International Journal of Nursing Studies 47 (2010) 534–541

Early miscarriage as ‘matter out of place’: An ethnographic study ofnursing practice in a hospital gynaecological unit

Fiona Murphy *, Susan Philpin

School of Health Science, Swansea University, United Kingdom

A R T I C L E I N F O

Article history:

Received 22 May 2009

Received in revised form 2 October 2009

Accepted 17 October 2009

Keywords:

Miscarriage

Ethnography

Transition

Pollution

Nursing

Gynaecology

A B S T R A C T

Background: Early miscarriage has been conceptualised as loss and bereavement where

nurses are urged to provide sympathetic, psychological care for women. However, the

reality of women’s experience is also about blood, ‘dirt’ and failure which are under

explored in the literature.

Objective: To explore the management and care of women having an early miscarriage

within a hospital setting.

Design: A qualitative, ethnographic study.

Setting: A gynaecological unit consisting of an early pregnancy clinic and two

gynaecological wards in a general hospital in an urban area of Wales, United Kingdom.

Participants: The first group was a purposive, volunteer sample of eight women who had

experienced an early miscarriage and were admitted to hospital for active management of

their miscarriage. The second was a purposive, volunteer sample of 16 hospital health

professionals actively involved in the care of women having an early miscarriage. This

included 10 nurses, three doctors and three ultrasonographers.

Methods: Three main methods were employed. Firstly, 20 months participant observation

working alongside gynaecological nurses in a gynaecological unit. Secondly, documentary

analysis of key documents such as nursing care plans. Finally, in-depth interviews with

women who had experienced early miscarriage and hospital health professionals involved

in their care.

Results: Three key categories emerged; ‘first signs and confirmation’, ‘losing the baby’ and

‘the aftermath’. ‘First signs’ relates to the women’s experiences when first realising that

their pregnancy is under threat. ‘Losing the baby’ further explores women’s accounts of

their experience and the ‘aftermath’ relates to the long term impact of miscarriage on them

and their lives. This paper focuses on the women’s experiences of the physical

manifestations of miscarriage in ‘losing the baby’. Drawing on anthropological literature

and the concepts of dirt and pollution, it is argued that miscarriage for both women and

health professionals can be considered as ambiguous and that miscarriage and the early

passage of the foetus can be seen as ‘matter out of place’.

Conclusion: This exploration of how women were managed in a hospital setting reinforced

the notion of the ambiguous nature of miscarriage and supports the position that

miscarriage may be considered as atypical bereavement. Furthermore, an analysis is

offered of the significance of the vaginal blood loss as polluting and gives insights into how

nurses manage this ambiguity.

� 2009 Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

* Corresponding author. Tel.: +01792 518572.

E-mail address: f.murphy@swan.ac.uk (F. Murphy).

0020-7489/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ijnurstu.2009.10.011

What is already known about the topic?

� E

arly miscarriage is common affecting 15–20% ofpregnancies.

F. Murphy, S. Philpin / International Journal of Nursing Studies 47 (2010) 534–541 535

� W

omen’s feelings about their miscarriage have tended tobe conceptualised as loss and bereavement. � N urses are expected to provide appropriate emotional

care for women having a miscarriage.

What this paper adds

� S

upport to the position that miscarriage is ambiguousand may be considered as an atypical bereavement. � A n anthropological analysis of the significance of the

vaginal blood loss as polluting and dangerous.

� In sights into how nurses manage this ambiguity and

pollution with recommendations for practice.

1. Introduction

Approximately 15–20% of all pregnancies end in mis-carriage making it a global health issue affecting significantnumbers of women. Miscarriage is viewed as a common butpre-dominantly negative experience for women which hasbeen conceptualised in Western cultures as loss andbereavement. This paper draws on the findings of aqualitative, ethnographic study exploring the managementand care of women having an early miscarriage (before 16weeks gestation) within a hospital setting. Drawing onsocial anthropological theories of transition (van Gennep,1909), pollution and dirt as ‘matter out of place’ (Douglas,1966), it will be argued that early miscarriage is ambiguousand uncertain and that the miscarried foetus can beconsidered as ‘matter out of place’ (Douglas, 1966). Thisoffers an additional perspective to the current conceptua-lisation of miscarriage as bereavement and offers insightsinto how nurses manage this ambiguity and pollution incaring for women after miscarriage.

2. Background

2.1. The management of early miscarriage

Miscarriage is considered as one of the commonestcomplications in humans (Campbell and Monga, 2000) andis defined as the premature expulsion of an embryo orfoetus from the uterus up to 23 weeks of pregnancy andweighing up to 500 g (World Health Organisation, 2001).

The characteristic symptoms of miscarriage are vaginalblood loss which may be accompanied by pain. There arevarious categorisations in that a miscarriage may becomplete with all the products of conception passed orincomplete in which some of the products are retainedwithin the uterus. There is an additional category of ‘silent’miscarriage or early foetal demise in which the foetus mayhave been dead for some weeks but has not yet beenexpelled from the uterus (Trinder et al., 2006).

