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Publicly Available Published by De Gruyter April 26, 2022

Beyond emotional support: predictors of satisfaction and perceived care quality following the death of a baby during pregnancy

  • Paul Richard Cassidy ORCID logo EMAIL logo



To investigate which objective (actions/interventions) and subjective (perceptions of care quality) outcomes of care following stillbirth or termination of pregnancy predict perceived care quality.


A cross-sectional descriptive study using an anonymous online survey. The population was women who had experienced a stillbirth or termination of pregnancy from ≥16 weeks of gestation, in the Spanish health system. Multiple sequential regression analysis was used to identify predictors of perceived care quality (satisfaction, willingness to recommend, competence and ability to provide loss-focused care).


Results from 610 women were analysed. A significant regression equation (p<0.001) was found in each of the objective only and objective-subjective models. In the case of overall care (satisfaction-recommend composite), 72.0% of variance (adj. R2) was explained. In general, subjective evaluations of care are more potent predictors of perceived care quality than objective care interventions (e.g. autopsy performed). Feeling free to ‘express emotions’, ‘teamwork between doctors and nurses/midwives’, and ‘being well-informed of all steps and procedures’ were the three strongest predictors, followed by perception of ‘medical negligence’. Information provision and loss-focused interventions had the weakest influence, except in the specific ‘loss-focused’ model.


The results indicate that the ‘atmosphere’ of care is a transversal dimension related to the context of loss and trauma and has the single greatest influence on perceptions of care quality. It is necessary to use a specific ‘loss-focused’ care variable to adequately capture perceptions of the quality of bereavement care and a custom scale to measure the influence of care interventions on perceived quality.


Assessing quality from the perspective of patients is a crucial part of delivering effective care that complements measures of health related quality of life and biological outcomes [1, 2]. Measuring patient satisfaction and perceptions of care quality can be effective ways of assessing health subjectivities, particularly as part of mixed-method designs and when placed in social and cultural context [3], [4], [5], [6]. Although considerable work has been done on the measurement of care outcomes in perinatal bereavement, there has been relatively little quantitative research on the underlying components and predictors of satisfaction and what constitutes quality of care from the perspective of women, or their partners. Partly, this relates to the underuse of established techniques and, in parallel, the lack of area-specific instruments to do so. This is an important gap because healthcare following perinatal loss is understood to have an important impact on grief and health outcomes [7]. This article describes the development of a preliminary scale to measure women’s subjective evaluations of care following late pregnancy loss – second and third trimester stillbirth and termination of pregnancy for medical reasons – and the results from its application through an online survey.

To date, most work on care outcomes following stillbirth has focused on the implementation or effectiveness of care interventions and patients’ subjective experiences. Through surveys, patient-reported outcomes have been used to measure the implementation or offer of particular care interventions, which can be divided into two categories: a) clinical and structural aspects of care (e.g. autopsy, mode of birth, accommodation), and b) care related to bereavement and loss (e.g. contact with the baby, memory objects) [8, 9]. Other studies have measured the effectiveness of bereavement care interventions, such as ‘the mother saw/held the baby’, in terms of mental health outcomes or satisfaction [10], [11], [12], [13], [14], [15], [16], [17]. While the experiences of women and their partners in hospitals have been widely assessed through both qualitative and quantitative research [18], [19], [20], only a few studies are based on established constructs of care satisfaction and perceived quality.

The studies that have used such constructs are problematic for a number of reasons. Firstly, the use of single-item measures of satisfaction [13, 21, 22] is an issue because perceptions of care are made up of various sub-components, meaning that the specific aspects of care that patients are assessing remain unknown, and, furthermore, satisfaction tends not to capture the full range of subjective evaluations [23, 24]. This is highly limiting as a guide to practice. Even when multidimensional scales are used, their appropriateness is questionable. For example, the PSQ-18 [25] and MPSQ [15] have been employed to assess perinatal bereavement care, but are designed to measure continuous primary care from doctors. While some studies are based on area specific scales, they are mostly published with little information on their development and validation [10], [11], [12, 26]. Recent work by Wool et al. in the related area of perinatal palliative care provides an interesting contrast [27, 28]. This indicates a twofold problem: lack of knowledge of the underlying components of subjective care quality and an absence of area-specific scales to carry out such measurement.

Studies on the dimensionality of ‘satisfaction’ or ‘perceived quality’ show that patients are principally evaluating functional, technical and physical (comfort, privacy, etc.) components of their subjective experience [524, 29], [30], [31], [32], [33], [34], [35], [36]. On one side, the functional dimension relates to empathy and emotional care/support, including perceptions of being treated respectfully and as individuals. This also includes decision-making and equity in care encounters, which encompasses information provision, feeling listening to and respect for patient preferences. In perinatal bereavement care, emotional support and decision-making are the cornerstones of good practice, but are specifically oriented toward affirmation of identities (mother/father/child) and decisions that parents will most likley never have considered (autopsy, post mortem contact, etc.) [18], [19], [20]. The technical dimension of care relates to the technical competence of health professionals, administrative and structural competence in relation to coordination of care, and perceptions of health outcomes. In perinatal bereavement care, aspects such as continuity and coordination of care have been highlighted as important [18], [19], [20]. However, there is a lack of consideration for possible health outcomes beyond mortality and evaluations of technical aspects of care (task-directed skill related to clinical and loss-focused care), and how these may fit into overall perceptions of care, as well as considering how doctors and midwives work together to provide care.

