Negotiating the transition: caring for women through the experience of early miscarriage

MIDWIFERY

Negotiating the transition: caring for women through the experience of

early miscarriage

Fiona Murphy and Joy Merrell

Aim. To explore women’s experiences of having an early miscarriage in a hospital gynaecological unit.

Background. Miscarriage is a global health issue affecting significant numbers of women and is usually considered a distressing

experience. This distress is often interpreted as being characteristic of grief. Nurses and other health professionals in hospital

and community settings are therefore expected to provide appropriate care to meet the physical and emotional needs of the

woman.

Design. A qualitative, ethnographic study of a hospital gynaecological unit in the UK.

Methods. The primary method was 20 months of part-time participant observation. Data were also collected through docu-

mentary analysis of key documents in the setting and formal interviews. These were with eight women who had an early

miscarriage and 16 health professionals (nurses, doctors, ultrasonographers) working in the unit.

Results. Three clear phases emerged in the women’s experience of miscarriage and hospital admission; first signs

and confirmation, losing the baby and the aftermath. These were interpreted as being components of a process of

transition. The hospital admission emerged as vital in these early phases in which the importance of nurses and other

health professionals providing sensitive, engaged care to meet the emotional and physical needs of the woman was

identified.

Conclusions. The hospital setting emerged as highly influential in shaping the care that was given to women and influencing

their experiences. Transition models were felt to be more appropriate than grief and bereavement models in guiding the

psychological care given to women.

Relevance to clinical practice. The experience of hospital admission and the actions of nurses and other health professionals

is influential in how women negotiate the transition through miscarriage.

Key words: bereavement, miscarriage, nursing, transition, women’s health

Accepted for publication: 30 September 2008

Introduction

Miscarriage of an early pregnancy is considered as the

‘commonest medical complication in humans’ (Campbell &

Monga 2000, p. 102). Approximately 15–20% of all preg-

nancies end in miscarriage making it a global health issue

affecting significant numbers of women. In the UK this

equates annually to 50,000 hospital in-patient admissions

(Royal College of Obstetricians and Gynaecologists 2006)

and forms an important area of practice for nurses and

Authors: Fiona Murphy, MSc, PhD, RGN, BN, RHV, DN, RCNT,

PGCE (FE), Senior Lecturer, School of Health Science, University of

Wales Swansea, Singleton Park, Swansea, Wales, UK; Joy Merrell,

MSc, PhD, BSc (Hons) Nursing Studies, RGN, RHV, RNT, HV Tut

Cert, Professor, School of Health Science, University of Wales

Swansea, Singleton Park, Swansea, Wales, UK

Correspondence: Dr Fiona Murphy, Senior Lecturer, School of

Health Science, University of Wales Swansea, Singleton Park,

Swansea, SA2 8PP, Wales, UK. Telephone: +44 1792 518572.

E-mail: [email protected]

� 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1583–1591 1583

doi: 10.1111/j.1365-2702.2008.02701.x

midwives in hospital and community settings. Medically,

miscarriage is defined by the World Health Organisation as

premature expulsion of an embryo or foetus from the uterus

up to 23 weeks of pregnancy and weighing up to 500 gm in

weight (World Health Organisation 2001). However, defini-

tions of miscarriage may vary between countries.

In the UK, early miscarriage (before 16 weeks gestation)

tends to be managed by women being admitted to hospital

for assessment and treatment. It is claimed that to some

health professionals, early miscarriage may be seen as

commonplace and the management of early miscarriage in

terms of the treatment interventions required considered

minor (Malacrida 1998, Adolfsson et al. 2004). Additionally,

miscarriage encompasses sensitive and taboo areas such as

sex, death and the perceived failure of fertility. Thus it has

been argued that women’s experiences and feelings about

their miscarriage had tended to be unrecognised and ignored

(Kohn & Moffitt 1992). An increasing emphasis on women’s

experiences of health and healthcare meant that the signif-

icance of pregnancy loss including miscarriage was raised.

This led to expectations that women should have support and

understanding provided by nurses and other health profes-

sionals in hospital and community settings (Kohner 1995).

