nz research

Improving Miscarriage Support in New Zealand
By Sarah Thompson (with her permission)
Supervised by Dr. Vivienne Elizabeth and Professor Maureen Baker

Abstract
Approximately 1 in 4 pregnancies in New Zealand (NZ) end in miscarriage (Personal communication with Carr, 2008). The experience of this is subject to change and is born within a social and cultural construction influenced by subjective feelings of what the pregnancy meant to the individual; and the negotiation of this, social and medical ideas of personhood, social acceptability of grief, and political influences with regard to employment leave and the funding of support groups. Through the pulling a-part of these differing factors I wished to consider how each may be influenced and to provide possible policy recommendations to improve upon the support and experience of miscarriage in NZ.

Introduction
That grief after a miscarriage occurs is not a new phenomenon. There are a multitude of studies which show that most women suffer some form of grief after a miscarriage (Athey & Spielvogel, 2000; Beutel, Deckardt, & Von Rad, 1995; Boyce, Condon, & Ellwood, 2002; Lok, 2007). This grief may lead to depression, anxiety (Nanda, Peloggia, Grimes, Lopez, & Nanda, 2007) and in the extreme, post traumatic stress disorder (Lok, 2007). This research therefore does not aim to show that which is already known, but instead aims to highlight the differing social factors that contribute to the experience of miscarriage and to consider the way parts of the social construction of miscarriage may be manipulated so that the experience itself, and the support offered may be improved. As the experience of pregnancy is often viewed socially as one that follows a linear path to birth I have followed a similar time line to develop the experience of miscarriage – from first knowledge of pregnancy to the act itself of miscarrying and the relations and experience of this which follow.

Background
Statistics
Miscarriage in Australia and New Zealand (NZ) is defined as a pregnancy that ends spontaneously before 20 weeks gestation (The Crown, 2007). The World Health Organisation (WHO) defines miscarriage as being up to 23 weeks of the pregnancy and 500 grams in weight (birth.com.au, 2009). Both definitions are medical and have an impact on the way a miscarriage is perceived both socially and politically.

A large NZ population based study recently found that 1 in 3 NZ women had experienced a miscarriage within their lifetime (Fanslow, Silva, Whitehead, & Robinson, 2008). As miscarriage is not a notifiable event in NZ, and no national research has been conducted into the occurrence per known pregnancy, the statistics available are only estimates. As such, in NZ it is estimated that 1 in 4 known pregnancies end in miscarriage with approximately 21,083 pregnancies ending in miscarriage in the year ending March, 2008 (Personal communication with Carr, 2008).

Western countries such as Australia, and the United Kingdom report a similar occurrence of miscarriage estimated at 15-20% of known pregnancies (birth.com.au, 2009; The Miscarriage Association, 2008). 50 percent of miscarriages are as a result of chromosomal abnormality (Huisjes cited in Moulder, 2001) and the cause for the other 50 percent is largely unknown (Regan & Rai, 2000). Advanced maternal and paternal age (35 years of age +) have been strongly linked to an increased risk of miscarriage (de La Rochebrochard & Thonneau, 2002; Nybo Andersen, Wohlfahrt, & Christens, 2000). Maternal age as a risk factor is therefore especially noteworthy with the increasing age that women in industrialised nations are experiencing their first pregnancy. In NZ this is true for all ethnicities and especially pakeha women (Statistics New Zealand, 2004). In addition, as a result of the increase in use of technology to conceive (Cote-Arsenault & Freije, 2004), and the early knowledge of pregnancy (as a result of home pregnancy kits) it is expected that the rate of miscarriage will increase (Simmons, Singh, Maconochie, Doyle, & Green, 2006).

International studies conducted into other factors such as alcohol, caffeine and tobacco consumption; high body mass and work schedule, have generated conflicting results with various studies noting these factors as potential risk influencers and others discounting this (Coste, Job-Spira, & Fernandez, 1991; de La Rochebrochard & Thonneau, 2002; Wen, Shu, Jacobs Jr, & Brown, 2001). The impact of these factors is of significant importance to Maori with almost one in three Maori women considered overweight (Ministry of Health, 2004). In addition Maori are twice as likely to smoke tobacco than non-Maori (Ministry of Health, 2005) and have a higher incidence of alcohol consumption than non-Maori (Ministry of Health, 2007).

A recent NZ study has shown that intimate partner violence (IPV) is associated with the occurrence of miscarriage (Fanslow et al., 2008). Results showed that those in a violent relationship were 1.4 times more likely to have experienced a miscarriage than those who had never experienced violence from a partner (Fanslow et al., 2008). This study, the only one in NZ to be carried out, also found the occurrence of miscarriage differed across the population based on ethnicity. Maori women were most likely to have experienced a miscarriage, followed by European/Pakeha, Pacific women and Asian women (Fanslow et al., 2008).

