EMPIRICAL STUDIES

doi: 10.1111/scs.12175

Deciding treatment for miscarriage – experiences of women and healthcare professionals Mette Linnet Olesen RN, MPH (PhD Student)1, Anette H. Graungaard MD, GP, PhD (Senior Researcher)2 and Gitte R. Husted RN, MScN, PhD (Researcher)3 1

Research Unit for Women’s and Children’s Health Department 7821, Copenhagen University Hospital, Rigshospitalet, Copenhagen Ø, Denmark, 2Department of Public Health, Section of general Practice, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark and 3The Paediatric Department, Nordsjaellands Hospital Hilleroed, University of Copenhagen, Hilleroed, Denmark

Scand J Caring Sci; 2015; 29; 386–394 Deciding treatment for miscarriage – experiences of women and healthcare professionals

Introduction: Women experiencing miscarriage are offered a choice of different treatments to terminate their wanted pregnancy at a time when they are often shocked and distressed. Women’s and healthcare professionals’ experiences of the decision-making process are not well described. We aimed to gain insight into this process and the circumstances that may affect it. Method: A qualitative study using a grounded theory approach. Data were obtained through semi-structured interviews with six women who had chosen and completed either surgical, medical or expectant treatment for miscarriage and five healthcare professionals involved in the decision-making at an emergency gynaecological department in Denmark. An inductive explorative method was chosen due to limited knowledge about the decision-making process, and a theoretical perspective was not applied until the final analysis. Results: Despite information and pretreatment counselling, choice of treatment was often determined by unspoken emotional considerations, including fear of seeing the foetus or fear of anaesthesia. These considerations

Introduction Close to a quarter of all pregnancies are estimated to end in miscarriage (1), and, as a result, millions of women are affected globally. In Denmark, there are approximately 9000 miscarriages per year (2). Management of miscarriage has radically changed during the last 20 years Correspondence to: Mette Linnet Olesen, Research Unit for Women’s and Children’s Health Department 7821, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark. E-mail: [email protected]

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were not discussed during the decision-making process, which was a time when the women were under time pressure and experienced emotional distress. Healthcare professionals did not explore women’s considerations for choosing a particular treatment and prioritised information differently. We found theory about coping and decision-making in stressful situations useful in increasing our understanding of the women’s reactions. In relation to theory about informed consent, our findings suggest that women need more understanding of the treatments before making a decision. This study is limited due to a small sample size, but it generates important findings that need to be examined in a larger sample. Conclusion: Frequently, women did not use information provided about treatment pros and cons in their decisionmaking process. Because of unspoken thoughts, and women’s needs being unexplored by healthcare professionals, information did not target women’s needs and their reasoning remained unapparent. Keywords: miscarriage, pregnancy loss, decision-making, treatment, grounded theory, communication, informed consent, autonomy, coping. Submitted 20 January 2014, Accepted 17 July 2014

(3) with medical treatment becoming an alternative to expectant and surgical treatment. The treatments involve different courses and follow-up. Surgical treatment is carried out in hospital over a short period of time using general anaesthesia, while medical and expectant treatment takes place over a longer period of time and often occurs at home (Table 1). Decision-making regarding treatment often takes place right after the diagnosis, at a time when the women may be shocked and vulnerable (4). Women’s preferences and acceptance of treatment have been explored as secondary outcome measures in randomised clinical trials (RCTs) (5–7) assessing treatment efficacy and side effects. Some of these studies have © 2014 Nordic College of Caring Science

Deciding treatment for miscarriage Table 1 Treatment options and their courses at the emergency gynaecology departmenta Medical treatment

care and information, and to support patient autonomy. The aims of this study were therefore to gain insight into the decision-making process for the treatment of miscarriage and the circumstances that may affect it.