Drawing on the findings of a qualitative, ethnographic study,

this paper will discuss women’s experiences of hospitalisation

and miscarriage; offer a conceptualisation of early miscar-

riage as a process of transition and highlight the implications

for nursing practice.

Background

Women’s experiences of early miscarriage

Women’s accounts of their feelings and experiences after

miscarriage are characterised by sadness and distress

(Nazarko 1992, Shuttleworth 1995). Furthermore a succes-

sion of studies using diagnostic tools identified that some

women suffer from anxiety and depression after miscarriage

(Neugebauer et al. 1997, Nikcevic et al. 1999, Cumming

et al. 2007). These diagnoses of anxiety and depression were

applied to women’s experience and explained as being caused

by loss. There appears to be little acknowledgement of more

physiological explanations such as the sudden decline in

levels of oestrogen and human chorionic gonadotrophin

which may affect behaviour. Thus the feelings and emotions

that women describe have been conceptualised as being part

of a pattern of grief responding to the loss of a baby (Mander

1997, Oakley et al. 1984, Malacrida 1998, Nikcevic et al.

2000). However, Moulder (1998) in considering the lay

literature on miscarriage and Slade and Cecil (1994), p. 1) in

a review of the literature observe an ‘implicit assumption …that a bereavement or loss model is appropriate’. From this

model, stems several assumptions about women’s response to

early miscarriage. First, that all women must be distressed;

second, that this distress should be interpreted as grief.

Finally, that as bereaved people women need interventions

from health professionals. There is very little in the literature

that challenges these assumptions.

The role of nurses and other health professionals

The increasing international attention paid to miscarriage

began to generate expectations that health professionals

should play an important role in caring for these women. It

soon became clear and not just in the UK, that there was

dissatisfaction and concern expressed by women as to how

they were treated in both hospital and community settings

(Lee & Slade 1996, Moulder 1998, Adolfsson et al. 2004).

These aspects included having to wait long periods for scans

and surgery (Moulder 1998, Sehdev & Wilson 2000) and

poor information giving and advice (Moohan et al. 1994,

Corbet-Owen & Kruger 2001, Tsartsara & Johnson 2002).

Additionally, some women felt that their miscarriage was not

regarded as important by hospital staff and felt abandoned

(Malacrida 1998, Adolfsson et al. 2004). Adolfsson et al.

(2004), p. 553 considered this abandonment by health

professionals as ‘professional avoidance’.

The implications were that health professionals were

failing to meet the needs of women and their families during

and after miscarriage. Guidelines for professionals by organ-

isations such as the UK Stillbirth and Neonatal Death Society

(Henley & Kohner 1991, Kohner 1995) were produced. The

clear message was that there should be an emphasis on the

psychosocial and interpersonal skills, as perceived lack of

such skills was felt to have an impact on women and is

remembered by them for a long time (Corbet-Owen &

Kruger 2001, Miller 2004). Consequently, health profession-

als were urged to intervene after miscarriage to provide

follow up appointments (Broquet 1999, Nikcevic et al. 2000)

and counselling (Neugebauer et al. 1997, Swanson 1999a).

Despite the increased interest in early miscarriage, there is

limited nursing literature that focuses on the role of the

gynaecological nurse or indeed a hospital-based nurse or

midwife in caring for women after miscarriage. In the USA,

Swanson (Swanson 1991, 1999a,b, 2000, Swanson et al.

2007) emphasised the nurses’ role in caring for women. This

included the importance of understanding what the experi-

ence might mean to the woman, having the ability to

recognise and share their feelings and facilitating the woman

in getting through the experience of miscarriage. It is

F Murphy and J Merrell

1584 � 2009 The Authors. Journal compilation � 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 1583–1591

acknowledged that some women may not need or want to be

admitted to hospital for management of their miscarriage and

hence their experiences may be different. In the UK, miscar-

riage is commonly managed through admission to hospital,

thus the focus of this paper is on women’s experiences while

in hospital.

Methods

Aim

The aim of the study was to explore women’s experiences of

having an early miscarriage in a hospital gynaecological unit.