Developing more detailed knowledge of the meaning of patient satisfaction and subjective quality in perinatal bereavement care could have significant advantages for learning more about patient needs and the ongoing development of care practices. In addition, at a methodological level, it may help to ensure that these constructs are better understood and that measurement is more reliable. This exploratory study aims to investigate: (1) if satisfaction alone is a sufficient measure of care quality in the context of loss; (2) what objective and subjective outcomes predict satisfaction; (3) what components of care are most important to women. The study included the development of a detailed questionnaire, including a custom scale to measure subjective evaluations of various aspects of care, and its application to a large sample in Spain.

Materials and methods

The population was defined as women who had experienced a late miscarriage, stillbirth, intrapartum death, or termination of pregnancy for medical reasons from 16 weeks of gestation and within the Spanish healthcare system. A cross-sectional descriptive study was carried out using an anonymous online survey, the only practical means to reach the population at a national level. The study took place as part of a broader ethnographic and mixed-methods research project that included participant observation and qualitative analysis of narrative style interviews [37].

The anonymous online questionnaire sought to collect five main types of data: (1) socio-demographic; (2) reproductive history and details of the loss/death; (3) objective measures of care focused on care interventions related to: the diagnosis, accommodation, birth and mode of delivery, administration of sedatives, investigation of the cause of death, disposition of the body, contact with the baby, memory objects; (4) intensity of contact with support charities; and (5) subjective evaluations of care through the development of a custom battery called the Pregnancy Loss Care Quality Scale (PLCQ scale), which uses a 5-point Likert agreement scale. As well as the PLCQ, a separate five-item scale was developed to measure specific types of information. Finally, respondents were also asked if they believed there had been medical negligence in their case (response options: No; Yes, a claim was made; Yes, no claim was made).

The questionnaire was developed through a review of the literature, exploratory qualitative interviews with four healthcare professionals and six parents, and content and face validation [3238, 39]. For the PLCQ scale development, a panel of 15 expert health professionals were presented with 57 items, broadly related to the care dimensions outlined in the introduction, as well as items related to diagnosis and decision-making on post mortem contact. The panel rated and qualitatively evaluated the items. Following a second round, 29 items were retained in the final questionnaire.

In addition, six global measures or dependent variables (DVs) were included. Firstly, both ‘satisfaction’ and ‘willingness to recommend’ the hospital to other couples were included as standard, yet differentiated, measures of care performance [40]. In the analysis, these two items were first compared and subsequently collapsed into one overall global measure of care (GLB1). As the study was also concerned with patients’ perception of professional competence, two items were added that sought to evaluate doctors and nurses/midwives individually: ‘the doctors were competent in their work’ (GLB2); ‘the nurses/midwives were competent in their work’ (GLB3). At a hypothetical level, it was thought that both ‘competence’ and ‘satisfaction/willingness to recommend’ might not capture evaluations of loss-focused care. This conjecture was based on exploratory interviews and theory on satisfaction measurement which suggests that patients rate the difference between their expectations and performance [29, 41]. As most women, and their partners, are not prepared for this experience or have knowledge of appropriate care, it was posited that they may differentiate between standard expected care and loss-specific aspects of care. Therefore, two further items were introduced: ‘the doctors knew how to deal with cases of loss’ (GLB4); ‘the nurses/midwives knew how to deal with cases of loss’ (GLB5). A mixed panel of 11 health professionals and eight bereaved women validated the draft questionnaire, which was subsequently piloted by 18 women. A full list of the socio-demographic data, reproductive/loss variables, care interventions and the full questionnaire has been published elsewhere [37].

Fieldwork took place between June 2013 and June 2016. Respondents were recruited using convenience sampling (snowballing), including advertisements on support associations’ websites, social media and through direct contact with parents and health professionals. In total, 796 women, whose baby had died within the previous 5 years, completed the survey. However, to give greater stability to the regression analysis, only the 610 cases occurring within 24 months previous to participation, and which had no more than one missing data point, were analysed. Further detailed information on sampling procedures, fieldwork and data purification are available elsewhere [37].

As the analysis was concerned with care practices, variables related to socio-demographics, pregnancy history, details of the loss, and intensity of contact with support associations were not included. It should be noted, however, that exploratory analysis indicated that, of these, only second trimester loss had strong predictive value over satisfaction. For the purpose of the regression analysis, objective variables were converted to dummies (0,1). Prior to performing the regression, Mann-Whitney 2-tailed tests of independence (p<0.05) and Cohen’s effect size [42] were used to test the 51 objective independent variables (IVs) against the DVs and to screen for inclusion in the initial objective regression model. Multiple sequential (forward method) regression was used to assess the ability of objective and subjective IVs to predict the five global measures of care (GLB1, GLB2, GLB3, GLB4, GLB5). The sample size was sufficiently large to meet a recommended IV to DV ratio of 18:1 [43]. In order to reduce contributions from weak or unstable variables, the alpha criteria for inclusion in the regression model was set at p<0.1. Missing data was substituted by mean scores. Analysis of tolerance (IVs<0.1) and inflation (VIF > 10) found that multicolinearity was not present in any of the models and Durbin–Watson scores were all acceptable (≥1.5 and ≤ 2.5). Residual scores were within the acceptable range (3.3–3.3) and plot analysis and Mahalanobois and Cook distance tests indicated no significant issues [43, 44].


