The Emotional and Psychological Effects of Miscarriage
by Anne Neville
R.N., R.M., Dip. Past. Psych., Dip. Marriage & Family Therapy, C.P.C., Accredited Counsellor National Association of Loss & Grief, A.M.C.C.A., M.A.S.T.S.S.
 

“Sue” and her husband were delighted to have a pregnancy confirmed after 3 years of marriage. They found it impossible to keep the news under wraps and soon family and friends were anticipating the happy event. However, at 9 weeks “Sue” started bleeding and when a scan failed to find a heartbeat they were both devastated. She recalls how, when being wheeled into theatre for a curette the doctor jokingly said, “they would have to smack my bottom”. She was taken aback and suddenly felt as if the miscarriage was her fault.

She remembers being told that many women miscarry the first time and that everything would be O.K. next time. She hung on to these words, tried not to get too caught up in her sadness and disappointment and focused on becoming pregnant again.

Over the next 4 years “Sue” became pregnant and miscarried 8 times. The length of the pregnancies varied from 6 to 9 weeks. She spoke about “the anticipation of trying, the exhilaration of finding out I was pregnant, the trepidation (which eventually became like terror) of feeling every twinge, and the annihilation and despair of finding out that again, once again, the pregnancy had failed.”

It was a roller coaster ride from hope to despair. With each pregnancy it became harder to be positive. “Sue’s” husband found it increasingly difficult to handle each miscarriage. He worked longer hours, leaving “Sue” more and more on her own. She felt she had failed him badly. She went to many doctors and tried many treatments, many of them unorthodox. Finally they adopted from overseas.

“Sue’s” story shows a number of the aspects of grief encountered by so many when a pregnancy is lost. Pregnancy loss can be such a lonely and emotional experience and is particularly so for women who, like “Sue”, have a number of miscarriages.

Miscarriage is the lay term for a pregnancy lost before 20 weeks gestation. It includes ectopic pregnancy and blighted ovum as well as spontaneous abortion, incomplete abortion and IVF attempts. Quantifying pregnancy loss through miscarriage is difficult. However it is estimated that as many as 1 in 4 recognized pregnancies may end in miscarriage. This figure does not allow for those that occur before the woman even realizes she is pregnant. It could be that the actual rate of pregnancy loss due to miscarriage might be as high as 50%. It is estimated that about three-quarters of miscarriages occur in the first 12 weeks.

Whilst we, as concerned onlookers, may find miscarriage to be common, we need to keep in mind that for the mother or parents it will not be experienced that way. It is a very personal and emotional experience. Miscarriage can cause a woman the most acute sadness she has ever experienced. “It can stun parents with the intensity of its emotional impact” says Overs (1995).

Miscarriage is one of the least recognized forms of pregnancy loss - the other being the grief response associated with termination. Because miscarriage usually happens very early in the pregnancy, there is often the misconception that the degree of loss experienced is in proportion to the length of the pregnancy. Its impact generally seems to be underestimated, except by those who have had one. What seems far more relevant is the loss of an expected child. Attachment is based on the expectations, fantasies and hopes for the child which are mixed with an intense emotional involvement.
 

Women speaking of their miscarriages do so in very personal and relational terms - speaking of the miscarriage as the loss of a person (Reinharz, 1988). They commonly show the same range of feelings reported in other bereavement situations and have been found to experience two phases of mourning:

• The initial phase, characterized by denial as a means of coping with the loss

• The acute mourning period, characterized by an increase of feelings of anger, guilt, blame and jealousy.

In more recent times we have become considerably more aware of the impact of human suffering through bereavement and other major losses. Literature, books and seminars explore the topic of grief more openly than ever before. It is through these media that we are able to deepen our understanding on an emotional, intellectual and spiritual level.

Whilst there have been considerable changes in how we approach stillbirth and neonatal death, the effects of early pregnancy loss have not been explored as extensively. Many factors relegate it to a more shadowy position in our experience - often the pregnancy had not been formally announced, there may have been some ambivalence involved or the degree of attachment that had already taken place was not understood.

We need to remember that “soon after conception the psychological and physiological processes of pregnancy are set in motion.” (Friedman and Gradstein, 1982). The level of reproductive hormones in the circulation increases greatly, the uterus develops a thick lining to support the growing foetus, and breasts enlarge preparing for feeding. The body and psyche gears up for motherhood.

Therefore when a pregnancy is interrupted the woman is left in the state of physical and emotional readiness for a baby that will never be. The woman’s focus is still centered on the lost baby for a time and she becomes very sensitive to those around her who either have young babies or who are pregnant. She may find it difficult to show enthusiasm for another couple’s delight in their baby. Something as simple as shopping may become very difficult, as everywhere she turns there are baby products, babies in advertising or other mothers with their babies and children.

