer to avoid contact with other pregnant patients and hospitalization during the same week as their last miscarriage, reflecting the emotional challenges they face. Patients with RPL frequently experience heightened stress, anxiety, and depression [17,18], as well as grief, the pressure to conceive, and difficulty coping with the psychological toll of another pregnancy loss [19]. To support these patients, healthcare providers can offer flexible scheduling, separate waiting areas (for those who request them), telehealth appointments, and access to counseling or support groups. These strategies create a safe, supportive space where patients can express emotions, share experiences, and receive coping guidance, ultimately helping them navigate the emotional challenges of RPL in a more personalized and comfortable manner. Understanding the cause of RPL and providing comprehensive testing is essential for these patients. Couples experiencing multiple losses need information about RPL causes, treatment success rates, and early access to diagnostics and treatment, as every loss matter. Recognizing the complexity of each couple’s journey with RPL is crucial. Offering thorough testing, accurate information, realistic treatment success rates, early diagnostics, and compassionate support can enhance both their experience and outcomes. The psychological impacts of RPL can persist for over a year [18]. While counseling by medical staff is preferred, it is often lacking due to insufficient training in emotional support [20]. Timely listening, consultation with psychologists, and a team-based approach with effective communication are crucial [21]. Integrating mental health services, offering coping resources like relaxation techniques or mindfulness practices, and adopting a holistic approach can effectively manage emotional well-being. There is a clear need to improve the implementation of SC for patients with RPL. Medical staff must understand individual care preferences and satisfaction levels. Future research should focus on the impact of personalized SC, including frequent ultrasound examinations and the preferred number of doctors, on successful pregnancy outcomes. Additionally, creating a clinically applicable list of SC options would ensure patients receive tailored care according to their preferences. 5 Conclusions Patients with RPL highly value individualized care plans that prioritize emotional support, psychological care, sensitivity, and empathy. Most patients prefer a single doctor and regular, weekly ultrasound exams to monitor progress. An individualized approach that considers each patient’s unique background, needs, and preferences, particularly during the first trimester of subsequent pregnancies, is crucial. An individualized approach to address these factors is essential for improving both emotional well-being and pregnancy outcomes. Author Contributions MN and SC contributed to the concept and design of the study. SC collected the data through questionnaires. SC and RA were responsible for the literature search and drafting the manuscript. SC, RA, TY, SL, AY and MN contributed to the interpretation of data and analysis. All the authors have read, revised critically and approved the final version of the paper. Acknowledgments We extend our heartfelt gratitude to all the patients who generously participated in this study. Ethics Statement This study was conducted with the approval of the ethics committee of the Graduate School of Health Sciences, Okayama University (Reference number: M18-07). The purpose and the nature of the study was explained verbally and provided in written. Filled questionnaires posted in the collection box was considered as the consent. Conflicts of Interest The authors declare no conflicts of interests. Data Availability Statement All data generated or analyzed during this study are included in this published article and its supplementary information files. References 1. Atik RB, Christiansen OB, Elson J, Kolte AM, Lewis S, Middeldorp S, Nelen W, Peramo B, Quenby S, Vermeulen N, Goddijn M. ESHRE guideline: recurrent pregnancy loss. Hum Reprod Open. 2018;1-12. 2. Practice Committee of the American Society for Reproductive Medicine (ASRM). Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril. 2012; 98 : 1103–1111. 3. Practice Committee of the American Society for Reproductive Medicine (ASRM). Definition of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril. 2020;113:533-535. 4. Dimitriadis E, Menkhorst E, Saito S, Kutteh WH, Brosens JJ. Recurrent pregnancy loss. Nat Rev Dis Primers. 2020;6:98. 5. Royal College of Obstetricians and Gynecologists (RCOG), Scientific Advisory Committee, Guidelines No. 17. The Investigation and treatment of couples with recurrent miscarriage, 2011. 