Miscarriage, the spontaneous loss of pregnancy before 20 weeks’ gestation, affects a substantial portion of pregnancies and can cause marked physical and emotional distress. This mixed-methods study aimed to understand patient experiences of women who miscarried a desired pregnancy during the COVID-19 stay-at-home mandates in North Carolina (March 30, 2020–February 24, 2021) and to examine relationships among patient experience, miscarriage management approach, psychological distress (perceived stress, anxiety, depression, and probable PTSD), and COVID-19–related stressors.
A convergent parallel mixed-methods design collected quantitative cross-sectional survey data and qualitative descriptive interviews concurrently and analyzed each component separately before integration. The research protocol received approval from the University and Medical Center Institutional Review Board at East Carolina University. All participants provided electronic informed consent.
Eligibility criteria included: age ≥ 18 years, identified as female, experienced miscarriage (< 20 weeks) of a desired pregnancy between March 30, 2020, and February 24, 2021, residence in North Carolina, and ability to read/speak English or Spanish. Recruitment occurred May 1–September 30, 2022, using convenience and snowball sampling via flyers distributed to 25 clinics, 437 Facebook pages, a university listserv, and a hospital newsletter. Seventy-one women completed the survey; 18 participated in in-depth interviews.
Study materials were available in English and Spanish; translation was performed electronically and verified by a bilingual principal investigator. Survey participants who provided email addresses were invited for interviews in order received. Interviews were offered in English or Spanish, conducted in person (with COVID-19 precautions) or via Microsoft Teams, recorded, and transcribed. Interviewers monitored participant distress, allowed pauses or discontinuation, and provided resource information post-interview. Two interviewers disclosed personal experiences with pregnancy loss to foster rapport. Interview durations ranged from 42 to 112 minutes; interview participants received a $50 debit card after completion.
The survey collected miscarriage history (number, date, gestational age, location, management type), reproductive characteristics, demographics, and prior mental health or trauma history. Key measures included:
A nine-item patient experience measure combining six CG-CAHPS items and three researcher items; items used a 3-point scale or yes/no responses. Higher scores indicated better experience. Internal consistency in this sample was α = 0.87.
COVID-19–related stressors: an 11-item researcher-developed checklist; analysis focused on the ability to bring a support person to visits and adequate access to medical care.
Miscarriage management: participants could report expectant, medical, and/or surgical management. For analysis, management was dichotomized into expectant-only versus any medical/surgical management using a hierarchical approach.
Psychological distress instruments: PSS-4 for perceived stress (α = 0.78), GAD-7 for anxiety (α = 0.93), PHQ-8 for depression (α = 0.93), and PC-PTSD-5 for probable PTSD (α = 0.68). Participants answered these scales reflecting on their pandemic miscarriage.
Quantitative analyses used SPSS-28. Descriptive statistics summarized participant characteristics, frequencies of positive patient experience responses, endorsement of COVID-19 stressors, and mean psychological distress scores. A two-step cluster procedure on five commonly endorsed patient experience items identified two subgroups labeled as good and poor patient experience. Chi-square tests examined differences in item endorsement between clusters. Group comparisons tested associations between patient experience cluster and psychological distress, and examined whether miscarriage management modified this relationship.
A semi-structured interview guide of 10 questions focused on how COVID-19 affected miscarriage experiences, emergency department visits, delivery of loss news and management discussions, and wishes for different care. Interviews were transcribed and analyzed using qualitative descriptive methods. The team documented field notes and took steps to create supportive interview environments. Saturation was assessed qualitatively: after 16 interviews no new salient themes emerged; two additional interviews were completed to enhance racial and ethnic representation.
Quantitative and qualitative findings for the subsample were integrated using a joint display to evaluate convergence. The integration assessed how qualitative categories aligned with quantitative cluster findings across domains such as provider interactions and access to care. The authors reported levels of convergence (strong, moderate, weak) across subcategories.
Survey results classified roughly half of participants as reporting poor patient experience (52%) and half as reporting good patient experience (48%). Endorsement of the two COVID-19–related healthcare stressors emphasized in this analysis (support person restrictions and access to care disruptions) did not significantly differ between experience groups. Participants in the poor patient experience group had significantly higher levels of perceived stress, anxiety, and depressive symptoms (p < .05). Among participants who received medical and/or surgical management, good patient experience was associated with lower psychological distress; this pattern did not appear among participants managed expectantly. Specific numerical effect sizes and complete statistical tables were not provided in the source summary.
Interview analysis identified four primary categories shaping care: Access to Care, Healthcare Provider Interactions, Healthcare Support Staff Interactions, and Healthcare System Interactions. The qualitative data emphasized that interpersonal elements—empathy, reassurance, clear communication, and follow-up from providers and nurses—were central to how women experienced miscarriage and their psychological recovery. Examples of supportive practices cited in the literature included emotional support, referrals to counseling or support groups, and suggestions for memorial activities; however, participants also reported feelings of abandonment and dismissal when interactions lacked sensitivity.
Data integration demonstrated strong convergence for subcategories within Healthcare Provider Interactions, moderate convergence for Access to Care, and weak convergence for support staff and system interaction categories. These integrated results underscore the dominant role of provider and nursing interpersonal care in shaping patient experience and psychological well-being after miscarriage, even amid COVID-19–related system disruptions. The authors highlight the need for structured follow-up, routine emotional support, consistent information about management options, shared decision-making, and attention to institutional policies that affect support-person presence and access during public health crises.
The study used convenience and snowball sampling and was conducted in a single U.S. state, which may limit generalizability. The source notes that full qualitative transcripts cannot be publicly shared due to confidentiality and re-identification risk; therefore, raw interview data are not available. Some detailed numerical results and full statistical output were not reported in the provided text. Funding sources included Sigma Nursing and a Sigma chapter; funders did not influence study conduct or reporting.