Tips for Health Care Providers: A Triangle of Treatment for Miscarriage Care

By Heather Heritage M.A.

The first trimester of my 4th pregnancy was rough. Not only was I exhausted with two young children and working full time, I had severe nausea and dehydration problems - so severe I ended up in the ER on more than one occasion. Most of the questions the ER staff askedwere perfunctory, trying to piece together my condition and background information to get a clear picture for treatment. But when a young physician’s assistant commented on my gestational and pregnancy history, imagine my shock when she bluntly stated, “oh, I see you had an abortion last year.”

​I had a miscarriage six months prior to that ER visit, and I knew that medical terminology technically classifies any pregnancy loss as an abortion of some sort. But knowing this didn't really take the sting out of her unempathetic words. In the end, I got the fluids I needed and went on my way, but couldn't shake the annoyance of the term “abortion” that was used to describe my miscarriage.

Using the word abortion when referencing a miscarriage can be hurtful and alienate the very patients a health care provider (HCP) is trying to build rapport with and treat, even if it is “proper” medical terminology. In the area of early pregnancy loss (miscarriage), there are large inconsistencies in how providers communicate to mothers about the loss they are experiencing, which can result in a lack of thorough treatment and care for these vulnerable patients.

A 2019 study explored early pregnancy loss and gaps in the physical, cognitive, and emotional treatment of patients. Using those criteria as a framework, I offer considerations in a triangle of treatment plan for health care providers to use with their patients who go through pregnancy loss.  

Physical Care
The first, and most pertinent point in the triangle, is caring for the physical needs of a patient. In 2019, the American Pregnancy Association reported that one in five women with recognized pregnancies end in miscarriage, making it a fairly common experience. Because of their often abrupt and sudden nature, many women seek help at the emergency room. However, there are significant gaps of care for patients, specifically in the ER, regarding communication, diagnostic testing and follow up instruction.

Delays in or failure to complete diagnostic tests occur, specifically with blood work and ultrasounds. In many situations, mothers have left a treatment center without knowing if they had lost their baby, what to expect, and without full comprehension of their condition.

Even if the tests are completed, often there are long wait times for results – which could mean leaving a patient for hours, worrying and stressing that their pregnancy is ending. Much of these wait times are due to logistical barriers; however, those delays or obstructions should be communicated and clarified to the patient.

There is another gap in treatment: scheduling follow-up visits, which are important for incomplete miscarriages, and cognitive and emotional healing. Often these follow-ups are never discussed or mentioned with a patient.

Tips for health care providers caring for the physical point in the triangle of treatment include:

1. Be aware of gaps in testing.
2. Advocate for faster and complete diagnostic testing
3. Facilitate and emphasize the need for follow-up appointments, including suggestions for accessing emotional support providers. 

Cognitive Care
The second point in the triangle of treatment focuses on cognitive care; specifically, using common terminology, and being able to explain what is happening and give thorough information.

There is a need for common language when it comes to early pregnancy loss. Early pregnancy loss means any fetal loss at or before 13 weeks of gestation. This is also referred to as: miscarriage, fetal death, perinatal loss, spontaneous abortion, missed abortion, etc. HCPs need to understand that language and terminology have different meanings to different people, and HCPs need to be aware of this when communicating with their patients. A good tip in getting the terminology right is to use mirroring terms. For example, if a patient uses the term “baby” or “child,” an HCP should mirror their language by referring to the loss in matching terms.

Patients also need more in‐depth explanation and communication on the causes of miscarriage, frequency of miscarriage, and their diagnostic test results. HCPs would do well to remember that this is a painful and emotional process for the patient. If a patient is being told the pregnancy is over; all of the hopes and dreams for a viable baby come to a glaring and final halt in that moment. They deserve explanation and information, both in verbal and written communication. Patients and their personal caretakers have said they want more information about physical complications, current treatment, resumption of menstruation, future pregnancies, and emotional health and healing.

Tips for HCPs in the cognitive point in the triangle of treatment include:

1. Inform the patient of the diagnosis in a clear and empathetic manner.
2. Include an explanation of diagnostic test results as well as normalizing these miscarriages.  This should be done to meet the health literacy level of the patient.​
3. Provide written materials with clear communication and options for support. Well-designed pamphlets with infographs, visual support, and contact information are encouraged.

Emotional Care
The third point in the triangle of treatment stresses emotional care for miscarrying patients. There are many opportunities for HCPs to communicate with empathy and offer comfort in bereavement support. Mothers are experiencing shock, sadness, worry, guilt, helplessness, and yet often, there is little empathy provided. In addition, in an ER, there is little privacy, space, and time to process the diagnosis or for providers to simply listen to a patient. More could be done in allowing for the opportunity for mothers to express their grief and emotions.

Tips for HCPs in the emotional point in the triangle of treatment include:

1. Encourage patient to talk and discuss their feelings. Give comfort specifically to alleviate feelings of guilt.

2. Encourage sharing of their experience when they are ready. Recommend social groups, websites, blogs, alternative therapies like poetry/art, etc. as it helps in the grieving process.

3. Encourage patients to read prominent stories of women in the public eye who have had a common experience, for example, Chrissy Teigen or Meghan, The Duchess of Sussex. This helps normalize the experience, and patients can find hope in common loss.

4. Understand, practice, and deliver bereavement support in the form of companion care. Dr. Wolfelt, Founder and Director of the Center for Loss and Life Transition defines companion care as:

• Offering comfort rituals
• Avoiding repetitive, cliché’ statements
• Informing on legal, end of life alternatives (funerals/burial, etc.)
• Offering holistic care support or recommendations
• Avoiding burnout of provider by practicing compassion over empathy

5. For providers in managerial roles: Consider the use of doulas who specialize in pregnancy loss. A doula is a non-medical person who supports a woman during labor and birth, pregnancy loss, bereavement, and postpartum healing, and are trained to provide one-on-one care, physical comfort, companion care and emotional support. There is often funding via grants or programs that can bring doula care into a treatment center.

Caring for the Whole Person
Early pregnancy loss is a highly emotional and nuanced situation for each individual. Health care providers are inconsistent in how they communicate to and support mothers going through this sorrow. Understanding these implications would help them treat their patients more effectively, using a triangle of treatment to meet the physical, cognitive and emotional needs of these patients. We’ve all been in highly emotional situations and know that compassion and empathy can go a long way in humanizing the situation. HCPs who implement these suggestions could have a positive impact on grieving mothers for years to come.

Heather Heritage is an Assistant Professor of Communication at Cedarville University.