Mental Health Crisis in Miscarriage–an Unrepresented Patient Population

By TAMARA MANNS

I walked into the emergency department already knowing the outcome. In these same rooms I had told women having the same symptoms as me, “I am so sorry, there is nothing we can do for a miscarriage”. I handed them the same box of single ply tissues I was now sobbing into, as I handed them a pen to sign their discharge paperwork.

Two weeks after my emergency room discharge, I continued to live life as if nothing happened, returning to work without any healthcare follow-up to address my emotional burden. Luckily, I had established obstetrician (OB) care with the physician who previously delivered my second child. At only nine weeks gestation I had not seen my OB physician yet, but I was able to follow up in the office to talk about my next steps.

After that two-week hospital follow up, I heard from no one.

Due to the environment of the emergency department, women often complain of unprepared providers with ineffective and impersonal delivery of miscarriage diagnosis and discharge education; this lack of emotional support can result in feelings of abandonment, guilt, and self-blame. Due to the psychological impact of pregnancy loss, a standard of care for screening and referral must be implemented at all facilities treating women experiencing miscarriage.

If I had not reached out to my healthcare provider after my miscarriage, I would have continued suffering through an aching depression without help.

Depression, anxiety, and grief are most severe in the first four months after miscarriage. The symptoms decrease in severity throughout the following year. These symptoms may influence future pregnancies by increasing maternal stress and fear, possibly leading to pregnancy complications.

In the United States (US), one in five women suffer with mood and anxiety disorders while pregnant, and up to one-year after delivery.

This means twenty percent of the population experiencing pregnancy in the US have an increased risk of complications and death related to abnormalities in their mental health state. While we know there are psychologic changes surrounding the pregnancy period, most women do not receive treatment due to personal and systematic barriers. These barriers include lack of referral to mental health providers, providers that are unable to take on new patients, initial wait times as long as two months, and lack of insurance coverage. Other factors include low rates of diagnosis, inadequate treatment, and relapse of symptoms.   

“Call your physician to make a follow up appointment. I’m sorry for your loss”.

Which physician? What if I don’t have one? What if I don’t have insurance? My primary care provider doesn’t know what to do for me, they say I need OB. I can’t get approved for an OB because I’m not currently pregnant. My primary care provider won’t start me on medication because I may want to try to become pregnant again. My OB isn’t sure what medicine to start me on, they want me to see a psychiatrist. I can’t make any appointments. They aren’t accepting new patients.

Mental health services are not easily obtainable, there is an increasing number of clients seeking providers that are already treating a greater-than-maximum capacity of patients. Unlike preventative care, insurance requires specialty co-pays for mental health coverage, further limiting services for patients on a tight budget. Even in women screening positive, treatment is not always identified or initiated, especially when psychotherapy is unavailable and providers are not comfortable managing psychiatric medications in those pregnant, trying to become pregnant, or nursing. How can we overcome the greater need for mental health coverage in such a specialized population?

Some states hold a current policy mandating postpartum depression screening to be completed within three to six weeks after childbirth. Screening can be easily completed for pregnant women, and those with infants, because they have increased contact with health care providers due to frequent follow-up visits (OB and then pediatrics). But, what of women suffering first trimester miscarriage? This mandate does not address necessary screening before and during pregnancy, nor follow up screening after the six-week postpartum period.

Given that early miscarriage typically occurs before 12 weeks of gestational age, women are often treated in the emergency department without any follow-up care, as they rarely have an established OB; in the case of complete miscarriage at home, women may choose not to see a health care provider. This is a stark contrast to the multitude of OB and infant visits where screening for perinatal mental health disorders can be easily completed.

We send them out of our emergency room doors with discharge paperwork and tend to the next patient waiting in triage. We don’t follow up, we don’t refer, and what we do explain-they can’t even digest.

It is a day they will never forget, and we already have.

When interviewing stakeholders, two themes emerge regarding the lack in healthcare policy surrounding miscarriage and mental health. One theme includes education to reduce stigma associated with miscarriage; the second theme addresses the need for funding, research, and dissemination of research findings regarding best practices and a standard of care for mental health referral after miscarriage.

So, how do we achieve these goals? Where do we gain funding? What avenues do we use to educate? How do we implement a standard of care for all facilities and providers? We’ve done it for strokes, heart attacks, and trauma. What will it take to bring awareness to the need of perinatal women and their mental health? How can we make a difference?

Tamara Manns, MSN RN, CCRN-Pediatrics is the President of the Shreveport District Nurses Association, an undergraduate nursing educator, an emergency room nurse, and a PhD in Nursing candidate focused on perinatal mental health.