Systematic Reviews to Inform Practice, July/August 2024

Recent estimates indicate that miscarriage, medically defined as a spontaneous abortion, is pregnancy loss prior to 20 weeks and occurs in 10% to 20% of all pregnancies. Nearly 80% of these are early pregnancy losses occurring in the first trimester.1,2 The physical well-being of the patient experiencing miscarriage is the priority of the health care provider and effective management is essential for minimizing complications and maximizing future fertility. However, the experience of miscarriage can be overwhelming due to the added emotional needs that patients must navigate, including grief, shame, and uncertainty about future fertility.3,4 Other challenges may include grief of partners and spouses going unrecognized, partners often having the burden of sharing the news with others, and the lack of any ceremonial events to acknowledge and memorialize the loss. Furthermore, there is often no legal process to acknowledge and establish any personhood when someone experiences a miscarriage.3 These complexities and needs often go unacknowledged and unaddressed by those providing care, possibly due to the experience of miscarriage being perceived as a common and, therefore, expected occurrence. Filippa et al5 conducted a scoping review aimed at examining the literature addressing individuals’ experiences with miscarriage and assessing alignment with clinical practice recommendations. As is the nature of scoping reviews, the authors identified reports of varying types that focused on the provision of information, emotional support, and follow-up care during miscarriage. Drawing on practice recommendations, the researchers also sought to identify gaps in clinical care. They included data from qualitative studies (n = 11), observational quantitative studies (n = 7), mixed-method studies (n = 4), randomized controlled trials (RCTs) (n = 6), literature reviews (n = 8), and clinical practice recommendations (n = 5), for a total of 41 studies that were selected for the review; 28 presented original data and 36 focused specifically on reporting patients’ experiences with miscarriage care. The authors stated that including literature reviews allowed them to consider summaries of data that they could not access and provided more context for practice recommendations. More than half of the reports were conducted in the United States (n = 11) or United Kingdom (n = 10), with a smaller number of reports from other countries including Canada, Australia, Sweden, South Africa, Scotland, Iran, and the Netherlands (ranging from 1 to 4 each). Six reports featured either multiple countries or did not specify countries of focus. Eleven reports spanned the years 1989 to 1999, with the remaining 30 ranging from 2000 to 2021. The authors identified several deficiencies in the care needs of patients experiencing a miscarriage. Across the domains of privacy, comfort, and ease in relation to accessibility of care addressed by 10 reports, patients often felt a lack of privacy that stemmed from multiple providers being involved in their care or being monitored within the general low-privacy holding rooms in emergency departments; felt distressed being cared for alongside patients with healthy pregnancies; and reported long wait times to be seen in both clinic and hospital settings. Regarding provision of information reported by 26 articles, the review revealed an overall perception of receiving little to no information or confusing information about various aspects of having a miscarriage. Of note, information about the expected timeframe of the miscarriage, discussion of treatment options, expected physical and emotional symptoms, and postmiscarriage care were reported as unsatisfactory. Patients were more satisfied with their care when they were provided possible explanations for their miscarriage, given anticipatory information about physical symptoms as well as emotional needs, and health care providers avoided using the term abortion to describe their miscarriage due to their categorization of abortion as an elective procedure and their pregnancy loss being an involuntary experience. Sources of dissatisfaction with emotional support included in 27 reports indicated treatment that was perceived as insensitive, cold, and detached. There were perceptions that providers approached miscarriage care as routine and minor and did not take time to acknowledge the emotional aspects of experiencing a miscarriage. One report also addressed a lack of care and support expressed by transmasculine and non-binary patients. Synthesizing data from 6 reports, the authors found that decision-making was a significant challenge during a miscarriage. Patients reported feeling overwhelmed trying to navigate their emotional responses while receiving information about management options and expressed trouble processing technical clinical language. From 21 studies reporting on follow-up care, feelings of distress and abandonment occurred with a lack of postmiscarriage care or care that only involved assessment of their physical recovery. In some cases, patients were not offered any follow-up care. Practice recommendations across each of the identified areas of miscarriage care address deficiencies reported in the review. These include providers acknowledging the emotional experience of miscarriage along with patients’ physical needs, providing information in simple terms and avoiding using the term abortion, protecting privacy and providing physical spaces separate from patients with healthy pregnancies during visits, addressing the unique emotional needs of transmasculine and non-binary patients, and expanding follow-up care to include acknowledgement and discussion of ongoing emotional needs. Scoping reviews are limited by the inclusion of a broad variety of reports, including those that do not provide empirical data on which to perform a risk of bias assessment. A particular limitation of the review by Fillipa et al was the inclusion of reports from multiple countries, reflecting multiple health care systems that follow varying practice guidelines with barriers unique to the characteristics of those systems. Perinatal bereavement services are one option for bridging the gap between patients and families experiencing a miscarriage and health care providers needing to balance patients’ clinical and physical needs with their emotional needs. Perinatal bereavement services consist of assistance