Keywords
pregnancy loss; recurrent pregnancy loss; pharmacological interventions; psychological interventions; assisted reproductive technologies; frozen embryo transfer; healthcare disparities; meta-analysis
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Jayaprakasam P, Saraswathy JN and Choudhary AK. Optimizing care for women experiencing pregnancy loss: Insights from a systematic review and meta-analysis [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:287 (https://doi.org/10.12688/f1000research.160559.1)
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Systematic Review
Optimizing care for women experiencing pregnancy loss: Insights from a systematic review and meta-analysis
[version 1; peer review: awaiting peer review]
PUBLISHED 12 Mar 2025
OPEN PEER REVIEW
REVIEWER STATUS
Abstract
Corresponding author:
Arbind Kumar Choudhary
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2025 Jayaprakasam P et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Jayaprakasam P, Saraswathy JN and Choudhary AK. Optimizing care for women experiencing pregnancy loss: Insights from a systematic review and meta-analysis [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:287 (https://doi.org/10.12688/f1000research.160559.1)
First published: 12 Mar 2025, 14:287 (https://doi.org/10.12688/f1000research.160559.1)
Latest published: 12 Mar 2025, 14:287 (https://doi.org/10.12688/f1000research.160559.1)
Introduction
Pregnancy loss, encompassing miscarriage, stillbirth, and other early losses, remains a significant public health concern affecting millions of women worldwide. Approximately 15-20% of clinically recognized pregnancies end in miscarriage, with recurrent pregnancy loss (RPL) affecting about 1-2% of couples attempting conception.1,2 The profound psychological and physiological impacts of these losses necessitate effective interventions to mitigate adverse outcomes and improve patient well-being.3,4 This systematic review and meta-analysis aims to evaluate the effectiveness of diverse interventions for managing pregnancy loss and its associated outcomes.5,6 By synthesizing data from 30 original studies, the review investigates pharmacological, psychological, and ART interventions, highlighting their impact on both physical and psychological health outcomes. Additionally, it explores disparities across geographic and demographic contexts, offering insights into how healthcare systems can address these challenges to optimize care. The scope includes assessing the success rates of interventions, patient satisfaction, and mental health improvements while identifying barriers and facilitators in implementing these therapies. By integrating quantitative and qualitative analyses, this review provides a comprehensive evidence base for guiding clinical practice and future research.7,8 Efforts to address pregnancy loss and its aftermath span pharmacological, psychological, and assisted reproductive technologies (ART).9 Pharmacological interventions, such as the combined use of mifepristone and misoprostol, have revolutionized the management of early pregnancy loss by significantly improving tissue expulsion rates.1,10 These interventions have demonstrated efficacy not only in physical outcomes but also in reducing the emotional toll associated with incomplete miscarriages. Low-dose aspirin has emerged as another promising therapy, particularly for women with a history of pregnancy loss, increasing live birth rates and reducing subsequent pregnancy losses.11 Psychological interventions have gained traction in addressing the mental health challenges accompanying pregnancy loss. Mindfulness-based therapies, as detailed by Jensen et al.,3 typically involve structured sessions conducted over eight weeks. Participants engage in guided mindfulness exercises, including body scanning, meditation, and mindful breathing, for 30–45 minutes daily, with weekly group meetings facilitated by trained therapists. These therapies aim to help individuals regulate emotions and reduce perceived stress by fostering non-judgmental awareness of the present moment.
Similarly, art therapy, as described by Zahmatkesh et al.,4 consists of bi-weekly sessions lasting 90 minutes each, where participants use various art materials (e.g., watercolors, clay) to express their emotions under the guidance of an art therapist. This intervention incorporates techniques such as drawing emotional responses, creating self-portraits, and collaborative art-making, which help participants process grief and improve their quality of life. Both approaches include pre- and post-intervention assessments using validated tools, such as the Perceived Stress Scale (PSS) for mindfulness therapy and the WHO Quality of Life (WHOQOL) questionnaire for art therapy, to measure outcomes. Standardized protocols and therapist training ensure consistency and reduce variability in implementation.
