Compassionate and comprehensive care for early pregnancy loss

On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham speak with Dr. Sarina Isenberg and Dr. Modupe Tunde-Byass about the emotional and systemic challenges surrounding early pregnancy loss care in Canada. The conversation builds on themes from the recent CMAJ article, “Diagnosis and management of early pregnancy loss,” in which the authors advocate for a dedicated EPL pathway to care that bypasses the emergency department.

Dr. Isenberg shares her personal experiences with early pregnancy loss and the stark disparity in care she received—from a lack of empathy in an emergency room to comprehensive support in a specialized clinic. Her story underscores the spectrum of care needed, particularly access to emotional support during one of the most vulnerable times in a patient’s life.

Dr. Tunde-Byass, co-author of the CMAJ article and an obstetrician at North York General Hospital, highlights the success of dedicated early pregnancy loss clinics, which provide timely diagnosis, options for management, and a supportive environment. She emphasizes that emergency departments, often overstretched and lacking privacy, are not designed for the unique needs of early pregnancy loss patients. Instead, she argues for dedicated spaces staffed by trained personnel, including nurses and counselors, who can provide both medical care and emotional support.

Together, they explore practical solutions, including integrated care pathways outside of emergency departments, self-referral options, and the provision of bereavement resources. Dr. Tunde-Byass advocates for a holistic approach that could be standardized across Canadian hospitals, enabling patients to access sensitive, informed care without the retraumatization that often comes from repeating their stories in high-stress environments.

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Transcript

Dr. Blair Bigham:
I'm Blair Bigham.

Dr. Mojola Omole:
I'm Mojola Omole, and this is the CMAJ podcast. So today, Blair, we are discussing an issue that affects a quarter of pregnant people, and that's early pregnancy loss. This is an interesting topic; I personally have had friends who’ve been affected by this, and we really want to look more at the diagnosis, management, and how we can support people as they're going through this extremely devastating experience.

Dr. Blair Bigham:
And this is one that I think emergency doctors would resonate strongly with. We do a pretty terrible job in the emergency department of providing support. Even something as simple as a private room where you can receive that news that maybe you've lost your pregnancy is not something that every emergency department can offer these days.

Dr. Mojola Omole:
There are many facets to this process. There's the management of the medical aspect of what's happening. But then a really important component is the management of the emotional aspect of what's happening.

Dr. Blair Bigham:
Absolutely. And there's a lot of—I mean, the emotional aspects are just so terribly cared for. And we've heard this story, and we'll hear it again today, that we're just not meeting the mark when it comes to emotional support in these situations. But I also don't know that we're meeting the medical mark. Being given your full range of options in an emergency department that's really busy might not happen every time, and heaven forbid, it’s like an ectopic pregnancy that gets missed—that could have life-threatening consequences. So yeah, this is really across the spectrum of how we care for patients. I just don't think we're meeting the mark.

Dr. Mojola Omole:
So we're going to look at alternatives to the emergency department for early pregnancy loss. We're going to be speaking to Dr. Modupe Tunde-Byass, who has been on the podcast before and is a co-author of the CMAJ article, “Diagnosis and management of early pregnancy loss.” She, fortunately, has experience working both in the UK and here, where in the UK they streamline people facing early pregnancy loss away from the general emergency department into specialized clinics.

Dr. Blair Bigham:
I'm really excited to hear about that idea. I think in Canada, the few times that we have tried to direct people away from an ER to somewhere special, it’s worked. So I'm really excited to speak to her. But first up, we're going to hear the story of a woman who knows firsthand what it's like to be both supported through an early pregnancy loss and not supported. That's up next.

Dr. Mojola Omole:
Dr. Sarina Isenberg had endured the devastating loss of two pregnancies, one at six weeks and the other at 20 weeks. She describes the care she received in both of these instances as night and day, revealing a stark contrast in support. Sarina, thank you so much for joining us today and sharing your stories.

Dr. Sarina Isenberg:
Thank you for inviting me to be here.

Dr. Mojola Omole:
So let's go back to your first pregnancy loss. What were the first signs?