for families through any type of pregnancy loss or terminal diagnosis through navigating options, grief counseling, memorial services, and overall advocacy with the health care team. Workers in bereavement programs are well-situated to provide education to health care professionals on ways to provide emotional support, sensitive information, and appropriate follow-up care for patients. They can also guide patients toward any memorial plans that might help to validate their loss. The most recent practice recommendations on early pregnancy loss from the American College of Obstetricians and Gynecologists (ACOG)1 focus on managing clinical and physical needs and lack guidance for providers on how to help meet the various identified emotional needs.5 However, ACOG does recommend a program for perinatal health care providers seeking more training in their Optimizing Care for Pregnancy Loss Program.6 The 2022 Dobbs vs. Jackson Women's Health Organization decision overturned the federal protection for abortion enacted by Roe v. Wade and returned to states the power to determine reproductive rights. Since then, miscarriage care has been complicated by restrictions on abortion procedures and mifepristone and misoprostol prescriptions. Given that the same options are used to manage miscarriage and many restrictions only use language of imminent threat to maternal life for exceptions, provider hesitancy to treat has become a significant barrier to care.7 To avoid possible penalties, some providers delay treatment until there is a complication and are fearful of engaging in proactive miscarriage management. All of the studies included in Filippa et al's review were published prior to the Dobbs decision. Therefore, studies investigating recent experiences of miscarriage and care needs are warranted, including those examining how state abortion restrictions have impacted provider practices and management of pregnancy loss. An integrative review including health care providers’ perceptions of barriers to providing optional emotional care during a miscarriage highlighted a need for specialized training and workplace constraints as key barriers to addressing emotional needs during miscarriage care.8 Studies further exploring barriers to comprehensive physical and emotional care from providers and facilities are also needed to devise effective, patient-centered strategies to bridge the gap between patient needs and miscarriage care. Cervical cancer screening rates in rural communities are consistently lower than in urban settings, which, along with other risk factors that are more prevalent in rural populations, contribute to higher cervical cancer prevalence rates.1-4 Health disparities in rural communities are influenced by lower access to health care providers and health care facilities and, in turn, lower access to health education. Residents of rural communities face distance and transportation barriers, lack of health care services, and unemployment or low-paying jobs that might not have adequate insurance benefits.2-5 Rural communities also struggle to maintain a workforce of dedicated health care providers and can experience high turnover due to geographical isolation and limited funds for competitive compensation.3 Thus, government incentives might be required to attract providers, but providers often relocate after their contract is served. This can impact trust-building and continuity of care in these communities and, in turn, contribute to health disparities. Washington et al5 included 11 studies in their systematic review of health education programs aimed at improving cervical cancer screening rates in rural US communities. They also sought to assess the adequacy of the study reports in addressing health equity. Selection criteria included RCTs or studies with a quasiexperimental design with a control group, composed of a psychosocial or educational intervention aimed at cervical cancer screening or prevention, conducted in a rural US setting with women above age 18, and featured in a peer-reviewed journal. Data were extracted for demographics, setting, study focus, theoretical framework, inclusion criteria, attrition, data collection strategy, design, intervention, measures and outcomes, and quality parameters such as validity and reliability. Six of the studies included in the systematic review included mostly Hispanic women, whereas the remaining 5 studies had a majority White sample. Outcomes, measured by self-report or health record review, examined across the 11 studies included screening behaviors, human papillomavirus (HPV) vaccination awareness and knowledge, and HPV vaccine uptake. Interventions were varied and included social media campaigns, novella (radio-based) health education, education led by lay health advisors, faith-based education, and education via DVD. Two studies expanded beyond the main study participant; one study included providers and parents and another had activities for individuals, small groups (such as health fairs, fun runs, and block parties), and community organizations. Although the majority of the RCTs randomized participants to either the intervention group or control group, the largest RCT (n = 6169) featured 3 arms: education only, patient navigation only, and a combination of education and patient navigation. One study implemented a waitlist arm to allow participants to receive the intervention after all follow-up data were collected. Using data from nearly 10,600 rural residents, the review demonstrated that those who received health education and awareness about cervical cancer screening were more than twice as likely to engage in screening practices (odds ratio [OR], 2.43; 95% CI, 1.49-3.97). One study that analyzed Hispanic and Latina women separately showed that they were almost 5 times as likely to participate in cervical cancer screening after multilevel, community-based interventions (OR, 4.86; 95% CI, 2.80-8.42). In the study that featured 3 arms, participants who received both education and patient navigation interventions had a 6-fold increase in likelihood of engaging in screening behaviors (OR, 6.16; 95% CI, 5.22-7.27). Two studies focused on prevention education and HPV vaccine uptake but had insignificant findings. Limitations of this review included varying methods of reporting for screening practices, difficulties with long-term recall for long screening intervals, lack of racial and ethnic diversity, and nonstandardized interventions