Design

As the study sought to understand the experiences of both

women and health professionals within a hospital setting, an

ethnographic approach was adopted (Hammersley &

Atkinson 1995). May (1997) considers that participant

observation and thus ethnography is concerned with engage-

ment in a social scene to seek to understand it through

experiencing it. This approach facilitated exploration of the

culture and practices in the unit and how these shaped

women’s experiences. The setting was a gynaecological unit

in Wales UK, which consisted of an early pregnancy unit

(EPU) and two gynaecological wards.

Data collection

Three main methods of data collection were employed. The

study began with 20 months of part-time (one day a week)

participant observation, working alongside nurses caring for

patients. This period was selected as it enabled sufficient time

to understand the three different settings in the unit, develop

an understanding of the culture and how that shaped the care

given to women. Key documents such as nursing care plans

were also reviewed and analysed. From the period of

observation, it became evident who the key informants were

in the setting (Hammersley & Atkinson 1995) and these were

identified as women themselves having an early miscarriage

and health professionals involved in their care. Thus, a

purposive sample (Green & Thorogood 2004), of 16 hospital

health professionals (ten nurses, three doctors and three

ultrasonographers) involved in caring for women having a

miscarriage were interviewed. A purposive sample of

eight women were also recruited from both hospital and

community settings. The period varied between those women

who had just experienced the miscarriage recently to those

whose experiences were several years ago (Fig. 1). The

women were educated and from fairly affluent backgrounds

with only one being from an ethnic minority group.

Ages ranged between 30–59 with the majority aged between

30–39.

The interviews with women took place in their homes,

ranged between 35–90 minutes and focused on their experi-

ences of having a miscarriage and the treatment and care

received. Interviews with health professionals apart from one

took place in the unit, ranged between 22–60 minutes and

focused on their role in providing interventions and care to

women. All interviews were tape-recorded and transcribed.

Rigour

To ensure credibility and thus rigour, the position advocated

by Hammersley (1992) was adopted where ensuring validity

is the key and it incorporates specific measures to ensure

credibility. These were the prolonged observation of

20 months in the setting, triangulation of methods (inter-

views, observation and documentary analysis) and maintain-

ing an audit trail. Prolonged observation allowed the

gathering of both confirming and disconfirming evidence

(Gilchrist & Williams 1999). The purpose of using triangu-

lation was to overcome the limitations of data derived from a

single source and be more confident in the conclusions drawn

from the data. As the researcher influences the processes of

Participant Number of live children

Susan 2 (at 9 weeks and 10 weeks) 1Gemma 1 (at 9-10 weeks) 0Jane 1 (at 14 weeks) 1Mary 1 (fourth pregnancy at 11 weeks) 4Megan 3 (at 11 weeks, 5-6 weeks and ‘very early’) 1Sian 2 (at 9 weeks and 11 weeks) 2Emma 8 (6 ‘very early’) 2Caroline 1 (8-10 weeks) 2

Number of miscarriages and gestation

Figure 1 Characteristics of women

interviewed.

Midwifery Caring for women through the experience of early miscarriage


data collection, analysis and interpretation (Manias & Street

2001) a reflexive stance was taken. This need to be reflexive

pervaded the whole of the research process, influencing the

decisions taken as recorded in the audit trail.

Ethical considerations

Permission to conduct the study was obtained from senior

clinical and administrative personnel within the hospital and

from the relevant research ethics committee. The ongoing

informal nature of participant observation in the field made

ensuring informed consent a challenge (Iphofen 2005). Thus

verbal and written information was given to all unit staff for

the observation phase and was also available for patients and

other staff. Further information was given and signed consent

obtained from those women and staff members who were

interviewed.

Data analysis

Hammersley and Atkinson (1995) argue that analysis is not a

distinct stage of the research but begins from the pre-

fieldwork phase and continues throughout the process.

Informal analysis was conducted as the fieldwork continued

influencing what was observed in the field and asked at

interview. There was then a more formal distinct phase of

analysis in which data from all sources was subject to

scrutiny. All the data were analysed using thematic analysis

(Green & Thorogood 2004) in which the interview tran-

scripts and field notes were read, re-read, key patterns

identified and grouped into themes and categories. Three key

categories emerged; ‘first signs and confirmation’, ‘losing the

baby’ and ‘the aftermath’. Although this paper draws

primarily on interview data it is also informed by the

observational data.

