UNIVERSITEIT GENT

Faculteit Geneeskunde en Gezondheidswetenschappen

Academiejaar 2015-2016

KENNIS, ATTITUDE EN PRAKTIJKERVARING VAN VLAAMSE

VROEDVROUWEN OMTRENT SPONTANE ABORTUS

KNOWLEDGE, ATTITUDE AND PRACTICES OF THE FLEMISH MIDWIVES

CONCERNING SPONTANEOUS ABORTION

A descriptive questionnaire-based research

Masterproef voorgelegd tot het behalen van de graad van

Master in de Verpleegkunde en de Vroedkunde

Door Marjon De Roose & Emmie Vanhooren

Promotor: Prof. dr. Els Clays

Co-promotor: Prof. dr. Inge Tency

UNIVERSITEIT GENT

Faculteit Geneeskunde en Gezondheidswetenschappen

Academiejaar 2015-2016

KENNIS, ATTITUDE EN PRAKTIJKERVARING VAN VLAAMSE

VROEDVROUWEN OMTRENT SPONTANE ABORTUS

KNOWLEDGE, ATTITUDE AND PRACTICES OF THE FLEMISH MIDWIVES

CONCERNING SPONTANEOUS ABORTION

A descriptive questionnaire-based research

Masterproef voorgelegd tot het behalen van de graad van

Master in de Verpleegkunde en de Vroedkunde

Door Marjon De Roose & Emmie Vanhooren

Promotor: Prof. dr. Els Clays

Co-promotor: Prof. dr. Inge Tency

Preface

First and foremost, we are grateful for the good cooperation and would like to express

our gratitude to each other for the efforts we both made for this thesis. We were always

able to count on each other. At the start of this project we were two strangers to one

another, but by the end of it we became two good friends.

During one year and a half, we worked together to complete this thesis. A lot of

patience and perseverance was necessary, but we also experienced this time as an

instructive and interesting trip. Executing this thesis would not have been possible

without the help of certain people. Therefore, we would like to thank some people for

their support.

We especially would like to thank our tutors, Prof. dr. Els Clays and Prof. dr. Inge

Tency, for their guidance. We are grateful for all of their help and support during

challenging times. They were always available to give advice or feedback and

motivated us to bring this thesis to a good end.

Furthermore, we also want to express our gratitude to the people who participated in the

Delphi procedure to develop our questionnaire. We would also like to thank the

hospitals that wanted to participate in our study and of course all the Flemish midwives

who were willing to complete our questionnaire. Furthermore, we would also like to

express our gratitude to the senior midwives for both motivating their team and

following up the response.

For critically reading and correcting our scientific article, we would like to thank Evi

Vanhooren, Laura McCarthy and Kim Collewaert. Finally, we are sincerely grateful to

our parents, sisters, and Cédric for all their support during the past two years.

Ghent, 17 May 2016.

Number of words thesis: 5,791 (preface, table of contents, abstract, tabels, appendices

and references excluded)

Explanation duo thesis

Two students were linked to this study on request of both the tutor and the co-tutor. This

thesis was a large-scale Knowledge, Attitude and Practical experience (KAP) study

where more than fifty different hospitals had to be included with an estimated number

of three thousand midwives. During data collection, students were responsible for

printing, distributing and collecting the questionnaires. Keeping into account the large

number of participating hospitals, this phase would have taken up too much time and

(transport) costs for one student. Furthermore, the data analysis phase was too extensive

for one student since each participant had to complete a questionnaire of ten pages. The

input and analysis of the data were mainly done by the students themselves. In the given

timeframe, collaboration between two students was necessary.

Both students continuously worked together on this thesis. All parts were brought about

together or were equally divided and then discussed together. That was the case for,

among other things, the composition of the questionnaire, the organization of the Delphi

procedure, contacting the hospitals, the distribution and collection of the questionnaires,

the input and analysis of the data and writing of the scientific article. Consequently,

both students have contributed equally to this thesis.

Table of contents

Preface .............................................................................................................................. 6

Explanation duo thesis ...................................................................................................... 7

Abstract (Dutch) ............................................................................................................. 10

Abstract ........................................................................................................................... 11

Introduction .................................................................................................................... 12

Methods .......................................................................................................................... 14

Study design and population ...................................................................................... 14

Setting and participants .............................................................................................. 14

Data collection ............................................................................................................ 15

Statistical analysis ...................................................................................................... 15

Ethical approval .......................................................................................................... 15

Findings .......................................................................................................................... 16

Characteristics of the participants............................................................................... 16

Knowledge .................................................................................................................. 18

Attitude ....................................................................................................................... 19

Practical experience of Flemish midwives ................................................................. 22

Barriers and perspectives ............................................................................................ 23

Discussion ....................................................................................................................... 26

Current knowledge of spontaneous abortion .............................................................. 26

The attitude of the Flemish midwife regarding spontaneous abortion ....................... 28

Spontaneous abortion and the current care provision ................................................. 30

Perceived barriers and perspectives ............................................................................ 30

Strengths and limitations of the study ........................................................................ 31

Conclusion and practical implications ............................................................................ 32

Conflict of interest .......................................................................................................... 33

Acknowledgements ........................................................................................................ 33

References ...................................................................................................................... 34

Appendix ........................................................................................................................ 36

Appendix 1: Information letter for the participants .................................................... 37

Appendix 2: Questionnaire ......................................................................................... 39

Appendix 3: Distribution of respondents over the wards ........................................... 49

Abstract (Dutch)

Achtergrond: Spontane abortus is een frequent voorkomend probleem. De vroedvrouw

is een van de belangrijkste zorgverleners voor koppels die geconfronteerd worden met

spontane abortus. Een grootschalige studie omtrent Kennis, Attitude en Praktijkvoering

(KAP) van Vlaamse vroedvrouwen (in België) ontbreekt echter tot op heden.

Doelstelling: Deze studie wil de kennis, attitude en praktijkvoering van Vlaamse

vroedvrouwen omtrent spontane abortus in kaart brengen.

Methodologie: Er werd gebruik gemaakt van een kwantitatief descriptief

onderzoeksdesign met een semi-gestructureerde vragenlijst.

Setting en participanten: Vroedvrouwen werkzaam op materniteit, verloskwartier,

gynaecologische diensten, maternale en neonatale (intensieve) zorgen, prenatale

consultaties en fertiliteitsafdelingen van 28 Vlaamse ziekenhuizen werden geïncludeerd.

Resultaten: In totaal werden 647 geldige vragenlijsten terugbezorgd (54%). De

gemiddelde kennisscore was 6,40 op 10. De meerderheid van de respondenten (97%)

ziet een sleutelrol weggelegd voor de vroedvrouw in de emotionele begeleiding van

koppels met spontane abortus. Minder dan de helft van de vroedvrouwen heeft in de

afgelopen zes maand koppels met een spontane abortus begeleid. Tijdsgebrek,

onbekwaamheid en de angst eigen emoties niet te kunnen beheersen, worden

aangegeven als voornaamste barrières in het geven van goede (emotionele)

ondersteuning. Maar liefst 89% geeft aan nood te hebben aan bijscholing omtrent

spontane abortus.