No fasting Medication (misoprostol) 4 hours of observation at the hospital The abortion often occurs at home Follow-up at the hospital after one week No treatment Follow-up after one week or individually Fasting Curettage in general anaesthesia 2–4 hours of observation at the hospital afterwards No follow-up

Expectant treatment Surgical treatment

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Methods Design This study used a grounded theory (GT) approach (12– 15). GT is suitable for investigating social and psychological events and human interactions, and for this reason, it was chosen as a means to explore the participants’ main concerns. The aim was to generate a theory grounded in data that described and explained behaviour patterns of the participants involved in the decision-making process (12). The sample consisted of 11 qualitative, semi-structured interviews with women aged 30–41 years and HCPs working in an emergency gynaecological department (Table 2). Interviews with the women were conducted 14 days after treatment. HCPs were interviewed in the same period.

a

At the time when the study was carried out.

found that women have different preferences regarding treatment. The results suggest that women should be given a choice based on comprehensive information about the treatments including pros and cons (6, 8). This is in line with two recent Cochrane reviews examining expectant care vs. surgical treatment (9), and medical treatments for incomplete miscarriage (10). Both reviews conclude that women’s preferences should be taken into account and that women should be offered an informed choice of treatment. There has been little research into how women experience the decision-making process for the treatment of miscarriage, but one study explored the decision-making process related to expectant vs. surgical treatment (11). Women choosing expectant management were motivated by a desire for a natural course of treatment and fear of surgery, whereas those choosing surgery valued quick resolution (11). We found no studies involving healthcare professionals’ (HCPs) perspectives on the decision-making process. Knowledge about the decision-making process is essential to optimise patient

Participants Eligible participants in this study consisted of pregnant women aged ≥18 years referred to an emergency gynaecological department at a university hospital in Copenhagen because of bleeding or pain. In line with routine care procedures, they saw a physician for a gynaecological examination and an ultrasound scan. When miscarriage was diagnosed, women were informed about treatment options (Table 1) and typically treated the same day or the day after. Inclusion criteria were women who were admitted with missed abortion or incomplete spontaneous abortion (Table 3) before the end of week 13, who were eligible

Table 2 Characteristics of participants Patients

Age in years

Children

Gestational age in weeks

Treatment

1 2 3 4 5 6

34 30 37 40 39 41

One None Two One None None

9 13 12 10 9 10

Medical Medical Surgical Surgical Surgical initially, but later medical Initially expectant, but later medical

Health care professionals

Length of service after education

Length of service in gynaecology

Specialist in obstetrics and gynaecology

Nurse 1 Nurse 2 Doctor 1 Doctor 2 Doctor 3

>4 years >4 years >10 years >10 years >3 years

>3 years >3 years >5 years >7 years 6 months

Yes Yes No

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Table 3 Definitions of incomplete spontaneous abortion and missed abortion according to the Danish National Guidelines (Tigrab) Missed abortion

Incomplete spontaneous abortion

Table 4 Themes in the interview guide Patients

Arriving at the hospital Experiences of examination and diagnosis Experiences of the decision-making process Considerations and thoughts about choosing treatment Perceptions of HCPs and their roles Feelings and emotions during the whole process

Health Care Professionals (HCPs)

Perceptions of the women during the process Experiences of the decision-making process Experiences of information given and used Perceptions of roles among HCPs Personal and professional perception of the treatments

Positive urine-HCG and/or S-HCG and no or minor bleeding, no or weak pain and Intrauterine lost pregnancy Positive urine-HCG and/or S-HCG and ongoing bleeding per vagina and Intrauterine lost pregnancy AP diameter >15 mm

AP: anteroposterior; HCG: human chorionic gonadotropin.

for at least two of the three different treatment options and who were treated according to their choice. Exclusion criteria were unwanted pregnancy or poor Danish language skills. Eligible HCPs were to have at least half a year of employment in the department. The doctors were not required to be specialists in obstetrics and gynaecology. Women were sampled for maximum variation (16), which aimed to include women that had chosen different treatments and those with or without children. HCPs with different levels of education and length of professional experience were sampled. Concomitant analysis furthermore guided the sampling by including temporary findings in the sampling strategy. This theoretical sampling (12) brought emerging themes into the sampling, for example the meaning of the word ‘clot’ to the participants – both women and HCPs used the word frequently. Data collection was completed after interviews with six women and five HCPs, where saturation was deemed to have been reached.