In NZ, with an estimated one in three women having experienced a miscarriage and approximately 20, 000 pregnancies ending this year in miscarriage, miscarriage can be seen as an issue potentially affecting all sexually active women of child bearing age.

Medicalisation of Pregnancy
The medicalisation of pregnancy has changed the experience of pregnancy itself. Prior to the medical management of pregnancy, women came to know of their pregnancy through bodily signs, such as a missed period and tender breasts (Layne, 2003a). These bodily changes are now considered mere signs of a possible pregnancy rather than definitive proof. With the aid of medical technology, women can now know of their ‘chemical pregnancy’ from the day of their first missed period via a self administered urine test, and with the use of a sonogram to confirm a viable physical pregnancy women can also experience the pregnancy visually, know the ‘babies’ sex, hear the thud of its heart beat and be given a ‘photo’ of their baby. All of this is possible well before fetal movement and long before a mother holds her baby in her arms.

This early knowledge and visual stimuli has consequences in turn for miscarriage. The medicalised experience of pregnancy enables earlier parent-child bonding (Frost, Bradley, Levitas, Smith, & Garcia, 2007), and as a result, investment in the personhood of the foetus and the social process of identity creation is able to occur sooner (Layne, 2003a). As the majority of miscarriages occur in the early weeks of pregnancies, this early knowledge of pregnancy has enabled many women to experience a miscarriage of what may otherwise been experienced as simply a slightly heavier than usual period (Cecil, 1994; Layne, 2003a).

Expecting the best
Expectations of pregnancy are socially produced and influenced by the interaction between a number of factors. Progress in biomedicine, an emphasis on women’s choice and empowerment, and society’s belief in the linear narrative that pregnancies end in live births, all influence the social construction of the expectation for our pregnancies. A major component of the loss incurred after a miscarriage arises out of high expectations for the trajectory of the pregnancy (Layne, 2003a). Through the belief in the power of biomedicine, the over-reporting of low infant mortality rates (in conjunction with the silence of women who have miscarried) (Cecil, 1994; Layne, 2003a), and medicine’s success with “miracle babies”, there is a society-wide belief in the progress of medicine and the idea that if and when you choose to have a baby, you can (Layne, 1996).

Narratives of women who have miscarried highlight a strong cultural belief in the right to a live childbirth, and an expectation that their pregnancy should go smoothly (Simmons et al., 2006). Unfortunately, while progress has been made in some areas of biomedicine, miscarriage rates have varied little and biomedicine has been unable to keep up with the cultural norms and expectations that have grown along side medical practices (Layne, 1996; Simmons et al., 2006). Further to this, popular pregnancy books reinforce the idea that pregnancies follow a linear narrative (not unlike the expected linear progress of biomedicine) from conception to birth with discussions of unexpected outcomes being seconded to the rear of the book (Layne, 2003a). These ‘unexpected outcomes’ challenge a linear narrative of conception through to birth. It has also been noted that physicians are wary of discussing possible pregnancy complications, for example miscarriage, for fear of unnecessarily worrying their patients (Layne, 2003a). As a result, the shock of miscarriage is greater than if the prevalence of such an event was known (Letherby, 1993).

Bodily experience
Miscarriage can occur anytime between conception and 20 weeks gestation (The Crown, 2007) as a result of chromosomal abnormalities, maternal and/or paternal age at conception, health factors or social influences such as IPV. Not all miscarriages will be complete however and medical intervention may be required to perform an ERPC (evacuation of the retained products of conception), commonly referred to as a D&C. There is debate as to the necessity of an ERPC and a recent World Health Organisation (WHO) study suggests that both waiting for a miscarriage to finish or having surgery are both appropriate options and that the decision for either should be the woman’s (Nanda et al., 2007).

Medical practitioners have been critiqued however for not adequately preparing women for the actual bodily event of a miscarriage (Moulder, 2001). The physical aspects may involve a considerable amount of pain, differing levels of bleeding, the passing of tissue and clots and in some instances an operation (Lee & Slade, 1996; Moulder, 2001). Many women talk of the polluting feeling that arises as a result of the amount and lack of control of the blood and tissue which is expelled (Moulder, 2001).

