---
title: "Patient experiences of miscarriage during COVID-19: mixed-methods study of grief, care, and distre"
id: "plos-one-11-navigating-grief-and-healthcare-mixed-methods-study-on-patient-experiences-of"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-11-navigating-grief-and-healthcare-mixed-methods-study-on-patient-experiences-of"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0359158"
published_at: "2026-09-24T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Patient experiences of miscarriage during COVID-19: mixed-methods study of grief, care, and distre
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-11-navigating-grief-and-healthcare-mixed-methods-study-on-patient-experiences-of
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0359158)
- **Published At:** 2026-09-24T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This convergent parallel mixed-methods study examined experiences of women in North Carolina who had a **miscarriage** during COVID-19 stay-at-home mandates (March 30, 2020–February 24, 2021). 71 women completed a cross-sectional survey and 18 took part in in-depth interviews. - Patient experience was measured with a nine-item instrument combining CG-CAHPS items and researcher items; responses clustered into two groups: **good patient experience** (48%) and **poor patient experience** (52%). - COVID-19–related healthcare stressors assessed included inability to have a support person present and disruptions in access to care; these stressors did not significantly differ between good and poor experience groups in this sample. - Participants reporting poor patient experience had significantly higher perceived stress, **anxiety**, and **depressive** symptoms (p < .05). The association between good patient experience and lower psychological distress was observed among those receiving medical and/or surgical management, but not among those who had expectant management only. - Qualitative analysis identified four categories shaping care: Access to Care, Healthcare Provider Interactions, Healthcare Support Staff Interactions, and Healthcare System Interactions; interpersonal interactions with providers and nurses emerged as central to patient experience and emotional outcomes. - Data integration showed strong convergence for provider interactions, moderate convergence for access to care, and weak convergence for support staff and system interactions, emphasizing the primacy of clinician/nurse interpersonal care even during pandemic system disruptions. - Study methods included validated psychometric measures: PSS-4 (perceived stress), GAD-7 (anxiety), PHQ-8 (depression), and PC-PTSD-5 (probable PTSD) with reported internal consistency estimates from the sample. - Recruitment used convenience and snowball sampling across clinics, community pages, and lists; English and Spanish materials were offered. The study was IRB-approved; qualitative transcripts cannot be publicly shared due to confidentiality. - Authors recommend structured follow-up, emotionally supportive care, and attention to organizational policies to improve miscarriage care during public health crises. Specific numeric results beyond group differences were not fully reported in the available source text.
## Clinical Analysis & Structured Key Points
Navigating grief and healthcare: Mixed-methods study on patient experiences of miscarriage during COVID-19 | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract This paper aims to understand the patient experiences of women who suffered a miscarriage during the COVID-19 pandemic and examine the relationships of patient experience with miscarriage management, psychological distress, and COVID-19-related stressors. A convergent parallel mixed-methods design combined cross-sectional survey data and qualitative descriptive interviews. Seventy-one women in North Carolina who experienced a miscarriage during the COVID-19 stay-at-home mandates were assessed on patient experience, miscarriage management, perceived stress, anxiety, depression, posttraumatic stress, and COVID-19–related stressors. In-depth interviews were conducted with a subsample of 18 participants. Quantitative and qualitative findings of the subsample were integrated using a joint display to examine the level of convergence. Approximately half of participants reported poor patient experiences (52%), and half reported good patient experiences (48%). COVID-19–related stressors, including inability to have a support person present and access to care disruptions, did not differ significantly between groups. Participants reporting poor patient experiences had significantly higher levels of perceived stress, anxiety, and depressive symptoms (p < .05). Among those receiving medical and/or surgical management, good patient experiences were associated with lower psychological distress; this pattern was not observed among participants undergoing expectant management. Qualitative findings identified four categories shaping miscarriage care: Access to Care, Healthcare Provider Interactions, Healthcare Support Staff Interactions, and Healthcare System Interactions. Data integration demonstrated strong convergence for all four subcategories of the Healthcare Provider Interactions category; moderate convergence for access to care; and weak convergence for healthcare support staff interactions and healthcare system interactions. Findings underscore the central role of provider and nursing interpersonal care in shaping patient experiences and psychological well-being following miscarriage, even amid COVID-19-related system disruptions. Results highlight the need for structured