Management of women with miscarriage optimallyinvolves rapid referral to an early pregnancy unit (EPU)with ultrasound confirmation that the pregnancy is notviable. Women may then be offered the option ofexpectant management where there is no active medicalintervention with the miscarriage proceeding of its ownaccord. Other options are surgical management, in whichthe retained products are evacuated usually under general

anaesthetic and medical in which medications are given toinduce uterine contractions and evacuation of retainedproducts usually without the need for surgical interven-tion. In the area under study, women were usuallyadmitted to a hospital gynaecological unit for medical orsurgical management.

2.2. Early miscarriage as bereavement

There has been increased awareness of the psycholo-gical consequences of miscarriage for women and theirpartners. International studies using diagnostic toolsidentified that some women suffer from anxiety anddepression after miscarriage (Neugebauer et al., 1997;Nikcevic et al., 1999; Stirtzinger et al., 1999). These andother feelings that women describe have been concep-tualised by many as being part of a pattern of grief inresponse to the loss of a baby (Mander, 1997; Malacrida,1998; Frost et al., 2007). However accounts from womenabout their hospital experiences were usually critical ofhow health professionals cared for them with littleawareness of their feelings of distress and with noeffective interventions to support them (Moohan et al.,1994; Harvey et al., 2001).

Both Moulder (1998) in considering the lay literature onmiscarriage and Slade and Cecil (1994, p. 1) in a review ofthe literature observe an ‘implicit assumption . . . that abereavement or loss model is appropriate’. However, earlymiscarriage can be considered as an atypical form ofbereavement (Malacrida, 1998; Frost et al., 2007) as thereis often not a tangible body. There are limited funeralrituals and it is considered the loss of a future rather than ofa past (Frost and Condon, 1996; Frost et al., 2007). Thusmiscarriage is considered as a potential trigger forcomplicated grief, as it is an intangible loss with no visibleobject to mourn and no public acknowledgement of theloss. This lack of ceremonial attention in pregnancy losshas been recognised and thus there have been calls forparents to have funeral services or services of remem-brance where there is no body (Kohner, 1995).

2.3. Nursing, caring and miscarriage

If miscarriage is considered as bereavement, thenhealth professionals are urged to be sensitive towomen’s emotional needs and provide for them in bothhospital and community settings. However, despite thisincreased interest in early miscarriage, there is little inthe nursing literature that focuses on the role of thegynaecological nurse or indeed a hospital-based nurse incaring for women after miscarriage. An exception to thisis the work of Swanson (1999a,b, 2000) and Swansonet al. (2007). Swanson’s conceptualisation of caring(Swanson, 1991) is influenced by the work of Watson(1988) and reflects this perspective in expecting nursesto provide appropriate, holistic, individualised psycho-social care for women. However, this exploration of thenature of caring after miscarriage reflects a particularperspective in which the psychological is privileged overthe physical and aspects of caring for the physical bodytend to be neglected.

Box 1. Characteristics of the women interviewed.

Pseudonym Number of miscarriages and gestation Number of

live children

Age Admitted

to hospital

Treatment type

Susan 2 (at 9 weeks and 10 weeks) 1 30s Yes Surgical

Gemma 1 (at 9–10 weeks) 0 30s Yes Medical

Jane 1 (at 14 weeks) 1 30s Yes Complete miscarriage

but haemorrhaged.

Emergency admission

for stabilisation

Mary 1 (fourth pregnancy at 11 weeks) 4 40s Yes Surgical

Megan 3 (at 11 weeks, 5–6 weeks, and very early) 1 30s Yes Medical

Sian 2 (at 9 weeks and 11 weeks) 2 30s Yes Surgical and medical

Emma 8 miscarriages in total. 6 miscarriages

then a child. Two more miscarriages

then another child

2 50s Yes Surgical

Caroline 1 (8–10 weeks) 2 40s No Complete miscarriage,

no treatment required

F. Murphy, S. Philpin / International Journal of Nursing Studies 47 (2010) 534–541536

3. Methods

3.1. Design

This was an ethnographic study of a hospital gynae-cological unit in Wales UK, which consisted of an earlypregnancy unit (EPU) and two gynaecological wards. Itaimed to explore women’s experiences of having an earlymiscarriage (before 16 weeks gestation) in the unit. Briefly,although there are variations in the ways in which the termethnography is used (Hammersley and Atkinson, 2007), itgenerally indicates studying people in their everydaysettings, referred to as ‘the field’. Methods of datageneration are employed which ‘capture their socialmeanings and ordinary activities, involving the researcherparticipating directly in the setting, if not also theactivities, in order to collect data in a systematic mannerbut without meaning being imposed upon them exter-nally’ (Brewer, 2000, p. 6).

The study began with a 20-month period of part-time(one day a week) participant observation, working along-side the nurses in the unit caring for patients. This allowedan exploration of the culture and practices of the unitparticularly the nursing care given. Field notes werewritten and Spradley’s (1980) ideas of the different types offield notes was employed. Firstly a condensed account, wasmade in the field consisting of short descriptions of whathad happened and after the period of observation thesewere expanded into a more complete description. A fieldjournal, in which thoughts and comments about what hadoccurred was also kept. Finally notes of analysis andinterpretation in which theoretical concepts and explana-tions were used to make sense of what was happening.