The hospital experience
Interactions with medical professionals play a defining role in the miscarriage event (Moulder, 2001). This experience is shaped by the dominant cultural norms within medical settings and a woman’s identity is negotiated within this framework. The medical profession has been historically shaped by males (Hartigan, 2001; National Coordinating Group on Health Care Reform and Women, 2003) and it is this medical knowledge that frames the care offered, and issues surrounding what is a baby, and therefore who is a mother. Perceptions of medical staff on what is considered a viable foetus influence this construction and studies of hospital staff found that miscarriage was viewed as less of a loss than that of a stillbirth (Stratton & Lloyd, 2008). Therefore, what may be experienced as a death to a woman may not be considered so by a doctor (Letherby, 1993). The material reflection of this is seen with no birth or death certificate of the event, this lack of documentation would seem to signify that a baby was never in existence.

Other aspects which contribute to the miscarriage experience include the sensitivity of treatment received. The emotional support offered within hospitals has been critiqued in a number of studies (Moulder, 2001; Wong, Crawford, Gask, & Grinyer, 2003). The medicalisation of the event over simplifies the complexity of miscarriage and “contributes to a sense that miscarriage is being trivialised and its seriousness for the woman denied” (Frost et al., 2007, 1005). In addition, where a woman is cared for within the hospital may have an impact on the event. Many women have reported feeling upset and uncomfortable when placed within a ward with other mothers whose pregnancies have resulted in a live birth (Tsartsara & Johnson, 2002).

Self-blame
Cultural norms surrounding the ideal (start to) pregnancy, in combination with the western neo-liberal perception of individual control, and meritocracy can lead to a woman shouldering blame for her loss (Layne, 2003b). Pregnancy books that stress self-regulation of alcohol and cigarette consumption, what foods a woman should or should not consume, how much exercise should be undertaken and urge control of stress levels, play a part in the notion that woman can control the outcome of their pregnancies (Layne, 2003b; Wall, 2009). The internalisation of this ideal start can lead to self-blame when a “pregnancy fails” despite the fact that miscarriage is largely out of the control of the woman (Layne, 2003a; Simmons et al., 2006). It is known that the provision of information on the causes of miscarriage significantly reduces feelings of self-blame and personal responsibility for the loss (Nikcevic, Tunkel, Kuczmierczyk, & Nicolaides, 1999) and also assists in finding meaning in, and coping with, the miscarriage experience (Athey & Spielvogel, 2000; Maker & Ogden, 2003).

Grief
Studies have shown that the grief experienced after a miscarriage can be as substantial as that felt after the death of any loved one (Stratton & Lloyd, 2008). This period of grieving varies with research outlining grief symptoms enduring between one month (Lee & Slade, 1996) to two years or more (Lok, 2007). Grief may also be felt around the anniversary of the event, or the expected due date (Lok, 2007). This grief is often experienced secretly, away from public view (Frost et al., 2007) and is characterised by feelings of sadness, desire to discuss the loss, yearning for the child, and a search for a meaningful explanation (Beutel et al., 1995). Men also experience bereavement effects such as loss, sadness, and feelings of hopelessness (Johnson & Puddifoot, 1996; Lok, 2007). Frost argues that the loss for men and women may be further heightened as a result of shrinking family sizes and family planning approaches that are more planned and controlled (2007).

How a miscarriage is viewed, experienced and managed, and how (and indeed, if) it is spoken of and expressed, may rest upon a wide range of social and cultural factors. A fundamental issue is likely to be the stage (pre- or post-partum) at which the foetus/baby is attributed with human status; this may vary widely across different cultures and at different periods in history (Cecil, 1996). The definition of when a foetus becomes a baby is hazy at best with no uniform definition in use. The concept of stillbirth, miscarriage or near death is socially constructed and thus not fixed (Lovell, 1997). The construction of the foetus as a baby is a product of a number of interactions such as technology, gifts, discourses and the media all of which construct people as parents and the foetus as a baby early in the pregnancy (Frost et al., 2007).

The acceptability of the grief over a miscarriage is shaped by cultural norms around what it is acceptable to grieve for, and how this grief may be socially shown. Implicated in this is the construction of what is, or is not a life. In contemporary Western society, it is often presumed that a death has not occurred when there has been no life - seen in patriarchal terms as a bounded body – separate from others, in conjunction with notions of identity which require a person to have lived in order to have created an identity that can be lost (Howarth, 2007). Yet the experience for many women is that of a life inside them. Miscarriage therefore may represent the loss of parental identity, the loss of life, and the loss of the future self whose identity may have been anticipated by the parents ( (Lok, 2007; Lovell, 1997).

