Miscarriage Care and Facilities in Scotland: Scoping Report National Overview
This report details the findings of a scoping exercise to enable better understanding of miscarriage care in Scotland nationally. The report seeks to aid policy makers and Health Boards in making decisions about what improvements are required to miscarriage care in Scotland.
Annex A
Source |
Commitment/Recommendation |
Progress Nationally |
|---|---|---|
PfG |
Ensure women's services in Health Boards have dedicated facilities for women who are experiencing unexpected pregnancy complications. |
In Scotland 13 of the 14 health boards reported that they have some dedicated facilities for women experiencing unexpected pregnancy complications, these facilities were often provided in the early pregnancy unit where there is an EPU on site. 13 of the 14 Health Boards have a separate room/area/ward available for women experiencing miscarriage. The number of separate rooms ranges between 1 and 12 rooms per site. In most sites these separate rooms are available on the gynaecology ward or on the maternity ward, where rooms are located away from the labour or postnatal rooms. It is noted that some rooms/areas are not solely used for miscarriage care and may be used for other pregnancy complications or loss. |
The Lancet: Miscarriage Matters |
A graded approach to the treatment of recurrent miscarriage |
In Scotland 13 of the 14 Health Board areas said a graded approach to the treatment of recurrent miscarriage is adopted or can be accessed. This covered 26 of the 44 sites included in the scoping exercise, with 17 sites providing this service on site. NHS Shetland stated a graded approach is not provided within the Health Board but is accessible in another Health Board area (NHS Grampian). NHS Forth Valley have not adopted a graded approach and do not have plans implement a graded approach. |
After First Miscarriage |
(Only sites with an Early Pregnancy Unit, Maternity Unit, Community Maternity Unit and/or Obstetrics and Gynaecology department were asked about information and services provided after a first miscarriage – 39 sites) |
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After the first miscarriage, women will be guided to information about miscarriage |
Provided in all 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
After the first miscarriage, women will be guided to resources to address their physical needs |
Provided in all 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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After the first miscarriage, women will be guided to resources to address mental health needs following pregnancy loss |
Provided in all 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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After the first miscarriage, women will be guided to ways to optimise their health for future pregnancy |
Provided in all 13 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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After First Miscarriage - this approach could involve: |
(Only sites with an Early Pregnancy Unit, Maternity Unit, Community Maternity Unit and/or Obstetrics and Gynaecology department were asked about information and services provided after a first miscarriage – 39 sites) |
|
Patient support groups |
Provided in all 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
Online self-help strategies for mental health |
Provided in 13 Health Board areas but not within all sites that could encounter women experiencing miscarriage. |
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Weight management |
Provided in 13 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Smoking and recreational drugs cessation services |
Provided in 13 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Information on appropriate preconceptual folate and vitamin D supplementation |
Provided in all 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Referral to necessary services for management and optimisation of chronic maternal medical conditions (e.g., diabetes, hypertension, heart disease, and epilepsy) |
Provided in all 12 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
Screening for mental health issues. |
Provided in 11 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
After Second Miscarriage |
(Only sites with an Early Pregnancy Unit, Maternity Unit, Community Maternity Unit and/or Obstetrics and Gynaecology department were asked about information and services provided after a second miscarriage – 39 sites) |
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Women will be offered an appointment at a miscarriage clinic nurse or midwifery-led |
6 Health Boards provide appointment at a nurse-led miscarriage clinic 5 Health Boards provide appointment at a midwifery-led miscarriage clinic |
|
Continuity of Care |
Provided in 11 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Tests for full blood count are offered |
Provided in 11 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
Tests for thyroid function are offered |
Provided in 10 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Discussion about lifestyle issues |
Provided in 13 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Referral for specialist care will be arranged if tests are abnormal or if there is a chronic medical or mental health problem. |
Provided in 13 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies. |
Provided in 12 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
After Third and subsequent Miscarriage |
(Only sites with an Early Pregnancy Unit, Maternity Unit, Community Maternity Unit and/or Obstetrics and Gynaecology department were asked about information and services provided after a third or subsequent miscarriage – 39 sites) |
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Women will be offered an appointment at a medical consultant-led clinic, in which additional tests and a full range of treatments can be offered. |
Provided in 13 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing. |
Provided in 12 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Blood tests for antiphospholipid antibodies will be arranged. |
Provided in 12 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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A pelvic ultrasound scan (ideally three dimensional transvaginal) will be arranged |
Provided in 12 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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If necessary, parental karyotyping will be offered depending on the clinical history and the results of the genetic analysis of pregnancy tissue from previous losses |