Conclusie: In Vlaanderen zijn vroedvrouwen betrokken in de zorg voor koppels met

een spontane abortus. Ze beschouwen zichzelf hierbij als een van de belangrijkste

zorgverleners. Meerdere barrières worden echter ervaren, zoals een tekort aan kennis.

Dit kan de kwaliteit van zorg (negatief) beïnvloeden. Extra aandacht voor (bij)scholing

van (student-)vroedvrouwen rond spontane abortus is daarom van groot belang.

Trefwoorden: Spontane abortus, Vroedvrouw, KAP-studie

Abstract

Background: Spontaneous abortion is a common problem in obstetrics. Midwives have

an important role in the care for couples dealing with spontaneous abortion. However,

no large scale study covering Knowledge, Attitude and Practical experience (KAP) of

midwives on this subject has been performed in Flanders (Belgium) before.

Objective: The objective of this study was to assess knowledge, attitude and practical

experience concerning spontaneous abortion of Flemish midwives.

Design: A quantitative descriptive KAP study was performed using a semi-structured

questionnaire.

Setting and participants: Midwives, working on maternity, labour and gynaecological

wards, maternal and neonatal (intensive) care units, antenatal consultations and

reproductive medicine within 28 Flemish hospitals, were included.

Findings: A total of 647 valid questionnaires was returned (54%). The mean knowledge

score was 6.40 out of 10. The majority (97%) indicated a key role for midwives in the

emotional guidance of couples with spontaneous abortion. About 47% of the midwives

recently guided such couples. Lack of time, incapability and fear of being overtaken by

feelings were indicated as main barriers for the delivery of (emotional) care. Almost

89% expressed the need for extra training on spontaneous abortion.

Key conclusions: Flemish midwives assist in the care for couples with spontaneous

abortion. They consider themselves as one of the prime care givers. However, midwives

experience several barriers, e.g. a lack of knowledge, which could influence the

provision of adequate care.

Implications for practice: The study highlights the importance of adequate training of

(student)midwives including theoretical knowledge on spontaneous abortion and

communicative skills.

Keywords: Spontaneous abortion, Midwives, KAP study

12

Introduction

Spontaneous abortion or miscarriage is one of the most common problems in obstetrics

with an incidence varying from 10 to 25% of all pregnancies (Buysse 2013, Carnarneiro

2015, KCE 2014, Regan 2000). The variation in incidence may be related to the use of

different definitions of spontaneous abortion in terms of presentation and weeks of

pregnancy.

For instance, spontaneous abortion can be classified in imminent, inevitable, incomplete

and complete abortion as well as missed abortion (Zeqiri 2010). Other definitions

include some of those categories (Graefe 2003, Tulandi 2015). Furthermore, there are

different definitions of spontaneous abortion and stillbirth according to the number of

weeks of pregnancy. The World Health Organization (WHO) advises to define a birth as

stillborn from the 22nd week of pregnancy or when the baby weighs at least 500 grams

(WHO 2006). However, the most common definition in Flanders for spontaneous

abortion is up to 16 weeks of pregnancy (Flikweert 2004, van Dale 2015).

According to several (inter)national organizations, the midwife has a considerable role

in guiding couples with spontaneous abortion. For example, one of the competencies in

the competency profile of the International Confederation of Midwives (ICM), is

completely dedicated to the facilitation of abortion-related care (ICM 2013). In contrast,

miscarriage or spontaneous abortion is not mentioned in the professional profile of the

Belgian midwives “Beroepsprofiel van de Belgische Vroedvrouw” (Federale Raad voor

de Vroedvrouwen 2015). However, the role of the midwife during spontaneous abortion

is acknowledged in the nomenclature of the National Institute for Health and Disability

Insurance (NIHDI). It is mentioned under obstetric care in article 9 as ‘monitoring and

attending a miscarriage at home and in a hospital environment’ (VLOV 2014). In other

words, the midwife is assumed to possess sufficient knowledge and skills to guide a

woman adequately during spontaneous abortion.

13

Research on knowledge, attitude and practical experience of (illegally) induced

abortions has already been performed, especially in developing countries. The

conducted research mainly concerns induced abortions (Abdi 2011, Afhami 2016,

Kestler 2012). Moreover, the transfer of those results to the Belgian context is difficult

due to the many differences between the health care system in developing countries and

the Belgian health care system. Knowledge, Attitude and Practical experience (KAP)

studies on spontaneous abortion are rare. Existing studies on spontaneous abortion focus

either on the knowledge, attitude or practical experience of midwives in relation to

spontaneous abortion (Engel 2016, Hill 2014, Montero 2011). Only one KAP-study

focusing on treatment possibilities for spontaneous abortion among different caregivers

was found (Dalton 2010). Since there is no research conducted in a context comparable

to the Belgian context concerning the wider knowledge, attitude and practical

experience on spontaneous abortion, the goal of this research was to perform a

widespread study that identifies the knowledge, attitude and practical experience of

spontaneous abortion of Flemish midwives.

Research objectives

The objectives of this KAP study were:

to investigate the knowledge of Flemish midwives about the definition,

aetiology, treatment, complications, and the Belgian legislation of spontaneous

abortion;

to explore the attitude of Flemish midwives concerning their role and specific

tasks in guiding couples with spontaneous abortion;

to examine how the Flemish midwife assists in the care of couples with

spontaneous abortion;

to discuss the barriers and perspectives experienced by Flemish midwives when

guiding couples with spontaneous abortion.

14

Methods

Study design and population

A quantitative research was conducted using a semi-structured, self-administered

questionnaire that investigated knowledge, attitude and practical experience towards

spontaneous abortion among midwives in Flanders (Northern region of Belgium). The

questionnaire was developed after an extensive literature research and a single Delphi

procedure amongst a panel of ten professionals who were not part of the study

population (obstetricians, general practitioners, lecturers in midwifery and midwives).

Ten non-professionals (secondary school students without any medical background and

university and university college students within health care sciences) were also asked

to give written feedback. The panel evaluated the questionnaire on the

comprehensibility, clarity and content validity. All feedback was integrated in the final

version of the questionnaire.

Setting and participants

The study population consisted of all midwives working on maternity wards, labour

wards/delivery rooms, neonatal care units (N*), neonatal intensive care units (NICU),

maternal intensive care units (MIC), antenatal consultations, reproductive medicine and

gynaecological wards within Flemish hospitals (n=55). This study was based on the

methodology used in the KAP study on female genital mutilation by Cappon and

L’Ecluse (Cappon 2015).

All hospitals in the five Flemish provinces and one Dutch-speaking hospital in the

Brussels-Capital Region were asked to participate in the study. That means that all

geographical regions in Flanders were included. An approval for distribution of the

questionnaires was requested from every hospital board and the departmental heads.

The non-responding hospitals were contacted by telephone or email and were invited to

participate.

15

Data collection

Every questionnaire included an information letter, explaining both the context and the

aim of the study. The information letter can be consulted in appendix 1. Written

instructions (such as ‘only one answer possible’) were also given in order to correctly

complete the questionnaire, which was anonymous. The questionnaire included

questions regarding the knowledge of spontaneous abortion and the medical and legal

context in Belgium, as well as questions on attitude and practical experience, when

caring for women who experienced spontaneous abortion. The questionnaire is included

in appendix 2. The questionnaires were distributed in all participating hospitals between

September 2015 and January 2016. Regularly, a reminder was sent to the senior

midwife or nurse to follow up the response. In February 2016, the survey was closed.