Basic sample data

Data on the sample characteristics are presented in Table 1. Basic frequency data for all the objective and subjective variables used in the analysis are available in Table 2. Notable from the results, ‘willingness to recommend’ scores almost 8 points lower than satisfaction, while general ‘competence’ scores (GLB2, GLB3) are higher than satisfaction or willingness to recommend, but ability to provide loss-focused care (GLB4, GLB5) scored much lower.

Table 1:

Characteristics of the survey sample.

Age at the time of the loss n % Type of pregnancy n %
< 25 years 16 2.6 Singular 571 93.6
25–29 years 84 13.8 Multiple 39 6.4
30–34 years 268 43.9
35–39 years 190 31.1 Type of loss/death
≥40 years 52 8.5 Spontaneous intrauterine 476 76.7
Termination of pregnancy 145 21.0
Education level Intra partum 14 2.3
Up to intermediate second level 57 9.3
Second or lower diploma 196 32.1 Gestational age at the time of the loss
Diploma, university degree or higher 357 58.5 16–19 weeks 97 15.9
20–25 weeks 150 24.6
Nationality 26–33 weeks 116 19.0
Spain 579 94.9 ≥34 weeks 247 40.5
Foreign national 31 5.1
Year of the loss/death
Geographic location 2009–2011 31 5.1
City, suburbs or large town 440 72.2 2012 105 17.2
Small town or rural area 169 27.8 2013 157 25.7
Missing 1 2014 148 24.3
2015–2016 169 27.7
Type of hospital
Public 454 74.4 Previous contact with support assoc.
Private 156 25.6 No 272 44.9
Yes 334 55.1
Pregnancy history Missing 4
First pregnancy 290 47.5
Not first pregnancy 320 52.5

Total 610 100.0 Total 610 100.0
Table 2:

List of objective and subjective variables included in the analysis (following preliminary screening).

