When I miscarried in Canada, the clinical encounter that followed felt like I was being handed a form when what I needed was a human being.
The room was efficient. The language was precise. And I left feeling utterly alone, not because anyone was unkind, but because the system had no vocabulary for what I had just lost.
I later wrote about that experience in an essay called Miscarriage in Silence, reflecting on the cold, detached language of clinical care at the moment of pregnancy loss. What surprised me was how many people wrote back. Dozens of them. From across the country. All saying the same thing: me too.
That response told me something important. This wasn’t a personal failure of one provider or one hospital visit. It was a structural pattern. And structural patterns can be measured.
Together with Professor Wendy Hall at UBC’s School of Nursing, I developed the Compassionate Disclosure of (Perinatal) Loss index, the CDL, a six-item psychometric instrument that captures what should happen, but too often doesn’t, when a person first receives news of their pregnancy loss.
- Did you have privacy?
- Was your support person present?
- Were you given time to process?
- Was the provider kind?
- Did they have the right skills?
- Were you given full information about your options?
Six questions. Each one representing a moment in which a health-care system either holds you or doesn’t.
In a study published in Birth, drawing on a national Canadian survey of 172 people who had experienced pregnancy loss, we found that those who miscarried were significantly less likely to report that their loss was communicated compassionately, about one-third as likely as those who experienced a later loss, such as stillbirth. Miscarriage affects approximately 15,000 people in British Columbia alone each year, making it the most common form of pregnancy loss in Canada, and yet it is consistently handled with less sensitivity than rarer, later losses.
In the language of our research, miscarriage is a disenfranchised loss: a grief the health-care system does not fully acknowledge.
The racial inequities we found were equally troubling. Indigenous, Black and racialized people reported markedly lower autonomy in decision-making and respectful care and were more than twice as likely to report that their concerns were not heard by providers leading up to the loss. These are not marginal differences – they are large, statistically significant and persistent even after accounting for income, education and other factors.
Taken together, these findings point to a consistent gap, not in clinical competence, but in how care is delivered at one of the most vulnerable moments in a patient’s life. And because these experiences are rarely measured, they remain largely invisible within health system performance frameworks.
While guidance exists – from the Society of Obstetricians and Gynaecologists of Canada, from Public Health Agency of Canada maternity guidelines and from provincial standards such as Ontario Health’s quality framework – Canada does not have a standardized or consistently implemented national approach to how pregnancy loss is communicated, nor is it routinely measured as a core indicator of quality in care. These guidelines emphasize compassion and patient-centred language, but implementation is fragmented across settings and no accountability mechanism tracks whether the standards are actually met.
The CDL index was built precisely to fill that gap. It gives health systems, policymakers and quality improvement teams a validated, measurable way to ask: are we meeting a basic standard of compassionate care at one of the most vulnerable moments in a person’s reproductive life?
What would it take to change our approach? Provider training in compassionate communication across all care settings, including emergency departments, where early losses are most often diagnosed. Standardized protocols ensuring privacy, the presence of support and adequate processing time. And equity-focused accountability, tracking how compassionate disclosure varies by race, geography and care setting, so that disparities no longer remain invisible.
What my experience revealed, and the data later made visible at scale, is that how loss is communicated is not a soft concern. It is a core component of quality in care, one that Canada’s health system has yet to fully reckon with.
Read the full paper: Hall, Malhotra et al. (2025), Birth.
Read the personal essay: Miscarriage in Silence.
Read the study: Inequities in Care During Pregnancy Loss.