Statistical analysis

SPSS statistics 22.0 software was used for the data analysis. The main analyses were

descriptive. A sum score was calculated for all knowledge questions. Each answer

possibility was assigned an equal weight. All answers to open-ended questions were

described and grouped separately. Chi2, independent samples T-tests, one-way

ANOVAs and logistic regressions were used to analyse differences between groups.

Results were considered as statistically significant if the p-value was ≤ 0.05.

Ethical approval

The study was approved by the Ethical Committee of Ghent University Hospital

(EC/2015/0589 and EC/2015/0590). By completing the questionnaire, the participant

automatically agreed to the terms of the study. All permission forms from the

participating hospitals were sent to the Ethical Committee of Ghent University Hospital

as amendment. If the hospital management required this, a supplementary application to

the local Ethical Committee of the hospital concerned was submitted.

16

Findings

Characteristics of the participants

Out of 55 Flemish hospitals 28 hospitals agreed to participate (51%). A total of 647

valid questionnaires were completed and returned (54%). Two university hospitals were

included, accounting for 82 out of 647 respondents (12.7%).

Almost all participating midwives were female (99.4%). The vast majority of the

participants was younger than 40 years (66.1%) and 69.2% of the participants had less

than 20 years of work experience. The older the midwife, the longer the work

experience (rs = 0.91, p < 0.001).

Most participants were employed at maternity ward (71.5%), labour ward/delivery room

(68.3%) and neonatal (intensive) care (33.4%). Approximately 42% of all participants

worked full-time. About one third (30.9%) worked less than seventy-five per cent, while

another 27.2% worked between seventy-five per cent and full-time. The older the

midwife, the lower the employment percentage (rs = -0.45, p < 0.001).

Table 1 gives an overview of the participant characteristics. Appendix 3 provides a

summary of the number of midwives employed at a single ward in comparison to the

number of midwives employed at multiple wards.

17

Table 1: Participant characteristics

Characteristics N valid Valid %

Sex (n = 634)

Female 630 99.4

Male 4 0.6

Age (years) (n= 634)

< 40 419 66.1

≥ 40 215 33.9

Type of hospital (n= 647)

Peripheral 565 87.3

University 82 12.7

Ward* (n= 635)

Maternity 454 71.5

Labour ward 433 68.3

N*/NICUa 212 33.4

MICb 71 11.2

Antenatal consultations 55 8.7

Reproductive medicine 51 8

Gynaecology ward 59 9.3

Position

Midwife 605 95.6

Senior midwife 28 4.4

Work experience (years) (n=620)

< 20 448 69.2

≥ 20 199 30.8

*Note that midwives can be employed at several wards a N* = Neonatal ward, NICU = Neonatal Intensive Care Unit b MIC = Maternal Intensive Care

18

Knowledge

The total sum-score for knowledge was calculated and ranged from 3.82 to 8.82 out of

10, with a mean score of 6.40 (s.d. = 0.92). About 23% of the participants were able to

give the correct definition of ‘spontaneous abortion’. Respectively 65.3% and 48.5% of

the respondents did not classify ‘abortus imminens’ and ‘abortus incipiens’ as

spontaneous abortion. The majority (70.5%) defined ‘abortus incipiens’ correctly.

Almost four out of five respondents (78.3%) identified at least half of the risk factors

for spontaneous abortion. However, both the use of Non-Steroidal Anti-Inflammatory

Drugs (NSAIDs) during the first trimester of pregnancy (71.4%) and a low sperm

quality (86%) were not recognized as possible risk factors. Furthermore, 42.9% of the

respondents were not aware that having two or more miscarriages in the obstetric

history is also a risk factor for spontaneous abortion.

The use of misoprostol in preparation to curettage as a treatment method for

spontaneous abortion, seemed to be well-known by most respondents (98.4%).

Nevertheless, only 7.3% of the participating midwives indicated the correct

recommended dose and route of administration for misoprostol. Mifepristone was

recognised as a preparation method for curettage by about half of the respondents

(49.1%). However, the use of laminaria (seaweed) to dilate the cervix in preparation for

curettage appeared to be rarely known (5.5%). Infection (89.2%) and uterine perforation

(84.4%) seemed to be well-known complications of a classical curettage. The

Asherman’s Syndrome (intrauterine adhesions), by contrast, was marked by 54.3% of

all participants.

With regard to the legal qualifications, 56.9% of all participants indicated that the

Belgian midwife is not authorized to diagnose pregnancy even though she is. Half of

them (51.7%) would refer women to an obstetrician to diagnose pregnancy.

Nevertheless, 37.2% of all midwives indicated that they are allowed to perform an

ultrasound scan for the pregnancy diagnosis, provided that they have the appropriate

qualifications. Only 35.3% answered correctly that the Belgian midwife is prohibited by

law to perform pregnancy termination (in case of a viable embryo). Two thirds of the

respondents (61.9%) assumed that the midwife is allowed to perform pregnancy

termination when ordered by a doctor.

19

The total sum-score for knowledge differed significantly between the hospitals. In

particular, the university hospitals scored significantly higher (x̅ = 6.73) compared to

the peripheral hospitals (x̅ = 6.36, p < 0.01). However, there was no significant

difference according to the geographical region. Differences in knowledge on

spontaneous abortion seemed to be irrespective of age, position, ward, employment

percentage, work experience and the availability of a standard procedure. In addition,

knowledge seemed not to be influenced by the search for additional information, by

whether the topic ‘spontaneous abortion’ was part of the midwifery education or not,

nor by the feeling of being adequately trained.

The results showed that spontaneous abortion was more often part of the midwifery

education of younger midwives (less than 40 years), than of midwives 40 years and

older (70.8% vs. 29.2%, p < 0.01). Midwives more often evaluated their knowledge as

adequate when spontaneous abortion was included in the midwifery education (31% vs.

17.3%, p < 0.001). In contrast, midwives aged 40 years and above experienced their

knowledge about spontaneous abortion as more sufficient compared to younger

midwives (less than 40 years) (32.2% vs. 23.8%, p < 0.05). Midwives indicating that

their knowledge on spontaneous abortion is adequate, had significantly higher scores

than midwives who estimated their knowledge as unsatisfactory (x̅ = 6.58 vs. x̅ = 6.35

out of 10, p < 0.05).

Attitude

The majority of the participants categorized spontaneous abortion as a normal event

induced by nature (38.6%), the loss of a child (35.4%) or a pathological outcome of

pregnancy (12.8%). The respondents indicated the midwife as an important

caregiver in psychological and emotional care both after spontaneous abortion (90.1%)

and at the time of diagnosis (89.9%). The midwife was also considered to be the

appropriate caregiver for the preparation on the medical treatment and/or on curettage of

spontaneous abortion (69.5%). However, many respondents did not consider the

midwife to be capable of being the only responsible for the diagnostics of spontaneous

abortion (87.8%), the medical follow-up (68.6%), nor the medical treatment of

spontaneous abortion without complications (59.3%).

20

The midwife, and not the obstetrician, was considered to be the prime caregiver in

psychological and emotional care (83.1%) and in informing the couple of discussion

groups, websites and follow-up (75.3%). Table 2 gives a more detailed overview of the

tasks within the care of spontaneous abortion and the prime caregiver of those tasks, as

indicated by the respondents.

