Miscarriage care in Scotland: delivery framework

Introduction

This document will use the term ‘women’/‘woman’ throughout. However, it is important to highlight that it is not only those who identify as women who require access to miscarriage care. For example, some transgender men, non-binary people, and intersex people or people with variations in sex characteristics may also experience miscarriage. Miscarriage services and the delivery of care must therefore be appropriate, inclusive and sensitive to individual needs. The term couple is used to describe two individuals of any sexuality or gender.

The Delivery Framework for Miscarriage Care in Scotland was developed by an Expert Short Life Working Group, along with a writing group, and outlines a plan for introducing a graded model of miscarriage care in Scotland. The groups brought together a wide range of expertise that informed discussions, including wide representation from third sector organisations. Annex A details the membership of the groups.

The Framework brings together professional guidance, including guidance from the National Institute for Clinical Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG), with the recommendations in the Lancet series, Miscarriage Matters. Miscarriage care in Scotland is generally considered to be of high quality and NHS Boards have been further improving miscarriage care as a result of the drivers set out in the above-mentioned guidance and recommendations, and both of the published Scottish Government, Programme for Government commitments on improving miscarriage care.

The group considers that 15 months is a reasonable timeframe for NHS Boards to implement the majority of the key actions/deliverables in this document but recognises that a few of the actions/deliverables listed as ‘medium’ status priority may take longer to put in place in a few areas.

The group suggests the following prioritisation categories of the actions/deliverables. However, it is recognised that miscarriage services in Scotland are at different stages of delivery against the actions/deliverables in the Framework, as many have been following good practice and implementing professional guidance, including offering progesterone treatment where appropriate, for some time. The actions/deliverables have been given the following status:

• N – priority now and implemented within 6 months
• S – should be implemented in the short term within 12 – 15 months
• M – should be implemented in the medium term within 15 – 24 months

The status given to each action will help NHS Boards prioritise change locally and move to a ‘One Scotland’ approach.

Review and Monitoring Progress

NHS Boards will be asked by Scottish Government to assess what their service is delivering now, and report on their progress towards implementing the key actions/deliverables. Annual and Local Delivery Plan guidance for NHS Boards from 2025-26 highlights improving miscarriage care and implementing this Framework as a specific planning priority. NHS Boards will therefore be expected to report to the Scottish Government on progress towards implementation.

Summary of Key Actions/Deliverables

1. Miscarriage can have significant emotional and psychological impacts. At all points of contact, healthcare services should provide compassionate, culturally competent, and high-quality bereavement care, including clear communication and appropriate support.

Priority status N - priority now and implemented within 6 months

2. All NHS Boards to fully implement all five National Bereavement Care Pathways (NBCP), including the Miscarriage, Ectopic and Molar Pregnancy Pathway. A link to the NBCP can be found at NBCP Scotland.

Priority status N - priority now and implemented within 6 months

3. Ensure patients are made aware that clear, easily accessible and translatable information is available on NHS inform about managing concerns in early pregnancy which includes details on accessing care within each NHS Board. Provide patient leaflets for additional support I think I'm having a miscarriage: leaflet and After a miscariage and Miscarriage: dads and partners.

Priority status N - priority now and implemented within 6 months

4. NHS Boards to ensure that information about their early pregnancy service is up to date, effectively communicated, and easily available to women, as highlighted in the Refreshed Framework for Maternity Services in Scotland (2011).

Priority status N - priority now and implemented within 6 months

5. NHS Boards to ensure that those experiencing complications in early pregnancy are able to self-refer to their nearest Early Pregnancy Unit /Assessment Service (EPU/EPAS) within opening hours.

Priority status N - priority now and implemented within 6 months

6. Women, who are clinically stable, with pain and/or bleeding and a positive pregnancy test who contact the Scottish Ambulance Service, 111, their GP or the Emergency Department should be directed to their nearest EPU/EPAS within opening hours.

Priority status N - priority now and implemented within 6 months

7. Outside EPU/EPAS opening hours it is important that women have access to advice to prevent unnecessary attendance at the out of hours service or Emergency Department. Each NHS Board should ensure that women have access to someone who can speak to them over the telephone 24-hours-a-day, 7-days-a-week, including via an interpreter in their preferred language if required. Clinically stable women should be directed to the EPU/EPAS service when the service opens. In-person assessment should be available to those who require to be seen urgently because of clinical concern no matter what time of day or night.