The lack of ritual and the silence surrounding the miscarriage event would seem to show that within the social construction of bereavement, miscarriage is “at the bottom of the ‘bereavement heap’” (Lovell, 1997). While pregnancy loss may now be more visible, the constant claims of women are that the experience is still cloaked in silence (Layne, 2003a). This grief may be hard to claim as a result of the unclear status of the foetus at the time of death and the lack of social ritual may extend the grieving process. The divide between the grief the women feels and the lack of social recognition of the event leads to the incompatibility of meanings and lends to the problem (Letherby, 1993). Contributing to this miscommunication may be the lack of available language to communicate the event. Leclerc notes the difficulty in finding the words to express the simultaneous feelings relating to birth and death, and the death of what may be considered by many never a life (cited in Cecil, 1996). This, along with the discrepancy between the experience of the individual and the understanding of the event by others, may mean those mourning are at odds with their social milieu and thus have to rely solely on their own coping mechanisms (Fowlkes, 1991 in Malacrida, 1999). This isolation can result in intensified and complicated mourning (Rando, 1984, 1992, 1993 cited in Malacrida, 1999).

CURRENT SUPPORT
Hospitals
The need for formal support and more sensitive care for those who have experienced a miscarriage has been conclusively shown (Evans, Lloyd, Considine, & Hancock, 2002; Lok, 2007). Researchers have suggested that perceptions of unsatisfactory care contribute to women’s distress after the experience of a miscarriage (Evans et al., 2002; Lee & Slade, 1996; Stratton & Lloyd, 2008; Thorstensen, 2000). In spite of this, and the high number of women who experience a miscarriage each year in NZ (20,000 plus), there is currently no formal protocol at the national level in order to ensure satisfactory care and support within NZ hospitals (Ministry of Health, 2008). In addition, while a number of DHBs surveyed provide counselling support via social work departments, many of the 21 DHB’s do not have formalised pregnancy loss services (Perinatal and Maternal Mortality Review Committee, 2007).

As outlined in a recent review of maternity services in the Wellington area (published by the MOH), “maternity services in New Zealand have been accorded a relatively low priority” (Ministry of Health, 2008, 9). The review highlights the need within maternity care for common-evidence-based standards to “which all relevant health professional groups subscribe” (Ministry of Health, 2008, 9). Such maternity care standards were produced in June 2008 by the United Kingdom Colleges of Obstetricians and Gynaecologists, Midwives, Anaesthetists and Paediatrics. While the Wellington review fails to mention miscarriage services, it does, however, state that the Maternity Care Standards outlined recently in the UK would provide an excellent template for New Zealand (Ministry of Health, 2008). The UK standards acknowledged that pregnancy loss can be extremely traumatic and the need for support for women and their families “both during the acute time of the event and continuing through the weeks or months afterwards” is highlighted (Royal College of Obstetricians and Gynaecologists, 2008, 48).

At the 2003 Fertility New Zealand Conference Judith Cameron presented a paper outlining the necessity of sensitive support systems within the National Women’s Hospital (NWH). At this time the NWH offered a follow up-call to all women who had presented miscarrying and was the only hospital in New Zealand to offer a free counselling service to all women and men who had experienced a miscarriage (Cameron, 2003). These practices have now been discontinued with the ADHB offering limited free counselling on request and no follow up call. A Miscarriage Support Auckland Inc. (Miscarriage Support Auckland) pamphlet is made available, although volunteer miscarriage support groups suggest that this pamphlet is not always offered (personal communication with Allan, 2009).

Middlemore Hospital currently offers a free counselling service to woman who have miscarried (personal communication with Underwood, 2009). If women do not wish to see a counsellor at that time a follow up call is made after discharge. In addition, all women who have miscarried receive a pamphlet entitled ‘Understanding Miscarriage’ which has a contact number for Miscarriage Support Auckland. The North Shore Hospital does not have a funded counselling service for women who have miscarried (personal communication with Cramond, 2008). Support, however, is offered to women who experience pregnancy loss within the hospital system and a follow-up call is provided to deal with initial feelings of loss and grief. Women seen within the Emergency Care System are only visited and/or contacted by one of the two social workers for women’s health if advised by the Medical/Surgical Social Work Team (personal communication with Cramond, 2008). These differing practices within the greater Auckland area highlight the lack of consistent protocol surrounding care of those who have miscarried.

A thorough online search of different databases that I conducted showed evidence of miscarriage support services having been implemented within some hospitals throughout Australia, the UK and Canada at different times. An overall picture of the current services offered within Australia, Canada and the UK is unavailable however, presumably as a result of the disjunct between different district health boards and jurisdictions.