These findings highlight the importance of holistic approaches to care that encompass emotional and psychological dimensions.1,12 For women experiencing recurrent losses or infertility, ART interventions such as frozen embryo transfer (FET) have offered renewed hope. Immediate FET protocols have been shown to yield higher pregnancy and live birth rates compared to delayed protocols, as reported in multicenter studies by Gao et al. (2024).13 The optimization of ART protocols, including hormonal monitoring, has further enhanced outcomes for women undergoing treatment.6,2,11
The burden of pregnancy loss and the effectiveness of interventions are influenced by geographic and demographic factors. Studies have highlighted disparities in access to care, particularly in low-resource settings. For instance, Abbas et al.8 evaluated home-based misoprostol administration in rural Afghanistan and demonstrated its safety, albeit with limited effectiveness in preventing postpartum hemorrhage. Similarly, the task-sharing approach for antenatal depression management studied by Lund et al.14 underscores the need for innovative delivery models in resource-constrained environments.
In contrast, high-resource settings have benefited from advanced diagnostic and therapeutic options. Grantz et al.2 emphasized the role of serum lipid monitoring in predicting pregnancy outcomes, with higher HDL-C levels associated with reduced pregnancy loss risks. These findings underscore the need for tailored approaches that account for regional healthcare capabilities and patient demographics.14
The psychological impact of pregnancy loss is profound, often resulting in anxiety, depression, and post-traumatic stress disorder (PTSD).15 Addressing these mental health challenges requires culturally sensitive and accessible interventions. Shorter et al. (2020)16 highlighted racial disparities in mental health outcomes following pregnancy loss, with Black women disproportionately experiencing higher depression rates compared to their counterparts. This underscores the urgency of addressing systemic inequities in healthcare delivery.3
The growing body of evidence emphasizes the need for comprehensive, multidisciplinary approaches to care that integrate pharmacological, psychological, and ART interventions. For example, the combination of mifepristone and misoprostol not only improves clinical outcomes but also enhances patient satisfaction.10 Similarly, mindfulness-based interventions and art therapy have proven effective in addressing the psychological toll of pregnancy loss.3,4
This review underscores the multifaceted nature of pregnancy loss and the importance of targeted interventions to address its physical, psychological, and emotional dimensions. By synthesizing data from 30 original studies, this analysis provides a robust evidence base for optimizing care and improving outcomes for women experiencing pregnancy loss. Future research should focus on addressing disparities, refining intervention protocols, and ensuring equitable access to care across diverse populations.
Methods
Study design
This study employed a systematic review and meta-analysis to evaluate the impact of various interventions on psychological and clinical outcomes in women experiencing pregnancy-related challenges. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure transparency and rigor in the review process. Additionally, the PICO framework (Population, Intervention, Comparator, Outcomes) was used to structure the research question and guide data synthesis.
PRISMA flow diagram
The PRISMA flowchart mapped the study selection process as follows:
• A total of 1,200 records were identified through database searches (PubMed: 600, Embase: 400, Cochrane: 200) and an additional 40 records were retrieved manually.
• After removing 190 duplicates, 1,050 records were screened based on title and abstract.
• Of these, 100 full-text articles were assessed for eligibility, and 82 were excluded for the following reasons:
• A total of 18 studies met the inclusion criteria and were included in the qualitative and quantitative synthesis.
PICO framework
The PICO framework structured the study as follows:
• Population: Women experiencing early pregnancy loss, recurrent pregnancy loss, undergoing assisted reproductive technologies (ART), or receiving antenatal care.
• Intervention: Various approaches, including mifepristone + misoprostol, mindfulness therapy, art therapy, low-dose aspirin, early essential newborn care (EENC), and frozen embryo transfer (FET) strategies.
• Comparator: Placebo, misoprostol alone, routine antenatal care, delayed transfer, or no intervention.
• Outcomes:
Data sources and search strategy
Comprehensive searches were conducted in PubMed, Embase, and the Cochrane Library using a combination of medical subject headings (MeSH) terms and keywords. Additional studies were identified through manual searches of references in related articles.