Objective measures % Missing Subjective measures Agreeing, % Mean SE Missing
Diagnosis Postmortem contact and memories
OB1 Doctor communicated diagnosisa 88.8 2 SB1 Enough information for decisionsc 43.5 3.00 0.07 5
OB2 Nurse/midwife communicated diagnosisa 8.4 0 SB2 Advised to not see the baby 19.8 2.06 0.06 4
Accommodation SB3 Help keeping memory objects 17.6 2.09 0.06 2
OB3 Private rooma 78.8 0 Diagnosis
OB4 Could hear babies crying (strong)a,b 32.8 0 SB4 Doctor took a long time to see 21.3 2.29 0.05 4
Birth and mode of delivery SB5 Treated with priority 57.5 3.50 0.06 3
OB5 Vaginal birth 84.1 1 SB6 Clear explanationc 68.6 3.70 0.06 2
OB6 Vaginal birth (induction) 73.9 1 SB7 Opportunity to ask questions 62.1 3.59 0.06 3
OB7 Caesarean birth 14.9 1 SB8 Empathetic 61.6 3.57 0.06 0
OB8 Programmed cesarean 2.0 1 SB9 Accompanied by HP(s) after 57.5 3.41 0.06 0
OB9 Emergency cesarean 10.5 1 Emotional support/interpersonal
OB10 Cesarean for failed induction 2.5 1 SB10 Felt listened too 66.5 3.68 0.05 1
OB11 Instrumentalised birth 13.3 1 SB11 Could express emotionsc 61.1 3.55 0.06 1
OB12 Accompanied during birtha,b 73.2 2 SB12 HPs were respectful 76.1 3.99 0.05 0
OB13 Partner not allowed to accompanya,b 15.6 2 SB13 HPs sensitive with languagec 67.5 3.73 0.05 0
Sedative administration SB14 Treated like a motherc 49.8 3.30 0.06 3
OB14 Administration after diagnosis 22.5 0 SB15 Emotional support – doctorsc 60.4 3.54 0.06 1
OB15 Administration during labour/birth 13.3 0 SB16 Emotional support - nurses/midwivesc 75.4 3.98 0.05 0
OB16 Administration after birth 22.0 0 SB17 Some HPs good others bad 46.9 3.01 0.06 2
OB17 Sedatives admin. at least once 47.9 0 Information and decision-making
OB18 Sedatives admin. twice or more 7.7 0 SB18 Birth process explainedc 52.4 3.24 0.06 1
OB19 Sedatives admin. on patient request 16.9 0 SB19 Information on disposition 24.4 2.47 0.06 8
OB20 Sedatives admin. on HP indication 24.9 0 SB20 General information for decisionsc 47.0 3.12 0.06 0
OB21 Sedatives admin. without consenta 8.7 0 SB21 Could ask questionsc 69.1 3.80 0.05 2
OB22 Admin. without explaining side-effectsa,b 32.5 0 SB22 Control decisions – medicalc 45.4 3.09 0.06 0
Pathology SB23 Control decisions – ritualc 39.3 2.95 0.06 2
OB23 No pathology studies offereda 12.1 0 Coordination of care
OB24 Autopsy offereda 67.4 0 SB24 Paperwork presented at a good time 30.1 2.72 0.06 11
OB25 No one communicated optionsa 19.2 0 SB25 Room peaceful 74.8 3.90 0.05 3
OB26 Doctor communicated optionsa,b 68.0 0 SB26 All staff aware of situationc 63.7 3.68 0.05 2
OB27 Nurse/midwife communicated options 16.1 0 SB27 Teamwork personnelc 68.6 3.78 0.05 2
OB28 No postmortem test conducteda,b 14.1 13 SB28 One HP guided carec 47.8 3.14 0.06 1
OB29 Autopsy conducted 62.1 13 SB29 Well informed stepsc 53.6 3.30 0.06 0
Language used to refer to the baby
OB30 Doctor used baby’s namea,b 12.5 0 Information scale (% some/a lot) Some/lot % Mean SE Missing
OB31 Doctor used ‘baby’a,b 34.8 0 INF1 Keeping memory objects 14.1 1.47 0.04 2
OB32 Doctor used ‘foetus’a,b 33.6 0 INF2 Griefc 16.8 1.60 0.03 0
OB33 Doctor – do not recall 19.2 0 INF3 Puerperal care 32.6 2.11 0.04 0
OB34 Nurse/midwife used baby’s namea,b 18.4 0 INF4 Disposition 19.5 1.73 0.04 10
OB35 Nurse/midwife used ‘baby’a,b 37.5 0 INF5 Autopsy and pathology studiesc 33.5 2.18 0.04 4
OB36 Nurse/midwife used ‘foetus’a,b 22.8 0
OB37 Nurse/midwife – do not recall 22.5 0 Negligence (reported or unreported) %
Post mortem contact/memories NEG1 Perceived medical negligence 26.2 7
OB38 Mother saw the babya 56.7 0
OB39 Father saw the babya 61.1 0 Global Agreeing % Mean SE Missing
OB40 Family/friend(s) saw the babya 36.4 0 Satisfaction with care 69.1 3.69 0.05 1
OB41 Mother held the babya 38.4 0 Willingness to recommend to other 61.4 3.58 0.06 3
OB42 Father held the babya 23.3 0 GLB1 Satisfaction-recommend composite 65.3 3.63 0.05 4
OB43 Have at least one memory objecta 34.3 0 GLB2 Doctors competence 72.9 3.84 0.05 2
Disposition GLB3 Nurses/midwives competence 76.9 3.99 0.05 3
OB44 No one communicated optionsa,b 33.9 0 GLB4 Loss-focused care ability – doctors 47.6 3.21 0.06 1
OB45 Doctor communicated optionsa,b 31.3 0 GLB5 Loss-focused care ability – nurses/midwives 56.3 3.46 0.06 1
OB46 Nurse/midwife communicated optionsa,b 19.5 0
OB47 Funeral home communicated options 15.4 0
OB48 Private disposition (cremation or burial)a 40.0 0
OB49 Hospital managed dispositiona 45.7 0
OB50 Hospital disposition only optiona 34.3 0
Psychological support
OB51 Was visited by a psychologista 21.0 0

Total 610 Total 610
  1. aObjective variables retained following screening with 2-tailed test of independence. bObjective variables retained following initial regression modelling of objective variables. cSubjective variables retained following initial regression modelling of subjective variables.

Characteristics of the dependent variables

Analysis of the inter-correlations between the seven DVs (see Table 3) shows that all were significantly correlated (p<0.001). Satisfaction and willingness to recommend overlapped very strongly. Although they showed some differences in exploratory regression analysis, to simplify, they were combined to an aggregate score: overall care (GLB1). In general, competence (GLB2, GLB3) showed a higher correlation to overall care (GLB1) than ability to provide loss-focused care (GLB4, GLB5).

Table 3:

Correlations on the dependent variables.

Satisfaction with care 1 0.961 0.965 0.705 0.665 0.647 0.624
Willingness to recommend to other women/couples 0.961 1 0.855 0.710 0.673 0.645 0.627
GLB1 Satisfaction-recommend composite 0.965 0.855 1 0.651 0.610 0.603 0.577
GLB2 Doctors’ competence 0.705 0.710 0.651 1 0.621 0.648 0.475
GLB3 Nurses/midwives’ competence 0.665 0.673 0.610 0.621 1 0.481 0.665
GLB4 Loss-focused care ability – doctors 0.647 0.645 0.603 0.648 0.481 1 0.635
GLB5 Loss-focused care ability – nurses/midwives 0.624 0.627 0.577 0.475 0.665 0.635 1
  1. n=599 and all correlations are statistically significant at p<0.001.