Creswell (1998) and Higginbottom (2004) identifythat for ethnographic studies, the sampling should bepurposive, comprehensive and typical case in that itcaptures the normal and the ordinary and that thesample is shaped according to some pre-determinedcriterion. Thus to achieve the research aims, keyinformants in the setting (Hammersley and Atkinson,2007) were identified from the field work as womenthemselves having an early miscarriage and healthprofessionals involved in their care. Thus, a purposive,

volunteer sample (Green and Thorogood, 2004), of 16hospital health professionals (ten nurses, three doctorsand three ultrasonographers) involved in the care ofwomen having a miscarriage and eight women (Box 1)were interviewed. Purposive sampling is the selection ofparticipants or events that can give the information thatsuits the purpose of the research (Green and Thorogood,2004; Higginbottom, 2004).

All interviews were tape-recorded and transcribed. Theinterviews with women took place in their homes, rangedbetween 35 and 90 min in length and focused on theirexperiences of having a miscarriage and the treatment andcare received. Interviews with health professionals apartfrom one took place in the unit, ranged between 22 and60 min and focused on their role in providing interventionsand care to women.

To ensure credibility and thus rigour, the positionadvocated by Hammersley (1992) was adopted. Specificmeasures to ensure credibility included prolonged obser-vation of 20 months in the setting, triangulation ofmethods (interviews, observation and documentary ana-lysis) and maintaining an audit trail. As the researcherinfluences the processes of data collection, analysis andinterpretation (Koch, 1994; Manias and Street, 2001) areflexive stance was taken (Davies, 1999) which influencedand shaped the decisions taken as recorded in the audittrail. Reflexivity can assist the researcher to minimisereactivity, monitor it and acknowledge the effects of theresearcher on the setting and in the preparation of the finalethnography.

3.2. Ethical considerations

The study was approved by the relevant research ethicscommittees with the key ethical issues identified asinformed consent, anonymity and confidentiality andpotential harm and benefits to participants from theirinvolvement in the study. The researcher adopted theobserver as participant role (Gold, 1958), whereby theresearcher gains entry to the field but does not workdirectly as part of the work force. However, the ongoinginformal nature of participant observation in the fieldmade ensuring informed consent a challenge (Iphofen,

F. Murphy, S. Philpin / International Journal of Nursing Studies 47 (2010) 534–541 537

2005). Thus the following strategies were employed. Ageneral information sheet outlining the researchers’identity and purpose of the research was produced andsubjected to scrutiny by the research ethics committee.This was made available to all staff in advance anddiscussed at the unit meeting before the period offieldwork began. Whilst in the field, copies were keptwith the researcher and discussed with any individual whorequested information. Further information was given andsigned consent obtained from those women and staffmembers who agreed to be interviewed. Here, it wasemphasised that participants could withdraw their con-sent and participation at any time without penalty. Therewas also opportunity to discuss any potential harm andbenefits to participants from their participation. Forexample, when interviewing women, information wasavailable on counselling services if required.

3.3. Data analysis

Hammersley and Atkinson (2007) argue that ethno-graphic analysis is not a distinct stage of the research as itbegins from the prefieldwork phase and continuesthroughout the process. Informal analysis was conductedas the fieldwork continued and influenced what wasattended to in the field and asked at interview. This was inaddition to a more formal distinct phase of analysis inwhich all the data was subject to scrutiny. All the datawere analysed using thematic analysis (Green andThorogood, 2004) in which the interview transcriptsand field notes were read, re-read, key patterns identifiedand grouped into themes and categories. This elicitation ofthemes and categories were subjected to many refine-ments and there were several versions produced. The endresult was an overall map of the core themes andcategories from all the data sources. Central to theanalysis was the women’s experience and the overarchingcategories of ‘first signs and confirmation’, ‘losing thebaby’, ‘the aftermath’ and ‘reflections’ were derived fromthe women’s interview data and were used to organise allthe data. ‘First signs’ relates to the women’s experienceswhen first realising that their pregnancy was under threat.The category of ‘losing the baby’ further exploredwomen’s accounts of their experience and was informedby data from the health professionals’ interviews andobserving practice on the wards. The ‘aftermath’ drawsprimarily on women’s accounts of the long term impact ofmiscarriage on them and their lives.

As Geertz (1973) argues, the ethnographer’s interpreta-

tion of the meaning of events, rather than simplydescribing them, is an essential part of the ethnographicendeavour. Drawing on the philosopher Gilbert Ryle,Geertz notes the task of ethnography is to produce ‘thickdescription’—a ‘reflexive interpretation’ of meanings,rather than an objective description. Thus the outcomeof the interpretation of the findings, was a proposal thatmiscarriage be conceptualised as transition rather thansolely as bereavement (Murphy and Merrell, 2009). Thispaper explores this further, in focusing on women’sphysical experience of miscarriage and how this wasmanaged in the hospital setting.

4. Findings

The findings presented here, draw on the categories of‘first signs and confirmation’ and ‘losing the baby’. All thewomen’s accounts of their experience always began withvivid descriptions of their physical symptoms and inparticular the vaginal loss they experienced. The presenceof vaginal blood loss was an important marker for thewomen as to them it signalled the end of the pregnancyand was always considered a serious sign that somethingwas wrong. Their experiences of vaginal loss were diverseranging from passing small amounts of old blood:

Well I was eight and a half weeks . . .. I went for an earlyscan because I just had a small bit of brown stain . . .