Up to 97.0% of the respondents indicated the midwife should have a key role in the

emotional support of couples with spontaneous abortion. Age, knowledge about the

subject, or the number of women with spontaneous abortion in the past six months did

not influence that attitude. However, midwives informed of the topic ‘spontaneous

abortion’ during their midwifery education compared to those who were not, more often

indicated that the midwife has an important role in the care for couples with

spontaneous abortion (respectively 98.8% and 94.1%, p = 0.001).

The following aspects are indicated as the most important elements of the provided

care: informing of pain (99.1%), psychological and emotional care (98.0%), informing

of blood loss (97.8%), medical care (95.9%) and informing of future chances of

pregnancy (91.8%). Table 3 gives an overview of the importance of all aspects of care

during spontaneous abortion according to the respondents.

More than half of the respondents (56.4%) looked up some additional information of

spontaneous abortion in the past. That information was mostly obtained via internet

(37.3%). Other channels used to obtain additional information were further training

(27.7%), colleagues (26.4%) and (reference) books (16.7%). Almost 89% of the

respondents would like to have extra training on this subject. Midwives who are less

than 40 years old more often indicated the need for extra training on spontaneous

abortion than midwives aged 40 and above (respectively 91.5% and 83.5%, p < 0.01).

Also, midwives who received less than 10 women with spontaneous abortion over the

past six months experienced a higher need for extra training than midwives who

received women more often (respectively 86.9% and 67.5%, p < 0.01).

The need for extra training did not differ according to the availability of a standard

procedure on the ward nor to past research for additional information.

21

Table 2 – Prime caregiver assigned to different tasks within the care of spontaneous abortion

Tasks within the care of spontaneous abortion Prime caregiver

Midwife Obstetrician Both

N valid

(Valid%)

N valid

(Valid%)

N valid

(Valid%)

Psychological and emotional care 528 (83.1%) 52 (8.2%) 55 (8.7%)

Informing of discussion groups, websites and follow-up 476 (75.3%) 113 (17.9%) 43 (6.8%)

Informing of pain 312 (49.1%) 266 (41.9%) 57 (9.0%)

Informing of blood loss 286 (45.2%) 283 (44.5%) 65 (10.3%)

Medical care 67 (10.5%) 537 (84.6%) 31 (4.9%)

Informing of future chances of pregnancy 38 (6.0%) 572 (89.9%) 26 (4.1%)

Informing of future reoccurrence of abortion 12 (1.9%) 606 (95.4%) 17 (2.7%)

Informing of possible causes of abortion 10 (1.6%) 608 (95.3%) 20 (3.1%)

Informing of additional diagnostic tests for causes 4 (0.6%) 621 (97.5%) 12 (1.9%)

Table 3 – Importance assigned to different elements of the care of spontaneous abortion

Elements of the care of spontaneous abortion Importance

Important Not important Neutral

N valid

(Valid%)

N valid

(Valid%)

N valid

(Valid%)

Informing of pain 610 (96.0%) 4 (0.5%) 22 (3.5%)

Psychological and emotional care 610 (96.0%) 8 (1.2%) 17 (2.8%)

Informing of blood loss 607 (95.4%) 12 (1.9%) 17 (2.7%)

Medical care 585 (93.0%) 18 (2.9%) 26 (4.1%)

Informing of future chances of pregnancy 568 (89.4%) 47 (7.4%) 20 (3.2%)

Informing of possible causes of abortion 555 (87.6%) 48 (7.6%) 30 (4.6%)

Informing of discussion groups, websites and follow-up 547 (86.3%) 56 (8.8%) 31 (4.9%)

Informing of additional diagnostic tests for causes 543 (86.0%) 65 (10.3%) 24 (3.7%)

Informing of future reoccurrence of abortion 513 (81.5%) 96 (15.2%) 21 (3.3%)

22

Practical experience of Flemish midwives

During the past six months, less than half of the participating midwives (46.9%) guided

women who faced spontaneous abortion. Of those midwives, the majority declared

that they had supervised between one to ten women (86.7%). Only 13.3% of the

participating midwives guided more than ten women. Of those women, 35.2% were

admitted to hospital for suction curettage, 31.2% for medical induction, 18.1% for

observation and 6.4% for classical curettage (as reported by the participants). Most of

the participating midwives (47.8%) indicated that a standard procedure (on the subject

of spontaneous abortion) is available at their ward(s) and that they act according to it.

Another 17.3% of the respondents declared that a standard procedure exists at the

ward(s), but sometimes they depart from it. Approximately one third (34.9%) said a

standard procedure is unavailable at the ward(s) where they work.

The number of women with spontaneous abortion supervised in the past six months

varied strongly across the ward(s). A detailed overview of the odds for midwives to

guide women with spontaneous abortion on different wards is included in table 4. A

total of 73% of the midwives working only at maternity ward did not care for any

women with spontaneous abortion in the past six months. Moreover, 95.2% of the

midwives who are solely employed at neonatal (intensive) care did not come into

contact with such women in the past six months. Midwives only working at labour ward

have 4.88 times higher odds to care for women with spontaneous abortion, compared to

midwives who solely work at reproductive medicine (p = 0.001). Working at different

wards increased the chance of being confronted with women who experienced

spontaneous abortion. For example, midwives working at maternity ward, labour ward

and antenatal consultations had 6.57 times higher odds (p < 0.01) to supervise women

with spontaneous abortion than midwives who only work at reproductive medicine.

The type of hospital also influenced the number of women -confronted with

spontaneous abortion- supervised by a midwife in the past six months. Midwives

working in university hospitals had 3.17 times higher odds to guide women within the

past six months than midwives who work in peripheral hospitals (p = 0.001). The

number of women guided, however, did not differ according to the employment

percentage, the age nor the function of the midwife.

23

Barriers and perspectives

In the care for couples with spontaneous abortion, certain barriers can be identified.

First of all, more than two thirds (66.8%) of the respondents indicated that they are not

able to give adequate emotional guidance to couples. The main issues were lack of time

(57.9%), incapability (49.5%) and the fear of being overtaken by their own feelings

(9.4%).

Whether a midwife indicated to be able to give adequate emotional guidance or not

depended on several factors, such as age, ward/department and geographical region.

Consult table 5 for a more detailed overview of the results.

Age was found to strongly correlate with work experience and employment percentage.

The feeling of being able to give adequate emotional guidance did not differ on those

variables when controlled for age. When a midwife is 40 years or older, she was 3.40

times more likely to feel like she is able to give an adequate emotional guidance to

couples with spontaneous abortion than a midwife of less than 40 years old. Midwives

who are working only at labour ward were 2.73 times more likely to feel able to give an

adequate emotional guidance than those employed only on reproductive medicine (p <

0.01). No other significant results were found on ward or department level.

Midwives in Antwerp, felt less able to give adequate emotional guidance to couples

with spontaneous abortion than midwives who are employed in other geographical

regions (Limburg and West Flanders). Midwives in Limburg and West Flanders were

respectively 3.02 and 1.97 times more likely to feel able to give sufficient emotional

care to couples with spontaneous abortion than midwives in Antwerp (p < 0.05). No

significant differences were found on hospital level.