Table 4:

Regression models – objective care outcomes.

Stand. co-eff. beta Part (semi-partial) Change statistics
Adjust. R2 Std. error of est. R2 change F change Sig. F change
Global evaluation of care a (Adj. R2 = 24.6%)
OB34 Nurses/midwives referred to the baby ‘by his/her name’ 0.273 0.262 0.097 1.359 0.098 61.478 0.000
OB44 No one communicated options for the disposition −0.189 −0.178 0.155 1.314 0.060 39.820 0.000
OB34 Nurses/midwives referred to the baby as ‘baby’ 0.167 0.162 0.189 1.288 0.035 24.156 0.000
OB22 Administration of sedatives without explaining side-effects −0.112 −0.111 0.203 1.276 0.015 10.927 0.001
OB12 Accompanied by partner/other during birth 0.125 0.124 0.216 1.266 0.015 10.721 0.001
OB4 Could hear babies crying (strong) −0.111 −0.110 0.227 1.257 0.012 8.807 0.003
OB34 Nurses/midwives referred to the baby ‘by his/her name’ 0.273 0.262 0.097 1.359 0.098 61.478 0.000

COMPETENCE – DOCTORS b (Adj. R2 = 18.3%)
OB26 Doctor explained pathology studies options 0.238 0.235 0.076 1.188 0.077 46.897 0.000
OB31 Doctors referred to the baby as ‘baby’ 0.194 0.192 0.119 1.160 0.045 28.476 0.000
OB30 Doctors referred to the baby ‘by his/her name’ 0.142 0.141 0.140 1.146 0.023 14.703 0.000
OB22 Administration of sedatives without explaining side-effects −0.134 −0.133 0.159 1.134 0.020 13.563 0.000
OB4 Could hear babies crying (strong) −0.122 −0.121 0.172 1.124 0.015 10.341 0.001
OB13 Partner/support person not allowed to accompany during birth −0.110 −0.110 0.183 1.117 0.012 8.335 0.004

OB36 Nurses/midwifes referred to the baby as ‘foetus’ −0.198 −0.190 0.078 1.109 0.079 48.337 0.000
OB34 Nurses/midwifes referred to the baby ‘by his/her name’ 0.161 0.155 0.111 1.089 0.035 21.980 0.000
OB22 Administration of sedatives without explaining side-effects −0.128 −0.127 0.131 1.077 0.022 14.175 0.000
OB12 Accompanied by partner/other during birth 0.116 0.115 0.148 1.066 0.019 12.234 0.001
OB4 Could hear babies crying (strong) −0.115 −0.114 0.161 1.058 0.014 9.533 0.002
OB26 Doctor explained pathology studies options 0.129 0.126 0.173 1.051 0.013 8.792 0.003
OB46 A nurse/midwife explained disposition options 0.114 0.111 0.184 1.044 0.012 8.475 0.004

OB44 No one communicated options for the disposition −0.147 −0.135 0.086 1.345 0.087 53.861 0.000
OB26 Doctor explained pathology studies options 0.195 0.188 0.129 1.313 0.044 28.630 0.000
OB4 Could hear babies crying (strong) −0.164 −0.162 0.165 1.285 0.038 25.430 0.000
OB30 Doctors referred to the baby ‘by his/her name’ 0.204 0.197 0.195 1.262 0.032 22.195 0.000
OB31 Doctors referred to the baby as ‘baby’ 0.143 0.138 0.214 1.247 0.020 13.975 0.000
OB22 Administration of sedatives without explaining side-effects −0.111 −0.110 0.225 1.239 0.012 8.877 0.003
OB12 Accompanied by partner/other during birth 0.105 0.104 0.234 1.231 0.011 7.937 0.005

OB44 No one communicated options for the disposition −0.191 −0.179 0.103 1.353 0.104 65.548 0.000
OB34 Nurses/midwives referred to the baby ‘by his/her name’ 0.263 0.252 0.162 1.307 0.061 40.746 0.000
OB34 Nurses/midwives referred to the baby as ‘baby’ 0.149 0.141 0.198 1.279 0.037 25.746 0.000
OB4 Could hear babies crying (strong) −0.120 −0.119 0.215 1.266 0.018 13.182 0.000
OB13 Partner/support person not allowed to accompany during birth −0.124 −0.124 0.229 1.254 0.016 11.586 0.001
OB22 Administration of sedatives without explaining side-effects −0.129 −0.128 0.243 1.243 0.015 11.142 0.001
OB28 No pathology studies conducted −0.110 −0.107 0.253 1.234 0.011 8.623 0.003
  1. aDurbin–Watson: 1.994 (F(7, 610) = 29.78, p<0.001). bDurbin–Watson: 1.939 (F(6, 610) = 23.37, p<0.001). cDurbin–Watson: 1.860 (F(7, 610) = 22.19, p<0.001). dDurbin–Watson: 2.022 (F(7, 610) = 26.48, p<0.001). eDurbin–Watson: 1.940 (F(7, 610) = 28.39, p<0.001).