Priority status S - should be implemented in the short term within 12 – 15 months

8. Wherever possible NHS Boards to build access to a seven-day early pregnancy assessment service with a same-day approach. Women with pain or bleeding in early pregnancy should be able to speak to someone with expertise in early pregnancy every day and be triaged for in-person assessment in the EPU/EPAS as required. All patients should be managed through EPU/EPAS within 24 hours of initial presentation as per MBRRACE-UK 2024 recommendations. MBRRACE-UK Maternal MAIN Report 2024

Priority status S - should be implemented in the short term within 12 – 15 months

9. NHS Boards that cannot provide a seven-day EPU/EPAS service within their Board should have agreements in place with neighbouring NHS Boards with clear lines of referral pathways. A networked approach within and between NHS Boards will ensure that patients and local non-specialist providers, including in primary care, are able to speak to someone with expertise in early pregnancy every day who can advise and arrange access to in-person assessment as required.

Priority status S - should be implemented in the short term within 12 – 15 months

10. Those experiencing miscarriage at any stage of pregnancy should be seen in a separate private space appropriate for bereavement, as advised in the NBCP Bereavement Care Standards, and if admitted to hospital, where possible, be treated in a single room. Generally, this should be located within maternity services away from other pregnant, labouring or postpartum women, or in an EPU/EPAS, or other clinically appropriate environment that has privacy in spaces sensitive to the needs of all individuals. Rooms should ideally have soundproofing.

Women/couples who wish to avoid walking through areas where there are other pregnant women should be given the choice of using a different exit, or if that is not possible, they should, if they wish, be compassionately accompanied through the shared area rather than being left to walk alone.

Priority status N - priority now and implemented within 6 months

11. NHS Boards should ensure that clear local procedures are in place, in line with NICE Guidelines, for the diagnosis of miscarriage using ultrasound scanning by appropriately trained and validated ultrasonography practitioners and conducted in single rooms.

Priority status N - priority now and implemented within 6 months

12. NHS Boards should facilitate the use of micronised progesterone treatment, as set out in professional guidance, for those with a previous miscarriage who are experiencing bleeding in early pregnancy, NHS Boards must follow the NHS Scotland National Guidance on the Use of Progesterone in the Management of Threatened Miscarriage and Recurrent Miscarriage.

Priority status N - priority now and implemented within 6 months

13. Clear written and verbal information on the miscarriage management options should be given to women and available for other care providers. Women need to be supported to choose the management approach that suits their needs and preferences. If required, interpretation services including British Sign Language (BSL) to be available for women, in-person where possible, throughout their assessment and care, ensuring that this is delivered compassionately.

Priority status N - priority now and implemented within 6 months

14. Where medical management is opted for, the use of mifepristone in advance of misoprostol should be standard practice as it increases the chance of success in missed miscarriage.

Priority status N - priority now and implemented within 6 months

15. Where surgical management of miscarriage is opted for, women are to be offered a choice of anaesthetic options including manual evacuation under local anaesthetic. Provide clear and realistic information, on each option, including intra and post-surgical pain relief, to support fully informed decisions.

Priority status S - should be implemented in the short term within 12 – 15 months

16. Where NHS Boards do not have all anaesthetic options available, the networked approach should be adopted, with clear formal agreements in place to seek care in an adjacent NHS Board to facilitate patient choice.

Priority status M - should be implemented in the medium term within 15 – 24 months

17. After a miscarriage, women are to be provided with written and verbal information about miscarriage and support available, signposted to the NHS inform miscarriage and pre-conception health pages, and, where appropriate, contraceptive advice should also be provided. The NHS inform information will be accessible to all and made available in translated and audio versions. NHS inform - early pregnancy units and NHS inform - losing a baby and NHS inform - after losing a baby.

Priority status N - priority now and implemented within 6 months

18. After miscarriage, women are to be provided with the Scottish Government/National Records of Scotland; leaflet on the memorial book of pregnancy and baby loss prior to 24 weeks and directed to the Scottish Government and National Records of Scotland; related webpages: Memorial Book of Pregnancy and Baby Loss Prior to 24 Weeks and The Memorial Book - National Records of Scotland.

Priority status N - priority now and implemented within 6 months

19. All NHS Boards to provide a graded model of miscarriage care as recommended in the Lancet series, Miscarriage Matters published in 2021.

Priority status S - should be implemented in the short term within 12 – 15 months

20. After a first miscarriage, women should be given and/or signposted to high-quality information to allow them to self-assess modifiable risks at a time appropriate to their individual circumstances.