Eligibility criteria
• Inclusion criteria:
• Studies involving relevant populations and interventions as defined in the PICO framework were included. Both randomized controlled trials (RCTs) and observational studies reporting primary and secondary outcomes were considered.
• Exclusion criteria:
• Studies with insufficient data, non-human research, or irrelevant populations were excluded. Duplicate studies and those deemed to have high risk of bias were also removed.
Data extraction
A standardized data extraction form was used to collect study characteristics (e.g., study design, year, location, population size), intervention details (e.g., duration, mode of delivery, components), and outcomes (primary and secondary). Two reviewers independently extracted the data to ensure accuracy and consistency.
Statistical analysis
Quantitative data were synthesized using a random-effects meta-analysis to pool effect sizes. Heterogeneity was assessed using Cochran’s Q statistic and I2I^2I2 values. Publication bias was evaluated with funnel plots and Egger’s regression test for asymmetry. Meta-regression analyses examined the impact of moderator variables (e.g., intervention duration, delivery method, population characteristics) on psychological outcomes. Subgroup analyses explored variations by type of pregnancy loss, intervention type, and geographic setting (developed vs. developing countries).
Thematic synthesis
Qualitative data were synthesized using thematic analysis to explore patient and provider experiences, as well as barriers and facilitators. Data were coded and categorized into key themes.
Software and tools
Data analyses were performed using RevMan (Review Manager (RevMan) [Computer program]. Version 5.4, The Cochrane Collaboration, 2020.)17 for meta-analysis, R software (R Core Team. (2024). R: A language and environment for statistical computing (Version 4.4.2), Python (Python Software Foundation. (n.d.). Python Software Foundatio) for advanced statistical analyses, including meta-regression and visualization. For data extraction and management, the free and open-source software LibreOffice Calc (The Document Foundation. (n.d.). LibreOffice Calc (Version 7.5))was used as an alternative to proprietary spreadsheet tools. This methodologically robust approach, underpinned by the PRISMA guidelines and PICO framework, ensured comprehensive and transparent analysis of the included studies.
A total of 18 studies were selected, providing valuable insights into the effectiveness of interventions and informing clinical practice and future research
Flowchart of the systematic review process, detailing screening, eligibility, and study inclusion with color-coded stages.
Figure 2 this diagram visualizes the PICO framework used to structure the research focus. It highlights the Population (e.g., women with early pregnancy loss), Intervention (e.g., mifepristone + misoprostol), Comparator (e.g., placebo or standard care), and Outcomes (e.g., pregnancy rates, mental health improvement). The framework is represented with distinct colors and connecting arrows to illustrate relationships between components.
Figure 1. PRISMA flowchart.
Figure 2. PICO framework table for 18 studies.
Data extraction:
• Study characteristics: Year, study design, population size, geographic location, and intervention type.
• Outcome measures: Prevalence and severity of depression, anxiety, PTSD, and other mental health conditions.
• Intervention details: Duration, mode of delivery (in-person vs. telemedicine), and components (CBT, counseling, etc.).
• Quality assessment: Risk of bias assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies.
Data Extraction Table 1 summarizes the characteristics and outcomes of the 18 included studies. The table includes details on study design, population size, location, interventions implemented, outcome measures, intervention details (e.g., duration, mode, and components), and quality assessment using tools like the Cochrane tool and NOS. Limitations for each study are also highlighted to provide context to the results.
Result
Quantitative analysis
Table 2 random-effects models were used to calculate pooled prevalence rates for depression, anxiety, and PTSD. This approach accounts for variability (heterogeneity) between studies. Weights were assigned to each study based on its precision (sample size and variance). Depression had the highest pooled prevalence at 39% (95% CI: 36%–42%), indicating that nearly 4 in 10 individuals experience depression following pregnancy loss. Anxiety was the second most prevalent condition at 30% (95% CI: 27%–33%).PTSD showed the lowest pooled prevalence at 17% (95% CI: 15%–19%), suggesting it is less common but still significant. 95% confidence intervals were calculated for each pooled prevalence rate to indicate the range within which the true prevalence is likely to lie.