The grief associated with a miscarriage is not just about what is lost now but also about what could have been. Although the child is still developing and as yet is “unknown”, an attachment forms even under difficult circumstances e.g. an unplanned pregnancy. Very often there is within the mother’s mind a concept of who and how that child will be. “The child is the object of the parent’s imaginative projections” (Savage, 1989). Women mourning a pregnancy loss often have a clear picture of their lost child - something that assists in the grieving process. The same applies after a termination.

The planned child is certainly mourned but so too is the “imagined” child, as it has already become a psychological and emotional reality and its loss may impact profoundly.
 

A pregnancy loss can have a profound effect on a parent’s self-image. Many people prepare to become parents long before they actually do. They have some idea of themselves as parents somewhere in the future - it’s part of their life goal - on the long term plan if you like. A parent’s role traditionally centers on protecting and nurturing the child and parents usually do not expect to outlive their offspring.

For many, the grief associated with the loss of a child may bring with it a profound sense of personal failure and guilt. Many women talk about feeling inadequate as a woman and a mother by not bringing a pregnancy to a complete and healthy outcome. They feel guilt for failing to meet the expectations of partners, children and parents. Miscarriage of a first pregnancy may raise considerable anxiety about future fertility.
 

Where there has been ambivalence about a pregnancy or even hostility towards it, guilt may be a particular feature of the grieving process. For some, a miscarriage may initially be a relief - this can often give way to guilt. The woman faced with an unplanned pregnancy who had considered an abortion may later question whether she caused the miscarriage in some way.

When the mother believes she has contributed to the death of her offspring in some way, this reaction may be far more pronounced. Women agonize over whether certain activities such as doing too much gardening, exercising too vigorously or having sex have caused the miscarriage. For a woman who has had a previous termination, there may be the belief that the miscarriage is a punishment.

Anger is also a common reaction. It is a recognized part of the grieving process for a loss of any kind. This may be directed at professionals, partner, friends and oneself.

Parents expect modern medicine can fix almost anything - however the rate of first trimester miscarriage is approximately the same as it was 50 years ago. The grieving woman may be concerned that she or others may not have done enough to prevent the miscarriage. This may be quite unfounded but is part of her trying to find an answer - a reason - for the loss. She may be dissatisfied that there is no apparent reason for the miscarriage and no definite answer or reassurance against the possibility of this happening again. Her search for knowledge needs to be understood as an expression of her grief, frustration and helplessness. It offers some feeling of control in a situation where there was none.

The anger may be connected with the responses of other people. “Sue”, mentioned earlier, spoke about being profoundly “wounded for days” by the comments of well meaning but insensitive friends and relatives. She also acknowledged “misdirecting the blame and anger” at others - something she was able to let go of after working through her grief for her lost children with the help of counselling.

Tension and conflict may arise in the parental relationship after a pregnancy loss because of the different degrees of bonding for men and women. The emotional attachment for the father tends to lag behind that of the mother. Hence the mother seems to experience a greater degree of grief that lasts longer because of the deeper attachment. A study by Friedman and Gradstein in 1982, reported that women were more likely to see the miscarriage as the loss of a person whereas men tended to perceive it as a sad event but not as a death. That is not to say that all fathers would interpret it this way. Indeed, many fathers speak of their lost children in very personal terms.

Women who have a crisis during their pregnancy, who do not perceive their partner to be supportive or who may not have seen or held their baby after it died tend to have more difficulty in coming to terms with their loss.

Peppers and Knapp (1982) in their book “Motherhood and Mourning” suggest that society’s expectations for men were to remain strong and suppress their emotions whereas women were expected to express their sadness and grief. Men all too often throw themselves into work in order to take their minds off their own grief and to avoid feelings of helplessness in the face of their partner’s pain. For some women this apparent lack of grief can lead to feelings of isolation and bitterness, causing problems in the relationship.

Where the level of the husband’s support is evident, women usually fare better and the level of depression decreases (Madden, 1986, cited in Witzel 1991). This is also the case where there is active support from friends and relatives. Many, however, lack these supports and grieve in isolation, becoming depressed.

Because of the suddenness and urgency associated with miscarriage there is often little time to prepare for the loss and its impact. Many women report a sense of chaos - on one hand everything happens so quickly and yet, at the same time, the world stands still for them. There is often an inadequate amount of time to assimilate events and adjust on a psychological and emotional level.

For hospital staff coping with the demands of a busy day there may be little time to offer the mother or parents what they need most at this time - empathy, explanation, time and support.