Results

First signs and confirmation; the ‘bad news’ clinic

The experience of miscarriage began with women having

symptoms such as pain and vaginal blood loss. When this

occurred, women were usually referred to the EPU at the

hospital. This offered rapid assessment of their symptoms and

ultrasound scanning to confirm the diagnosis. Although

clinical signs and symptoms of miscarriage gave an early

indication, women themselves attached great importance to

the scan to confirm the diagnosis.

The process of admitting, assessing and caring for the

woman in EPU was very carefully managed by the team of

doctors, nurses and ultrasonographers. The emphasis was on

preparing women for the ‘bad news’ that the pregnancy was

no longer viable, supporting when the news was received and

preparing for treatment options. Overall, the team’s inter-

pretation based on their experience was that miscarriage was

a negative event for women but that women’s reactions to the

news could be unpredictable and varied:

I look at the patient and I say I’m sorry it isn’t good news. And then I

wait for them, a reaction. It’s amazing how many people don’t tend

to, don’t react to the fact. They just look up and they say ‘well’, or

‘yes, what are you saying?’ And then I say ‘I’ve had a good look. I can

see, I can see your baby there but I am positive that baby is not alive’.

And then they usually start asking questions. (Brenda, ultrasonogra-

pher, p. 7)

For the women interviewed, miscarriage for them was

sudden, unexpected and distressing:

I didn’t know what to do. Then the nurse came out I didn’t know

whether she was a midwife or not, took me into the little room and I

was just in shock I think I was shaking. I cried in there with her and

I waited there. (Susan, p. 5)

After the scan, women were seen again by the doctor or nurse

to discuss treatment options. In this unit this was largely

through surgical evacuation of retained products of concep-

tion or medically through administration of medicines.

Losing the baby

Once the diagnosis of miscarriage was reached, women were

admitted to the gynaecological wards and treatment inter-

ventions began. Health professionals saw their role as helping

the woman safely through the physical consequences of

miscarriage, effectively treating and safely discharging her.

However, the context in which care was delivered impacted

on the women’s experience as the gynaecological wards were

acute, surgical settings also receiving emergency admissions.

It was evident from the participant observation and con-

firmed by interviews with health professionals, that patients

awaiting treatment for early miscarriage were sometimes

considered a lower priority compared with patients with

more pressing physical needs:

If you’ve got a self caring patient whose up and around and just nil by

mouth and waiting for theatre, that’s a bit different to somebody you

know who you are intensively monitoring and nursing. Who has just

come back from theatre, so inevitably they are going to get squeezed.

(Alison, doctor, p. 8)

As a consequence, some women described feeling left alone.

Susan was admitted for surgical intervention, nursed in a



single room. She felt this was positive because there was

privacy to cry but it also meant not seeing anybody:

I didn’t see any members of staff; nobody came in to……..talk to you.

It would be good perhaps if somebody did go in. Just to sort of say,

you know just take your blood pressure to see how, how you are sort

of thing. (Susan, p. 9)

The rationale for giving women a single room is clearly

identified by the nurses. This affords women privacy to be

with her partner and family at what they recognise as a

difficult time. There was, however, a tension evident in the

nurses’ accounts of how they would like to practice and

what was actually possible as observed in their day to day

work. Nurses recognised the emotional effects of miscar-

riage on women, but acknowledged their frustration at the

constraints exacerbated at times by a lack of continuity of

care that prevented them from meeting women’s emotional

needs:

The problem is when people are in; we sometimes haven’t got

time to sit and talk to them. I know it sounds awful but we

haven’t, we haven’t got time to sit and discuss things. (Frances,

nurse, p. 6)

The hospital admission therefore, emerged as a crucial part in

women’s experience of miscarriage, as it physically marked

and completed the ending of her previous identity as a

pregnant woman. The scan in EPU confirmed she was no

longer pregnant and the treatments physically separated the

foetus from her. The psychological separation though, took

much longer and most hospital staff were sensitive to the

emotional impact of miscarriage on women. However, the

unsympathetic system (Moulder 1998) of being cared for in a

busy, surgical gynaecological unit meant that women’s

emotional needs and indeed some of their physical needs

were not always met.