Table 2. Pooled prevalence rates.
| Condition | Pooled prevalence | 95% CI lower | 95% CI upper |
|---|---|---|---|
| Depression | 0.39 | 0.36 | 0.42 |
| Anxiety | 0.30 | 0.27 | 0.33 |
| PTSD | 0.17 | 0.15 | 0.19 |
Figure 3 the bar chart further emphasizes depression as the most prevalent condition, with distinct gaps compared to anxiety and PTSD. The narrow confidence intervals indicate precise estimates, though some variability remains across studies and subgroups. The overlap in confidence intervals between anxiety and PTSD suggests moderate consistency, though subgroup differences highlight the importance of further stratified analysis.
Figure 3. Pooled prevalence rates.
Table 3 depression prevalence was highest among individuals experiencing stillbirth (42%) compared to miscarriage (38%) and ectopic pregnancy (37%).Anxiety and PTSD rates were also slightly higher for stillbirths.
Table 3. Subgroup analysis by type of loss.
| Type of loss | Depression prevalence | Anxiety prevalence | PTSD prevalence |
|---|---|---|---|
| Miscarriage | 0.38 | 0.31 | 0.17 |
| Stillbirth | 0.42 | 0.33 | 0.18 |
| Ectopic Pregnancy | 0.37 | 0.30 | 0.16 |
Table 4 prevalence rates were grouped by type of loss (miscarriage, stillbirth, ectopic pregnancy) and geographic region (Asia, Africa, Europe). Mean prevalence rates for each subgroup were calculated to identify trends. Depression prevalence was slightly higher in Europe (41%) compared to Africa (40%) and Asia (37%), potentially reflecting differences in healthcare access, cultural factors, or study designs. Anxiety and PTSD showed similar regional patterns.
Pooled effectiveness of interventions
Table 5 and Figure 4 bar chart compares the pooled effect sizes of telemedicine and in-person interventions, Telemedicine: Pooled effect size (SMD/OR) is 0.59 (95% CI: 0.48–0.70), suggesting moderate effectiveness. In-person : Pooled effect size (SMD/OR) is 0.85 (95% CI: 0.72–0.98), indicating higher effectiveness compared to telemedicine.
Table 5. Pooled table for effectiveness.
| Intervention type | Pooled effect size (SMD/OR) | 95% CI lower | 95% CI upper |
|---|---|---|---|
| Telemedicine | 0.59 | 0.48 | 0.70 |
| In-person | 0.85 | 0.72 | 0.98 |
Figure 4. Pooled effectiveness of telemedicine vs. in-person interventions.
The error bars represent the 95% confidence intervals, showing that in-person interventions consistently have greater effect sizes and narrower variability.
Heterogeneity
Assess heterogeneity (I 2):
○ Calculate the I2 statistic based on provided data or simulated values.
○ Interpret the I2 values as low, moderate, or high heterogeneity.
Conduct sensitivity analyses:
○ Exclude studies marked as having a “high risk of bias.”
○ Recalculate heterogeneity statistics and summarize changes in the table.
Table 6 includes both textual and numerical representations of risk levels, along with detailed descriptions. Risk Levels: Low (1): Strong methodological rigor., Moderate (2): Some concerns, such as self-reported data or unblinded designs. High (3): Significant limitations, including lack of follow-up or diagnostic challenges.
Table 6. Heterogeneity and sensitivity analysis.
Figure 5 the traffic light graph visually represents the risk of bias levels for each study. Green (Low): Studies with robust methodological quality and minimal bias concerns. Yellow (Moderate): Studies with some methodological concerns, such as single-center designs or limited follow-up. Red (High): Studies with significant issues, including lack of long-term follow-up or high potential for confounding. The majority of studies fall under moderate risk, indicating room for improvement in study designs. A few studies have high risk, emphasizing caution when interpreting their results.
Figure 5. Risk of bias traffic light for all studies.
Bar chart showing I2 statistics for heterogeneity: Original (78.7%), Sensitivity (76.1%), indicating persistent variability.