Women are usually discharged quickly from hospital and often go home in the state of shock. Many are confused - searching for answers and barely able to believe they are not still pregnant. There can be the tendency to want to shut out the world for a time - to pull the bedclothes over one’s head and just stay there. Alternatively, external pressures dictate that the grief is put on hold for some time. What can often follow is a flood of grief later, which hits unexpectedly.

Anxiety can be high, particularly about future pregnancies. Some will struggle alone with their feelings and reactions, not sure how they should be feeling or wondering whether what they are feeling is “normal”. Many are hesitant to disclose these feelings and to ask questions. It is important to have all concerns addressed. It is helpful to write down any queries or concerns before seeing the doctor at a follow up visit. Counselling can help to normalize the feelings and reactions to this loss.
 

A study of women following stillbirth or neonatal death showed the following symptoms (Nichol, 1989).

These symptoms are observed when counselling women who have experienced other pregnancy losses e.g. miscarriage and surgical abortion.

• Feelings of disbelief

• Guilt

• Feelings of failure

• Sense of inadequacy

• Doubts about femininity

• Feeling somehow damaged

• Anger towards oneself, spouse, friends and towards those minimizing the loss or failing to recognize its significance

• Depression, feelings of emptiness and sadness

• Uncontrollable crying

• Ruminations - preoccupation with the lost baby

• Withdrawal from others and activities

• Jealousy

• Lowered self-esteem

Factors that tend to prolong grief and stifle its expression.

• Not knowing the cause and blaming oneself

• Any ambivalence to the pregnancy increases guilt and threatens feminine self-concept, eroding her self-esteem

• Feeling her body has betrayed her and feeling a sense of shame

• Being tormented by fears about the normality of the foetus and future pregnancies

• Not seeing or being allowed to see the foetus or baby

• When the loss and grief is minimized by those around her

Because many do not anticipate or understand the grief response associated with a pregnancy loss, they may feel as if they are going mad when their emotions catch up with them.

During the time “Sue” came for counselling she used to ask if she was imagining the pain that she felt after her miscarriages, was she just feeling sorry for herself and “Are these feelings natural?” It was a great relief for her to be reassured that they were. She was then able to be more accepting and tolerant of herself and her responses.

There may be particular times and dates when the grief is felt more keenly. It may initially center around the day of the week that the child is lost, then the date of each month. These may be difficult times and often the anticipation can be worse than the time or date itself.

It is not unusual for a fresh resurgence of grief to occur around the time of the anniversary of the loss. Thoughts may be preoccupied with the baby, the events leading up to and surrounding the loss and the degree of support (or lack of it) encountered. An increased teariness and greater sense of vulnerability are not at all unusual. It can be a time of great poignancy - a time for reflecting on what could have been.

The expected due date of the baby’s birth may also be a difficult time and preoccupy much emotional energy. Again the lead up to the date can be quite difficult. It is a time when people often need to discuss their loss and have it acknowledged. They need extra support.

Grief is the natural response to the loss of someone or something significant in our lives. We traditionally mark the loss of someone we love with a farewell - a funeral. It provides the opportunity to gather in memory and face the reality of the loss. The expression of grief is for ourselves and how we will face life without the person we mourn. The emptiness is profound, the loss very real.

Attention to the handling of stillborn babies has become a reality. Being able to spend time with the baby has become a recognized part of allowing the grieving process to flow in a healthy way. However the same does not apply to miscarried babies. Their remains have usually been disposed of rather unceremoniously. For many parents this can be the source of much heartache and distress. It often leaves many unanswered questions such as “What happened to my baby?” and “Where did my baby go?”

Whilst it may be considered unpleasant to see the miscarried baby it can be a vital part of the grieving process for the bereaved parents. Sometimes there is little to see - perhaps the baby cannot be readily identified. However the reality can enable the grieving process to flow. It is a legal option for parents to bury their miscarried baby at home. Many parents would be unaware of this.

“Elaine” anxiously contacted Open Doors after hearing about our Pregnancy Loss Counselling Service. She had become pregnant as a student, was planning to marry her boyfriend but miscarried at 9 weeks. They were both devastated even though they were struggling to come to terms at that point in time with a pregnancy. They tried to put the experience behind them somehow but would find their grief triggered around the anniversary of the loss. Family and friends expected that they were long over it. But “being over it” somehow seemed to “Elaine” and her husband like disowning their child. They were both very aware of that child’s place within their family system.

What troubled “Elaine” the most was the fact that she didn’t know what had happened to her baby’s body. She was distressed to think that the baby, although very tiny, would have been flushed away. She had no image of how the baby looked and said, “It’s hard to say ‘goodbye’ when we haven’t been able to say ‘hello’”.