Ethical considerations Due to the women’s vulnerable situation, ethical reflection was continuously carried out. Written informed consent was obtained from patients and HCPs after they received both verbal and written information about participating in the study. Permission was obtained from all participants to digitally record the interviews. According to Danish law, interview studies are exempt from ethical review. This was confirmed by the Ethics Committee of the Capital Region, Denmark (H-1-2010-FSP). Data handling was approved by the Danish Data Protection Agency.

Interviews A semi-structured interview guide was used to allow flexibility to explore participants’ main concern (12). Interview themes are outlined in Table 4. The interview guide was continuously adjusted according to emerging findings to explore and compare findings and patterns (12, 14). The interviews were conducted by first author (MLO), lasted 50–90 minutes and were transcribed by MLO.

Analysis Data were analysed using NVivo (version 8, QSR International, Australia) by MLO. MLO and GRH (last author) read all interviews and discussed sampling and changes in the interview guide. All three authors discussed findings to further validate the process. The inductive process using the constant comparative method in GT was performed in four steps. 1) We started out analysing data to answer the overall research question: ‘How do women and HCPs experience the decision-making process?’ Firstly, open coding (12) was performed after each interview and in vivo and tentative codes were labelled. 2) Secondly, when main categories were created, theoretical coding families were considered (12) to examine whether any theoretical codes could increase the understanding of the relationship between the categories. The six Cs comprising causes, contexts, contingencies, consequences, co-variances and conditions were particularly inspiring. 3) Thirdly, the categories’ mutual relationships focusing on context, circumstances and consequences were identified (17). 4) The main finding ‘unspoken emotional considerations guided the decision-making’ was chosen because of its ability to explain most of the data and was related to the main categories in the selective coding phase (12). Interviews were re-read and recoded several times to secure grounding in data and to validate the analyses. Memos, including reflections and hypotheses about codes and, later on, categories and their mutual relationships were written as tools to maintain and develop the analyses. In the beginning, the memos were descriptive, but as the analysis progressed they became more abstract. The main finding and the related categories are displayed in Table 5. © 2014 Nordic College of Caring Science

Deciding treatment for miscarriage Table 5 Main finding and the related categories Main finding 1. Unspoken emotional considerations guided the decision-making

Anaesthesia being a relief Fear of seeing the foetus “Clots”



Fear of anaesthesia

The psychological context

• • •

Distress and chaos Feeling guilt and shame Creating meaning and normalising

The physical context

3. Personal autonomy and responsibility

4. Different information priorities among health care professionals

we discuss our findings in relation to ethical aspects of patient autonomy.

Considerations for surgical treatment

• • •

Considerations for medical treatment Related categories 2. The psychological and physical context of the decision-making

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• •

Time pressure Information and choice given right after diagnosis

• • •

Appreciated self-determination and autonomy Difficult Ignored feelings

• •

Doctors biomedical focus Nurses psychological focus

Theoretical interpretation The study was conducted inductively during all stages, and a theoretical perspective was not applied until the final analysis (12). Literature about the topic was known beforehand, but a focused literature review was not carried out before the final analysis to assess how the findings correlated with existing theory and literature, as recommended by Glaser (12). We found coping theory as described by Lazarus and Folkmann (18) useful to further increase our understanding of women’s reactions during the decision-making process following a diagnosis of miscarriage. They define coping as ‘the constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person’ (18). Coping strategies are often classified as problem-focused coping, emotionfocused coping and meaning-based coping (18, 19). Furthermore, the theoretical framework ‘A Conflict Model of Decision-Making’ was utilised (20), which explains people’s reactions when decision-making occurs in stressful situations. The Conflict Model of Decision-Making also involves coping strategies to explain people’s reactions. These two theories involving coping strategies will be further elaborated in the discussion of our findings. Finally,

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Results Results will be presented as follows: (i) main finding: unspoken emotional considerations guided the decisionmaking; (ii) the psychological and physical context of the decision-making process; (iii) personal autonomy and responsibility; and (iv) different information priorities among the HCPs.