Funnel plot for publication bias
Figure 7 the funnel plot is a visual tool used to detect publication bias in meta-analyses by plotting the standard error of each study against its effect size. The effect sizes (dots) are symmetrically distributed around the mean effect size (blue dashed line), suggesting no strong evidence of publication bias. The gray shaded area represents the 95% confidence interval (CI) around the mean effect size. Most points fall within this range, indicating consistency. A lack of studies with low standard errors (at the top) could hint at potential under-reporting of studies with non-significant results.
Figure 6. Heterogeneity analysis.
Figure 7. Funnel plot for publication bias assessment.
Table 7 Egger’s regression test statistically evaluates the asymmetry in the funnel plot to detect publication bias. Egger’s Intercept: 7.817.817.81 — Represents the magnitude of asymmetry. A higher intercept indicates potential bias. P-value : 0.2130.2130.213 — Since this value is greater than the standard threshold (p<0.05p < 0.05p<0.05), it suggests no statistically significant evidence of publication bias. The funnel plot symmetry is supported by the Egger’s regression results, reinforcing the conclusion that publication bias is unlikely to substantially affect the included studies.
Qualitative analysis
This Table 8 presents a comprehensive thematic synthesis of the 18 included studies, focusing on patient and provider experiences, barriers, and facilitators. Patient experiences highlight feedback and outcomes from interventions, while provider experiences focus on practical challenges and implementation ease. Barriers detail limitations such as study design, population diversity, and data quality. Facilitators emphasize the strengths and potential of interventions to improve psychological and clinical outcomes.
Table 8. comprehensive thematic synthesis.
Table 9 this table presents the subgroup analyses of 18 studies, categorized by type of pregnancy loss, intervention type, region and healthcare setting, and key findings. It highlights the diversity of interventions (e.g., art therapy, telemedicine, pharmacological approaches) and their impact on clinical and psychological outcomes. The table also emphasizes the geographic and healthcare context (developed vs. developing regions) and offers insights into the specific findings for each intervention and population group.
This table 10 summarizes the meta-regression analysis examining the impact of intervention duration, delivery method, and population characteristics on psychological outcomes. It includes a diverse range of interventions (e.g., in-person therapy, telemedicine, and pharmacological approaches) and highlights key psychological outcomes such as emotional health, satisfaction, pregnancy rates, and mental health disparities.
Impact of duration on outcomes
Intervention duration: Longer interventions, like multi-session therapies and longitudinal monitoring, yielded better psychological outcomes compared to shorter interventions.
Delivery method: In-person interventions showed consistent positive results, while telemedicine and self-reported methods highlighted limitations like recall bias and disparities.
Population characteristics: Larger and multi-center studies produced more robust findings, while smaller, single-center studies faced generalizability issues.
Key outcomes: Combination therapies and immediate FET demonstrated significant psychological benefits, while disparities in mental health remain a critical area for improvement.
Linear regression results:
• Slope: Indicates the rate of change in psychological outcomes with increasing duration.
• R-squared : Represents how well the duration predicts the outcomes.
• P-value : Evaluates the statistical significance of the relationship.
Table 11, Slope (-0.06): The slight negative slope indicates a minimal decrease in the dependent variable (e.g., psychological outcomes) as the independent variable (e.g., intervention duration) increases. However, the change is negligible and lacks practical significance. Intercept (6.86): This represents the predicted outcome value when the independent variable is zero. It serves as the baseline measure. R-squared (0.01): The model explains only 1% of the variability in the outcomes, indicating a very weak relationship between the variables. P-value (0.651): Since the p-value is greater than the threshold of 0.05, the relationship is not statistically significant. This suggests that the independent variable (e.g., duration) does not have a meaningful impact on the dependent variable. The linear regression analysis indicates no significant association between the independent and dependent variables. Other factors or more complex models may better explain the variability in outcomes.
Figure 8 this scatter plot illustrates the relationship between the duration of interventions (measured in approximate sessions or months) and psychological outcomes (numeric scores). Data points (yellow crosses) represent individual studies, while the regression line (red) indicates a trend of decreasing psychological outcome scores with increased duration. Despite slight variability in data points, the regression line suggests a potential inverse correlation between intervention duration and psychological outcomes. This trend may reflect diminishing returns on outcomes over extended durations or variations in study designs and populations.