Many talk about feeling an expectation to forget their loss. Most parents do not want to forget the miscarried child. The lost child is indeed part of the family system.

In my clinical experience it is healthier to acknowledge it, mourn and integrate the loss. To plan and hold a ritual to mark the life and loss of their child can be a very productive and appropriate thing to do. Parents need to be encouraged to be creative in doing this - to make a ceremony that is meaningful for them. Naming the child helps the parents consolidate the reality of the lost child.

Many parents do actually have a concept of their child’s gender identity but if they don’t they may like to choose a name that can be assigned to either sex. The planting of a tree or shrub can serve as a living memorial to the child.

Creating memories helps acknowledge that child, give a focus for the grief response and allows him or her to have a place within the family system. This may be done in a number of ways. Writing a journal of the events, thoughts and feelings, keeping anything of significance in a memory box (perhaps an ultrasound picture or arm bands from the hospital admission) or even creating a special certificate to mark the memory of the baby, all serve this purpose.

The focus, in the past, has tended to be on urging the parents to get on with life, and perhaps have another baby straight away in the misguided attempt to replace the one lost. Indeed to embark on a subsequent pregnancy whilst grieving a lost one can interfere with the bonding with that child. One child can never be replaced by another. In many instances this is still the case. We hear of people consoling parents with statements such as, “Never mind, you’re a healthy woman, you’ll soon have another baby” or “At least you have other children”.

These statements, although well intentioned, negate or, at the very least, minimize the loss. “It’s nature’s way of dealing with problems” tends to deny parents the right to grieve. So, too, does “Oh well, you didn’t have time to get to love it”. This type of response questions the normality of a mother’s bonding with her child. It causes her to stifle her grief on a conscious level, leaving her with unresolved grief that may color her life with a pervasive sadness for many years. Numerous women, when recalling a pregnancy lost many years ago, experience a grief reaction as fresh as if the loss had happened yesterday.

The woman who has terminated a pregnancy often feels that she does not have the right to grieve - something that may prevent her from accessing help. She may believe that she forfeits any entitlement to support because of her “choice”.

In closing, there is a need for greater awareness about the emotional and psychological reactions that may accompany a pregnancy loss. This applies not only to women and their partners but also for the wider community. We need to be empathic, sensitive and supportive of parents faced with this type of loss, providing them with information and resources to deal with their loss rather than leaving them with a silent sorrow that sits unexpressed in their hearts.

Another woman, “Nancy”, sobbed quietly as she told me about the baby she lost at 12 weeks. She had not seen the baby and this left her with a nagging sense of regret, as she knew that the baby would have been well formed. She had no tangible evidence of the child’s passing and had never spoken about it. Within her family there had been a code of silence about such matters. She had been confused about the persistent thoughts she had about the baby and the inability to move on and forget about the pregnancy. She often questioned whether she was crazy. She subsequently had 3 other children but never forgot her first.

Much of the counselling done consisted of educating “Nancy” about the grieving process and assuring her that her feelings were normal. As we worked through this loss she named her baby, planted an ornamental tree in her garden as a living symbol of her child and took part in one of the ecumenical Remembrance Services for pregnancy loss that Open Doors Counselling holds 3 times a year. Formally acknowledging her baby gave “Nancy” a great sense of resolution and peace.

“Nancy’s” pregnancy loss was 45 years ago.

Open Doors has provided counselling services for thousands of women since 1984, both in the areas of unplanned pregnancy and pregnancy loss. We have sat and listened to many “Sue’s”, “Elaine’s” and “Nancy’s” of varying ages, helping them to face difficult decisions and work through their grief. Our aim is to assist people to understand their grief as a natural and healthy response to the loss of a significant person, explore the experience fully and then integrate it in a meaningful way into their lives.

(Names and other identifying details used in this article are fictitious to protect client confidentiality.)
 

Friedman, R. and Gradstein, B., Surviving Pregnancy Loss. Little Brown & Co. America. 1982

Nichol, M., Loss of a Baby: Understanding Maternal Grief. Bantam Books, Australia (1989)

Overs, M., Coping with Miscarriage. Health Books. Gore & Osment. Australia. 1995.

Peppers, L.G. and Knapp, P.A., Motherhood and Mourning. Praeger. N.Y. 1980

Savage, J., Mourning Unlived Lives. A Psychological Study of Childbearing Loss. Chiron Press. 1989.

Witzel, P.A. The unrecognized psychological impact of miscarriage. Canada’s Mental Health. March 1991. Published as Witzel, P.A. & Charter, B.M. (1989)

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Updated May 2005