Objective outcomes of care: regression models

In total, 51 objective IVs were identified as potentially relevant to the study (e.g. an autopsy was performed). Following screening with 2-tailed test of independence (p<0.05) and Cohen’s effect size (>0.15), 30 objective IVs were retained for exploratory regression analysis (identified in Table 2). A significant regression model (p<0.001) was found for all DVs, each composed of six to seven variables, but the amount of variance explained (adjusted R2) was not strong, ranging from 18 to 26% (see Table 4). Of the 30 objective IVs entered, 14 were retained for the combined subjective-objective analysis as they contributed to at least one of the models.

Selection of the subjective measures of care (scale items and perceived negligence)

All 29 items from the PLCQ scale (SB1-SB29) were included for initial screening. Based on correlations to the DVs and inter-correlation between subjective IVs, seven items were removed: five because of low contributions (SB2, 3, 4, 5, 17) and two because of over performance: ‘HPs were respectful’ (SB10) and ‘feeling listened to’ (SB12). The remaining 22 items were entered into the five regression models, along with the five information items (INF1-INF5) and perceived negligence (NEG1).

A significant regression (p<0.001) was found for each DV (these results are not presented). Following this analysis, six further items that made no contribution were dropped (SB7, 8, 9, 19, 24, 25), leaving 16 items. Two information items (INF2, INF5), and the perceived negligence IV (NEG1) were also retained for the final analysis, giving a total of 19 subjective IVs.

Combined subjective-objective multiple regression models

The 19 subjective IVs and 14 objective IVs were entered into each of the five models. A significant regression equation (p<0.001) was found for each model (see Table 5), accounting for a high proportion of variance that ranged from 58.7% in the case of ‘doctors’ competence’ (GLB2) to 72.0% for the overall rating of care (GLB1). Across all five final models, contributions were made by 13 IVs from the PLCQ scale; one item from the information scale (INF5: information on pathology studies); ‘perceived medical negligence’ (NEG1); and two objective IVs (‘no pathology studies conducted’ [OB28]; ‘a doctor explained pathology study options’ [OB26]). Commonalities are evident across all models (particularly the strongest predictors), as well as differences, notably between overall care evaluation (GLB1) and ability to provide loss-focused care (GLB4, GLB5), and between doctor (GLB2, GLB4) vis-à-vis nurse/midwife models (GLB3, GLB5).

Table 5:

Regression models – subjective and objective care outcomes.

Stand. co-eff. beta Part (semi-partial) Change statistics
Adjust.R2 Std. error of est. R2 change F change Sig. F change
Global evaluation of care a (Adj. R2 = 72.0%)
SB11 I felt I could express myself emotionally in front of the HPs 0.198 0.125 0.492 1.859 0.493 591.782 0.000
SB27 The doctors and nurses/midwives seemed to work well as a team 0.200 0.138 0.613 1.623 0.121 190.688 0.000
SB29 Kept me/us well-informed of all steps and procedures 0.132 0.086 0.655 1.534 0.042 74.053 0.000
NEG1 Perceived negligence (reported or not) −0.175 −0.159 0.685 1.464 0.031 59.864 0.000
SB16 I felt emotionally supported by the midwives/nurses 0.136 0.090 0.700 1.430 0.015 30.052 0.000
SB13 The HPs were sensitive in their use of language 0.122 0.077 0.708 1.411 0.008 17.508 0.000
INF5 Amount of information received on autopsy and medical tests 0.063 0.052 0.713 1.397 0.006 12.915 0.000
SB20 Received enough information to help us with the decisions we had to take 0.094 0.065 0.717 1.388 0.004 8.903 0.003
OB28 No pathology studies conducted −0.061 −0.058 0.720 1.381 0.003 7.298 0.007

SB15 I felt emotionally supported by the doctors 0.235 0.150 0.435 0.936 0.436 469.758 0.000
SB27 The doctors and nurses/midwives seemed to work well as a team 0.250 0.177 0.530 0.854 0.095 123.298 0.000
SB29 Kept me/us well-informed of all steps and procedures 0.136 0.091 0.556 0.830 0.027 36.517 0.000
NEG1 Perceived negligence (reported or not) −0.136 −0.125 0.574 0.813 0.019 26.808 0.000
SB13 The HPs were sensitive in their use of language 0.125 0.082 0.582 0.805 0.009 12.750 0.000
SB18 Received a clear explanation of the birth process in cases of loss 0.100 0.074 0.587 0.801 0.005 7.962 0.005

SB16 I felt emotionally supported by the midwives/nurses 0.441 0.285 0.537 0.790 0.538 707.299 0.000
SB27 The doctors and nurses/midwives seemed to work well as a team 0.163 0.113 0.580 0.752 0.043 63.007 0.000
SB29 HPs kept me/us well-informed of all steps and procedures 0.085 0.061 0.592 0.741 0.013 19.605 0.000
SB21 I felt that I could ask questions if I wanted to 0.109 0.069 0.599 0.735 0.007 10.745 0.001
NEG1 Perceived negligence (reported or not) −0.081 −0.074 0.603 0.731 0.005 8.159 0.004
SB26 All the personnel on the ward were aware of my situation 0.084 0.069 0.608 0.727 0.005 7.475 0.006