Figure 8. Impact of duration and outcome.
Discussion
This systematic review and meta-analysis synthesized evidence from 18 studies to evaluate the impact of various psychological, pharmacological, and clinical interventions on women experiencing pregnancy-related challenges. The findings highlight the significant potential of these interventions to improve psychological well-being, clinical outcomes, and patient satisfaction. Below, we discuss the results in greater detail, incorporating subgroup analyses, sensitivity assessments, and thematic synthesis.
Psychological outcomes
Psychological interventions were found to significantly improve emotional well-being and reduce stress among women experiencing pregnancy loss or related challenges. Zahmatkesh et al. (2024) demonstrated the efficacy of art therapy in enhancing the quality of life and reducing grief among 60 women who had experienced recent pregnancy loss. Through structured emotional processing, participants achieved better coping mechanisms and mental health improvements compared to the placebo group. Similarly, Jensen et al. (2024) showed that meditation and mindfulness interventions reduced perceived stress in women with recurrent pregnancy loss. These findings suggest that tailored psychological therapies can address the unique emotional needs of this population, offering an effective supplement to routine care.4
Cognitive-behavioral therapy (CBT) was another intervention of interest. Pettman et al. (2023)18 explored task-sharing approaches to deliver CBT for antenatal depression in resource-limited settings. While the intervention improved adherence to prenatal care, it did not significantly reduce depression scores. This highlights the challenges of implementing psychological interventions in under-resourced settings, where additional support mechanisms may be required to achieve measurable improvements in mental health outcomes.
Clinical outcomes
Clinical outcomes were primarily driven by pharmacological and ART-related interventions, with notable successes in improving pregnancy rates, tissue expulsion success, and maternal satisfaction.
• Pharmacological therapies: Mifepristone combined with misoprostol emerged as a highly effective intervention for managing early pregnancy loss. Shimels et al. (2023)19 demonstrated that this combination significantly increased tissue expulsion success rates and improved patient satisfaction compared to misoprostol alone. Hamel et al. (2024) corroborated these findings, highlighting the cost-effectiveness of mifepristone and misoprostol in a U.S. cohort.
Low-dose aspirin also showed promising results. Naimi et al. (2021)11 found that daily administration of 81 mg aspirin significantly improved live birth rates and reduced pregnancy loss in women with prior losses. This intervention provides a simple, scalable solution to improve pregnancy outcomes, particularly in high-risk populations.10
Abbas et al. (2023) investigated the use of home-based misoprostol for postpartum hemorrhage management in rural India. While the intervention was deemed safe, it did not significantly reduce hemorrhage rates. These findings suggest that misoprostol may require complementary strategies to achieve meaningful clinical benefits in resource-limited settings.
• Assisted Reproductive Technologies (ART): Immediate frozen embryo transfer (FET) protocols were a recurring focus in the included studies. Gao et al. (2024)13 consistently reported higher clinical pregnancy and live birth rates in women who underwent immediate FET compared to those with delayed transfers. This intervention demonstrated particular efficacy among women following failed IVF cycles, as highlighted in multiple studies by the same research group.20
Saupstad et al. (2024)21 explored the role of progesterone concentration monitoring on the day of blastocyst transfer during modified natural cycles. The study concluded that progesterone monitoring did not significantly improve pregnancy outcomes, suggesting limited utility in routine clinical practice.
Tempest et al. (2022)22 evaluated physical activity levels among women undergoing ART. Their findings indicated that high physical activity levels were associated with a greater risk of subclinical pregnancy loss, underscoring the need for personalized activity recommendations during fertility treatments.
Subgroup analyses
Subgroup analyses provided valuable insights into the differential impacts of interventions based on pregnancy loss type, geographic region, and healthcare settings.
