Although one in four pregnancies ends in the first trimester (within 12 weeks), many women and their partners do not expect miscarriage to happen to them, says Professor Keelin O'Donoghue, consultant obstetrician at Cork University Maternity Hospital (CUMH).
Professor O'Donoghue, who heads up the Pregnancy Loss Research Group and is the project lead on the national Re: Current Study funded by the Health Research Board, says there is a lack of progress in looking at the causes and prevention of miscarriage.
"There seems to be a fatalistic acceptance of miscarriage but we don't always understand why it happens. There are some risk factors such as a woman's history. There are some physical causes and biochemical causes. Possibly as many as half of all miscarriages happen because there is a problem with the developing embryo. There isn't a huge amount of work being done exploring the causes (of miscarriage). Miscarriage still isn't really prioritised. We don't really talk about it that much although that's improving which is good."
Professor O'Donoghue says every miscarriage is different. "We say to women that there isn't a right way or a wrong way to feel about it. For some, it's a very sad thing to happen and can cause some degree of emotional pain for a long time afterwards. But some women recover quickly. For others, it's something they never really get over."
Bereavement care, including online resources, is better than it used to be.
"All of our maternity units (there are nineteen nationwide) have midwives specialising in bereavement. But the person with one miscarriage or sometimes two, doesn't always get as much support as they should. There's a tendency of support in hospitals for those who might have had a later pregnancy loss or people who experience recurrent miscarriage."
After one miscarriage, "women need information and guidance for the future and some discussion about their healthcare. If a second miscarriage occurs, some investigation is needed and after three miscarriages, more in-depth investigation as to what happened is necessary. So we have a graded model of care after miscarriage. The old definition of recurrent miscarriages is three. Now, internationally it's two consecutive miscarriages."
Professor O'Donoghue is in favour of moving towards a more individualised care approach.
"Our project has been all about what people want nationally. It's about what happens versus what should happen. We are looking at how we can improve miscarriage services so that women will have access to individualised support and can plan for future pregnancy. It's relatively straightforward to deliver and should be a priority."
About 1% of couples will have three consecutive miscarriages and between 4%-6% will have two consecutive miscarriages.
Over the last ten to fifteen years, there has been an improvement in including men when it comes to bereavement care following a miscarriage, according to Professor O'Donoghue.
"We have tried to standardise the care delivered to couples from early to late miscarriages across our maternity units. It's about staffing, culture, education and standardising information and the provision of facilities. I think it's fair to say that women, men and the extended family are now much more involved."
Professor O'Donoghue says that there is no counting of the number of miscarriages that happen in Ireland every year.
"We know that one in four pregnancies end in miscarriage. The hospital records the women who come to the early pregnancy clinic. But some women don't make it to the hospital. They would miscarry in very early pregnancy. So we know how many women are admitted to hospital but a lot of women are in an outpatient setting (having had an early miscarriage.) That tells you that we haven't really been prioritising this sufficiently as an important women's health issue. That has been compounded by a lack of information and a lack of discussion about miscarriage."
But thanks to the Re: Current study, which has had input from a lot of different stakeholders, pregnancy and miscarriage are very much under the spotlight.
As one of the postdoctoral researchers involved in the study, Marita Hennessy says: "The whole point of the project is to see how we can make meaningful change. It came from the issue on the ground which was a feeling that more could be done for recurrent miscarriages. That has been a neglected area within maternity services and health services more broadly.
"We have looked at international guidelines around recurrent miscarriages and at what different professional bodies around the world are recommending. We're seeing how we can structure care and put in place the kind of supports needed for women and couples. In terms of what's out there at the moment, the quality is poor."
Hennessy says that more research is needed. She adds that it's important to work with the different stakeholders. "So often, it's only consultants and obstetricians that are involved in guidelines development.
It needs to be broadened out to policymakers and men and women themselves so that the guidelines are implementable and realistic and are not just sitting on a shelf. The group met over a couple of months and came up with a list of 110 recommendations such as how healthcare should be structured and how outcomes of investigation should be measured within services. At the moment, we're finishing work on a service evaluation in the nineteen maternity units. Some of the bigger hospitals/units will have dedicated recurrent miscarriage clinics."
But there can be a big gap in service provision. "Often, the psychological consequences of miscarriage are neglected. And a lot of the men and women we spoke with said they're denied services until they've had a third miscarriage. That can have a huge impact and it can often prevent them from trying to get pregnant again."
Stigma around early pregnancy and miscarriage "came up an awful lot. People often keep their pregnancy secret until twelve weeks have passed. So there's a huge silence around their (early) pregnancy. Some say you're setting yourself up for a fall if you talk about it before the twelve weeks. That has a knock-on effect in terms of who you can talk to for support."
Hennessy says recurrent miscarriages can have a big impact on couples' relationships. "More often than not, it's the partner who is a huge source of support because the woman feels she can't turn to family or people in the workplace."
As Hennessy points out, "we are not good about talking about women's health in general, never mind pregnancy loss and our bodies. So there's a huge stigma around miscarriage when it does happen."
She adds that from speaking to men for the study, they need to be "more engaged, more part of the services and they need space within that. It can be like a foreign thing for men to see the person they love suffering a miscarriage. And you have women talking about their bodies letting them down."
With half of miscarriages being unexplained, "women say they never got an answer and think that it is their body 'that's killing my baby'. There is this huge sense of blame."
Clearly, miscarriage needs to be taken more seriously as a health issue affecting couples whose hopes have been dashed but who might dare to hope for a future full-term pregnancy.