(Susan, p. 6).

to bleeding very heavily:

I was then losing a lot of blood, a lot of clots . . . and thenit got heavier and heavier (Gemma, p. 2).

For some women, the amount of blood loss could beincapacitating:

I remember walking in (to the hospital) I was thenlosing a lot of blood and that was difficult, a lot of clotswhich was a bit distressing and when we got in, I couldbarely walk (Mary, p. 1).

Other women recounted how the blood loss threatenedtheir life and they had to be admitted as an emergencyadmission for treatment and stabilisation:

I started spotting . . . and that night, just in the middle ofthe night my waters broke. I passed out at that point . . .

lost quite a lot of blood (Jane, p. 2).

In early miscarriage, it is not always possible to clearlydiscern the foetal body in the vaginal loss passed. However,some women were very aware that they had passed thefoetus:

I can remember going to the toilet and passing the hum. . . it’s an experience you just can’t describe! Really, itwasn’t, it was very painful but it wasn’t the pain it was,you could actually feel it passing out of you into thetoilet really (Emma, p. 2).

Not all of the women experienced pain but for some,the pain was a significant part of their experience ofmiscarriage:

I had such heavy bleeding and I had such pain . . . theytook me to the emergency GP (general practitioner). Iwas in so much pain I could not walk . . . and so then headmitted me (Gemma, p. 4).

In the interviews with the nurses, they rarely men-tioned these physical manifestations of miscarriage,placing more emphasis on the psychological care thatthe women might need. However, the field observations ofthe gynaecological wards noted how central the observa-tion and recording of the women’s vaginal loss was. Whena miscarrying woman was admitted to the ward, she was

F. Murphy, S. Philpin / International Journal of Nursing Studies 47 (2010) 534–541538

asked to use a disposable bedpan every time she went tothe toilet and then present the bedpan to the nurse. Thiswas to allow inspection of the contents for signs ofproducts of conception. This was very carefully done,sometimes just visually and sometimes manually. Thenurse using universal precautions for the handling ofbodily fluids; would put on gloves and sift their fingersthrough the blood clots carefully looking for pieces oftissue that would indicate that all the products ofconception had been passed. Then in accord with thepolicy for the sensitive disposal of foetal remains (RoyalCollege of Obstetricians and Gynaecologists, 2005) wouldtransfer the contents in appropriate containers for trans-port to the mortuary. The amount and type of vaginal losswould then be recorded in the patient’s nursing care plan,which also included instructions as to the importance offrequent monitoring and recording of the loss. At thehandover between nurses as they changed shifts, thiswould be one of the key pieces of information transmittedabout the patient. If the loss was considered heavy orabnormal, this would be highlighted as the women may beat risk from potential haemorrhage.

The physical manifestations of miscarriage of pain andvaginal blood loss were an important part of the women’sexperience. There was a tension between their actualphysical experience of passing blood clots, fragments oftissue, gestational sacs and in some cases intact foetusesand their conceptualisation of their pregnancy as a baby.This was reflected in the words they used to describe theirpregnancy as they revealed a mixed picture in the wordsused to talk about what had been lost. Women oscillatedbetween using impersonal terms such as ‘it’, technicalterms such as ‘foetus’ and ‘embryo’ and terms such as‘baby’ and ‘child’:

She sent me down to the EPU and so I had a scan, and itshowed that I’d lost the baby hum, embryo, foetus whatever you call it, it’s a baby really isn’t it at the end of theday? (Sian, p. 1).

Gemma had a ‘silent’ miscarriage and had passed arecognisable but small ‘sac’:

I passed it and I knew what it was like, it’s like a little,little sac that came out . . .. You think you’re ten weekspregnant and therefore it does appear likely that this,this thing (author’s emphasis) has stopped developing atfive and a half weeks (Gemma, p. 2).

Caroline who had a complete early miscarriage of 8–10weeks gestation, had realised that something was wrongand had gone to the toilet for privacy to investigate whatwas happening. She realised she had miscarried but wasvery concerned that she could not allow her ‘baby’ to bepassed into the toilet:

I remember thinking, alright at least it’s in my hand it’snot down the toilet, you know. At the time ‘oh God, I’dhave to fish it out!’ Wouldn’t want to do that . . . but Iwould have done it; I know would have done it, if it hadgone down the toilet. I would have got it out myself . . .

thank goodness it landed on my hand then so I didn’thave to . . . (Caroline, p. 4).

For Jane, thinking of the foetus as a baby depended onwhether she had felt foetal movements. She had hermiscarriage at 14 weeks gestation that is before 16 weeksat which point a woman in her first pregnancy mightexpect to feel movements. The hospital in accordance withguidelines given to health professionals dealing withpregnancy loss (Henley and Kohner, 1991), offered herthe opportunity to see the baby but she had refused:

The first day they were in and out quite a lot and err andthey asked if I wanted to see . . . the foetus. Which wasnot something we wanted to do because we hadn’t feltit kick or, to us it wasn’t a baby yet err and we said no,you know that was fine (Jane, p. 2).