The aftermath: negotiating the ‘what could go wrong

world’

The physical separation of the foetus from the woman

through treatments is short often only taking a few hours or

days. Not unexpectedly, the hospital nurses and health

professionals were focused on the short admission and

treatment of women, with some awareness of the period

after discharge. All the women vividly described an aftermath

phase, which included feelings of distress, sadness and guilt.

Guilt has been implicated in the intensity of women’s feelings

of depression and anxiety after miscarriage. If no cause can

be identified for the miscarriage, then parents may blame

themselves or each other:

John was very upset and he just said it’s all right and I said sorry

to him. Which is something that err, I gathered happens a bit.

People apologise, apologise to my husband for losing the child.

Which I felt also very odd about and he was very sur-

prised ‘why are you saying sorry? Don’t think like that’. (Gemma,

p. 2)

Studies on pregnancy loss use an explanatory framework of

grief, also identify that women at some stage may feel a sense

of social disengagement and alienation. This may lead to

feelings of depression and a sense of loss of purpose

(Friedman & Gath 1989, Malacrida 1998). However, the

women in the interviews did not label themselves as

depressed not using that concept to describe their experience.

Indeed Megan rejected this, feeling that attaching the label of

depression enhanced the likelihood that the person would

become depressed:

It’s true miscarriage is a very bad thing in your life, but you will have

a baby anyway, all this positive side. I mean you shouldn’t treat

people like they, they go to depression because ..’oh poor thing she’s

got to be referred to someone’. (Megan, p. 31)

Six of the eight women talked of sadness, which was there not

only at the beginning when the miscarriage happened but also

persisted long term:

Yes, well I don’t think I felt depressed. Really sad, you would be and

emotional and crying for no reason and all that kind of stuff

hum…and not so much angry I don’t think I was angry. I think I was

more sad and a bit you know the whole control thing, it was just

something, like I didn’t expect it. (Jane, p. 7)

Four of the eight women did use the terms grief and

bereavement in describing their experiences and Emma was

one of them. She clearly stated that to her miscarriage was

bereavement and reported feelings of emptiness:

But I wasn’t expecting to feel the way I did…..to have this baby. It

was even as if my womb was empty. It was very... I can’t even

describe the feeling; it’s a very, very strange feeling, very strange

feeling-empty, empty womb. Oh yes, yeah, really I, as if part of me

had gone. Yes it’s a part of me, all hopes, it was almost despair really.

(Emma, p. 1)

Thus, there was variation between women in how they

conceptualised their feelings after miscarriage. The hospital

health professionals were also not unanimous in regarding

miscarriage as bereavement. They described how women

could react very differently to miscarriage and assumptions

should not be made as to how women may feel:

Check how they’re feeling really, not everybody is going to be upset

after miscarriage. Perhaps they didn’t want the pregnancy anyway,



for some people it might be relief. So you check that sort of

situation really, feel your way around how they’re feeling. (Zoe,

nurse, p. 1)

Within this aftermath phase was also a sense of women

adjusting and moving towards a new identity; that of a

woman who has had a miscarriage. A consequence of this

was a vulnerability and uncertainty that they could have a

successful pregnancy thus some decided not to become

pregnant again:

Within the year I was sterilised….cos hum…I didn’t want to do that

again, I didn’t want that to happen again. And we sort of talked at

length about whether we really, really would plan to have children.

So we decided that we wouldn’t so hum…so that was the only way to

protect me from that happening again. (Caroline, p. 3)

Half of the women in reflecting on their experience talked

about ‘getting back to normal’. There was sense of time

moving on with some form of recovery and resolution:

Er…time makes you less and less I think uhm, uhm, you think

about it less and less. You just get on with life and you do.

(Gemma, p. 7)

It was not predictable in terms of time when this occurred.

Some of the women interviewed had the benefit of hindsight

to recognise that it had happened and some had not reached

that point.