Dr. Sarina Isenberg:
So I was six weeks along and I experienced heavy bleeding and some mild cramping. I called my family doctor's office, and they advised me to get beta HCG testing and instructed me that I would get the blood test that same day. Then I would go again two days later, and they would look at the differential in the levels. They kind of assured me things would be okay; some bleeding is normal. So I got the blood test that day, and the next day, the bleeding continued, and I was really concerned. I called my doctor's office again, and the receptionist said, the only option for you is either to wait until the next blood test or go to the emergency department.

Dr. Mojola Omole:
And what did you choose to do?

Dr. Sarina Isenberg:
So I went into the ED, and I was completely alone. My husband was unable to accompany me. It was July 2022, and at that time, there were visitor restrictions in the emergency department. I didn't really know much about what to expect or how miscarriages play out or any of that stuff.

Dr. Mojola Omole:
And how was the staff to you when you first presented to the ED?

Dr. Sarina Isenberg:
So the triage nurse was pretty straightforward, not necessarily empathetic about how concerned I was, and just asked very dry questions, as is often the case. Then I waited several hours in the general emergency department space, along with everyone else who was coming in for a variety of things.

Dr. Mojola Omole:
How did that feel?

Dr. Sarina Isenberg:
Very scary. I also felt strange because, from an outside perspective, I didn't seem like I had anything wrong with me, but I was internally freaking out over the bleeding and the concerns about the pregnancy. I really did not like being in a busy emergency room. I wanted my husband with me, and I wanted comfort. I was furiously Googling things on my phone to try and understand potential causes of bleeding so early on in a pregnancy, but there was no one available for me to ask questions of. And when I did interact with the medical staff at all, I didn't feel like I had an opportunity to even vocalize my concerns. Certainly not anything like psychosocial concerns. It was really very much about the physical condition that was going on.

Dr. Mojola Omole:
What were you first told the first time you saw the physician?

Dr. Sarina Isenberg:
So I was told that really the only way to ascertain what was going on was both the physical exam and an ultrasound, and the physical exam didn't really show one way or another. So then I was told to wait for an ultrasound.

Dr. Mojola Omole:
And then how long was that wait?

Dr. Sarina Isenberg:
Oh gosh, maybe two, three hours.

Dr. Mojola Omole:
Oh wow. Okay. And what was going through your head at that time?

Dr. Sarina Isenberg:
That I had lost the baby. I was really worried that I had lost the baby, or that it was an ectopic pregnancy or a molar pregnancy, or any number of potential things that I had Googled. My mind was going to the absolute worst-case scenario, thinking something terrible was going on.

Dr. Mojola Omole:
Did you feel that your inner world, what was happening—the chaos, the anxiety—do you think that that was reflected by the physicians, by the staff? Was it matching?

Dr. Sarina Isenberg:
Absolutely not. I did not receive compassionate care. In my research, I look at patient-provider communication, and I can say quite confidently that I was not communicated with. The gravitas of the situation for me did not match the level of empathy I was receiving from the clinician. Especially after the ultrasound, I was waiting for the results, and then an ED physician comes in and just says, really nonchalantly, "Oh, so you have a subchorionic hematoma," as though I would know what that means.

Dr. Mojola Omole:
I was about to say even I'm like, I have to remember what that is again. Okay.

Dr. Sarina Isenberg:
Yeah. And so he says that, but the fetus is still alive, though the heartbeat's really faint, and you have an ultrasound scheduled for the following week, so you'll just be followed by your family doc and get that ultrasound and see what's going on. And of course, I had so many questions. What is a subchorionic hematoma? Is there a correlation between these hematomas and miscarriage? Is there a concern for the amount of blood loss for me? What are signs that things will shift? I appreciated that the fetus was still alive at that point, but is there something that would indicate to me that it had died if and when it does?

Dr. Mojola Omole:

Was all of this explained to you?

Dr. Sarina Isenberg:
No, absolutely not.

Dr. Mojola Omole:
So you left thinking what when you left emerg that day?