follow-up, emotionally supportive care, and attention to organizational policies to improve miscarriage care during public health crises. Citation: Fernandez-Pineda M, Swift A, Dolbier C, Swanson M, Choufani MR, Guard Banasiewicz K (2026) Navigating grief and healthcare: Mixed-methods study on patient experiences of miscarriage during COVID-19. PLoS One 21(9): e0359158. https://doi.org/10.1371/journal.pone.0359158 Editor: Taiwo Opeyemi Aremu, Touro University California College of Pharmacy, UNITED STATES OF AMERICA Received: March 2, 2026; Accepted: September 10, 2026; Published: September 24, 2026 Copyright: © 2026 Fernandez-Pineda et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The qualitative data underlying the findings of this study cannot be shared publicly due to ethical and legal restrictions related to participant confidentiality. The in-depth interviews describe experiences of pregnancy loss and may contain potentially identifiable details, even after de-identification. Public release of the full transcripts could therefore pose a risk of participant re-identification and would violate IRB-approved confidentiality protections. Funding: This study examines patient experiences among women who experienced miscarriage during the COVID-19 stay-at-home mandates and evaluates the relationships between patient experience, miscarriage management, psychological distress, and COVID-19–related stressors. Using a convergent parallel mixed-methods design, we combined cross-sectional survey data (n = 71) with qualitative interviews (n = 18). This study was funded by Sigma Nursing (Proposal No. 22-0320; $5,000) in Summer 2022 and the Sigma Beta Nu Chapter (Proposal No. 22-0460; $1,000) in Spring 2023. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction Miscarriage, the spontaneous loss of pregnancy before 20 weeks of gestation, affects about 10–20% of pregnancies [ 1 ]. This distressing event can cause significant physical and emotional distress, including intense pain, heavy bleeding, hospitalization, and prolonged uncertainty [ 2 ]. The emotional impact also includes increased anxiety, depression, post-traumatic stress disorder (PTSD), and feelings of isolation, often exacerbated by inadequate social support and lack of recognition of the loss [ 3 , 4 ]. Women have recognized empathy, sympathy, and reassurance from nurses as crucial to their well-being and long-term coping after miscarriage [ 5 ]. Emotional support, referral to support groups/counseling, testing, and suggestions for memorial services (e.g., lighting candles, making necklaces, and naming ceremonies) from healthcare providers have helped provide closure [ 6 ]. Despite recognizing the importance of such support, many women still report dissatisfaction with the bereavement care they receive. Patient experience refers to patients’ interactions within the healthcare system, including encounters with doctors, nurses, and other staff, and how well the care provided respects and responds to individual preferences, needs, and values [ 7 ]. Women have expressed feeling abandoned and desiring more information, follow-up, sensitivity, emotional support, transparency, and interaction from their providers during and after miscarriage [ 6 , 8 ]. Many felt their experience was dismissed as a routine pregnancy outcome [ 6 ]. Women’s psychological distress is often unrecognized by healthcare providers, family, and friends. One important, yet understudied, component of the miscarriage experience is the management approach offered to patients. While several randomized controlled trials have found no significant differences in psychosocial outcomes or satisfaction between the management type: expectant management (at home waiting for spontaneous expulsion of contents of conception) vs medical management (oral medications to induce expulsion of contents of conception) vs surgical miscarriage management (dilation and curettage) [ 9 , 10 ], the quality of provider interaction during decision-making appears to significantly influence women’s emotional outcomes. Shared decision-making fosters empowerment and individualized care [ 11 , 12 ], particularly when providers demonstrate empathy and support [ 11 ]. In contrast, impersonal or dismissive interactions may exacerbate emotional distress [ 11 ]. Despite recommendations from the research community, clinicians do not always offer the full range and thorough explanations of management options [ 13 ], nor do they consistently provide follow-up care or psychological screening [ 3 , 14 ]. This lack of comprehensive support contributes to the enduring emotional burden following miscarriage. Additionally, research indicates that the quality of care from support staff and the healthcare system impacts patient experience and health outcomes [ 15 – 17 ]. Furthermore, the COVID-19 pandemic introduced additional challenges for women coping with the status of their pregnancy, including disruptions to healthcare practices such as reduced clinic hours and staffing, increased reliance on telehealth, restrictions on support person presence at antenatal visits, and the need to manage or prevent [ 18 , 19 ]. These pandemic-related challenges, particularly limitations on support person presence and delays or changes in access to care, represent distinct stressors that may shape patient experience and psychological distress following miscarriage [ 20 ]. Therefore, the aims of this study were to 1) understand the patient experiences of women who miscarried a desired pregnancy during the stay-at-home mandates of the COVID-19 pandemic in North Carolina (March 30, 2020 – February 24, 2021); and 2) examine the