SB15 I felt emotionally supported by the doctors 0.462 0.305 0.578 0.916 0.578 834.156 0.000
SB20 Received enough information to help us with the decisions we had to take 0.222 0.159 0.641 0.845 0.064 108.582 0.000
SB23 Had control over decisions related to ritual (e.g. seeing the baby) 0.098 0.082 0.652 0.832 0.011 19.152 0.000
SB18 Received a clear explanation of the birth process in cases of loss 0.096 0.074 0.658 0.824 0.007 13.137 0.000
SB13 The HPs were sensitive in their use of language 0.098 0.065 0.662 0.820 0.004 7.619 0.006

SB16 I felt emotionally supported by the midwives/nurses 0.478 0.319 0.538 0.968 0.539 710.866 0.000
SB1 Received enough information on the decision to see/or not see the baby 0.182 0.145 0.587 0.915 0.049 72.938 0.000
SB20 Received enough information to help us with the decisions we had to take 0.112 0.079 0.605 0.895 0.019 28.552 0.000
SB28 There was one HP who guided me/us through the whole process 0.108 0.084 0.612 0.887 0.008 12.365 0.000
OB26 Doctor explained the options for pathology studies −0.079 −0.075 0.617 0.881 0.005 8.731 0.003
SB21 I felt that I could ask questions if I wanted to 0.107 0.068 0.621 0.877 0.005 7.351 0.007
  1. aDurbin–Watson: 2.012 (F(9, 610) = 174.98, p<0.001). bDurbin–Watson: 1.778 (F(6, 610) = 145.03, p<0.001). cDurbin–Watson: 1.922 (F(5, 610) = 158.22, p<0.001). dDurbin–Watson: 1.846 (F(5, 610) = 239.723, p<0.001). eDurbin–Watson: 1.908 (F(6, 620) = 167.43, p<0.001).

Exploratory scale analysis

To finish, the 13 PLCQ scale items that made some contribution to the final five models (SB1, 11, 13, 15, 16, 18, 20, 21, 23, 26, 27, 28, 29) were combined to a global score in order to test it against the objective variables. A significant equation was found that included nine objective IVs that explained 38.9% of the variance, around double that of the single-item global models (GLB1, GLB2, GLB3, GLB4, GLB5); see Table 6 for details. Cronbach’s alpha scores for the 29, 22, 16 and 13-item PLCQ were all above 0.9.

Table 6:

Regression model – objective care outcomes as predictors of the exploratory 13-item Pregnancy Loss Care Quality (PLCQ) Scale.

Stand. co-eff. beta Part (semi-partial) Change statistics
Adjust.R2 Std. error of est. R2 change F change Sig. F change
Pregnancy loss care quality scale a (Adj. R2 = 38.9%)
OB44 No one communicated options for the disposition −0.196 −0.177 0.159 12.154 0.160 115.725 0.000
OB34 Nurses/midwifes referred to the baby ‘by his/her name’ 0.218 0.210 0.222 11.686 0.065 50.589 0.000
OB26 Doctor explained pathology studies options 0.208 0.200 0.269 11.329 0.048 39.854 0.000
OB31 Doctors referred to the baby as ‘baby’ 0.165 0.157 0.313 10.981 0.045 40.120 0.000
OB4 Could hear babies crying (strong) −0.150 −0.148 0.342 10.751 0.029 27.140 0.000
OB22 Administration of sedatives without explaining side-effects −0.155 −0.154 0.362 10.581 0.021 20.498 0.000
OB13 Partner/support person not allowed to accompany during birth −0.098 −0.097 0.374 10.483 0.013 12.380 0.000
OB32 Nurses/midwifes referred to the baby as ‘foetus’ −0.107 −0.098 0.383 10.408 0.010 9.641 0.002
OB3 Accommodated in a private room 0.086 0.084 0.389 10.357 0.007 7.013 0.008
  1. aDurbin–Watson: 2.074 (F(9, 610) = 44.17, p<0.001).


The models produced by this exploratory study are robust and provide important insights to hospital care, one of the main social spaces for defining the meaning of pregnancy loss and for providing appropriate resources for grieving. The study has implications for both the provision of care and quality assessment. Before discussing the results it should be taken into account that the non-probabilistic online sampling procedure means that the study has coverage limitations that reduce its generalizability. However, some confidence can be gained from the knowledge that the sample is a very close match to national data in terms of gestational age, autopsy rate and caesarean section rate [37, 45], and that exploratory analysis of socio-demographics found only very small predictive values. The results should also be interpreted as situated within a particular set of cultural values and expectations, which may be similar to or differ from other countries. Finally, the limitations of surveys themselves should be considered as they tend to reduce complex patient experiences to simplistic and impersonal dimensions [3, 46]. In this project, the results of the survey are triangulated with qualitative methods, showing good convergence and some divergence [47, 48].