Dr. Sarina Isenberg:
I left hopeful that the fetus would survive but thinking that, more likely than not, I was going to miscarry, and I felt very helpless. I felt like there was nothing I could do to help ensure the fetus's survival. There was nothing I could do in terms of reaching out to medical professionals to advise me. My family doctor's office, they were wonderful in many ways, but they were pretty clear that there was not much they could do except wait for the next ultrasound. It was left up to me to do the research into what a subchorionic hematoma is and the association between them and miscarriage, and up to me to research, okay, if the levels of bleeding get to X amount, then I need to return to the ED, and all of that.

Dr. Mojola Omole:
That wasn't conveyed to you—that you should come back to the ED if you were bleeding heavier or...?

Dr. Sarina Isenberg:
It was in such vague terms that I felt like I didn't have enough information in terms of the quantity of bleeding and whatnot. So I felt like I had to rely on myself to look that up.

Dr. Mojola Omole:
That's awful. So when did you find out that you lost the pregnancy, or how?

Dr. Sarina Isenberg:
Yeah, so the ED visit was when I was six weeks pregnant. The ultrasound was the following week at seven weeks. And that ultrasound also, it was a very disturbing experience because my husband came, and your first dating ultrasound, you're really excited. They tell you, okay, your partner can come in with you, but after we do the initial assessment or whatever, so we'll bring your partner in at the end to see the... whatever. And so the technician's taking a really long time, and then she finishes and says, "Okay, you can get dressed." And I'm like, wait, but my husband was going to come in. She's like, "Oh, maybe next time."

Dr. Mojola Omole:
Goodness gracious.

Dr. Sarina Isenberg:
And I was like, what does that mean? So I'm calling all my friends who've had babies, being like, did this ever happen to you? Did the technician just say, maybe next time? And then the next day, I got a phone call from my family doctor's receptionist, who communicated the news.

Dr. Mojola Omole:
So not even a physician, but... Oh, wow.

Dr. Blair Bigham:
Over the phone.

Dr. Sarina Isenberg:
Yeah, I believe she is a registered nurse as well in a dual role as a receptionist. But I didn't feel like, it was essentially, "We're sorry to tell you, Sarina, you've miscarried." And then I was like, okay, now what? And so I was asking the receptionist, what do I do? And she said, "Oh, well, I don't know. I'll talk to your family doctor, and we'll get back to you." So he referred me out to an OB-GYN, and that took a week to see the OB-GYN. So, yeah.

Dr. Mojola Omole:
Oh wow. So throughout this, just on a human level, how did this whole entire experience leave you?

Dr. Sarina Isenberg:
It made me feel like I had no control over my body or over the situation. It made me helpless. It made me frustrated with our healthcare system. It also frustrated me because my husband and I have resources at our disposal. We both have several degrees, and we are able to navigate the healthcare system. We both work adjacent to medicine, so we kind of understand the medical language. And it just made me feel like if I'm having difficulty navigating this, I don't know how other people who don't have this level of education, this level of English proficiency—all of these considerations—it just made me upset for myself, but also upset for so many other women who are going through this.

Dr. Mojola Omole:
For sure.

Dr. Sarina Isenberg:
Yeah.

Dr. Mojola Omole:
So unfortunately, you also experienced a loss at 20 weeks. Let's contrast that with this experience that you had. What were the first signs there was an issue in that pregnancy?

Dr. Sarina Isenberg:
So as is the case in Ontario, I was provided with a nuchal translucency ultrasound, which assesses the fluid at the back of the fetus's neck, and those results came back abnormal. I also had undergone non-invasive prenatal testing, and those results came back normal, but the nuchal translucency results triggered a referral to a prenatal diagnosis clinic in my region. And so I got an email from this clinic saying, "Okay, your appointment is this day, and your next ultrasound is this day." It was in caps lock—or at least I thought it was caps lock—"high-risk pregnancy."

Of course, after our experience with the miscarriage, I was terrified. So I called that clinic and said, "I just got a referral to you. I don't understand why." And they just said, "Oh, you had an abnormal ultrasound. Often this doesn't mean anything. Most of the time, it's not a big deal. Just you'll meet with our team and then you'll get another ultrasound." And so, in this ultrasound, the technician keeps on saying, "Oh, baby's not really moving." I knew it was a girl. "She's stuck in a particular position, and you're going to need to get up, walk around, go grab lunch, come back." So my husband and I are not thinking it's a big deal, and we're joking, "Oh, she's stubborn like her mom and dad," or stuff like that. Overall, that ultrasound took two hours, considering the stops and starts.