Informal
A common feature within NZ, Australia and the UK is the lack of funding for informal support groups. Miscarriage Support Auckland, has chapters throughout the country and is the most referenced form of support. This is provided by a group of female volunteers who have experienced a miscarriage (Miscarriage Support Auckland Inc., 2009). This support group is funded by donations and grants and does not receive any direct government funding (personal communication with Allan, 2009). A review of the major miscarriage support groups in the UK and Australia highlights a similar lack of funding, with the UK Miscarriage Association receiving only £10,000 of government funding (5% of their funds) (The Miscarriage Association, 2008); and Bonnie Babes in Australia receiving no government funding despite the Howard government promising $800,000 AUS at the last election (Macdonald, 2008).

In addition there are a multitude of web based support groups many with mediated online chat rooms (Layne, 2003a). These online communities have been found to offer greater ease of access to support, greater expertise and afford participants a forum where they may more easily express themselves (Walter and Boyd cited in Layne, 2003a).

Informal support may be received from friends and family of those who have miscarried. Studies have shown that this form of support may often be unhelpful, misguided or unavailable as a result of decreased family size and increased population mobility (Cote-Arsenault & Freije, 2004). For this reason, support groups provide a much needed service. In NZ, however, there are currently no state-funded support structures (Perinatal and Maternal Mortality Review Committee, 2007).

Employment
Miscarriage, for many, can be a time of grief and physical pain (Nanda et al., 2007), the degree of which will depend on the individual’s feelings of loss and the type of miscarriage experienced (whether a D&C is required or invasive surgery for example). For this reason, considerable time off work for recovery is often required with a World Health Organisation study showing 21 days as the median time taken by those who underwent medical or surgical management of their miscarriage (Nanda et al., 2007).

Few countries offer specific maternity leave to those who have miscarried. In contrast, many countries, including New Zealand and the UK, offer paid maternity leave to those who give birth to a stillborn baby (or equivalent to 24 weeks gestation) (Department of Labour, 2009a; This highlights the possible legal implications surrounding the medical definitions of fetal viability.Directgov, 2009).
I was unable to find any information online in regards to Canadian miscarriage support groups.

Within New Zealand, Section 12 of the Parental Leave Act 1987 allows for maternity leave of up to 14 weeks in the case of miscarriage provided the woman has applied 3 months prior to taking this leave (Department of Labour, 2009a). Maternity leave would therefore be near impossible to claim as the majority of women miscarry between 8-12 weeks gestation, and many women do not speak of their pregnancy until after the first trimester (Bansen & Stevens, 1992). Sick leave may be taken (Department of Labour, 2009a) if any of the employee’s allocation (of 5 days per year – based on minimum employment rights) remains (Department of Labour, 2009b). If an employee is eligible for bereavement leave, they may apply to take one day of this after a miscarriage, this will be given at the discretion of the employer if they believe a bereavement has occurred (Department of Labour, 2009a, 2009b). The lack of paid leave available to women who have miscarried may have implications, such as women returning to work before they are either physically or mentally able.

Under the Australian Fair Pay and Conditions Standard, women who miscarry are eligible to take special unpaid maternity leave for the duration specified by a medical certificate (Australian Government, 2009). Shared federal-provincial responsibility complicates the Canadian context. The Canada Labour Code covers those working within federal jurisdiction. This Code does not provide paid or unpaid maternity leave to those who have miscarried prior to 20 weeks gestation (Edmondson, 2007). Sick leave may however be applied for (up to a maximum of 15 weeks) through the Canadian Employment Insurance program if the employee is eligible (Service Canada, 2009). The basic benefit rate is set at 55% of your average insured earnings (up to a maximum of $447 Canadian per week) (Service Canada, 2009).

Policy Implications
As this review of the current support shows, services and support (both financial and emotional) are limited within New Zealand and other liberal countries. There is clearly a need for greater recognition of the emotional and financial support required by those who have experienced a miscarriage. The two major areas for policy implications relate to hospital and medical care and government funding and protocol.

Hospital/medical care
The lack of hospital support may be seen as a result of two things – the decrease in funding of maternity services, and the lack of perceived demand for such services. Within NZ (and other western countries) there has been a substantial change in the age-structural demographic with fertility rates decreasing and the ageing population increasing (Stephenson & Scobie, 2002). This has led to a shift in hospital funding away from maternity care and towards other programs (personal communication with Cramond, 2008). DHBs in NZ have the responsibility of managing resources and delivering services to best meet the needs of communities (Glover, Hetzel, & Tennant, 2008); the Ministry of Health states that this devolution will strengthen community ‘voice’ so that “local people can have their voice heard in the planning and delivery of services” and “empower communities to have a greater say in determining their own health needs” (King, 2001, iii). With the silence surrounding the miscarriage event however, the support required may not be asked for by those who most need it leading hospitals to mistakenly believe that there is a lack of demand (Cameron, 2003). Further to this, the minimisation of miscarriage by medical staff, and the gendered division of labour within hospitals - which sees men predominantly within positions of power and decision making, may add to the lack of demand from within (Hartigan, 2001; National Coordinating Group on Health Care Reform and Women, 2003).