Main finding: unspoken emotional considerations guided the decision-making The main finding was that women’s choices were often based on unspoken emotional considerations. Unspoken because they were not expressed; it is even possible the women were not conscious of these reasons during the decision-making process. Sometimes, these reasons were grounded in unrealistic beliefs about the course of the treatment. Women kept their reasons to themselves, and the HCPs did not explore them. The women’s thoughts and beliefs about treatments remained unspoken during pretreatment counselling. Consequently, the decisionmaking process consisted of both a spoken and an unspoken layer. Figure 1 visualises the main finding and its interaction with the related categories. Women who chose surgical treatment were scared of seeing the foetus and felt relieved by anaesthesia. In contrast, women often chose medical treatment because they feared anaesthesia. Unspoken emotional considerations dominated women’s reasons for choosing a specific treatment, despite pretreatment counselling that provided detailed information about the different treatments’ efficacy and risk of side effects. HCPs, on the other hand, believed women’s decisions were based on information given about the biomedical pros and cons: Doctor 2: ‘They are in fact using the information they receive to choose their treatment, so it is safe to say that it’s a crucial piece of information. And that is exactly why it should be user friendly. It’s no good if it becomes too complicated’. For women choosing surgical treatment, the word ‘clot’ became critical to their choice. HCPs often used the word to illustrate heavy bleeding with coagels, but the women thought it referred to parts of the foetus. Woman 3: ‘I’m not doing that! I will not wear a large pad for several days. And I will under no circumstances wear a pad with clots in it, and even though it’s totally morbid, start thinking I see things; was that a hand or what was it?’ (Surgically treated) Furthermore, women choosing surgical treatment felt they could not cope with having an abortion at home;

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Figure 1 The main finding and its interaction with the related categories.

they felt insecure about how and where the abortion would take place. Women choosing medical treatment used arguments, such as it was the gentlest treatment with few side effects, but when asked about their primary reason for choosing the treatment, they substantiated that it was to avoid anaesthesia. Woman 1: ‘I would actually much prefer not to undergo anaesthesia as I’ve never tried it before. For this reason, I think it was a good decision for me’. (Medically treated)

The psychological and physical context of the decision-making process. The psychological context. The emotional reasons that remained unspoken during pretreatment counselling might be a consequence of the context of the decisionmaking process where the women had just received information about the loss of the foetus. Women were asked to choose between treatments immediately after the miscarriage was diagnosed, and they described themselves as being in distress. It was also consistent that women felt guilty about the miscarriage. They searched for explanations and blamed themselves for what had happened. Woman 5: ‘What have I done to make this foetus die? I know it is said to be a chromosome failure. However, I also think it’s a convenient excuse for someone like me; it has nothing to do with you, it’s not your fault. Not having killed your own foetus is a bit easier to come to terms with’. (Surgically treated) Some women found miscarriage to be shameful, but it was difficult for them to articulate that feeling. The doctors prioritised explaining to the women that miscarriage frequently occurs in early pregnancy. This knowledge

helped the women in their process of creating meaning, and it comforted them. The information women remembered and used was selective: ‘It is normal and I can become pregnant again’. Feelings concerning the miscarriage experience were an important context of the decision-making process, and, according to the women, these feelings were not addressed during the pretreatment counselling. The physical context. Women received information about treatment options in a busy hospital clinic right after the diagnosis. They listened to the information given and tried to ignore their distress. In their descriptions, it became clear that they had problems processing the information. Woman 2: ‘I remember sitting there and thinking. I was in a bit of a state of shock, getting information and letting it sink in. I’m pretty sure I didn’t hear everything as I was lost in my own thoughts’. (Medically treated) Most HCPs often experienced women who were not capable of processing information right away. Nurse 2: ‘Their heads are absolutely spinning in most cases, so they probably do not actually hear much’. When HCPs perceived that the decision-making process was too difficult for the women, they tried to think of other solutions, such as encouraging them to go for a walk and consider the options, which gave the women a little more time to decide.