A fundamental difference between women’s experi-ences and practitioners is that miscarriage to healthprofessionals is a common part of their everyday work butto the woman it is usually a unique experience with theloss of that particular baby (Moulder, 1998). An importantreason for this is the difference between health profes-sionals and women’s conceptualisation of the foetus. Fromthe fieldwork observations, it was apparent that practi-tioners actually see foetuses not just on one occasion as thewoman may do but many, many times. The nurses anddoctors who worked on the wards were faced with thereality of the foetal body almost daily. The nurses inparticular, had to examine and interpret the products ofconception, as well as dealing with the reality of intact,recognisable foetuses over 12 weeks gestation deliveredthrough later miscarriages or termination of pregnancy.

This reality is in stark contrast with the parents’conceptualisation of the dream child (Kohn and Moffitt,1992) where parents imagine a fully formed baby whenthinking about their pregnancy. The image of the foetus isnow more openly and publicly displayed (Duden, 1993)than before but it is still unusual for lay people to seefoetuses:

They do see it (the foetus) and they just don’t expect itto look like it does. Although like I said to you earlierthey visualise as a baby, that’s what they’ve got in theirhead to actually see it is completely different and theydo see it, because more often than not it’s when they’rein the toilet (Frances, nurse 2, p. 7).

Despite these differences, it was apparent that thenurses and doctors recognised or at least said that to thewoman the foetus is a baby, a potential child:

Yes, straightaway, they see it as a baby.Interviewer: So miscarriage is more than just losing afoetus?Oh no, they don’t see that at all. No woman I’ve nursedhave said to me ‘oh yes it’s only like a lump of jelly’ orit’s only like this’. They don’t, they all see it as a baby andrefer to it as a baby. Because that’s how they see it orfrom my experience that’s how women see it, as a baby(Frances, nurse 2, p. 4).

These conceptualisations may also be shaped bycultural norms (Morgan, 2006). The population understudy had a relatively low ethnic minority population, but

F. Murphy, S. Philpin / International Journal of Nursing Studies 47 (2010) 534–541 539

an initial clue that the response to miscarriage may beculturally constructed came from a fieldwork conversationwith a doctor from an African culture:

He said in Ghana they see things differently. ‘It is God’swill (he raises his arms); they don’t talk about ‘mybaby’. Here they have a miscarriage at six weeks andthey are crying for their baby!’ I asked at what stagewould women in Ghana talk about their baby, whenmovements are felt? He said ‘yes’, he had to change hisapproach when he came here, because he couldn’tunderstand why everyone was so upset. He’s gettingbetter at it now (Field notes EPU, p. 20).

5. Discussion

5.1. Explaining and managing ambiguity: transition,

marginality and pollution

The findings presented here focused on the woman’sexperience of their miscarriage with the physical symp-toms of pain and blood loss being very important. Therewas a tension between the idea of early miscarriage aslosing a baby and the actual reality of their physicalexperience. Women were confronted with the reality ofpassing the foetus as blood clots rather than a discernable‘baby’. The findings of this study support Frost et al. (2007)in suggesting that miscarriage can be considered as anatypical bereavement because the miscarried foetus, isitself a source of the profoundest ambiguity. There isuncertainty surrounding its status as a human being as it isliving but not yet alive and falls between the categories of‘human or non-human’ (Casper, 1994). Ambiguity, a keyconcept in social anthropology, literally refers to some-thing which may be interpreted in two ways. It is oftenassociated with uncertainty and is also often linked, as inthis paper, to notions of marginality, where things falloutside normal classificatory systems.

This ambiguity can be explored by utilising anthro-pological theories of transition which draw on van Gennep’s(1909) classic rites de passage study. This describes the use ofrituals (rites) to deal with people’s passage throughchanging phases of time and status, while at the same timeaffirming and protecting the group’s important culturalvalues. In van Gennep’s analysis there is a sequence of threestages of social transition as people move from one socialstatus to another: rites of separation, rites of transition andrites of incorporation. The first stage describes people’sremoval from their normal social status, usually involvingparticular ‘rites of separation’. In the second stage, havingleft their normal social status and not yet joined their newstatus, people are considered to be in a marginal or ‘liminal’(from the Latin limen meaning threshold) state. This liminalstate is regarded as separated from normal life and societyand its inhabitants, by virtue of being in neither one categorynor the other, are perceived as both dangerous andvulnerable in terms of being polluting or at risk of pollution(van Gennep, 1909; Gluckman, 1962; Douglas, 1966).Finally, van Gennep describes the third stage of incorpora-tion where people attain their new social role, againaccompanied by specific rites.