Research shows that improved hospital services within a humanistic environment are required. I argue that this could be achieved through the implementation of a nationwide maternity care protocol that outlines minimum standards of services – like that of the UK discussed above. This should enforce specific requirements such as follow-up care and services to be provided through Early Pregnancy Assessment Units (EPAU). Early Pregnancy Assessment Units are beneficial as they provide a place to go with specialised nurses who, following a miscarriage, can best serve a woman’s needs (Tsartsara & Johnson, 2002). A follow-up appointment after a miscarriage is also desirable. A recent study revealed 92% of survey participants desired this service, with 70% showing a significant reduction in psychological morbidity as a result of such care (Stratton & Lloyd, 2008). This appointment should address both medical and emotional issues, including reinforcing information regarding the cause of miscarriage (where possible), implications for future pregnancies, and an ongoing offer of grief counselling (Lee & Slade, 1996; Lok, 2007).

Employment contracts
Changes to employment contracts are required to allow women to take time off work to recover both emotionally and physically after a miscarriage. As shown by the WHO survey, women who had experienced a miscarriage and received either medical or surgical care had a median leave time from work of 21 days (Nanda et al., 2007). The current maternity leave system in most countries is configured in such a way that women may take maternity leave if their pregnancy ends in still birth but not miscarriage. It is unclear whether this differentiation in eligibility is as a result of the presumed increase in trauma (physical or mental) incurred, or if there may be some correlation with the medical conception of what is considered a viable foetus (24 weeks). Regardless of the underlying justification, it is clear that women require time to heal after a miscarriage and the sick or bereavement leave available currently is insubstantial.

Government funding
In addition to changes in employment legislation and leave allocation, government funding is required to assist groups such as Miscarriage Support Auckland in NZ which provides support and information to those who have miscarried. This form of community group allows the empowerment of those who have experienced a miscarriage to support others. Currently however this group receives no government funding and as a result it is unable to provide the breadth of services it would like (personal communication with Allan, 2009). Presently the group runs an extensive website with resources for advice and information about miscarriage and also pamphlets on how loved ones may better acknowledge and offer support to friends and family (Miscarriage Support Auckland Inc., 2009). This part of their service is of importance with studies showing family and friends are often misguided in the support they offer others.

Public awareness
Along with policy implications to improve the miscarriage experience post-event, much can be done prior to conception and early in pregnancy. As Allan (personal communication, 2008) and Layne (2003b) argue, the miscarriage experience can be greatly influenced by information regarding the prevalence and experience of miscarriage prior to experiencing the event. Knowledge of the high chance of miscarriage has been shown to decrease the elevated expectations for pregnancy outcomes and thus decrease the emotional impact due to the shock of the occurrence (Layne, 2003b). In addition greater education of both men and women would allow for increased understanding and ability to support others who have miscarried. For this reason I would argue for the addition of miscarriage information within sex education classes currently taught at high schools.

Conclusion
One in three NZ women will suffer a miscarriage, the experience of which is socially and culturally situated. Major aspects that influence the event include the medicalisation of pregnancy, minimal hospital support services, zero funding for non-profit support services, lack of public information on the occurrence of the event and no financial provisions made within employment contracts for necessary leave. That miscarriage as an event is still largely unacknowledged, support under funded and often unavailable, speaks of the societal and political lack of recognition of the event.

With the advent of technologies that allow earlier foetal bonding, the pregnancy narrative has changed.  Women are inadvertently (or otherwise) encouraged in the creation of foetal personhood, however, when these pregnancies do not produce a live birth they are faced with an old narrative which does not allow for support of the prospective parents or the grieving of this socially created identity.  As the age that women conceive increases the occurrence of miscarriage will in-turn increase, therefore, now more than ever, policy implications as outlined above are needed to improve miscarriage support in New Zealand.