Personal autonomy and responsibility Despite difficulties, it was a general pattern that almost all participants appreciated the opportunity for self-determination and valued being involved in the decisionmaking process. © 2014 Nordic College of Caring Science

Deciding treatment for miscarriage Woman 2: ‘I’m not sure if it is dependent on whom you are as a person. . .but I really like. . . it gives you a feeling of taking matters into your own hands’. (Medically treated) Women tried to ignore the chaos they experienced to manage the decision-making process, and they felt they were acting responsibly by choosing which treatment option to pursue. Nevertheless, several women found it quite difficult due to the context of unexpected loss. Woman 5: ‘It’s a lot of responsibility to give people in such a vulnerable situation. It is a tragic event that has occurred in your life, and all of a sudden you’re asked to decide how to get rid of this foetus, which was supposed to be your baby’. (Surgically treated) Healthcare professionals experienced a dilemma when women asked them what they would choose. Doctor 3: ‘What would you choose in my situation? That is the typical question I get. And my answer to that is, I cannot. . .no. . .it has to be your choice. Mmmm. . .I actually would not know what to choose if I were in that situation. . .no’. Healthcare professionals answered this question differently. Some gave advice according to their own conviction, while others believed it did not help the woman to know their personal preference.

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of telling her about the various things about it, such as when and how it happens. That you have to be prepared for bleeding at home, sometimes heavily for several hours. . .and the unpredictability of it. . .that you have to be patient, you have to be mentally strong to have a medical abortion’. The nurses often received phone calls from women during medical treatment, where they had to repeat information which had either been forgotten or misunderstood. If the women were informed that medical treatment was easy and gentle, nurses experienced a dilemma and sought to supplement the information afterwards to provide the women with, from their point of view, a more realistic assessment of the treatment. Nurse 2: When choosing the treatment, it’s not only relevant to consider whether the foetus is 20 mm, it’s also very much a case of taking the woman’s mental situation into account. . . whether they are able to handle medical abortion. Sometimes the medical abortion sounds easier and more gentle than it actually is’. Typically information was provided verbally in the decision-making process. Written information was handed out only after the women had made their choice of treatment.

Discussion Different information priorities among healthcare professionals Healthcare professionals had different perspectives on the content of information that should be given. Doctors tended to counsel individually ‘I do not start the conversation in the same way for all patients’, and information was primarily related to biomedical aspects of treatment. Doctor 2: ‘I tell them that we have two different treatments. I describe the surgical [treatment] first and that the benefit is shorter bleeding time. Then I say that with the medical [treatment] general anaesthesia is avoided and the risk of infection is halved. And then I mention that it has the disadvantage that you bleed longer and you must attend more follow-up visits than with surgical [treatment]. These are the things I initially mention’. Nurses felt they had clinical knowledge about the psychological and physical challenges that especially medical treatment caused, and that medical treatment could often take the women by surprise due to heavy bleeding, pain and the unpredictable course of the treatment. Aside from backing-up the biomedical information, nurses found it essential to also inform the women about their experience of the psychological dimensions of the treatments to try to ensure that the women had adequate resources to manage their chosen treatment. Nurse 2: ‘I share my experience if I think she needs it. If she is to have a medical abortion and I, for some reason, do not think she is suitable for it. . . I may make a point © 2014 Nordic College of Caring Science