Priority status N - priority now and implemented within 6 months

21. After a first miscarriage, women/couples should be able to speak to a nurse/midwife with expertise in early pregnancy complications and care if they have additional questions and require additional support after accessing the above information, and self-assessing.

Priority status S - should be implemented in the short term within 12 – 15 months

22. After a second miscarriage, women should be offered an appointment with an early pregnancy nurse/midwife where personalised care and initial investigations can take place or be organised. Where abnormal investigation results are found, a local pathway should be developed to manage these results including, where appropriate, a referral to an appropriate primary or secondary care doctor.

Priority status M - should be implemented in the medium term within 15 – 24 months

23. After two miscarriages, women should be offered full blood count, thyroid function testing and screening for obstetric antiphospholipid syndrome (APS) using anticardiolipin antibodies and lupus anticoagulant tests.

Priority status M - should be implemented in the medium term within 15 – 24 months

24. After two or more previous miscarriages, an early ultrasound scan in a subsequent pregnancy should be offered, at a time most sensitive to the couple’s needs, but not before 7 weeks’ gestation if asymptomatic (no pain or bleeding).

Priority status S - should be implemented in the short term within 12 – 15 months

25. After three miscarriages, women/couples should be offered the opportunity to attend a specialist recurrent miscarriage clinic. All NHS Boards should provide specialist consultant or equivalent medical staffing within these clinics and ensure dedicated time is allocated, or develop a formal agreement where women can be referred to their preferred NHS Board that can provide such a recurrent miscarriage clinic.

Priority status N - priority now and implemented within 6 months

26. After three miscarriages, women should be offered uterine imaging for congenital and acquired uterine abnormalities using 3D ultrasound. 3D ultrasound has been shown to improve detection of uterine anomalies therefore NHS Boards should develop access to this service where it is not available.

Priority status S - should be implemented in the short term within 12 – 15 months

27. Where 3D ultrasound is not available, 2D ultrasound should be offered after a third miscarriage. Where any abnormality is suspected, further imaging with 3D ultrasound, at a different site or with an agreement with another NHS Board, or MRI, should be offered.

Priority status N - priority now and implemented within 6 months

28. Cytogenetic analysis should be offered on pregnancy tissue of the third and subsequent miscarriage(s). This may require a maternal blood sample to check that the fetal genotype has been tested.

Priority status S - should be implemented in the short term within 12 – 15 months

29. Asymptomatic women with four previous miscarriages should be offered vaginal micronised progesterone from a positive urine pregnancy test until 12 weeks of gestation, where clinically appropriate. They should be provided with written information on available evidence and potential benefits/risks. An ultrasound scan should be provided at 6 weeks’ gestation, for these women treated with progesterone, in order to confirm intrauterine gestation.

Priority status N - priority now and implemented within 6 months

30. Couples with five or more previous miscarriages should be offered parental karyotyping where no results of genetic testing of pregnancy tissue are available (including previous maternal cell contamination, or where no pregnancy tissue is available for testing). National discussions are ongoing to support this deliverable.

Priority status M - should be implemented in the medium term within 15 – 24 months

31. All NHS Boards should have a nurse-led or midwife-led team with specialist training and expertise in recurrent miscarriage and time allocated commensurate with local service needs to provide support to couples with recurrent miscarriage and work alongside the specialist medical clinic.

Priority status S - should be implemented in the short term within 12 – 15 months

32. NHS Boards should ensure staff receive training in providing compassionate, culturally competent care after miscarriage and other early pregnancy complications. Training should include supporting bereaved individuals, peer support for staff, and aligning with the NBCP Miscarriage, Ectopic and Molar Pregnancy Pathway.

Priority status N - priority now and implemented within 6 months

33. NHS Boards should develop their bereavement counselling services towards offering counselling (including online platforms) to women who have experienced a miscarriage.

Priority status M - should be implemented in the medium term within 15 – 24 months

34. NHS Boards should ensure that those who experience miscarriage have access to culturally competent, trauma-informed and responsive services which embed the principles of choice, collaboration, empowerment, safety and trust. This means services which recognise the prevalence of trauma and its impact (including amongst their own staff) and which respond in ways that support recovery. It also means services that follow the key principles of trauma-informed care, that do not unintentionally retraumatise, and that allow individuals to easily access the appropriate care and support, including appropriate third sector support, which they need.

Priority status M - should be implemented in the medium term within 15 – 24 months