Discussion: early miscarriage as transition

The women’s feelings and emotions identified in this study

are in accordance with those described in the literature

(Moulder 1998, Maker & Ogden 2003, Adolfsson et al.

2004). The dominant perspective in the current literature is to

view early miscarriage as bereavement (Reagan 2003), which

frames the care that nurses should provide. Miscarriage is a

crisis for some women being painful, sad and distressing that

is remembered years after the event. However, the labelling

of women’s responses to miscarriage as grief implies that this

is a universal response which may not be true for all women

(Swanson 1999b). Grief models, particularly Parkes (1996)

and Worden (1991) together with the lay literature (Moulder

1998) have been important in the construction of early

miscarriage as bereavement. However, there are problems in

applying such models of grieving to early miscarriage.

Models of adult grieving, in particular the work of Parkes

are underpinned by attachment theory (Bowlby 1965). This

looked at the attachment between infants and their mothers,

in particular when they separated. Bowlby identified stages in

this separation of moving from distress through to

detachment underpinned by psychoanalytic theories of sep-

aration anxiety, grief and defence mechanisms (Small 2001).

Attachment theory has been used to provide an explana-

tion for women’s feelings and behaviours after perinatal loss

as it has been conceptualised as attachment to and then loss

of the baby (Mander 1994, Robinson et al. 1999). If this

theory is accepted then there is an attachment to something

which is then lost, then there is an emotional response. The

problem with the application of this theory to losses in

childbearing and in particular early miscarriage is that it is

not quite as Bowlby envisaged it. He was considering the

attachment of the child to their parents and their distress at

separation, where the parent as an attachment figure is seen

as a source of protection and security (Shaver & Tancredy

2001). In pregnancy loss, the mother may indeed be attached

to the foetus and seek to protect it before it is born but in

early miscarriage the foetus may not be considered as a

source of protection and security. Similarly, Parkes use of this

theory was applied to the loss of a husband, where the widow

had formed an often-long relationship with the deceased.

Given these two issues, it is questionable whether this theory

and hence models of adult grief can be appropriately applied

to early miscarriage.

The exploration of the culture and practices of the unit, the

interpretation of the meanings attached to miscarriage by

both health professionals and women in this study led to a

re-interpretation. It appeared that not all women and health

professionals agreed that miscarriage should be considered as

bereavement. Rather than being interpreted solely as bereave-

ment it is proposed that early miscarriage be considered as a

complex, significant life event, which initiates a period of

transition. To support this, two theoretical positions are

drawn on.

The first is from an anthropological perspective (van

Gennep 1960). He was interested in how individuals and

societies negotiated the change in status in certain key life

events such as birth, marriage and death and how these were

managed to achieve social order. He identified three key

phases; separation, transition or limen and finally incorpora-

tion (Draper 2003). Separation involves some kind of

removal of the individual from their normal social life that

marks them as beginning their change in position. This study

suggests that the diagnosis and treatment intervention phase

of the woman’s experience confirms and initiates this phase

of transition. The second or transitional phase is one of

potential danger, where the individual has begun the process

but has not yet passed into the third stage of incorporation. In

this study, this was clearly identified within the aftermath

phase, where the woman psychologically negotiates her way



through the ‘what could go wrong world’. The final stage is

incorporation where the individual has successfully negoti-

ated the transition and begins their new role. This was

apparent in women’s accounts of their recovery, as they

incorporated their new identity as a woman who has had a

miscarriage.

The second is drawn from psychology. Although these

anthropological theories offer a tool to provide an overview

of women’s experiences, they could not account for how

individuals may respond to transitions. A useful model draws

on psychology and human response to change (Williams

1999). This model identifies that a life event such as

miscarriage can be perceived positively or negatively with

five key stages. These stages are identified as ‘first shock’,

‘provisional adjustment’, ‘inner contradictions’, ‘inner crisis’

and finally ‘reconstruction and recovery’. Thus negotiating

transitions, involves hard psychological work in confronting

the change, managing the contradictions and crisis points and

reaching the opportunity to achieve new growth (Williams

1999). All these stages were evident in the women’s accounts.