Our results indicate that women’s psychological reactions to the miscarriage and the physical circumstances of the pretreatment counselling substantially influenced their ability to process and use the information provided. Their choice of treatment was based on unspoken emotional considerations which were not explored by the HCPs. In the following discussion, we will relate our findings to the existing literature about women’s experience of miscarriage and theory regarding coping and decisionmaking in stressful situations. The psychological context of the women’s decisionmaking process, which we found to include shock, distress and feelings of guilt and shame, has also been found in other studies of women’s experience of miscarriage (4, 21, 22). One of the main findings concerning thoughts about seeing the foetus is consistent with those of others. Smith and colleagues (6) found that some women wanted to avoid seeing the foetus during treatment, while others wished to see it and say goodbye. Moulder found that women had unanswered questions after their abortion, such as ‘was the clot the baby?’ (23). A qualitative study exploring women’s experience of miscarriage found that to the women it was not a loss of an embryo or a foetus, but their child that they had prepared themselves for (4). It is, however, not very likely that the foetus will be visible during medical treatment. According to the Danish National Guidelines (24), medical treatment is an option for missed abortions when the foetus is up to 20 mm

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(25). Thus, hands and feet of the foetus in this early stage of development cannot be seen by the human eye. Our finding of fear of anaesthesia is also described in other studies (6, 8). If this fear is based on complication rates, it may be argued that the risk is so low (26) that the fear rather stems from insufficient information and a lack of dialogue between the woman and the HCP. We found that women were preoccupied by searching for meaning through ‘normalising’ and that they were more aware of information supporting this need than information about treatments. Searching for meaning during miscarriage is consistent with findings in other qualitative studies (4, 11, 21) and in narratives related to miscarriage described by Simmons et al.(22). Folkman (19) has described how creating meaning by finding a redeeming value in loss helps people cope with stressful and unchangeable events. In our study, this process was intrusive during the decision-making process of choice of treatment, which increased the likelihood of the patient not being able to give the decision-making their full attention and ultimately make an informed choice. Making decisions in stressful situations has been described by Janis and Mann in ‘A Conflict Model of Decision-Making’ (27). They state that rational decision-making models have problems describing how people make decisions under stress (20, 27). They describe how the decision maker’s problem-solving capability is reduced with impaired attention and perception resulting in, for example, inefficient information gathering and evaluation (27). The framework describes five basic coping patterns used by persons who experience a characteristic level of decisional stress. One of them is the coping pattern ‘defensive avoidance’. This pattern leads the person to avoid cues that stimulate anxiety and painful feelings, and the person reacts by being ‘selectively inattentive’ and avoids the conflict by shifting the responsibility to someone else (20). Our findings concerning women’s fear of seeing the foetus and of anaesthesia might be an expression of the strategy ‘defensive avoidance’, and when the women asked HCPs ‘what would you do?’, it could be to shift the responsibility for the choice to the HCP, indicating that the women were actually not capable of rational decision-making at that point. We found that HCPs prioritised the content of information differently. This may be attributed to differences in working contexts, where nurses have more continuous contact with the women during the course of treatment and provide them with insight into other women’s experiences, whereas doctors’ pretreatment counselling may be based on medical evidence of treatment effects and side effects. This is in line with a study of nurses’ role in informed consent, where nurses found that most clinicians viewed informed consent as a one-time encounter, instead of a process that occurred over time (28). This limited the opportunities to repeat and provide individual

information in different ways and styles and rarely gave patients an opportunity to re-evaluate their decision (28). This notion supports the findings from our study where the nurses reported that they had to give or repeat additional information during treatment. Both women and HCPs valued increased patient autonomy in our study, although both parties found it difficult in the particular context, and our findings suggest that women did not have relevant knowledge about the courses of treatments after pretreatment counselling. Informed consent is intended to promote patient autonomy and well-being (29). In biomedical ethics, informed consent involves competence, disclosure, understanding, voluntariness and consent (30). In relation to patients’ understanding, a wide variation has been found to exist in clinical practice, and there is no consensus about the level of understanding essential for valid consent (30). However, it is suggested that people should have acquired relevant information and have relevant beliefs about the nature and consequences of their actions (30). According to relational autonomy theory, decision-making is not just a matter of choice, but must be seen in social and situational contexts (31). If the only focus is giving a choice without paying attention to the context of the decision-making process, patients may feel abandoned (31). In a social context, miscarriages are taboo in society, in the media, and in the scientific literature, miscarriage has been called ‘the hidden experience’ (32). We found that women’s feelings of distress, guilt and shame were not sufficiently taken into account in the busy hospital environment, where choosing treatment was considered a simple decision. It is questionable whether women in our study were actually given a truly informed choice due to the context of the decision-making.