And thankfully, after the ultrasound, I just waited 45 to 60 minutes to see a physician who read the results to me and communicated what they found. So that took away a lot of the uncertainty and the anxiety around, okay, something was going on in this ultrasound. When we met with the physician, there was also a genetic counselor present, as well as a social worker. They communicated that the ultrasound results were abnormal. It looked like the baby had anencephaly, wherein the neck is hyperextended back. And I didn't know what that condition was. I had no idea what it was. So they took a lot of time answering our questions. They met with us in a private room. They had tissues on the table, and I was like, "Oh, this is a little presumptuous." But then, of course, we used those tissues. They explained, "We don't know for certain if it's anencephaly, but despite your moving around, the baby's neck remained in the same position."

It was very gentle, and they kind of advised, "Look, next steps would be to do genetic testing through amniocentesis, as well as have you and your husband do genetic testing to see whether there could be a condition explaining it.” Because there are genetic causes for cephalic issues. But then it was again a waiting period, but it was still better because we had the supports. So you have to wait a couple of weeks before you can get amniocentesis. So I underwent that procedure, and in the meantime, my husband and I did the blood work for our own genetic testing.  And every time results became available, the genetic counselor would call or email me to communicate the results and talk to me about what we were going through. Then eventually, I came back for a scan, maybe it was 15 or 16 weeks along, and right after the scan, we went up to the clinic and waited for the physician to read the results and communicate with us what they found. At that appointment, again, there was the physician, genetic counselor, social worker, and then at one point, a geneticist came in, and they communicated to us that the fetus was still in that position. The physician communicated to me that it was a lethal condition, so the fetus would not be able to breathe outside the womb. If I were to carry to term, the fetus would die shortly after birth, and they wouldn't even be able to attempt intubation or resuscitation because of the positioning of the neck. We had a lot of time to ask questions of all the health professionals in the room, which was really appreciated because it was a very difficult decision, and we really wanted...

Dr. Mojola Omole:
You were far along.

Dr. Sarina Isenberg:
At that point, I was around 16, 17 weeks, and there was always this hope, right? That maybe she's okay, right? Maybe something might be better. But we decided we would go for another scan at 19 weeks and then make a decision. And all that while, we're getting support from the clinic; I have my psychologist who's supporting me and my psychiatrist. Then at 19 weeks, it's still the same position, and there are some other indicators at that point that there are other developmental issues. So the physician says, okay, what do you want to do? And we said, if this is indeed a lethal condition, I didn't want to carry the pregnancy to term because that, to me, would just be so heartbreaking and because of the positioning of the fetus, if I were to carry to term, it would have to be planned c-section.

Dr. Mojola Omole:
Oh my goodness.

Dr. Sarina Isenberg:
It wouldn't have been safe for me to do a vaginal delivery. So anyway, we opted to terminate the pregnancy, and when we had a planned appointment at the hospital for the induction, I arrived at the hospital. We don’t go to the labor and delivery ward; they put us in the maternal health ward, which was fantastic. I think if I was hearing newborn babies crying, that would've just broken my heart even further. They gave me a private room, and on the door leading to the room, they had the butterfly, which indicated to the other health professionals that this was a sensitive situation. So everyone from all the medical staff down to the aide who was giving my meals was just very gentle. I also had a nurse in a one-to-one ratio, which was fantastic. They just explained everything so thoroughly and answered all our questions. The social worker who had been following me came to visit me in my room.

   Dr. Mojola Omole:
So you had that continuity of care there.

Dr. Sarina Isenberg:
Absolutely. Absolutely. And she also gave us a bunch of brochures about various supports and books that have been written by women in this situation. One thing the social worker told us about was the Pregnancy and Infant Loss Network, or PAIL, which is based out of Sunnybrook Hospital in Toronto. They offer virtual support groups for people experiencing loss, and they have a support group for early pregnancy loss, which I didn't know about when I went through that the first time. They have a support group for termination for medical reasons, which was the situation that we were in. They have support groups for stillbirth, and also they have support groups for pregnancy after loss and how to navigate that.