6. Hunter A, Tussis L, MacBeth A. The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: A meta-analysis. J Affect Disord. 2017;223:153-164. 7. Stray-Pedersen B, Stray-Pedersen S. Recurrent abortion: the role of psychotherapy. In: Beard RW, Ship F, editors. Early pregnancy loss: mechanisms and treatment. New York: Springer-Verlag; 1988:433–40. 8. Stray-Pedersen B，Stray-Pedersen S. Etiologic factors and subsequent reproductive performance in 195 couples with a prior history of habitual abortion. Am. J. Obstet. Gynecol. 1984;148:140-146. 9. Liddell HS, Pattison NS, Zanderigo A. Recurrent miscarriage – outcome after supportive care in early pregnancy. Aust NZJ Obstet Gynecol. 1991; 31: 320–322. 10. Clifford K, Rai R, Regan L. Future pregnancy outcome in unexplained recurrent first trimester miscarriage. Hum Reprod. 1997;12:387-389． 11. Musters AM, Taminiau-Bloem EF, van den Boogaard E, van der Veen F, Goddijn M. Supportive care for women with unexplained recurrent miscarriage: patients’ perspectives. Hum Reprod. 2011;26:873-877． 12. Musters AM, Koot YEM, van den Boogaard NM, Kaaijk E, Macklon NS, van der Veen F, Nieuwkerk PT, Goddijn M. Supportive care for women with recurrent miscarriage: a survey to quantify women’s preferences. Hum Reprod. 2013;28:398-405. 13. Ishikawa M. What a midwife can do for recurrent miscarriage patients and their families-Practice report ①; Mental support in the recurrent pregnancy loss outpatient and in the ward. The Japanese journal of Midwives. 2012;66:824-827 (In Japanese). 14. Kagami M, Maruyama T, Koizumi T, Miyazaki K, Nishikawa-Uchida S, Oda H, et al. Psychological adjustment and psychosocial stress among Japanese couples with a history of recurrent pregnancy loss. Hum Reprod. 2012;27:787-94. 15. Jauniaux E, Farquharson RG, Christiansen OB, Exalto N. Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage. Hum Reprod. 2006;21:2216–2222. 16. Bellhouse C, Temple-Smith M, Watson S, Bilardi J. ”The loss was traumatic… some healthcare providers added to that”: Women’s experiences of miscarriage. Women Birth. 2019;32:137-146. 17. Hada K, Kuse E, Nakatsuka M. Women with recurrent pregnancy loss: Their psychology during late pregnancy and the supportive behavior of their partners. Acta Medica Okayama. 2018;72(4):387-394. 18. He L, Wang T, Xu H, Chen C, Liu Z, Kang X, Zhao A. Prevalence of depression and anxiety in women with recurrent pregnancy loss and the associated risk factors. Arch Gynecol Obstet. 2019;300:1061-1066. 19. Koert E, Malling GMH, Sylvest R, Krog MC, Kolte AM, Schmidt L, Nielsen HS. Recurrent pregnancy loss: couples’ perspectives on their need for treatment, support and follow up. Hum Reprod. 2011;34:291–296. 20. Jensen KLB, Temple-Smith MJ, Bilardi JE. Health professionals’ roles and practices in supporting women experiencing miscarriage: A qualitative study. Aust NZJ Obstet Gynecol. 2019;59:508-513. 21. Nakatsuka M. Basic knowledge of recurrent miscarriage and points of patient support. Strengthening clinical midwifery care skills. 2013;5:52-55 (In Japanese). Supplementary Material File (figure 1.docx) Download 63.66 KB File (table 1.docx) Download 14.85 KB File (table 2.docx) Download 16.25 KB File (table 3.docx) Download 16.61 KB File (table s1.docx) Download 30.29 KB File (table s2.docx) Download 23.30 KB Information & Authors Information Version history V1 Version 1 09 January 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords early pregnancy loss: diagnosis fertility and assisted reproduction miscarriage: recurrent psychology termination of pregnancy Authors Affiliations S. Chiba Okayama Daigaku Byoin View all articles by this author R. Athurupana 0000-0002-7796-6781 Okayama Daigaku Igakubu Hoken Gakka Daigakuin Hokengaku Kenkyuka View all articles by this author T. Yang Okayama Daigaku Daigakuin Ishiyakugaku Sogo Kenkyuka Igakubu Sogo Naika View all articles by this author S. Liu Hangzhou Normal University Department of Nursing View all articles by this author A. Yokomizo Kagawa Prefectural University of Health Sciences View all articles by this author M. Nakatsuka [email protected] Okayama Daigaku Byoin View all articles by this author Metrics & Citations Metrics Article Usage 254 views 132 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation S. Chiba, R. Athurupana, T. Yang, et al. Individualized Supportive Care for Patients with Recurrent Pregnancy Loss: A Prospective Survey Study Addressing Preferences and Providing Personalized Support. Authorea . 09 January 2025. DOI: https://doi.org/10.22541/au.173640884.45658289/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.173640884.45658289/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9ff54690fbd68e2e',t:'MTc3OTM4NDI3Ng=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();