Thus, the initial physical signs of miscarriage can beconsidered as indicative as those of a transitional statebetween pregnancy and non-pregnancy (Murphy andMerrell, 2009). The women herself is vulnerable to thephysical effects of excessive blood loss and the foetus is ofcourse endangered. In this sense both the foetus (asunborn) and the woman (between being pregnant andnon-pregnant) are in a marginal state. The confirmatorydiagnostic scan and the initiation of active treatmentsbegins the physical separation of the woman from thefoetus. During the process, the foetal body and the vaginalblood loss in early miscarriage can be considered asdangerous and polluting. Anthropological ideas of dirt andpollution which draw heavily on the work of Douglas(1966) have recently been applied to childbirth andreproductive health (see Kirkham, 2007). In taking ananthropological view on the nature of dirt, Douglasacknowledges the contribution of bacteriology and thetransmission of pathogens on perceptions of dirt. How-ever, she wanted to go back before that for a definition inwhich dirt is defined as ‘matter out of place’ (Douglas,1966, p. 36). Being ‘out of place’ implies some kind ofordered system of dirt and pollution where pollution ‘is amatter of aesthetics, hygiene or etiquette which onlybecomes grave in so far as it may create socialembarrassment’ (Douglas, 1966, p. 74). Developing vanGennep’s notions of liminality, Douglas argues that whenboundaries between categories are unclear, contradictoryor broken down, the resulting category confusion is oftenregarded as marginal, neither here nor there, and hencepolluting and potentially dangerous, requiring contain-ment strategies. Thus it will be argued that earlymiscarriage can be considered as dirt and pollution intwo ways. The first is through the link with menstruationand the second relates to the fact that the miscarriedfoetus can be considered as ‘matter out of place’.

The loss of vaginal blood associated with miscarriage issimilar to an exaggerated form of menstruation. Althoughmenstruation can be seen positively as evidence of fertilityit is feared in some cultures (Douglas, 1966; Miles, 1991;Bharj, 2007). Some anthropological accounts also link theidea of miscarriage as pollution where pregnancy loss isseen as the release of the ‘dirty’ menstrual blood (Buckleyand Gottlieb, 1988; Martin, 1987; Jeffery and Jeffery,1996). Laws (1990) applied this idea of pollution to theetiquette surrounding the management of menstrualblood of which the need to maintain secrecy is important.However, miscarriage unlike menstruation can be difficultto manage in quite the same way, so that evidence of bloodloss is hidden. This is because the amount of blood loss canbe very heavy and secondly, because this blood loss comeswithin the gaze of others, namely health professionals,particularly nurses. The elimination of bodily fluids such asurine, faeces and menstrual blood are certainly associatedwith dirt and pollution. Normally, such products ofelimination are dealt with privately in the backstage areaof the toilet (Martin, 1987). In these hospital wards, thesebackstage areas were in fact quite public. They were sharedwith others and part of the role of the nurses on the wardwas to enter these areas and monitor the amount andnature of bodily wastes eliminated.

F. Murphy, S. Philpin / International Journal of Nursing Studies 47 (2010) 534–541540

It is also possible to consider the foetus as ‘dirt’, not in aderogatory sense but as Douglas (1966) defines, simply as‘matter out of place’. This resonates with her analysis ofthe perceived pollution dangers arising when categoriesbecome unclear, leading to ambiguity. Thus, like men-strual blood which has crossed a bodily boundary (Britton,1996), the foetus also crosses this boundary but at tooearly a stage. The pattern of ordered expectations(Douglas, 1966) is that foetuses will not usually be seenuntil they are delivered as neonates after a successfulpregnancy. The findings illustrate that, the reality ongynaecological wards is that the foetus is seen, sometimesas hardly recognisable except to a trained eye amongblood clots and sometimes as very recognisable in latermiscarriages and terminations. Overtly, there was nosuggestion that the nurses considered the women as being‘dirty’ when passing blood vaginally, but the examinationof the day to day practice of the nurses in this particularcontext revealed that nurses in doing the ‘dirty work’ ofgynaecological nursing (Bolton, 2005) had evolvedspecific practices. These were clearly concerned withthe safe handling, inspection, description and sensitivedisposal of the bodily fluids produced as a result ofmiscarriage. Working with such breached boundaries hasbeen identified as dangerous in nursing work (Lawler,1991; Littlewood, 1991; Philpin, 2007), thus the nurses intheir practices considered this loss as potentially pollutingbut with an awareness of what this loss represented andtherefore handled it with care.

5.2. Implications for practice

This exploration of the culture of the unit and theapplication of anthropological theories offers some impli-cations for nursing practice Firstly; nurses should continueto work to understand women’s conceptualisation of thefoetus which in early miscarriage may be uncertain andambiguous, culturally mediated and which contrasts withtheir own experience of the reality of the foetal body.Second, the emphasis in the nursing literature has been oncaring for the emotions of women after miscarriage butwith an apparent neglect of the physical body. This link toelimination, menstruation, dirt and pollution is rarelydiscussed in the literature but as was observed, was animportant part of both the woman and the nurses’experiences. It is not normally permissible to talk freelyabout blood, blood clots and the products of conception. Asa result, this part of the women’s experience remainsprivate to her and further serves to distance her from thewider culture. Nursing practice and discourse around thecare of women having early miscarriage should re-focusattention back to the physical body. Nurses have tended toemphasise the ‘clean’ aspects of caring, those relating toemotions rather than the ‘dirty’ physical care required(Patistea, 1999).