We actually, in the timeline, the social worker told us about this before we went to the hospital for the termination. And so it just turned out that the night before our termination was one of those termination-for-medical-reasons support groups. So my husband and I attended, and it really changed our minds in how we were going to approach the termination in terms of whether to name the baby, whether to hold the baby, and just how to talk about the baby afterward. So I was super supported. And I guess going back to when we were in the hospital for the termination, the social worker was there helping us, and the procedure unfolded. It didn't quite go smoothly. I ended up being in the hospital—I think we checked in on a Wednesday morning. The baby was born on a Thursday afternoon.  It was long. It was a long time to be in contractions and just really emotionally distraught over the whole experience. And then afterward, the genetic counselor and the social worker followed up with us to make sure we were doing okay. So that was a heartbreaking loss, but every step of the journey, we felt so unbelievably supported. And I had a third pregnancy, which resulted in a healthy baby boy.

Dr. Mojola Omole:
What's his name?

Dr. Sarina Isenberg:
His name is Fritz, and he is four months old now.

Dr. Mojola Omole:
Amazing.

Dr. Sarina Isenberg:
Yeah, so it's been an interesting fertility journey for sure.

Dr. Blair Bigham:
Interesting seems like such an understatement. You've been through so much and you've been so poorly served in some cases by the system.

Dr. Sarina Isenberg:
Yeah. Interesting is a word to me that is loaded with so many meanings. But I know that the article today that is related to what we're talking about suggests these early pregnancy assessment centers, and I absolutely wish we had that option.

Dr. Blair Bigham:
Sarina, thank you so much for sharing your stories with us and for graciousness in using the word “interesting”.

Dr. Sarina Isenberg:
Thank you. Well, I hope that my story can help improve the experiences of others so they don't have to go through what my husband and I went through.

Dr. Blair Bigham:
Dr. Sarina Isenberg is in Dundas, Ontario.

Dr. Modupe Tunde-Byass is co-author of a review article in CMAJ, entitled "Diagnosis and Management of Early Pregnancy Loss." Dr. Tunde-Byass is an obstetrician and gynecologist at North York General Hospital in Toronto, and a friend of the podcast. Modupe, welcome back.

Dr. Modupe Tunde-Byass:
Thank you so much Blair, nice to see you.

Dr. Blair Bigham:
I am a little nervous about our conversation, Modupe, because I am an emergency doctor, and I work in an environment that does a huge disservice to people when it comes to this topic. Can we just start from the very beginning and define early pregnancy loss?

Dr. Modupe Tunde-Byass:
So, just to let you know, early pregnancy loss or complications, it's when you have bleeding or pain in the first trimester, which is before 13 weeks.

Dr. Blair Bigham:
Before 13 weeks?

Dr. Modupe Tunde-Byass:
Thirteen weeks. And that accounts for about 80% of the time where you see this loss happen in the first trimester.

Dr. Blair Bigham:
And how common is it to have a first trimester loss?

Dr. Modupe Tunde-Byass:
So you could imagine one out of every four pregnancies is going to end up in a loss, so it's fairly, fairly common.

Dr. Blair Bigham:
Wow. And do losses sometimes occur without people even knowing it?

Dr. Modupe Tunde-Byass:
Of course, some people may not have bleeding; they may not have pain. They may typically show up for their usual ultrasound and are told that there's a baby, but the heartbeat is no longer present, and that's called a missed miscarriage. So that's the silent miscarriage, which takes you unaware.

Dr. Blair Bigham:
But that's not your main concern about how we're delivering care now. You are more worried about people who present with bleeding and then have to be told, maybe in an under-resourced setting like an emergency room, that they've lost their baby. Tell me more about what inspired you to write this article.