In the care for couples with spontaneous abortion, some perspectives could be

identified. Only 41.8% of the midwives felt adequately trained in technical skills and

11.8% in theoretical knowledge. Furthermore, 13.4% felt poorly trained in technical

skills as well as theoretical knowledge and communicative skills. However, 75.4% of

the respondents felt adequately trained in communicative skills. Those midwives more

often thought they can offer a sufficient emotional guidance during spontaneous

abortion in comparison with midwives who did not feel adequately trained in

communicative skills (77.7% versus 33.8%, p<0.001).

24

Also, 72.4% of the respondents said that they do not have sufficient knowledge of

spontaneous abortion. Furthermore, 88.6% would like to have more extra training on

this subject, even though 66.6% of respondents indicated that spontaneous abortion was

a part of their midwifery education.

Variable Crude OR (CI 95%) Adjusted OR* (CI 95%)

Type of hospital

Peripheral hospitals 1.00 1.00

University hospitals 11.10 (5.63 - 21.88) 3.17 (1.64 - 6.13)

Ward

Reproductive medicine 1.00 1.00

N*/NICU 0.07 (0.01 - 0.56) 0.07 (0.01 - 0.55)

Maternity ward 0.50 (0.22 - 1.16) 0.97 (0.38 - 2.50)

Labour ward 3.55 (1.52 - 8.32) 4.88 (1.96 - 12.14)

Maternity and labour ward 1.20 (0.58 - 2.47) 2.25 (0.97 - 5.23)

Maternity ward and N*/NICU 0.34 (0.08 - 1.39) 0.66 (0.15 - 2.88)

Labour ward and MIC 2.03 (0.68 - 6.05) 3.76 (1.16 - 12.13)

Combination 11

1.74 (0.85 - 3.54) 3.37 (1.46 - 7.76)

Combination 221.60 (0.58 - 4.43) 1.86 (0.64 - 5.40)

Combination 33

3.38 (0.91 - 12.64) 6.57 (1.64 - 26.31)

Combination 44

0.74 (0.23 - 2.39) 1.43 (0.41 - 5.02)

Combination 550.83 (0.28 - 2.45) 1.62 (0.50 - 5.18)

* Odds Ratios are mutually adjusted among predictors1 N*/NICU, maternity and labour ward 2 MIC, maternity and labour ward

3 Antenatal consultations, maternity and labour ward 4 Gynaecology, maternity and labour ward

5 N*/NICU, gynaecology, maternity and labour ward

Table 4 - Multiple logistic regression model of factors associated to the number of

guided women with spontaneous abortion

25

Variable Crude OR (CI 95%) Adjusted OR* (CI 95%)

Age

less than 40 years old 1.00 1.00

40 years old and more 3.17 (2.10 - 4.78) 3.40 (2.16 - 5.27)

Ward

Reproductive medicine 1.00 1.00

N*/NICU 0.44 (0.16 - 1.22) 0.56 (0.17 - 1.78)

Maternity ward 0.93 (0.48 - 1.81) 0.85 (0.35 - 2.04)

Labour ward 2.69 (1.19 - 6.06) 2.73 (1.01 - 7.39)

Maternity and labour ward 1.49 (0.82 - 2.71) 1.83 (0.81 - 4.17)

Maternity ward and N*/NICU 1.32 (0.46 - 3.82) 0.62 (0.17 - 2.20)

Labour ward and MIC 0.72 (0.29 - 1.80) 1.94 (0.55 - 6.82)

Combination 111.71 (0.96 - 3.06) 1.84 (0.83 - 4.09)

Combination 22

1.99 (0.60 - 6.60) 1.42 (0.48 - 4.18)

Combination 33

0.70 (0.23 - 2.10) NI

Combination 44

0.61 (0.29 - 1.30) 2.72 (0.70 - 10.50)

Combination 551.71 (0.56 - 5.19) 1.92 (0.53 - 6.99)

Region

Antwerp 1.00 1.00

East Flanders 1.33 (0.83 - 2.21) 1.68 (0.97 - 2.89)

West Flanders 1.90 (1.13 - 3.19) 1.97 (1.09 - 3.55)

Flemish Brabant 1.87 (0.68 - 5.13) 1.72 (0.56 - 5.30)

Limburg 2.53 (1.33 - 4.81) 3.02 (1.45 - 6.30)

Brussels-Capital Region 0.88 (0.41 - 1.87) 1.26 (0.47 - 3.38)

* Odds Ratios are mutually adjusted among predictors 1 N*/NICU, maternity and labour ward

2 MIC, maternity and labour ward

3 Antenatal consultations, maternity and labour ward 4 Gynaecology, maternity and labour ward 5 N*/NICU, gynaecology, maternity and labour ward

Table 5 - Multiple logistic regression model of factors associated to the feeling to be able to give an adequate emotional guidance

26

Discussion

Current knowledge of spontaneous abortion

The results showed an overall knowledge score of 6.40 out of 10. However, a low score

regarding the definition of spontaneous abortion was observed. Only 23.3% of the

respondents could indicate all categories of spontaneous abortion. That may be

explained by the absence of an unambiguous definition of spontaneous abortion.

Another possible explanation could be that the Latin terms are not well known and are

currently less used by Flemish midwives. However, when asking for the meaning of one

of the Latin terms (abortus incipiens), 70.5% could indicate the right answer.

At least half of the risk factors of spontaneous abortion could be identified by almost

four out of five respondents. It is of great concern, however, that the risks of using

NSAIDs in early pregnancy were underestimated. Current literature indicates that the

use of NSAIDs during pregnancy is contradictory and that NSAIDs are associated with

a higher risk of miscarriage (Antonucci 2012, BCFI 2016, Tulandi 2015). Therefore, the

use of NSAIDs during pregnancy should be discouraged. Other risk factors that were

often ignored are low sperm quality and habitual miscarriages. The limited knowledge

on certain risk factors could be related to the attitude of midwives, who believed that it

is the responsibility of the obstetrician to inform couples of possible causes of

spontaneous abortion. The current lack of knowledge could induce that attitude.

However, the attitude might also cause midwives to show little interest in being well-

informed on risk factors.

Likewise, the limited knowledge on medical treatment could be related to the attitude

that this is a responsibility of the obstetrician. In Flanders, misoprostol is a well-known

drug in the medical treatment of spontaneous abortion. The route of administration of

misoprostol was recognized by almost all of the respondents. However, the

recommended dose was often misjudged. Respondents were possibly misled by the

alternating use of milligrams and micrograms in the answer possibilities. The use of

mifepristone and laminaria as a method to prepare for curettage was less known than the

use of misoprostol. That may be explained by the fact that those methods are less

common in Flanders.

27

When asking for complications for spontaneous abortion, only half of the respondents

could indicate Asherman’s syndrome as a possible complication of classical curettage,

even though curettage accounts for 90% of the cases of Asherman’s syndrome

(International Asherman's Association n.d.). However, the term ‘Asherman’s syndrome’

might not be well-known by Flemish midwives, while the use of ‘adhesions’ for

example is perhaps more common.