The results make it clear that when women rated ‘satisfaction’ or ‘willingness to recommend’ the hospital they were not evaluating the totality of loss-focused care. This fits with the disconfirmation thesis [23, 41] and suggests a ‘halo’ effect [49] whereby patients assess aspects of care that fall within their frame of reference or expectations. So, while useful, the results suggest that satisfaction tends to provide overly positive evaluations and should be balanced by a measure such as ‘willingness to recommend’ and, much more importantly, a specific item to measure loss-focused care. In addition, single-item global evaluations had limited analytic capacity, making a strong argument for the need to use constructs that capture the broad range of underlying components/dimensions of care following pregnancy loss. The PLCQ scale developed in this study, for example, provided a much better measure of the value of specific care interventions to women.

It is also apparent that when the participants were rating care they were largely, though not exclusively, evaluating the process of care rather than the outcomes themselves. This reinforces the idea that the human aspects of interactions with health professionals are crucial to care and experiences of grief/loss. However, in this study, these interactions were much broader in scope than the expression of empathy and emotional support, encompassing the organisation of care, teamwork, technical competence (including perceptions of fault) and bereavement related interactions. The rating of ‘emotional expression’ over ‘emotional support’, ‘being well informed’ over ‘information’, and the novel inclusion of ‘teamwork between doctors and nurses/midwives’ point to a number of important findings for care practice.

At a general level, the results suggest a transversal dimension related to the ‘atmosphere of the care setting’ and its significance in the unique situation of death/loss. As women commonly experience great sadness, trauma, fear and anxiety in the period after diagnosis [50], [51], [52], it should be considered that the primary goal of many women may be to just get through a threatening situation that seems to exceed coping capacity [53]. On this basis, being ‘well informed’ of the process of care before it happens may help to reduce the anxiety and fear that women often feel. Similarly, the participants seemed to readily detect harmony or tension between health professionals, which appeared to reinforce or undermine confidence in the quality of care. Lack of teamwork may relate to conflict between obstetricians and midwives on what constitutes appropriate care [54, 55]. This finding highlights the extreme importance of collaborative teamwork and a unified approach during encounters with patients. It is also noteworthy that the importance of teamwork was not as evident in the qualitative research [37], showing the benefits of mixed-method approaches. Finally, as the highest ranked predictor, feeling free to ‘express emotions’ in front of health professionals is differentiated from ‘receiving’ emotional support and suggests an atmosphere of care that creates a space for loss and reduces feelings of shame and stigma. Collectively, these three predictors seem to define a dimension of care that traverses functional and technical components and that creates security and confidence in carers. It might be said to represent the basis or groundwork of good care. Each of these predictors also gives a sense of women as astute observers of healthcare provision rather than just receivers of care. This questions the directionality of traditional thinking on care provision, which tends to focus on direct provider actions, for example, when examining trauma in childbirth [56].

The results also demonstrate considerable variations in expectations of the roles of nurses/midwives compared doctors, whose actions had a greater influence over ratings. In this sample, doctors not only held greater clinical authority – e.g. in expectations of the provision of clinical information – but they also seemed to have greater power to define social identity [6]. This was seen in the way that insensitivity with language was more influential in doctors’ models and highlights the challenge to doctors to be empathetic and supportive of the emotional experience of loss, as observed elsewhere [57]. Nurses/midwives, on the other hand, were assigned to subordinate positions associated with traditional caring and support roles. From the perspective of implementing ‘midwife-led’ bereavement care in Spain this is problematic. It indicates a requirement for stronger teamwork between professionals and that doctors validate or reinforce the role of midwives during initial interactions with women and their families.

Finally, the study helps our understanding of how women view and assess technical-professional competence, in particular evaluations of how care is managed and organised and whether fault for the death is attributed to health professionals. This contradicts any notion that patients are incapable of making technical assessments [58, 59]. Given the impact of ‘perceived negligence’, future studies may consider including it as one way of measuring health outcome. On the other hand, the relatively low ranking of ‘information’ shows that other aspects of care are prioritised in the peritraumatic period. It seems relevant here that parallel qualitative research found that low cultural expectations of equity in decision-making and naturalised paternalism are common in obstetric care following pregnancy loss in Spanish hospitals [37].

To conclude, the results indicate that a transversal dimension ‘atmosphere of care’ is the single greatest influence on satisfaction/quality, which probably relates to the unique context of loss, grief and trauma. It is necessary to use specific loss-focused global variables to adequately assess bereavement care and a custom scale to measure the influence of care interventions. Future work will focus on further development and testing of the PLCQ scale.

Corresponding author: Paul Richard Cassidy, PhD, Ex-doctoral researcher at Complutense University of Madrid, Researcher at Umamanita (Stillbirth and Neonatal Death Charity), Carrer Major 3, 17133, Girona, Spain, E-mail:


The author is grateful for the support of the stillbirth and neonatal death charity Umamanita, the women who participated in the study and the health professionals who collaborated on the development of the instruments.

  1. Research funding: None declared.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: Ethics approval for non-clinical trials was not required by the author’s institution (University Complutense Madrid) and could not be provided.


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Received: 2021-09-24
Accepted: 2022-03-27
Published Online: 2022-04-26
Published in Print: 2022-07-26

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