1. Miscarriages must be recorded so that the rate of miscarriage can be measured nationally
Data on the number of miscarriages must be made available along with stillbirth and preterm birth rates. This will allow us to fully understand the scope of the problem and enable the setting of targets for reduction.
Recommendation: A process for recording miscarriage exists, however standardisation of data entry and then centralised data collation is the challenge. Look to the Department of Health to incorporate miscarriage data into a women’s reproductive data set tocomplement the maternity data set.
2. Access to care after miscarriage must be available with a clear pathway for follow-up mental health support
Women must receive appropriate, standardised care during and after their first miscarriage, including the best management of miscarriage and pre-conceptual support to intervene on modifiable risk factors. Women and partners should have access to follow-up mental health support to help reduce mental illness post-miscarriage.
Recommendation: Healthcare professionals who are involved in the care of a woman who has miscarried and their partner to follow guidance within The National Bereavement Care Pathway developed to improve bereavement care and reduce variability in provision for families after miscarriage. This includes providing information about the emotional support available via the hospital Trust, primary care colleagues and via local and national support organisations, as well as standards for follow-up appointments, and a referral for a mental health assessment and, where appropriate, treatment. See also NICE guidance on antenatal/postnatal mental health (https://www.nice.org.uk/guidance/qs115).
3. Tests and treatments must be standardised across the UK through a ‘graded approach’ to recurrent miscarriage
Health services should standardise and structure care using a ‘graded model’, where women are offered online healthcare advice and support after one miscarriage, care in a nurse or midwife-led clinic after two miscarriages, and care in a medical consultant-led clinic after three miscarriages. This approach balances the need for evidence-based management and supportive care, whilst targeting health care resources appropriately. Where Early Pregnancy Units and miscarriage clinics already exist, these services are well-structured to deliver care within this graded model.
Recommendation: Implementation of a pre-conceptual care package after first miscarriage through the Public Health Outcomes Framework. Nurse-led care after second miscarriage and consultantled care after third miscarriage through Trust miscarriage services or Early Pregnancy Unit. See model on page 9.
4. Specific, personalised care pathways should be established for high risk women
At-risk groups, including Black women, women over the age of 40 and women with existing medical conditions, must receive personalised care according to their individual risk factors, which may include a closer level of care and monitoring in early pregnancy.
Recommendation: Appropriate care pathways using a modified ‘graded approach’ to recurrent miscarriage should be established for these groups.
5. A clear pathway for preconception support and guidance must be established
Support and advice to plan and be ready for pregnancy should not only be widely available but also targeted to high-risk groups, including women with long-term conditions and those with multiple vulnerabilities. These groups should receive help early to plan pregnancy and additional support to have a healthy pregnancy.
Recommendation: To build on the existing work of Public Health England and NHS England’s Maternity Transformation Programme in developing a preconception pathway and preconception indicators. Preconception care to be offered by GPs or preconception clinics in some cases, using existing information and resources including the Tommy’s ‘Planning for Pregnancy’ tool.