Dr. Modupe Tunde-Byass:
So this early pregnancy loss and complication has been in my DNA for quite a while. Being a junior resident in the UK in the very early nineties, about 1991 when this started, I felt that this is something that has helped a lot of pregnant individuals bypass the emergency room, and it has worked very well. So coming to this country, there was this huge gap whereby almost four out of five pregnant individuals with pain or bleeding go to the emergency room to receive care, and I felt that this was a huge gap. When I came on staff at North York General Hospital, I was tasked to start such a clinic, and we opened doors in 2005. We have been providing this streamlined, compassionate care for almost 20 years, and it's really made a huge difference in terms of compassion and sensitivity in looking after pregnant individuals going through this loss.

So, it’s an approach whereby they come to a dedicated clinic, we start with an intake process. We take the history, find out more about why they've come to the clinic. Because we're obstetricians, we're able to do our own ultrasound. So we do the ultrasound, decide what kind of diagnosis it is, then take it from there. If it's an ectopic pregnancy, we know that they do need strict follow-up. So we do the blood test, we have the opportunity of talking about the different modes of management, and with shared decision process we are able to support women on the choice that they make based on their preferences, their time at work, their values, et cetera. And we also provide the follow-up. So the key is to have a dedicated place where they have the diagnosis, and they're able to come back for follow-up. That is what you probably may not have in emerg or should not be having in the emergency room—people coming back for follow-up because it's just crazy busy there, right?

Dr. Blair Bigham:
Absolutely. And we're going to talk more about your clinic and the solution that it offers. But for so many clinicians, they do work in under-resourced settings, whether emergency rooms, walk-in clinics, or family clinics. What do they need to know about diagnosing early pregnancy loss and then treating it thoroughly?

Dr. Modupe Tunde-Byass:
So what they need to know is to provide that compassionate care. I think that's number one. If they don't have an ultrasound—let's assume there's bleeding, there's pain—you want to get the blood test, you want to get the ultrasound. You also want to speak to that individual and explain what they have. So if the pregnancy is within the uterus, and they're not bleeding too heavily, that kind of patient can wait. They don't have to go to the emergency room. If there's no pregnancy inside the uterus, then the conundrum is could this be an ectopic pregnancy? If there's pain, then the emergency becomes the place to go because going to the emergency room saves lives. Also, if someone is hemorrhaging, which means they are changing one pad every hour for the next two to four hours, they need somewhere to go. So that'll be the emergency room. If none of those severe complications happen, those patients can wait to be seen in such a setup like mine. Or if the family doctor is comfortable, they can begin to manage that patient by giving them different options.

Dr. Blair Bigham:
Remind us what the treatment options are for a miscarriage.

Dr. Modupe Tunde-Byass:
I was just going to go to that. So the first option is always wait and see. This could be, so we call that conservative management, which means the body can actually decide, and then you bleed and it's over. So that can happen within the confines of your home. That being said, it's important to know that pain is really huge, so you do need some form of pain relief. You also need to know what is not normal, which is what I alluded to earlier. If the bleeding is not stopping after four hours, you need help. So that's the first option. The second option is medical treatment. So the medical treatment, whereby we give you some medication depending on the type of miscarriage, whether you use misoprostol or have a pre-treatment with mifepristone, which is a combination of both. But with the medical treatment, you also need pain relief as well, and also knowing when to seek help. And the last option is surgical management, which is just the cleaning; it's done. Usually, it could be in a clinic setting, or it could be in the hospital. You may have to have a short anesthetic, or it may be done locally with local anesthetic being injected around the cervix. So depending on where you are, you may be offered that. So those are the three options that are available in managing early pregnancy loss.

Dr. Blair Bigham:
I feel like this question is a bit of a softball, but it still needs to be asked. Emergency departments are the right place, say, if you're hemorrhaging or having a ruptured ectopic. Tell us why they're not the right place for so many other women who might have bleeding in the first trimester or early pregnancy loss in the first trimester.

Dr. Modupe Tunde-Byass:
So, like you said, the emergency room is for situations that are complicated, where people are not stable. So for people who have just slight bleeding, and we know it's not ectopic, it's not the right place. One, because of the long wait time, the inaccessibility of timely ultrasound, and just being in the waiting area full of people where there's no privacy. So you can imagine someone is bleeding, it's upsetting losing a pregnancy, but also being in a place where you have no control. Oftentimes there's even no room available to you, or you get put in a room, you are assessed, then there's somebody emergent coming, and you get put back in the waiting area. So that's not comfortable. Additionally, you are seen by multiple providers. So you're seen by the emergency doctor, then you're referred to a gynecologist, and you have to retell your story again and again. So that leads to retraumatization, having to talk and talk.

