When I had a miscarriage, I was shocked by the ferocity and finality of it. I'd been bleeding for a few days and knew this probably meant my pregnancy was on the wane, but I hadn't anticipated a torrent of blood. Was this normal for a miscarriage, or was I bleeding to death?
My GP surgery was about to shut. They allowed me a brief phone consultation. 'It's probably OK,' said the GP, 'but I can't leave a patient at home haemorrhaging without suggesting that going to A&E might be appropriate.' She sounded sympathetic but I also think she was covering her back.
A referral to an Early Pregnancy Unit (EPU) would have been far more inviting - only at the time I didn't know such a thing existed.
My GP opted for a wait-and-see policy, or 'expectant management'.
I stayed at home and recovered.
My miscarriage was as good as it gets - I already had a beautiful daughter, I had got pregnant quickly, the miscarriage occurred at seven weeks, there was no need for surgery, and now I'm pregnant again. I was lucky.
But are women who have more than one miscarriage better supported? Yes, but only after they have been put through the mill. Doctors only refer women for further investigation after they have had three miscarriages. From a resource point of view this makes good sense. One in five pregnancies ends in miscarriage. Second miscarriages are also common. It is only after a third that a medical cause is likely to be discovered, and even then one is not always found.
Many women complain that this rule is applied too stringently, with no concessions for women nearing the end of their child-bearing years or those with a history of fertility problems. In addition, they speak of unbelievable insensitivity.
When Barbara Hepworth-Jones had a second miscarriage, she was scanned in a room alongside joyous expectant mums. After miscarrying a third time, she was devastated. 'No one at work knew, and when a friend became pregnant, I couldn't face seeing her. Had the Miscarriage Association not put me in touch with a peer support group I don't know how I would have got through it.'
When Jane Wright* was called to A&E with a suspected ectopic pregnancy following two previous miscarriages, she was put on the maternity ward, then scanned in a room full of medical students. 'The obstetrician told them: "This is unusual - it's got a heartbeat."'
Despite being traumatised, Jane was offered no counselling or information about The Miscarriage Association. When she asked for a referral to a specialist unit she was told that she didn't qualify because the lost pregnancy was ectopic rather than a miscarriage. The advice was draconian - doctors are allowed to use their discretion, and most would have been more sympathetic. And this is the crux of the problem: how women fare depends on who they see and where they are seen. Where services are good, they are referred to EPUs with multidisciplinary staff trained to deal with miscarriage and there is a 'quiet' room for breaking bad news. Patients are offered a 'reassurance' scan, told about their options, and given appropriate treatment. There are more than 200 EPUs in the UK.
Professor Lesley Regan, head of obstetrics and gynaecology at St Mary's Hospital, Paddington, says research shows that women attending these units do better with subsequent pregnancies than women who don't. She says the emotional wellbeing of the patient is paramount, especially given the link between recurrent miscarriage and depression. Roy Farquharson, clinical director of gynaecology at Liverpool Women's Hospital, says women go through a bereavement process following a miscarriage. 'This can become cumulative with recurrent miscarriages,' he says. This is why recurrent miscarriage clinics (where women are referred after three miscarriages) try to offer reassurance in addition to physical checks such as chromosomal and hormonal tests. Women who have experienced three consecutive miscarriages have a 60 per cent chance of the next pregnancy being successful. Barbara Hepworth-Jones now has three children.
A major epidemiological study, instigated by The Miscarriage Association, is examining the effects of stress, diet, working patterns, air travel and other factors on pregnancy. The results will be published next year. And research into miscarriage is yielding 'promising results', says Farquharson. For example, scientists have discovered 'killer cells' which build up on the lining of the womb, making it hostile to the embryo. The condition appears to be treatable with steroids. Researchers in Australia believe they may eventually develop a blood test for a natural body chemical that will predict whether a woman has a high risk of miscarriage. And consultant gynaecologist Dr Melanie Davies predicts that every hospital will have an EPU within the next few years.
Whether her optimism is realistic remains to be seen. Ruth Bender Atik, national director of The Miscarriage Association, is still lobbying for units to open their doors 24 hours a day and to accept self-referral. With limited resources, this is proving hard to achieve. But how much would it cost for women who experience pregnancy loss to be treated with more compassion?
As Jane Wright explains: 'Miscarriage takes its toll on your relationships, your physical life and your emotions. The way I was treated made things worse. Surely it doesn't cost anything to have a decent bedside manner?'
· The Miscarriage Association (miscarriageassociation.org.uk). Association of Early Pregnancy Units (earlypregnancy.org.uk/index.asp). Royal College of Obstetricians and Gynaecologists (rcog.org.uk/mainpages.asp?PageID=1559)
*Name changed to protect anonymity