5.3. Limitations

The study was limited to one particular setting over atime-limited period in one particular culture. Like otherqualitative research studies it does not attempt to

generalise the findings but suggests that they may betransferable to other similar settings (Mason, 2002; Greenand Thorogood, 2004). The women interviewed, werepredominantly from white ethnic groups, only one beingfrom an ethnic minority. All the women were educatedpast the age of compulsory education and all apart fromtwo were working outside the home. They representtherefore a small, fairly narrow spectrum of all womenwho may have miscarried. Although the sample size ofwomen was small, it was considered to be adequate andappropriate (Kuzel, 1999). The decision to focus primarilyon the woman and not include the experience of herpartner and family may also be considered a potentiallimitation. Finally, all the healthcare professionals inter-viewed were female.

6. Conclusion

This study further reinforces the notion of theambiguous nature of miscarriage and supports the positionthat miscarriage may be considered as an atypicalbereavement. An analysis is offered of the significance ofthe vaginal blood loss as polluting and gives insights intohow nurses manage this ambiguity. Raising awareness ofthis may be a first step towards nurses managing thissensitively and critically examining their practice.

References

Bharj, K., 2007. Pollution: midwives defiling South Asian women. In:Kirkham, M. (Ed.), Exploring the Dirty Side of Women’s Health.Routledge, London, pp. 60–71.

Bolton, S.C., 2005. Women’s work, dirty work: the gynaecology nurse as‘other’. Gender, Work and Organization 12 (2), 169–186.

Brewer, J.D., 2000. Ethnography. Open University Press, Buckingham.Britton, C.J., 1996. Learning about ‘‘the curse’’. An anthropological per-

spective on experiences of menstruation. Women’s Studies Interna-tional Forum 19 (6), 645–653.

Buckley, T., Gottlieb, A., 1988. A critical appraisal of theories of menstrualsymbolism. In: Buckley, T., Gottlieb, A. (Eds.), Blood Magic: TheAnthropology of Menstruation. University of California Press,Berkeley, pp. 3–50.

Campbell, S., Monga, A., 2000. Disorders of early pregnancy (ectopic,miscarriage, GTD). In: Campbell, S., Monga, A. (Eds.), Gynaecologyby Ten Teachers. Arnold, London, pp. 99–112.

Casper, M., 1994. At the margins of humanity: fetal positions in scienceand medicine. Science, Technology and Human Values 19 (3), 307–323.

Creswell, J., 1998. Qualitative Inquiry and Research Design. Sage, Thou-sand Oaks.

Davies, C.A., 1999. Reflexive Ethnography. A Guide to Researching Selvesand Others. Routledge, London.

Douglas, M., 1966. Purity and Danger. An Analysis of the Concepts ofPollution and Taboo. Routledge, London.

Duden, B., 1993. Disembodying Women. Perspectives on Pregnancy andthe Unborn. Harvard University Press, Cambridge Massachusetts.

Frost, M., Condon, J.T., 1996. The psychological sequelae of miscarriage: acritical review of the literature. Australian and New Zealand Journal ofPsychiatry 30 (1), 54–62.

Frost, J., Bradley, H., Levitas, R., Smith, L., Garcia, J., 2007. The loss ofpossibility: scientisation of death and the special case of early mis-carriage. Sociology of Health and Illness 29 (7), 1003–1022.

Geertz, C., 1973. The Interpretation of Cultures. Basic Books, New York.Gluckman, M., 1962. Essays on the Ritual of Social Relations. Manchester

University Press, Manchester.Gold, R., 1958. Roles in sociological field observation. Social Forces 36,

217–223.Green, J., Thorogood, N., 2004. Qualitative Methods for Health Research.

Sage, London.Hammersley, M., 1992. What’s Wrong with Ethnography? Routledge,

London.

F. Murphy, S. Philpin / International Journal of Nursing Studies 47 (2010) 534–541 541

Hammersley, M., Atkinson, P., 2007. Ethnography. Principles in Practice,third ed. Routledge, London.

Harvey, J., Moyle, W., Creedy, D., 2001. Women’s experience of miscar-riage: a phenomenological study. The Australian Journal of AdvancedNursing 19 (1), 8–14.

Henley, A., Kohner, N., 1991. Miscarriage, Stillbirth and Neonatal Death:Guidelines for Professionals. Stillbirth and Neonatal Death Society,London.

Higginbottom, G.M.A., 2004. Sampling issues in qualitative research.Nurse Researcher 12 (1), 7–19.

Iphofen, R., 2005. Ethical issues in qualitative health research. In: Hollo-way, I. (Ed.), Qualitative Research in Health Care. Open UniversityPress, Berkshire, pp. 17–35.

Jeffery, P., Jeffery, R., 1996. Delayed periods and falling babies: theethnophysiology and politics of pregnancy loss in rural North India.In: Cecil, R. (Ed.), The Anthropology of Pregnancy Loss. ComparativeStudies in Miscarriage, Stillbirth and Neonatal Death. Berg, Oxford,pp. 16–37.

Kirkham, M. (Ed.), 2007. Exploring the Dirty Side of Women’s Health.Routledge, London.

Koch, T., 1994. Establishing rigour in qualitative research: the decisiontrial. Journal of Advanced Nursing 19, 976–986.

Kohn, I., Moffitt, P.L., 1992. Pregnancy Loss. A Silent Sorrow. Headway.Hodder and Stoughton, London.

Kuzel, A.J., 1999. Sampling in qualitative inquiry. In: Crabtree, B.F., Miller,W.L. (Eds.), Doing Qualitative Research. second ed. Sage, ThousandOaks.