So that's one. The other thing is that when you're going through this, there's a significant emotional component to it. As providers—not necessarily just being an emergency physician, even as a gynecologist—we view this as a medical problem. So it should be dealt with medically, which means, “Oh, you are having a miscarriage. Okay, that's it. We're just going to do this, goodbye.”

Forgetting that we need to address the emotional and the psychological aspects of that. You don't have that time in the emergency room to do that. So this is where there's a disconnect about the way the care is perceived by women going through this care. They see it as they're wasting health providers' time or they're just not having the opportunity to discuss how they're feeling. So that kind of insensitive care is what we are talking about, and that's what makes the emergency room not the place to go. In people who are stable, it's important they go to a place that is dedicated and is able to meet their needs.

Dr. Mojola Omole:
What does that look like? What are some of the experiences you have in the UK that we can create something like that?

Dr. Modupe Tunde-Byass:
So in the UK, it's a place that is dedicated. It's open seven days a week. And if in a situation where you have a clinic that is closed, you must have an alternative area that these individuals can go to. It could be a GYN ward; it could be somewhere created. But bypassing emerg, that place should be run by people who are trained to understand and interpret blood tests with ultrasound findings. More importantly, they should be trained in delivering bad news and be able to provide that sensitive and compassionate care.

Dr. Mojola Omole:
So it doesn't have to be a physician then?

Dr. Modupe Tunde-Byass:
It does not have to be a physician. I'm glad that you mentioned that. And the clinic should be able to offer people the right options. Okay. And the last thing also is that there should be provision for follow-up, and more importantly, women who have experienced previous losses or who have had ectopic pregnancies should be able to self-refer. They do not have to have a referral to access those kinds of clinics. So this is the kind of model that has been done in the UK. And some hospitals here in Ontario or the GTA have different kinds of models. So to your point Mojola, it does not have to be physician-led.

Dr. Mojola Omole:
How demanding is it? From a resource point of view, we're always under constraint for everything. How much more do hospitals have to do to be able to set up this sort of clinic?

Dr. Modupe Tunde-Byass:
I may be biased. I honestly don't think you need an ivory tower. You just need a room, a dedicated place. We are talking about location, a dedicated place, and you have someone who is trained. It could be a family doctor, it could be a specialist, an OB-GYN, it could be a nurse, it could be a nurse practitioner. It could be a combination of all these healthcare providers. In fact, according to a study that was done in the UK, where they looked at 6,600 women over 44 sites, the best configuration is a trained nurse with the provision of a sonographer who can do the ultrasound and a consultant who will be a specialist acting as a backup if there are questions. So you can have the algorithm to help you be able to triage which patient needs this or that, as long as you have that backup. So I don't think it's something that is not doable, and it's not that high of a resource to be honest with you.

Dr. Blair Bigham:
I imagine that over the 20 years you've been running this type of solution at North York General, you've learned a couple of lessons. What tips would you have for our listeners who are maybe saying, we should do this where I work?

Dr. Modupe Tunde-Byass:
Absolutely. I think the first thing is to think about why you're doing it. Everybody knows someone who has had a miscarriage, so this is a huge problem. The magnitude of the problem is huge, such that it should be addressed. When you're starting this kind of clinic, I think looking at your impact analysis, you should think big. Do not think about having some clinic that is like half a day, twice a week. It should be a daily access to care. You also should collaborate with your diagnostic imaging. Your radiologist should be your friend so that you can set up a model whereby maybe they dedicate an hour or first thing in the morning, they do all your ultrasounds for you. You should also collaborate with your labs so that once they see the blood coming from your clinic, they're able to process that blood quickly. The operating room facility should also be in your back pocket.

