Miscarriage Care and Facilities in Scotland: Scoping Report National Overview

Key Messages

The findings of this scoping exercise are presented in a table in Annex A mapped to the recommendations from the Lancet series on Miscarriage Matters and the Scottish Government Programme for Government commitments.

Miscarriage services and dedicated facilities

• All Health Boards in Scotland have services available for women experiencing miscarriage, the services and provision available varies across Scotland.
• Early pregnancy services are available in all Health Boards in Scotland. 10 of 14 Health Boards have a dedicated early pregnancy unit and 4 Health Boards deliver early pregnancy services within existing services.
• Some dedicated facilities for women experiencing unexpected pregnancy complications at any gestation are available in all Health Board areas. Some women may need to travel significant distances to access these facilities particularly in more rural areas and in areas where miscarriage care is provided at one or two main locations within a Health Board.
• Not all Health Boards have a separate room/area/ward away from the labour ward for women that are miscarrying. Where this is available, rooms are usually located in the gynaecology ward or the maternity unit (often away from the labour and postnatal wards).
• 11 of the 14 Health Boards provide services for recurrent miscarriage.
• Seven out of the 14 Health Boards said that they have a separate area to carry out complication/investigative scans separated from women with a continuing pregnancy.

Miscarriage Management

• All Health Boards in Scotland routinely provide written information about the treatment options for the management of miscarriage and what to expect next in terms of miscarriage care.
• Written information about third party services for mental health or bereavement support is provided in most Health Boards.
• Expectant management is offered in all Health Boards, however, in some areas expectant management may not be chosen by women due to the potential for multiple long journeys to the site where provision is located.
• Medical management with misoprostol is offered in all Health Boards. 13 of the 14 Health Boards offer medical management with mifepristone and misoprostol with one Health Board not offering this service.
• Surgical management with general anaesthetic is offered in all Health Boards, while surgical management with manual vacuum aspiration is provided in 10 Health Board areas, with two further Health Boards able to access this management option upon request.
• All Health Boards stated that women are free to choose their preferred management approach based on their needs and preferences, local guidance and gestation at which management approaches are offered to women varies across Scotland.
• The choices that women make about management options can be impacted by the travel distances to the site where the management option is provided.

Graded Approach to Recurrent Miscarriage

• Elements of the graded approach to recurrent miscarriage are adopted or can be accessed in 13 Health Boards, however, none of the 13 Health Boards consistently deliver all elements of the graded approach particularly after a first or second miscarriage. One Health Board does not plan to implement the graded approach.
• The care and options provided to women in relation to recurrent miscarriage is often dependent on the site at which women attend or are referred to.
• Key elements of the graded approach such as the provision of vaginal micronised progesterone and medical management with mifepristone and misoprostol have not yet been fully implemented in all Health Boards.
• Many of the elements that the Lancet series recommends should be provided after a first miscarriage, are provided in all Health Board areas but not in all sites that may care for women experiencing miscarriage. Screening for mental health issues and individualised care plans are not provided in all Health Boards.
• No Health Board offers all elements that the Lancet series recommends should be provided after a second miscarriage. There is variability in approach within and between Health Board areas.
• After a second miscarriage, the Lancet recommends that women are offered appointments at nurse-led or midwifery-led miscarriage clinics. Many Boards have no plans to implement this as miscarriage clinics are consultant-led. In more than half of the Health Board areas in Scotland women are seen at a miscarriage clinic by a consultant rather than a nurse or midwife.
• After a second miscarriage, it is not routine for all Health Boards or sites to offer continuity of carer, tests for full blood count and thyroid function and discussions about lifestyle issues in relation to future pregnancies.
• No Health Board offers all elements that the Lancet series recommends should be provided after a third or subsequent miscarriage. The service provision is variable, and while almost all options are being delivered in all Health Boards, this is site dependent.
• Screening for mental health issues after a third or subsequent miscarriage is provided in 12 of the 14 Health Boards. Although it is unclear if screening is routine for all women in all sites and whether a validated tool is being used across all Health Boards.

Referrals, Assessments, Skills and Training and Data

• Referral pathways directly from secondary care to mental health support, for women experiencing miscarriage, are not always available in early pregnancy or maternity services with referrals pathways often via primary care.
• All Health Boards have written clinical guidance for clinical staff on the appropriate treatment and care for miscarriage at all gestations.
• The training and skills of staff providing miscarriage care varied across Health Boards. Often specialist training was centralised within one or two units within a Health Board area. Some Health Boards operate a more medical approach to miscarriage care with consultant-led provision and doctors trained to provide comprehensive miscarriage care. Fewer Health Boards have nurses or midwives with additional specialist training.
• 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.