relationships of patient experience with miscarriage management, psychological distress (anxiety, perceived stress, depression, and PTSD), and COVID-19-related stressors. We seek to explore women’s perceptions of the psychosocial care they received, identify the specific challenges faced, and provide insights into how healthcare teams and systems can better support them, informing future healthcare practices and policies. Methods Design This paper is part of a larger study exploring miscarriage experiences during the COVID-19 pandemic among women in NC. Given the complexity of the topic, different aspects of the study were addressed in separate manuscripts [ 4 , 21 ] to provide a comprehensive analysis. This cross-sectional mixed-methods study employed a convergent parallel design, in which quantitative and qualitative data were collected and analyzed concurrently but separately, then integrated to provide a comprehensive understanding of participants’ experiences [ 22 ]. The quantitative component utilized a cross-sectional approach [ 23 ], while the qualitative component followed a qualitative descriptive approach [ 24 ]. The study was approved by the University and Medical Center Institutional Review Board at East Carolina University, and all participants provided electronic written informed consent for study participation. The research team included nurse scientists with expertise in women’s health and pregnancy loss, one who is bilingual in English and Spanish, a psychologist specializing in perinatal mental health, and a biostatistician. Participants and recruitment Eligible participants were women aged 18 or older who identified as female, experienced a miscarriage (<20 weeks of gestation) of a desired pregnancy between March 30, 2020, and February 24, 2021; spoke and read English or Spanish; and resided in NC. The inclusion of desired pregnancy loss ensured conceptual alignment with the study’s focus on bereavement experiences and psychological distress, as pregnancy intention may shape emotional attachment, coping, and meaning-making following miscarriage. Additionally, Spanish-language study materials were included to reduce language-related barriers and allow participation by eligible Spanish-speaking women, who are often underrepresented in health research. The research team recruited from May 1 to September 30, 2022, using convenience and snowball sampling. We distributed flyers in English and Spanish with the survey link through 25 NC clinics (22 health departments, two obstetrics and gynecology, and one primary care), 437 Facebook pages (support groups, mom groups, health departments, and community groups), a university faculty/staff listserv, and a major hospital newsletter. Then we invited participants who completed the survey and provided their email for in-depth interviews in the order they were received. After 16 interviews, no new salient themes were emerging. Two additional interviews were conducted to enhance racial and ethnic representation among participants. Procedures The second author translated study materials from English to Spanish using electronic translation software, which were then reviewed and verified for accuracy by the bilingual principal investigator (PI). Participants accessed the online survey in their preferred language, provided electronic informed consent, and completed eligibility screening and study questionnaires. Upon completion, participants received contact information for local and national support groups and mental health resources. In-depth interviews were conducted in English or Spanish and in person (following COVID-19 precautions) or via Microsoft Teams audioconferencing based on participant preference. All interviews were recorded and transcribed using Microsoft Teams. As interviewers, we addressed participant questions, explained participation rights, facilitated the discussion, and documented field notes [ 25 , 26 ]. To foster rapport and create a supportive environment, two of the interviewers disclosed their personal experiences with pregnancy loss, which has been recognized as an effective approach in qualitative research involving sensitive topics and vulnerable populations [ 27 ]. Interviewers monitored participants for signs of emotional distress throughout the interview. Participants were reminded that they could pause or discontinue the interview at any time. If distress was observed or expressed, interviewers offered breaks as needed. Following completion of the interview, all participants were emailed information on local and national bereavement support organizations and mental health resources. Interviews lasted between 42 and 112 minutes, and participants only received a $50 debit card after completing the interview. Assessments Survey. The survey assessed miscarriage history (i.e., number, date, weeks’ gestation, location, and management type), reproductive characteristics (e.g., reproductive and infertility treatment history), demographic characteristics, and mental health history (yes/no questions about prior mental health diagnosis and trauma not including pregnancy losses). Key variables included patient experiences, COVID-19-related stressors, and psychological distress specific to miscarriage. Additionally, personal significance of miscarriage, coping strategies, and social support were assessed, but are not addressed by the aims of this paper. Patient experience. A nine-item measure of patient experience was developed using six items from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey (CG-CAHPS) [ 28 ] and three items by the researchers. Participants rated the care they received from their