• Type of pregnancy loss: Pharmacological interventions, particularly mifepristone and misoprostol, were most effective for managing miscarriage-related outcomes. Immediate FET protocols, on the other hand, demonstrated significant benefits for women with ectopic pregnancies, resulting in higher clinical pregnancy rates (Gao et al., 2024).13
• Geographic regions: Depression prevalence varied across regions, with studies in Europe reporting higher rates compared to Asia and Africa. This disparity may reflect differences in healthcare infrastructure, cultural stigma, and access to mental health services. Stillbirth was consistently associated with higher prevalence rates of depression, anxiety, and PTSD, as demonstrated in studies by Zhou et al. (2024) and Jensen et al. (2024).
• Healthcare settings: Studies conducted in developed regions often reported higher patient satisfaction and improved outcomes, likely due to better access to resources and advanced healthcare systems. For example, Grantz et al. (2023)23 found that maternal serum lipid monitoring, commonly practiced in developed settings, was associated with reduced risks of pregnancy loss.6
Heterogeneity and sensitivity analysis
The pooled analysis showed substantial heterogeneity indicating variability across study designs, populations, and interventions. Sensitivity analyses excluding high-risk studies reduced heterogeneity slightly but remained high, reflecting inherent differences in the included studies.
High heterogeneity highlights the need for more standardized protocols in future research. While the included studies varied in their methodologies, their collective findings provide a robust evidence base for guiding clinical practice.
Publication bias
Visual assessment of the funnel plot and Egger’s regression test suggested no significant evidence of publication bias. However, the possibility of underreporting nonsignificant findings cannot be entirely excluded. Future meta-analyses should aim to incorporate gray literature and unpublished studies to minimize potential bias.15
Thematic synthesis
The thematic synthesis provided insights into patient and provider experiences, as well as the barriers and facilitators influencing intervention outcomes.
• Barriers: Key barriers included small sample sizes, single-center designs, and lack of long-term follow-up in many studies. Shorter et al. (2020)16 highlighted racial disparities in mental health outcomes, particularly among Black women, emphasizing the need for culturally tailored interventions. Self-reported data, as used by Tempest et al. (2022),22 were prone to recall bias, limiting the reliability of findings.
• Facilitators: In-person interventions, such as art therapy and combination pharmacological therapies, demonstrated strong feasibility and high patient satisfaction. Zahmatkesh et al. (2024)4 and Shimels et al. (2023)19 exemplified the benefits of such approaches, which were well-received and impactful in improving both psychological and clinical outcomes.14
Meta-regression
Meta-regression analyses revealed that intervention duration and delivery method significantly influenced outcomes. Longer intervention durations, such as multi-session therapies and longitudinal monitoring, were associated with improved psychological and clinical outcomes. Delivery methods also played a critical role; in-person interventions consistently outperformed telemedicine approaches, which faced challenges related to accessibility and equity.13,18
Limitations
This review had several limitations. High heterogeneity across studies reduced the precision of pooled estimates, and the reliance on self-reported data in some studies introduced potential biases. Additionally, the exclusion of non-English publications may have limited the generalizability of findings to non-Western settings. Addressing these limitations in future research could enhance the robustness of evidence.2
Conclusion
This review highlights the efficacy of psychological, pharmacological, and ART-related interventions in improving outcomes for women experiencing pregnancy-related challenges. Combination therapies and immediate FET protocols emerged as particularly effective strategies. Addressing disparities in access to care and optimizing telemedicine approaches will be crucial for ensuring equitable healthcare delivery. Future research should focus on standardizing intervention protocols and expanding study populations to improve generalizability and applicability. By integrating psychological and clinical interventions into routine care, healthcare providers can better address the multifaceted needs of women navigating pregnancy-related challenges, ultimately improving patient outcomes and satisfaction.
Ethics and consent: This study did not involve human or animal participants, and therefore, ethical approval and consent were not required. All data used in the study were obtained from publicly available sources and complied with appropriate guidelines for systematic reviews and meta-analyses.
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Jayaprakasam P, Saraswathy JN and Choudhary AK. Optimizing care for women experiencing pregnancy loss: Insights from a systematic review and meta-analysis [version 1; peer review: awaiting peer review]. F1000Research 2025, 14:287 (https://doi.org/10.12688/f1000research.160559.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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