References
Allan, V. (2009). Personal communication with S. Thompson (Ed.). Auckland.
Athey, J., & Spielvogel, A. (2000). Risk factors and interventions for psychological sequelae in women after miscarriage. Primary Care Update for Obstetrics/Gynecology, 7(2), 64-69.
Australian Government. (2009). Australian Fair Pay and Conditions Standard. Retrieved 24 February 2009, from http://www.workplaceauthority.gov.au
Bansen, S. S., & Stevens, H. A. (1992). Women's experiences of miscarriage in early pregnancy. Journal of Nurse-Midwifery, 37(2), 84-90.
Beutel, M., Deckardt, R., & Von Rad, M. (1995). Grief and depression after miscarriage: their seperation, antecedents and course. Pscyhosomatic Medicine, 57, 517-526.
birth.com.au. (2009). Miscarriage. Retrieved 25 February, 2009, from http://www.birth.com.au/Info.asp?class=6620&page=1
Boyce, P. M., Condon, J. T., & Ellwood, D. A. (2002). Pregnancy loss: A major life event affecting emotional health and well-being. Medical Journal of Australia, 176(6), 250-251.
Cameron, J. (2003). Miscarriage: The dilemmas of unacknowledged loss. Paper presented at the Fertility New Zealand Conference.
Carr, L. (2008). Personal communication with S. Thompson (Ed.). Auckland.
Cecil, R. (1994). "I wouldn't have minded a wee one running about": Miscarriage and the family. Social Science and Medicine, 38(10), 1415-1422.
Cecil, R. (1996). Introduction: an insignificant event? Literary and anthropological perspectives on pregnancy loss. In R. Cecil (Ed.), The anthropology of pregnancy loss; Comparative studies in miscarriage, stillbirth and neonatal death. Oxford: Berg.
Coste, J., Job-Spira, N., & Fernandez, H. (1991). Risk factors for spontaneous abortion: a case-contro in France. Human Reproduction, 6, 1332-1337.
Cote-Arsenault, D., & Freije, M. M. (2004). Support groups helping women through pregnancies after loss. Western Journal of Nursing Research, 26(6), 650-670.
Cramond, H. (2008). Personal communication with S. Thompson (Ed.). Auckland.
De La Rochebrochard, E., & Thonneau, P. (2002). Paternal age and maternal age are risk factors for miscarriage; results of a multicentre European study. Human Reproduction, 17(6), 1649-1656.
Department of Labour. (2009a). Personal Communication with S. Thompson (Ed.)
Department of Labour. (2009b). Minimum employment rights. Retrieved April 6, 2009, 2009, from http://www.ers.dol.govt.nz/relationships/minimum_print.html
Directgov. (2009). Taking your maternity leave. Retrieved 24 February 2009, from http://www.direct.gov.uk/
Edmondson, W. (2007). Maternity Leave, Canada Labour Code, part III, division VII. Retrieved 24 February 2009, from http://www.hrsdc.gc.ca/eng/lp/lo/opd-ipg/ipg/017.shtml
Evans, L., Lloyd, D., Considine, R., & Hancock, L. (2002). Contrasting views of staff and patients regarding psychosocial care for Australian women who miscarry: a hospital based study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 42(2), 155.
Fanslow, J., Silva, M., Whitehead, A., & Robinson, E. (2008). Pregnancy outcomes and intimate partner violence in New Zealand. Australian and New Zealand Journal of Obstetrics and Gynaecology, 48(4), 391-397.
Frost, J., Bradley, H., Levitas, R., Smith, L., & Garcia, J. (2007). The loss of possibility: scientisation of death and the special case of early miscarriage. Sociology of Health & Illness, 29(7), 1003-1022.
Glover, J. D., Hetzel, D. M. S., & Tennant, S. K. (2008). Health systems of Australia and New Zealand. International Encylcopedia of Public Health, 255-267.
Hartigan, P. (2001). The importance of gender in defining and improving quality of care: some conceptual issues. Health Policy and Planning, 16(1), 7-12.
Howarth, G. (2007). Death & dying: A sociological introduction. Cambridge: Polity Press.
Johnson, M. P., & Puddifoot, J. E. (1996). The grief response in partners of women who miscarry. British Journal of Medical Psychology, 69, 313-327.
King, A. (2001). The primary health care strategy. Retrieved. from.
Layne, L. (1996). 'Never such innocence again': Irony, nature and technoscience in narratives of pregnancy loss. In R. Cecil (Ed.), The anthropology of pregnancy loss; Comparitive studies in miscarriage, stillbirth and neonatal death. Oxford: Berg.
Layne, L. (2003a). Motherhood lost: a feminist account of pregnancy loss in America. London: Routledge.
Layne, L. (2003b). Unhappy endings: A feminist reappraisal of the women's health movement from the vantage of pregnancy loss. Social Science and Medicine, 56, 1881-1891.
Lee, C., & Slade, P. (1996). Miscarriage as a traumatic event: A review of the literature and new implications for intervention. Journal of Psychosomatic Research, 40(3), 235-244.