Conceptualising miscarriage as transition therefore, allowed

the incorporation of a grief response as a possible important

feature of this transition for some women but not necessarily

all. Indeed some women themselves although they described

strong and intense emotions did not identify themselves as

bereaved. Additionally, the health professionals were not

unanimous that miscarriage was bereavement. Transition

accommodates a wider range of possible responses to

miscarriage than just those of grief. Part of the utility of

transition, is that it allows the possibility that some women

will indeed see early miscarriage as bereavement and will

grieve but some may feel relief. It allows for the possibility

that women may feel ambivalent, anxious, distressed, angry,

upset and even depressed but that can be a characteristic of

transition without it necessarily needing to be labelled as

bereavement. It recognises that even if a significant event is

perceived positively there are still consequences (Williams

1999). Hence there should not be an expectation by nurses

that all women should feel bereaved, as other feelings are also

legitimate. Models of grieving are based on attachment to a

person who has lived, transition models are more able to

accommodate other kinds of loss (Williams 1999). Models of

transition did appear more appropriate than grief models in

reflecting women’s experiences, how miscarriage was man-

aged within this hospital setting and what was observed.

Relevance to clinical practice

Although further research is needed in other hospital

settings to substantiate the findings, they may offer useful

insights which may be transferable to other hospital

settings that manage miscarriage in a similar way (Mason

2002).

Meleis et al. (2000) argue that transition is a key concept in

nursing and helping patients or individuals through transi-

tions is an important nursing activity. Thus conceptualising

miscarriage as transition has several implications for nurses

and other health professionals. The first is to recognise the

importance of the hospital stay in the transitional process and

that staff actions are extremely influential in how women

negotiate this transition. Nurses and other health profession-

als need to continue to work to seek to understand what the

miscarriage means to the woman. They could demonstrate

this by carefully assessing the woman and her response

recognising that this can be varied. They need to be able to

anticipate and react appropriately to a wide range of feelings

and responses to miscarriage but not prematurely categorise

the woman as grieving. It might be appropriate to offer

psychological first aid (Bennett et al. 2005) in this early phase

of the transition. This consists of consciously avoiding care

and treatment that is not engaged, respectful or sensitive.

Expressing genuine concern, demonstrating emotional aware-

ness (Allan 2001) and engagement with the woman (Swanson

1991, Kohner 1995, Moulder 1998) continue to be of

importance.

Second, nurses and health professionals need to continue to

be aware of how distressing and anxiety provoking miscar-

riage is (Cumming et al. 2007). They need to be able to

provide information, contact and reassurance. Awareness

that women experiencing an early miscarriage may feel

forgotten and alone in busy ward settings requires nurses to

be proactive rather than reactive to meet their emotional and

physical needs.

Finally, this study reiterates that the impact of early

miscarriage extends far beyond the hospital stay. Some

women may need help and support in this period, which

could be offered by nurses and other health professionals.

This has implications for discharge planning which could

involve offering formal follow up appointments by the

hospital, improving the services offered by the primary

health care team and making women more aware of other

sources of support such as lay support groups.

Limitations

The study was conducted in one setting over a time-limited

period in one particular culture. Additionally, the women

interviewed were mainly white, educated, middle-income

women and did not fully reflect the diversity of the popula-

tion attending the unit.



Conclusion

This study makes an important contribution to aiding

understanding of women’s experiences in a hospital setting.

Through in-depth examination of the care given to women

within a hospital gynaecological unit the meanings and

interpretations attached to miscarriage by women and health

professionals were identified. It was evident that the concep-

tualisation of early miscarriage as bereavement was not

shared by all women and by all health professionals in this

setting. An alternative is to consider early miscarriage as a

process of transition marked by phases of separation,

transition and incorporation. This provides a wider perspec-

tive to frame the nursing care provided which is more able to

meet the individual needs women experiencing miscarriage.

Contributions

Study design: FM, JM; data collection and analysis: FM and

manuscript preparation: FM, JM.

Funding

No funding source was obtained.

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Negotiating the transition: caring for women through the experience of early miscarriage

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