‘We’re done. See yah’: Why miscarriage is badly managed in Canada

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Bleeding and in pain, pregnant women who miscarry in a Canadian emergency room often receive such poor care that some have passed a recognizable fetus in the waiting room. 

“Those situations occur more often than we would like to think,” said Dr. Catherine Varner, a Toronto emergency physician and deputy editor of the Canadian Medical Association Journal, who, in an editorial published this week, describes the often-harrowing care women experience when losing a pregnancy in Canada. 

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Varner and the authors of a related review article are calling for more “streamlined” and compassionate miscarriage care, ideally by diverting women away from emergency rooms altogether to special clinics that offer emergency help for women with a suspected miscarriage or ectopic pregnancy, a serious complication where the embryo implants outside the uterus. 

The United Kingdom has 200 early pregnancy assessment clinics. In Canada, they’re mostly a pipe dream, Varner wrote.

Up to 20 per cent of all confirmed pregnancies end in miscarriage, with around half due to chromosomal abnormalities in the developing embryo, a risk that increases significantly in women older than 35.

But while they’re common, often devastating, miscarriages are poorly managed in Canada, the CMAJ authors wrote.

Stories in the media have described women left on gurneys in emergency hallways overnight, bleeding from an untreated miscarriage. Ontario’s patient ombudsman once investigated a case involving a woman who nearly passed out in an emergency room bathroom while actively bleeding. 

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Women have been told their ultrasound shows “fetal demise,” meaning no heartbeat, with only a curtain separating them from other patients, or, “You’re experiencing a spontaneous abortion,” the medical terminology used for pregnancy loss before 20 weeks’ gestation. “Patients really struggle, understandably, with that,” Varner said. “The lack of attention to the language that they hear around loss.” 

Because they’re often not considered as having an “emergency” condition, women have been made to feel like they don’t belong in emergency, even though it’s the safest place for a massive uterine hemorrhage, or suspected ectopic pregnancy. “Family doctors are well trained to care for early pregnancy complications like spotting or bleeding in the first trimester,” Varner said, but 6.5 million Canadians don’t have access to a family doctor. When women call a telehealth line, they’re often told to go to an ER, Varner said, which is also often the only option on nights or weekends. A 2020 Ontario study found four in five women with a threatened or spontaneous pregnancy loss visited emergency.

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Once there, women face long stays and a lack of compassion, a recent Toronto workshop heard. In Canada’s overcrowded, understaffed ER’s, hundreds of patients languish on stretchers for hours waiting for care. But the added layer for a woman miscarrying “is that they’re experiencing a psychological trauma,” said Varner.

“They’re having this very devastating experience and really no one acknowledging that.” 

“Our society doesn’t talk a lot about miscarriage,” she said. “It historically is a hush-hush topic. But the morbidity of early pregnancy loss — the psychological trauma — is often not talked about. It has a huge, psychological toll that lasts for months, if not years.” 

As many as half of women who miscarry will have a spontaneous miscarriage, passing the pregnancy naturally within a week of miscarriage. But women have described feeling unprepared for what to expect when they were sent home from hospital. “And then it was just like, ‘Okay, we’re done. See yah,” one Toronto research team heard. “And it’s like you just walk out of there and you’re going, ‘Did that really happen? And was that …. is that it?”

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Some women require drugs used for medical abortions, or a surgical procedure to “evacuate” incomplete miscarriages. But many are discharged without a follow-up plan. Between one in three, to one in two, end up back in emergency, a “staggering” rate of return visits, Varner said, higher than for any other emergency department condition except maybe for health conditions related to homelessness. 

Even when women are added to waitlists for urgent surgery, they’re often still waiting when they suddenly pass tissue resembling a fetus at home or in an emergency waiting room, Varner wrote in her editorial. 

Those cases involve later first, or second trimester pregnancy losses. Most miscarriages happen earlier. 

For women, “one of the biggest challenges is not knowing what’s going on, not understanding whether the pregnancy is going to continue or not,” said Dr. Modupe Tunde-Byass, an obstetrician/gynecologist at North York General Hospital.

She and her coauthors of a review on the diagnosis and management of miscarriage hope to raise awareness among health-care providers “about what women go through, the emotional, the psychological aspects, not just the medical aspect.”

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Better care is achievable, Varner said. It doesn’t require expensive technology. “It just has not been a priority.”  

It’s also a uniquely Canadian problem, she said. 

“The U.K, the U.S., the Netherlands, they don’t understand why patients need to come to the emergency department. It’s something that just doesn’t happen when they have more easily accessed, more appropriate locations of care that can provide more compassionate care than the waiting room of an emergency department.” 

National Post 

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