Letherby, G. (1993). The meanings of miscarriage. Women's Studies International Forum, 16(2), 165-180.
Lok, I. H. (2007). Psychological morbidity following miscarriage. Best Practice and Research Clinical Obstetrics and Gynaecology, 21(2).
Lovell, A. (1997). Death at the beginning of life. In D. Field, J. Hockey & N. Small (Eds.), Death, gender and ethnicity. London: Routledge.
Macdonald, E. (2008). Hue and cry over funding snub for grief counselling foundation. The Canberra Times,
Maker, C., & Ogden, J. (2003). The miscarriage experience: More than just a trigger to psychological morbidity? Psychology and Health, 18(3), 403-415.
Malacrida, C. (1999). Complicating mourning: The social economy of perinatal death. Qualitative Health Research, 9(4), 504-519.
Ministry of Health. (2004). Tracking the obesity epidemic: New Zealand 1977-2003. Retrieved. from.
Ministry of Health. (2007). Alcohol use in New Zealand: Analysis of the 2004 New Zealand health behaviours survey - alcohol use. Retrieved. from.
Ministry of Health. (2008). Review of the quality, safety and management of maternity services in the Wellington area. Retrieved. from
http://www.moh.govt.nz/moh.nsf/indexmh/wgtn-maternity-services-review-oct08.
Miscarriage Support Auckland Inc. (2009) Who we are/accolades/contributions. Retrieved from http://www.miscarriagesupport.org.nz/whoweare.html
Moulder, C. (2001). Miscarriage: Women's experiences and needs. London: Routledge.
Nanda, K., Peloggia, A., Grimes, D., Lopez, L., & Nanda, G. (2007). Expectant care versus surgical treatment for miscarriage (review). The Chochrane Library, 4.
National Coordinating Group on Health Care Reform and Women. (2003). Reading Romanow; The implications of the final report of the commission on the future of health care in Canada for Women. Toronto.
Nikcevic, A. V., Tunkel, S., Kuczmierczyk, A. R., & Nicolaides, K. H. (1999). Investigation of the cause of miscarriage and its influence on women's psychological distress. British Journal of Obstetrics and Gynaecology, 106(8), 808-813.
Nybo Andersen, A., Wohlfahrt, J., & Christens, P. (2000). Maternal age and fetal loss: population based register linkage study. British Medical Journal, 320, 1708-1712.
Perinatal and Maternal Mortality Review Committee. (2007). First report to the Minister of Health: June 2005 to June 2007. Wellington.
Regan, L., & Rai, R. (2000). Epidemiology and the medical causes of miscarriage. Baillieres Best Practice & Research in Clinical Obstetrics & Gynaecology, 14(5), 839-854.
Royal College of Obstetricians and Gynaecologists. (2008). Standards for maternity care: Royal College of Obstetricians and Gynaecologists.
Service Canada. (2009). Employment Insurance (EI) and maternity, parental and sickness benefits. Retrieved 24 February 2009, from http://www1.servicecanada.gc.ca/eng/ei/types/special.shtml#Sickness3
Simmons, R. K., Singh, G., Maconochie, N., Doyle, P., & Green, J. (2006). Experience of miscarriage in the UK: Qualitative findings from the National Women's Health study. Social Science and Medicine, 63(7), 1934-1946.
Stephenson, J., & Scobie, G. (2002). The economics of population ageing: NZ Treasury.
Stratton, K., & Lloyd, L. (2008). Hospital-based interventions at and following miscarriage: Literature to inform a research-practice initiative. Australian and New Zealand Journal of Obstetrics and Gynaecology, 48(1), 5-11.
The Crown. (2007). Maternity services: Notice pursuant to section 88 of the New Zealand Public Health and Disability Act 2000. Retrieved. from http://www.moh.govt.nz
The Miscarriage Association. (2008). The Miscarriage Association; Annual report 2007-2008. Oldham.
Thorstensen, K. (2000). Midwifery management of first trimester and bleeding and early pregnancy loss. Journal of Midwifery and Womens Health, 45.
Tsartsara, E., & Johnson, M. P. (2002). Women's experience of care at a specialised miscarriage unit: An interpretative phenomenological study. Clinical Effectiveness in Nursing, 6, 55-65.
Underwood, M. (2009). Personal communication with S. Thompson (Ed.). Auckland.
Wall, G. (2009). Childhood and child rearing. In M. Baker (Ed.), Families: Changing trends in Canada (6th edition ed.). Toronto: McGraw-Hill Ryerson.
Wen, W., Shu, X., Jacobs Jr, D., & Brown, J. (2001). The associations of maternal caffeine consumption and nausea with spontaneous abortion. Epidemiology, 12(1), 38-42.
Wong, M. K., Crawford, T. J., Gask, L., & Grinyer, A. (2003). A qualitative investigation into women's experiences after a miscarriage: Implications for the primary healthcare team. British Journal of General Practice, 53, 697-702.