By Belgian law, a midwife is allowed to diagnose pregnancy (K.B. 1991). However,

more than half of the respondents believed they are not authorised to do so. That could

be explained by the Belgian hospital finance system where a fee-for-service payment is

standard (KCE 2014). The obstetrician, and not the midwife, is the caregiver entitled to

the payment for the services delivered in hospitals. That implicates that the obstetrician

often performs pregnancy diagnosis. In addition, more than one third of the respondents

thought they can legally perform an ultrasound scan to diagnose pregnancy when

having the appropriate qualifications. However, the law that gives this authority to the

midwife has not yet been enforced (Federale Raad voor de Vroedvrouwen 2015).

According to the Belgian law, a midwife is not allowed to perform pregnancy

termination (K.B. 2007). However, almost two thirds of the respondents assumed that

the midwife can terminate a pregnancy when ordered by a doctor. That may indicate

that Flemish midwives are not well-informed about the laws concerning their practice.

Moreover, the law can also be interpreted in more than one way, since it is not specified

whether it concerns a termination with a viable embryo or not.

The knowledge on spontaneous abortion of the midwives in university hospitals was

significantly higher than of those in peripheral hospitals. That difference in knowledge

might be linked to the fact that midwives in university hospitals had higher odds to

guide women with spontaneous abortion.

Remarkably, knowledge did not differ between midwives who searched for additional

information on the subject and those who did not. Nor did it differ between midwives

who indicated that the subject was part of their education and those who indicated that it

was not. That may indicate that the (current) midwifery education programmes, which

include the subject, do not provide adequate basic knowledge or the information given

is not well retained by students.

28

Moreover, it seemed that existing information needs of midwives are insufficiently

addressed, since the majority indicated the need for extra training on spontaneous

abortion. Although, that may be the result of a socially desirable response, or it could

also be influenced by the feeling of scoring badly in the questionnaire.

Although there was no significant difference in knowledge score, there were differences

in the perception of having adequate knowledge. Midwives, who indicated that

spontaneous abortion was part of their educational programme, significantly more often

believed that they have adequate knowledge of the subject. Moreover, midwives aged

40 years and above more often believed that they have sufficient knowledge compared

to midwives younger than 40 years. It is important to note that age correlated strongly

with work experience. Consequently, it is not clear whether that could be ascribed to the

difference in age or practical experience (e.g. the total number of women guided).

The attitude of the Flemish midwife regarding spontaneous abortion

The results showed that the majority of Flemish midwives categorise spontaneous

abortion as a normal event induced by nature or the loss of a child. It is possible that

those results were influenced by the personal history of the midwife. Midwives, who

have once experienced spontaneous abortion themselves, could believe that the

emotional significance of this event is more important, compared to midwives who did

not have such an experience.

Flemish midwives also considered themselves as important caregivers in psychological

and emotional care at the time of (the diagnosis of) spontaneous abortion. Providing

couples with information of discussion groups, websites and follow-up was considered

to be even more important than informing couples of medical aspects. Nevertheless, the

Flemish midwife was convinced of the importance of the medical aspect and considered

the midwife to be an appropriate caregiver in the preparation of the medical treatment

and/or of curettage. Importantly, many respondents did not consider the midwife to be

capable of being the only responsible for the diagnostics, the medical follow-up, and the

medical treatment of spontaneous abortion without complications. Those results could

be attributed to a number of factors, such as an inadequate education, which could cause

a lack of knowledge and anxiety when confronted with spontaneous abortion.

29

The results could also be attributed to the current organization of health care in

Belgium, where the obstetrician in particular is responsible for the medical aspects of

treatment. That could highlight the importance of a multidisciplinary approach in the

care of couples with spontaneous abortion. The multidisciplinary nature of this obstetric

complication is also described in literature (Montero 2011).

The vast majority of the Flemish midwives believed that they should have a key role in

the emotional support for couples with spontaneous abortion, irrespective of their age,

knowledge or practical experience. It is remarkable that midwives who received an

education, which included the subject ‘spontaneous abortion’, were more convinced of

that. That highlights the importance of education and extra training in creating a

positive attitude towards spontaneous abortion.

The results showed that midwives who supervised fewer women with spontaneous

abortion, indicated a higher need for extra training. Furthermore, midwives aged 40

years and above indicated less often that need in comparison with those less than 40

years old. Those results may be influenced by work experience (and thus the total

number of women guided), which may induce the feeling of being more competent. The

results could also be attributed to the education. It could be possible that learning about

spontaneous abortion induces a higher awareness of the importance of this subject. That

might explain why midwives of 40 years old and above seemed less willing to attend

training and less interested in the subject, since the subject was less often part of their

educational programme. Contrarily to the highly expressed need for extra training, only

43.6% of the Flemish midwives looked up some additional information of this subject.

Since the majority of the Flemish midwives were not often confronted with women who

faced spontaneous abortion, they might consider this subject as less important.

30

Spontaneous abortion and the current care provision

Less than half of the respondents (46.9%) assisted in the care of women with

spontaneous abortion in the past six months. Nevertheless, spontaneous abortion is a

common problem with an incidence of 10 to 25% (Buysse 2013, Carnarneiro 2015,

Regan 2000). One explanation could be that women with spontaneous abortion are not

hospitalized and might just get ambulatory care. Another possibility is that they have

curettage in an outpatient surgery clinic. It is also plausible that gynaecology wards

receive more women with spontaneous abortion. However, few midwives are employed

at the gynaecology ward, and this ward is often part of a surgery ward (which was not

included in this study). Therefore, gynaecology wards might be underrepresented in this

study.

According to the results, university hospitals were more likely to receive women with

spontaneous abortion in comparison with peripheral hospitals. That could be related to a

higher number of patients consulting university hospitals generally. The presence of

highly developed fertility clinics in those hospitals may also be an influencing factor.

More than one third (34.9%) of the midwives indicated that a standard procedure for

spontaneous abortion was not available. However, the availability of a standard

procedure was not formally confirmed, so it is possible that some of the midwives were

unaware of the existence of it.

Perceived barriers and perspectives

Some barriers in providing adequate emotional guidance to couples were identified.

The main barriers in this study seemed to be lack of time, incapability and the fear of

being overtaken by the own feelings Those barriers were also confirmed in research of

Graefe (2003) and Montero et al. (2011). The barriers found could be partially attributed

to the midwifery education, as midwives who indicated to be adequately trained in

communicative skills were significantly more often of the opinion to be able to provide

an adequate emotional guidance. That highlights the importance of training

communicative skills, both during the midwifery education as well as in extra training,

which is also documented in literature (Graefe 2003, Montero 2011).

31

Moreover, it seemed that the older the midwife gets, the more capable she feels of

giving emotional guidance. That could be due to a number of factors such as maturity or

a work experience of many years which could induce more self-confidence.

Not only barriers in the care for couples with spontaneous abortion, but also some

perspectives could be identified. Midwives were interested in extra training about

spontaneous abortion and they recognized the need for this. Furthermore, 97% of all

midwives thought that they should have a key role in the emotional support. Midwives

who received an education, which covered the subject of spontaneous abortion, were

significantly more convinced that the midwife should have a key role within this care.

That again highlights the importance of education and extra training in creating a

positive attitude towards this subject.

Strengths and limitations of the study

This research was the first study to evaluate the knowledge, attitude and practical

experience of Flemish midwives about spontaneous abortion. Although this research

was descriptive of nature, the findings might be of great importance for further research.

During the study, the researchers strictly followed their methodology, which was

comparable to the methodology used in a similar research of L’Ecluse and Cappon

(2015): “Female genital mutilation: knowledge, attitude and practices of Flemish

midwives”.