Provided in 12 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Appropriate screening for mental health issues |
Provided in 12 of 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
Appropriate care for mental health issues |
Provided in all 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
Overall Recommendations |
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Appropriate screening and care for future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth. |
Provided in all 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
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Appropriate screening and care for future obstetric risks and mental health issues will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage. |
Not assessed |
|
Consider giving vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage |
Provided in 10 of 14 Health Board areas after a first miscarriage. Provided in 12 of 14 Health Board areas after a second miscarriage. Provided in 13 of 14 Health Board areas after a third or subsequent miscarriage. Not provided within all sites that could encounter women experiencing miscarriage |
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We urge health-care funders and providers to invest in early pregnancy care, with specific focus on training for clinical nurse specialists and doctors to provide comprehensive miscarriage care within the setting of dedicated early pregnancy units. |
17 dedicated early pregnancy units are available in 10 Health Boards. 11 Health Board areas have midwives/nurses with additional specialist training to provide comprehensive miscarriage care. 13 Health Boards have doctors trained to provide comprehensive miscarriage care. |
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Early pregnancy services need to focus on providing an effective ultrasound service, as it is central to the diagnosis of miscarriage, and be able to provide expectant management of miscarriage, medical management with mifepristone and misoprostol, and surgical management with manual vacuum aspiration |
6 Health Boards were able to carry out ultrasound scans in the EPU separated from women with a continuing pregnancy. All health boards offered all expectant, medical and surgical management for the treatment of miscarriage. Not all management options could be accessed in all Health Board areas. Expectant management is available in all Health Board areas but due to the geography in Scotland some women may need to travel significant distances to access expectant management. Medical management and the use of mifepristone and misoprostol is available in all Health Boards except for NHS Fife where multiple doses of misoprostol are provided. Surgical management with manual vacuum aspiration is available in 10 of the 14 Health Boards. |
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Recommend that miscarriage data are gathered and reported to facilitate comparison of rates among countries, to accelerate research, and to improve patient care and policy development. We recommend that every country reports annual aggregate miscarriage data, similarly to the reporting of stillbirth. |
Currently data gathering on miscarriage varies both between and within Health Board areas. There is a lack of consensus on what would be recorded as a miscarriage, what data about miscarriage should be recorded (such as maternal characteristics and gestation) and where data should be reviewed. |
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Identifying women at risk of psychological distress following miscarriage |
Provided in 14 Health Board areas but not within all sites that could encounter women experiencing miscarriage. Assessment of women at risk of psychological distress is often referred to specialist mental health services or GPs. |
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Identifying women at risk of psychological distress following miscarriage and the development of optimal treatment strategies have been recognised as research priorities. |
Not assessed |
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Women with a history of miscarriage, particularly those with three or more miscarriages, are at an increased risk of obstetric complications including preterm birth. Therefore, these women should be treated as patients at high risk during antenatal and intrapartum care. |
Provided in 13 Health Board areas but not within all sites that could encounter women experiencing miscarriage |
|
Miscarriage Management - women should be presented with the available evidence and be free to choose the management approach that suits their needs and preferences |
Provided in 14 Health Board areas said that women are free to choose the management approach that suits their needs, but not within all sites that could encounter women experiencing miscarriage. The geography in Scotland has implications for women in terms of how they can access their chosen approach. While expectant management is often available locally, for medical or surgical management women may have to travel to another site that provides this service which could be some distance away particularly in more rural areas. |
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Consider pathways of care for miscarriage management, treatment of women with a history of miscarriage and care following a miscarriage. |
Not assessed |
|
The Lancet: Miscarriage Matters Research Recommendations |
Key epidemiological research priority 1 - Establishing how we can monitor miscarriage rates on a population basis. |
Project underway with Scottish Government and Public Health Scotland |
Key epidemiological research priority 2 - Ascertaining if miscarriage risk and prevalence differ across nations and ethnic groups. |
Project underway with Scottish Government and Public Health Scotland |
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Key epidemiological research priority 3 - Whether miscarriage rate is increasing, and if so why; what the key outcomes are from women's point of view. |
Work to follow from research priorities 1 and 2 above. |
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Key epidemiological research priority 4 - Which risk factors for miscarriage are potentially causative and modifiable; and the effect of modification of the risk factor on clinical outcomes |
Work to follow from research priorities 1 and 2 above. |
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Contact
Email: socialresearch@gov.scot
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