in some studies. Most of the studies were susceptible to selection bias because they did not use randomized assignment to interventions. Furthermore, although most of the studies included references to health equity, there was a significant lack of analyses of health equity in relation to study outcomes or reporting of whether studies possibly had any unintended inequities because of the interventions. High efficacy in studies involving community-based interventions and featured activities for the community reflect the importance of establishing trust and partnerships in populations that have multiple barriers to health care. Education aimed at prevention of cervical cancer consists of minimizing risky sexual behaviors, providing information about the HPV vaccination, ensuring adherence to screening guidelines, and highlighting the importance of close follow-up if abnormalities are discovered. The availability of education in various forms and self-sampling kits for HPV screening would address key barriers to low screening rates in rural communities. Future studies should include more diverse rural communities known to have higher incidence and mortality rates such as Native American, Alaskan Native, and African American communities.5 As many as 70% to 80% of women will develop uterine fibroids by age 50.1-4 As the most common benign tumor in women, symptomatic fibroids present with pelvic pain, heavy bleeding, and anemia-related fatigue that can significantly impact one's quality of life (QOL) and mental health, resulting in higher rates of depression and anxiety compared with those without fibroids. Patients with symptomatic fibroids have medical, radiographic, and surgical options for treatment, but research comparing the association of different treatment options with QOL measures is lacking.4 A previous systematic review demonstrated that myomectomy and uterine artery embolization had the best evidence for the most significant improvements in overall QOL measures.3 Insights into the relationship between fibroid treatment options and QOL can contribute to informed consent as patients are considering the best treatment for their physical and QOL-related symptoms. Neumann et al4 conducted a systematic review to examine the impact of radiologic, medical, and surgical interventions for uterine fibroids on QOL and mental health. They included 67 studies, consisting of 18 RCTs and 49 observational cohort studies, from January 1990 to October 2023 in their review; they focused on those that included imaging-confirmed fibroids in premenopausal women and validated measures of QOL pre- and posttreatment. This review builds on a previous review with the same aim by incorporating an additional 10 studies. The review used data from more than 8300 participants to compare QOL and mental health outcomes across the 3 treatment categories. Radiologic treatments included uterine artery embolization, uterine fibroid embolization, magnetic resonance-guided focused ultrasound surgery, magnetic resonance-guided high-intensity focused ultrasound, radiofrequency volumetric thermal ablation (or radiofrequency ablation), ultrasound or percutaneous-guided microwave transcervical ablation, and ultrasound-guided high-intensity focused ultrasound. Surgical treatments included laparoscopic, robotic, or abdominal myomectomy or hysterectomy, hysteroscopic myomectomy, and transcervical fibroid ablation. Medical treatments included mifepristone, ulipristal, ulipristal acetate, herbal formula guizhi fuling wan, and relugolix. The review included studies that used fibroid-specific QOL measures as well as general QOL measures. These included the Uterine Fibroid Symptom and Quality of Life Questionnaire (UFS-QOL); the Medical Outcomes Study 36-Item Short Form Health Survey; Medical Outcomes Study Short Form-12; European Quality of Life 5-Dimension Scale Summary Index and Visual Analogue Scale; World Health Organization Quality of Life-BREF questionnaire; Female Sexual Function Index (FSFI); Urogenital Distress Inventory; Prolapse and Incontinence Sexual Questionnaire; Sexual activity questionnaire; Symptom Checklist 90; questionnaire for screening sexual dysfunctions; and Brief Index of Sexual Functioning. Approximately 80% of the studies were rated as having good or fair quality in the assessment of risk bias according to the Newcastle-Ottawa Scale. In studies that reported on fibroid-specific QOL using the UFS-QOL, radiologic, surgical, and medical treatments were individually and significantly associated with average 33-point increases in QOL and average 31-point decreases in symptom severity (reference range, 0-100). Radiologic treatments showed the greatest improvements in QOL scores. General QOL data showed improvements in scores, although the increases in scores were smaller than the fibroid-specific measures. When measures of posttreatment emotional and mental health scores were examined, scores increased by 40.4% and 13.9%, respectively. Although posttreatment scores for the Symptom Checklist 90, FSFI, Sexual Activity Questionnaire, Urogenital Distress Inventory, and Brief Inventory of Sexual Function were higher, significant changes in scores were not detected in the analysis. This review was limited by the variety of general QOL measures used across the included studies as well as the timeframes for posttreatment data collection, which ranged from 1 month to 3 years. The authors did not perform a meta-analysis because of the heterogeneity of the data and small sample sizes across studies. Nevertheless, findings demonstrate the importance of using QOL and symptom severity measures, such as the UFS-QOL, in the plan of care for patients experiencing symptoms from uterine fibroids. Health care providers should acknowledge impacts to QOL as a part of patient-centered, equitable health care. Disparities in symptoms, access to timely care, and the presentations of treatment options are well-documented. African American patients experience a higher prevalence of fibroids with more severe symptoms, are diagnosed at younger ages, face greater delays in treatment, and are offered more invasive treatment options than White patients.1 Future studies that compare treatment options and QOL outcomes within more consistent posttreatment timeframes would provide needed clarity into the burden of living with fibroids and the impact of available treatments on patients’ QOL.2,4

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