This research concerning spontaneous abortion was a large-scale KAP study in which

all participating midwives were distributed equally among the different geographical

regions. That could promote the generalizability of the results. However, only midwives

employed in hospitals in Flanders were represented. Independent midwives, working in

primary health care, were excluded because of practical reasons. The number of

employed midwives in Flanders is not (yet) available. Consequently, it is unknown how

many midwives are working at (other) nursing departments and/or in primary health

care (BMA 2014).

32

In this KAP study, the researchers used a semi-structured self-administered

questionnaire. The questionnaire was developed after an extensive literature research

and partially based on the questionnaire of the similar KAP study of Cappon et al.

(2015). However, the questionnaire was validated in a limited way with a single Delphi

procedure among a panel of ten professionals and ten non-professionals. The people

who participated in the Delphi procedure were of different ages, backgrounds and

education levels. The single Delphi procedure contributed to the comprehensibility,

clarity and content validity of the questionnaire. An information letter with instructions

to complete the questionnaire had a positive impact on its reliability.

Nevertheless, the results of the knowledge part in the questionnaire could be slightly

biased. The main cause of bias could be the help of external sources (such as the

internet and colleagues), since the participating midwives were not supervised when

completing the questionnaire. That may have a negative impact on the validity of the

results concerning knowledge. Furthermore, the correctness of the statistical analysis

was double-checked, and random checks were carried out to verify the accuracy of the

data-input.

Conclusion and practical implications

Although spontaneous abortion is a common problem, there is no unambiguous

definition for this obstetric complication. It is therefore important to develop a clear and

precise definition for practical and research purposes.

Flemish midwives assist in the care for couples with spontaneous abortion. They

considered themselves as a key care giver in the emotional guidance of those couples.

However, midwives experience several barriers, e.g. incapability, which could influence

the provision of adequate care. Important skills in emotional guidance are the

communicative skills. That highlights the importance of adequate training in

communication skills in the midwifery education.

33

The educational programme should also include a strong theoretical component on the

subject of spontaneous abortion as it creates an awareness of the potential key role of

the midwife in the care of couples with spontaneous abortion. Theoretical knowledge,

however, was found to be insufficient, as indicated by the midwives. That knowledge

gap could be partially filled by an adequate basic educational programme. Moreover,

extra training should be provided to the midwives who already graduated as the

majority of the midwives expressed the need for those extra theoretical insights. It is

unclear how educational programmes in Flanders integrate the subject ‘spontaneous

abortion’ in their curricula today. This could be a subject for further research.

Since it is unclear how many women are hospitalised (and on what departments) or

followed up in outpatient care, future research on the current practice in Flanders

concerning couples with spontaneous abortion is needed. Current treatment practices

and the involvement of the midwife in those practices also need further consideration.

Furthermore, the attitude of the midwives towards their role in the care for couples with

spontaneous abortion could also be further explored in qualitative research.

Conflict of interest

No conflict of interest has been declared by the authors.

Acknowledgements

The authors would wish to acknowledge Evi Vanhooren for linguistic assistance and

Master of Laws Marlies Eggermont for the advice concerning the juridical questions.

34

References

Abdi, J., Gebremariam, M.B. (2011) Health Providers' Perception towards Safe

Abortion Service at Selected Health Facilities in Addis Ababa. African Journal

of Reproductive Health, 31-36.

Afhami, N., Bahadoran, P., Taleghani, H. & Nekuei, N. (2016) The knowledge and

attitudes of midwives regarding legal and religious commandments on induced

abortion and their relationship with some demographic characteristics Iranian

Journal of Nursing and Midwifery Research, 21(2), 177-182.

Antonucci, R., Zaffanello, M., Elisabetta, P., Porcella, A., Cuzzolin, L., Pilloni, M.D. &

Fanos, V. (2012) Use of Non-steroidal Anti-infammatory Drugs in Pregnancy:

Impact on the Fetus and Newborn. Current Drug Metabolism, 13, 1-17.

BCFI (2016) Niet-steroïdale anti-inflammatoire middelen. Vol. 2016

www.bcfi.be/nl/chapters/10?frag=6767.

BMA (2014) Memorandum in voorbereiding van de nieuwe regering Belgian Midwives

Association & Federale Raad van Vroedvrouwen

Buysse, A., Enzlin P., Lievens J., T'Sjoen, G., Van Houtte, M. & Vermeersch H. (2013)

Sexpert. In Basisgegevens van de survey naar seksuele gezondheid in

Vlaanderen.

Cappon, S., L'Ecluse, C., Clays, E., Tency, I., Leye, E. (2015) Female genital

mutilation: knowledge, attitude and practices of Flemish midwives. Midwifery,

31(3), e29-35.

Carnarneiro, A., Maciel, J., da Silveira, R. (2015) Experiences of spontaneous abortion

in primigravidae during the first trimester of pregnancy: a phenomenological

study. Revista de Enfermagem Referência 5, 109-118.

Dalton, V. (2010) Provider knowledge, attitudes, and treatment preferences for early

pregnancy failure. American Journal of Obstetrics and Gynecology.

Engel, J., Rempel, L. (2016) Health Professionals' Practices and Attitudes About

Miscarriage. The American Journal of Maternal Child Nursing 41(1), 51-57.

Federale Raad voor de Vroedvrouwen (2015) Het beroeps- en competentieprofiel van

de Belgische vroedvrouw.

http://www.vroedvrouwen.be/sites/default/files/Beroepsprofiel%2012%2005-

1.pdf.

Flikweert, S., Wieringa-de Waard, M., Meijer, LJ., De Jonge, A., Van Balen, JAM.

(2004) NHG-Standaard Miskraam (Tweede herziening) Huisarts en

Wetenschap, 47(3), 147-155.

Graefe, W. (2003) Midwifery Management of First Trimester Spontaneous Abortions

Midwifery Institute of Philadelphia University

http://www.instituteofmidwifery.org/MSFinalProj.nsf/82fd56378e8efc3c852568

4f005bc9f1/043f8f858180076f85256ddd00582cbd?OpenDocument.

Hill, J., White, S., Hutti, M. & Polivka, B. (2014) The meaning, Experiences and

Behaviors of Nurses Caring for Women With a Perinatal Loss. Journal of

Obstetric, Gynecologic, & Neonatal Nursing 43, 68-80.

35

ICM (2013) Essential competencies for basic midwifery practice. International

Confederation of Midwives

http://www.internationalmidwives.org/assets/uploads/documents/CoreDocument

s/ICM%20Essential%20Competencies%20for%20Basic%20Midwifery%20Prac

tice%202010,%20revised%202013.pdf.

International Asherman's Association (n.d.) Asherman's Syndrome Vol. 2016

http://www.ashermans.org/home/.

K.B. (1991) Koninklijk besluit betreffende de uitoefening van het beroep vroedvrouw.

K.B. (2007) Koninklijk besluit houdende wijziging van het koninklijk besluit van 1

februari 1991 betreffende de uitoefening van het beroep van vroedvrouw 8 juni

2007.

KCE (2014) Conceptueel Kader voor de Hervorming van de Ziekenhuisfinanciering In

KCE Report 229AsFederaal Kenniscentrum voor de Gezondheidszorg

Kestler, E. (2012) Obstetrician-gynecologists' knowledge of and attitudes toward

medical abortion. International Journal of Gynecology and Obstetrics, 120-123.