healthcare provider (e.g., communication, emotional support, follow-up, etc.) during their pandemic miscarriage on a 3-point scale (1 = No, 2 = Yes, somewhat, 3 = Yes, definitely) for items 1–7. Items 8 and 9 required a “yes/no” response, and item 9 was answered only if participants answered “yes” to item 8. Higher ratings indicated better patient experience. Cronbach’s alpha estimates indicated good internal consistency in this study (α = 0.87). COVID-19 related stressors. The researchers developed an item to assess ways the COVID-19 pandemic caused stress while experiencing miscarriage. Participants selected any of the 11 stressors that applied to them. For this analysis, we focused on two stressors that most closely reflected healthcare experiences: the ability to bring a support person to healthcare visits and adequate access to medical care. Miscarriage management. Participants were asked, “How was the miscarriage(s) (< 20 weeks gestation) you experienced between March 30, 2020, and February 24, 2021, managed? Select all that apply.” Response options included: Expectant (I waited for my body to miscarry on its own without medicine or surgery), Surgical (Dilation and curettage procedure, or another surgical procedure), and Medical (a pill, or a medication taken by mouth). Psychological distress. Participants’ psychological distress from the pandemic miscarriage was assessed using four established scales. Participants were instructed to respond to each measure while reflecting on their COVID-19 pandemic miscarriage. Perceived stress was measured with the 4-item Perceived Stress Scale (PSS-4) [ 29 ]. Items use a 5-point scale, from 0 (Never) to 4 (Very often), and are summed after reverse-scoring two items. Scores range from 0 to 16, with higher scores indicating greater perceived stress. The PSS-4 was internally consistent in this study, with Cronbach’s alpha estimate of α = 0.78. Anxiety symptoms were assessed with the 7-item Generalized Anxiety Disorder Scale (GAD-7) [ 30 ]. Items use a 4-point scale from 0 (Not at all) to 3 (Nearly every day). Summed scores are interpreted as: minimal (0–4), mild (5–9), moderate (10–14), and severe anxiety (15–21), with scores ≥ 10 indicating clinically significant anxiety symptoms [ 30 ]. Cronbach’s alpha estimates for GAD-7 indicated good internal consistency in this study (α = 0.93). Depression symptoms were assessed with the 8-item Patient Health Questionnaire (PHQ-8) [ 31 ]. Items use a 4-point scale from 0 (Not at all) to 3 (Nearly every day). Summed scores are interpreted as: minimal (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe depression (20–24), with scores ≥ 10 indicating clinically significant depressive symptoms [ 31 ]. The PHQ-8 was internally consistent in this study (α = 0.93). PTSD symptoms were assessed with the 5-item Primary Care PTSD screen for DSM-5 (PC-PTSD-5) [ 32 ]. Items use Yes or No options. Three or more “yes” responses indicate probable PTSD [ 32 ]. In this study, the PC-PTSD-5 demonstrated acceptable-to-marginal internal consistency (α = 0.68). In-depth interviews. The first three authors developed a 10-question semi-structured interview guide based on existing research regarding patient-provider interactions during miscarriage [ 5 , 6 , 8 , 33 ], the psychological impact of miscarriage [ 2 , 3 , 34 ], and maternal health stressors during COVID-19 [ 18 , 19 ]. Four questions of our interview guide closely aligned with the aims of this paper including describing: 1) how the COVID-19 pandemic affected participants’ miscarriage experience; 2) their experience if they visited an emergency department (ED) or an obstetrics ED at any time during/after the loss; 3) how the news was delivered or how they found out about their loss and how their miscarriage was managed (including: what was discussed, and if follow-up and mental health resources were offered); and 4) if they wished something about their care had been different. The complete interview guide was previously published as supplementary material [ 4 ] and is reproduced as S1 File for the current manuscript. Data analysis Survey. Quantitative data were analyzed using SPSS-28. Descriptive statistics described sociodemographic characteristics, frequencies of the participants responding “yes-definitely/yes” to each of the patient experience items, endorsement of COVID-19 stressors, and mean scores on the psychological distress measures. Miscarriage management was recoded into a binary variable reflecting level of clinical intervention: expectant management only versus any medical and/or surgical management. Because participants could select multiple management types (expectant, medical, surgical), responses were categorized using a hierarchical approach. Participants reporting expectant management only were classified in the expectant group, whereas those reporting any medical and/or surgical management were classified in the medical/surgical group, regardless of whether expectant management was also endorsed. This classification reflected the highest level of clinical intervention received. A two-step cluster procedure identified two subgroups (good and poor patient experience groups) based on responses to the five most frequently endorsed “yes-definitely/yes” patient experience survey items. A two-step cluster procedure was selected to identify naturally occurring groupings in patient experience responses rather than imposing an a priori cutoff. Chi-square tests for independence examined differences between the two groups in frequencies of those who responded “yes-definitely/yes” on survey items to vali
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