Why do I say that? If your patient decides to go for a surgical operation, they do not have to be on the same operating list with somebody coming for bowel obstruction, somebody who needs an eight-hour surgery. They should have a dedicated operating room to manage these cases, which could be half a day in a week. I don't think that's too much to do. You should also have a private place where people can grieve, where they have the opportunity to talk, and location, location  is important. You don't want such a clinic near pregnant individuals, like the labor floor or where people are breastfeeding, because of the emotional aspect of it. So that's extremely important. And you should have facilities for bereavement support. You don't have to do all the bereavement, but you should have the opportunity to link them up to a peer support group or to our partner called PAIL, which is the Pregnancy and Infant Loss program at Sunnybrook, which is very well established. They can communicate by phone, by video. So these resources are available. That would be my advice to people who are setting this up. I also think it should be a standard of care for every hospital whereby you can truly bypass the emergency room unless you have true emergency situations.

Dr. Blair Bigham:
That is quite a call to action.

Dr. Modupe Tunde-Byass:
Indeed.

Dr. Blair Bigham:
Dr. Tunde-Byass, thank you so much for joining us again on our podcast.

Dr. Modupe Tunde-Byass:
Thank you so much, Blair and Mojola. It's always a pleasure, and thank you for the work that you do.

Dr. Blair Bigham:
Thank you so much. Dr. Tunde-Byass is an obstetrician and gynecologist at North York General Hospital in Toronto.

Well, Jola, I don't know. Is this a good news story or a bad news story?

Dr. Mojola Omole:
Well, I think it's a good news story. It seems as if what gives the best experience for her patients and what actually is healthcare is a holistic approach to care. And I think that all of us physicians want that. We want to be able to do this. We want to be able to provide better care to our patients, but the structure of our healthcare system does not allow us. But I do think that it's important for the public, for politicians to listen to healthcare providers when funding programs and realizing that it's not just funding hospital beds; it's funding social workers, geneticists...

Dr. Blair Bigham:
Right. That's the trick—it’s not just physicians at a clinic like the one Dr. Tunde-Byass has. It's a whole team of people, and that takes money. And I don't know... We don't have the control over getting those resources and necessarily…

Dr. Mojola Omole:
And we don't prioritize that. We don't prioritize that aspect of healthcare. We like to just say, "Oh, we have more beds. Oh, we have a new ventilator." But what really matters is this holistic care for patients.

Dr. Blair Bigham:
So how do we achieve that across the country so that it's not just North York General, this hospital-by-hospital approach, where a single obstetrician has to invest blood, sweat, and tears, social capital, and all this effort just to make the right thing happen? How do we mass-produce that? This is probably a question that applies beyond early pregnancy loss clinics, but I guess I'll try to keep it tight. How do we do this? Do we legislate performance metrics? Do we bring about the political will? Do communities just have to demand it? What's the answer?

Dr. Mojola Omole:
I think we have to demand it. I think not just the community demands it because we are also part of the community, right?

Dr. Blair Bigham:
Oh, right. We can demand it.

Dr. Mojola Omole:
But also as physicians, we need to demand it. We need to demand that we are able to take care of our patients. But I do think that one thing that we're not good at as physicians is rallying together and actually standing up for something. And maybe it starts with something like early pregnancy loss, where we literally just want a room and a social worker dedicated to this, a process that makes it easier, where maybe we're actually not costing more money. We're just being more inventive with what we have.

Dr. Blair Bigham:
Just reorganizing...

Dr. Mojola Omole:
I think as physicians, we have to demand this from our healthcare administration and from our politicians.

Dr. Blair Bigham:
Well, I hope that Sarina's story, which she bravely shared with us, and Dr. Tunde-Byass's success bring about that effort for physicians to put their foot down and say, we will do better. We will find these creative solutions. We will advocate  for these additional resources. Maybe they're not even additional; maybe they're just reconfigured. But on this topic, it's so clear that we need to do better.

Dr. Mojola Omole:
If we know better, we do better.

Dr. Blair Bigham:
That's it for this episode of the CMAJ podcast. Please like, share, or comment wherever it is that you download your audio. It helps us get the message out and bring on new listeners. The CMAJ podcast is produced by PodCraft Productions. I'm Blair Bigham.

Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.