Montero, S., Sánchez, J., Montoro, C., Crespo, M., Jaén, A., Tirado, M. (2011)

Experiences with perinatal loss from the health professionals' perspective

Revista Latino-Americana de Enfermagem, 19(6), 1405-1412.

Regan, L.R., Rai, R. (2000) Epidemiology and the medical causes of miscarriage.

Baillière's Clinical Obstetrics and Gynaecology, 839-854.

Tulandi, T., Al-Fozan, H.M. (2015) Spontaneous abortion: Risk factors, etiology,

clinical manifestations, and diagnostic evaluation. UpToDate.

van Dale (2015) miskraam. Vol. 2016 van Dale, http://vandale.ugent.be/.

VLOV (2014) Nomenclatuur voor vroedvrouwen vanaf 1 januari 2014.

http://www.vroedvrouwen.be/sites/default/files/Nomenclatuur%202014%20na%

201%20juni%202014%20met%20aanpassingen.pdf.

WHO (2006) Neonatal and perinatal mortality: country, regional and global estimates.

Zeqiri, F., Paçarada, M., Kongjeli, N., Zeqiri, V., Kongjeli, G. (2010) Missed abortion

and application of misoprostol. Medicinski Arhiv, 64(3).

36

Appendix

Appendix 1: information letter for the participants

Appendix 2: Questionnaire

Appendix 3: Distribution of respondents over the wards

37

Appendix 1: Information letter for the participants

Informatiebrief deelnemers

Geachte vroedvrouw,

Wij zijn Marjon De Roose en Emmie Vanhooren, studenten van de Masteropleiding ‘Verpleeg

–en Vroedkunde’ aan de Universiteit Gent. In samenwerking met Universiteit Gent en Odisee

Hogeschool doen we een onderzoek naar de kennis, attitude en praktijkervaring bij Vlaamse

vroedvrouwen omtrent spontane abortus.

Aan de hand van een vragenlijst willen we nagaan in welke mate Vlaamse vroedvrouwen in

aanraking komen met spontane abortus. Tevens willen we de kennis en attitude hieromtrent in

kaart brengen. Tenslotte is het belangrijk om eventuele knelpunten te ontdekken bij de zorg

voor patiënten met een spontane abortus. Inzicht in deze materie is noodzakelijk om concrete

aanbevelingen te formuleren voor de klinische praktijk en om de kwaliteit van zorgverlening te

optimaliseren.

Om die reden nodigen wij u uit om een eenmalige, schriftelijke vragenlijst in te vullen.

Dit zal ongeveer 30 minuten van uw tijd in beslag nemen.

Wij hopen hiervoor op uw gewaardeerde medewerking te kunnen rekenen.

Deelname aan het onderzoek is vrijwillig. Voor u beslist om deel te nemen, kan u de

onderstaande informatie over vertrouwelijkheid, kosten en vergoeding, risico’s en voordelen, en

verzekering raadplegen.

Vertrouwelijkheid

Uw deelname aan het onderzoek is volstrekt vertrouwelijk. De door u verstrekte informatie zal

ook als dusdanig worden behandeld. U hoeft nergens uw naam op te geven. Om een betere

gegevensverwerking mogelijk te maken, wordt per ziekenhuis een code toegekend om de

response te kunnen berekenen. In de resultaten en publicaties van deze studie zal u echter noch

bij naam noch op een andere manier geïdentificeerd kunnen worden. Enkel onderzoekers die

verbonden zijn aan deze studie zullen toegang krijgen tot de gegevens.

Het onderzoek gebeurt in overeenstemming met de Belgische wet van 8 december 1992 en de

Belgische wet van 22 augustus 2002 betreffende de bescherming van de persoonlijke

levenssfeer. Elke bekendmaking van resultaten en conclusies zal gebeuren zonder de privacy

van de deelnemers te schenden. U heeft het recht op inzage in uw persoonlijke informatie en

onjuiste gegevens kunnen op uw verzoek verbeterd worden.

38

Kosten en vergoeding

Deze studie brengt voor deelnemers geen extra kosten met zich mee en voorziet geen financiële

vergoeding.

Verzekering

De onderzoekers voorzien een vergoeding in geval van schade ten gevolge van deelname aan de

studie. De waarschijnlijkheid dat u door deelname aan deze studie enige schade ondervindt, is

echter extreem laag. In het geval dit toch zou gebeuren, wat uiterst zeldzaam is, werd een

verzekering afgesloten conform de Belgische wet van 7 mei 2004 inzake experimenten op de

menselijke persoon, die deze mogelijkheid dekt.

Risico’s en voordelen

U heeft het recht om op elk ogenblik vragen te stellen over mogelijke risico’s of nadelen van

deze studie. U kan het onderzoeksteam bereiken via studie.spontaneabortus@gmail.com.

Zoals eerder vermeld, is de kans dat u door deze studie schade oploopt echter minimaal. Deze

studie biedt geen voordelen voor uzelf. We hopen echter dat de bekomen resultaten zullen

leiden tot concrete aanbevelingen voor de klinische praktijk en tot een optimalisatie in de

kwaliteit van de zorgverlening bij het begeleiden van vrouwen met spontane abortus.

Goedkeuring Ethische Commissie

De studie werd goedgekeurd door een onafhankelijke Commissie voor Medische Ethiek,

verbonden aan het UZ Gent. Het onderzoek wordt uitgevoerd volgens de richtlijnen voor de

goede klinische praktijk (ICH/GCP) en de verklaring van Helsinki, opgesteld ter bescherming

van mensen die deelnemen aan klinische studies. U dient de goedkeuring door de Commissie

voor Medische Ethiek in geen geval te beschouwen als een aanzet om deel te nemen aan de

studie.

Door het invullen van de vragenlijst geeft u automatisch toestemming om deel te nemen aan de

studie. U kunt zich op elk moment terugtrekken uit de studie zonder dat u hiervoor een reden

moet opgeven. Concrete aanwijzingen voor het invullen van de vragenlijst vindt u terug op

de vragenlijst zelf. Bij elke vraag is er aangegeven of u al dan niet meerdere antwoorden

kan geven. Gelieve de ingevulde vragenlijst in gesloten omslag te bezorgen aan het hoofd

van uw afdeling.

Als u meer informatie wenst omtrent deze studie, kan u steeds contact opnemen met de

onderzoekers door te mailen naar studie.spontaneabortus@gmail.com.

Wij danken u alvast voor uw medewerking.

Marjon De Roose en Emmie Vanhooren

Promotor: Prof. Dr. Els Clays Co-promotor: dr. Inge Tency

Els.Clays@UGent.be inge.tency@odisee.be

09/332.49.94 03/776.43.48

39

Appendix 2: Questionnaire

40

41

42

43

44

45

46

47

48

49

Appendix 3: Distribution of respondents over the wards

Combination of

wards 137 113 24 22 20 17 15 14 8 5 5 5

One ward

MIC 12 X X X

NICU/N* 21 X X X X

MATERNITY 64 X X X X X X X X X X X

LABOUR 58 X X X X X X X X

GYNAECOLOGY 1 X X X X

FERTILITY 40

ANTENATAL 15 X X X