Kohner, N., 1995. Pregnancy Loss and the Death of a Baby: Guidelines forProfessionals. Stillbirth and Neonatal Death Society, London.

Laws, S., 1990. Issues of Blood. The Politics of Menstruation. Macmillan,London.

Lawler, J., 1991. Behind the Screens. Nursing, Somology and the Problemof the Body. Churchill Livingstone, Melbourne.

Littlewood, J., 1991. Care and ambiguity: towards a concept of nursing. In:Holden, P., Littlewood, J. (Eds.), Anthropology and Nursing. Routledge,London, pp. 70–189.

Malacrida, C., 1998. Mourning the Dreams. Qual Institute Press, Alberta,Canada.

Mander, R., 1997. Perinatal grief: understanding the bereaved and theircarers. In: Alexander, J., Roth, C., Levy, V. (Eds.), Midwifery Practice.Core Topics, vol. 3. Macmillan, Basingstoke, pp. 29–50.

Manias, E., Street, A., 2001. Rethinking ethnography: reconstructingnursing relationships. Journal of Advanced Nursing 33 (2), 234–242.

Martin, E., 1987. The Woman in the Body. Open University Press, MiltonKeynes.

Mason, J., 2002. Qualitative Researching, second ed. Sage, London.Miles, A., 1991. Women, Health and Medicine. Open University Press,

Milton Keynes.Moohan, J., Ashe, R.G., Cecil, R., 1994. The management of miscarriage:

results from a survey at one hospital. Journal of Reproductive andInfant Psychology 12, 17–19.

Morgan, L., 2006. Imagining the unborn in the Andes. In: Lewin, E.(Ed.), Feminist Anthropology: A Reader. Blackwell Publishing,Oxford, pp. 358–374.

Moulder, C., 1998. Understanding Pregnancy Loss. Perspectives and Issuesin Care. Macmillan, Basingstoke.

Murphy, F., Merrell, J., 2009. Negotiating the transition: caring for womenthrough the experience of early miscarriage. Journal of Clinical Nur-sing 18, 1583–1591.

Neugebauer, R., Kline, J., Shrout, P., Skodol, A., O’Connor, P., Geller, P., Stein,Z., Susser, M., 1997. Major depressive disorder in the 6 months aftermiscarriage. JAMA 277 (5), 383–388.

Nikcevic, A., Tunkel, S., Kuczmierczyk, A., 1999. Investigation of the causeof miscarriage and its influence on women’s psychological distress.British Journal of Obstetrics and Gynaecology 106 (8), 808–813.

Patistea, E., 1999. Nurses’ perceptions of caring as documented in theoryand research. Journal of Clinical Nursing 8, 487–495.

Philpin, S., 2007. Managing ambiguity and danger in an intensive ther-apy unit: ritual practices and sequestration. Nursing Inquiry 14 (1),51–59.

Royal College of Obstetricians and Gynaecologists, 2005. Disposal follow-ing pregnancy loss before 24 weeks of gestation. Good Practice, No. 5,January, pp. 1–5.

Slade, P., Cecil, R., 1994. Understanding the experience and emotionalconsequences of miscarriage—editorial. Journal of Reproductive andInfant Psychology 12, 1–3.

Spradley, J.P., 1980. Participant Observation. Holt, Rinehart and Winston,New York.

Stirtzinger, R.M., Robinson, G.E., Stewart, D.E., Ralevski, E., 1999. Para-meters of grieving in spontaneous abortion. The International Journalof Psychiatry in Medicine 29 (2), 235–249.

Swanson, K.M., 1991. Empirical development of a middle range theory ofcaring. Nursing Research 40 (3), 161–166.

Swanson, K.M., 1999a. Effects of caring, measurement and time on mis-carriage impact and women’s well-being. Nursing Research 48 (6),288–298.

Swanson, K.M., 1999b. Research-based practice with women who havehad miscarriages. Image: Journal of Nursing Scholarship 31 (4),339–345.

Swanson, K.M., 2000. Predicting depressive symptoms after miscarriage:a path analysis based on the Lazarus paradigm. Journal of Women’sHealth & Gender-Based Medicine 9 (2), 191–206.

Swanson, K.M., Connor, S., Jolley, S.N., Pettinato, M., Wang, T.J., 2007.Context and evolution of women’s responses to miscarriage duringthe first year after loss. Research in Nursing and Health 30, 2–16.

Trinder, J., Brocklehurst, P., Porter, R., Read, M., Vyas, S., Smith, L., 2006.Management of miscarriage: expectant, medical or surgical? Resultsof randomized controlled trial (miscarriage treatment (MIST) trial).British Medical Journal 332, 1235–1240.

van Gennep, A., 1909. The Rites of Passage. Routledge and Kegan Paul,London.

Watson, J., 1988. Human Science and Human Care. A Theory of Nursing.National League for Nursing, New York.

World Health Organisation, 2001. Definitions and Indicators in FamilyPlanning, Maternal & Child Health and Reproductive Health. Repro-ductive. Maternal and Child Health European Regional Office. WorldHealth Organisation. Available at: http://www.euro.who.int/document/e68459.pdf (Accessed on 14 April 2009).