The strength of the study To our knowledge, this is the only study that explores the decision-making process among this group of patients. The strengths of the study include its explorative qualitative design, and triangulation including both women and HCPs. Furthermore, three researchers were involved in sampling and analysis. The constant comparative analyses validated the analysis and strengthened grounding in data. The first author’s lengthy clinical work in the studied field may have provided thorough inside knowledge of the clinical setting and its challenges, but also presents a risk of interpretation bias. This was alleviated by continuous discussion with the other two authors who do not work in the same specialty.

Limitations of the study The study had a small sample size, and the findings should be explored further in a larger sample with other © 2014 Nordic College of Caring Science

Deciding treatment for miscarriage subgroups and more information about women’s preconceptions and emotional reactions. Included women had a high age, so the study might not be representative of younger women. Furthermore, the findings might not be transferable to women with different ethnic backgrounds, including populations where women are not given a choice of treatment and instead follow their doctor’s advice. The results may not be valid for women with unwanted pregnancies, who may experience miscarriage as a relief (33). We conducted interviews 14 days after treatment, which may only inform about the short-term experience of the decision-making. However, this is also a strength because the women still recalled the episode, and we aimed to explore the decision-making process rather than the long-term consequences.

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these unrevealed considerations. To a large extent, women did not make sufficient use of the information provided about treatment pros and cons in their decisionmaking process, nor did they use it in a relevant manner. This may be due to time pressure, shock and emotional distress, factors which were not taken into account by HCPs. We found that women had problems processing the given information because they were mentally preoccupied coping with their loss during the pretreatment counselling. Because of the unspoken thoughts unknown to and unexplored by HCPs, information and pretreatment counselling did not target women’s needs and the reasoning behind their treatment choice remained unapparent.

Acknowledgements Perspectives Our findings should be examined in a larger population, but they suggest that the decision-making process can be improved. In addition, this may improve patient wellbeing during the course of medical treatment at home. A proactive dialogue with use of open questions might reveal women’s unspoken considerations. Use of a recent developed checklist to reveal women’s preferences may contribute to an improved dialogue and thereby target women’s specific concerns (1). The women’s processing of information and involvement is likely to be improved if the decision-making process is re-organised in cases where treatment is not immediately required. More time will allow the women to adapt to their loss and take their stress level into account. In addition, verbal and written information should be available before choosing treatment. HCPs should be aware of the significance of this choice to the patients, even if treatment for miscarriage is a minor clinical procedure. Our suggestions may help increase patient autonomy, which was highly valued by the women, but was quite difficult for them to deal with in the particular context.

We wish to thank the women for sharing their experiences with us at a stressful time, and doctors and nurses for contributing with their points of view.

Author contributions Mette L. Olesen (MLO) designed the study in collaboration with Gitte R. Husted (GRH). MLO conducted and transcribed all interviews but discussed sampling and development of the interview guide continuously with GRH. All interviews were read and analysed by all authors, MLO, GRH and Anette H. Graungaard (AHG). All three authors have been involved in drafting the manuscript and have approved the final version.

Ethical approval According to Danish law, interview studies are exempt from ethical review; this was confirmed by the Ethics Committee of the Capital Region, Denmark (H-1-2010FSP). Data handling was approved by the Danish Data Protection Agency.

Conclusions

Funding

The women had unspoken emotional reasons for choosing a specific treatment, and the HCPs did not explore

The study was funded by The Health Foundation (2009B087).

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© 2014 Nordic College of Caring Science

Deciding treatment for miscarriage--experiences of women and healthcare professionals.

Women experiencing miscarriage are offered a choice of different treatments to terminate their wanted pregnancy at a time when they are often shocked ...
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