by Anne Neville
R.N., R.M., Dip. Past. Psych., Dip. Marriage & Family Therapy,Cert. Interpersonal Relationship Therapy, Accredited Grief & Loss Counsellor National Association of Loss & Grief (Vic) Clinical Member CAPAV. PACFA Reg: 21127
updated January 2016.
“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.”
Parental self image
The hospital experience
Marking the loss
Types of Pregnancy loss
Impact of early pregnancy loss on mothers, fathers, relationships
Creating rituals and memories
Implications for hospital staff and counsellors
(All names and identifying details have been changed to protect client confidentiality.)
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. 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 in which shock, disbelief and numbness can play a large part is a totally normal response. A miscarriage is often sudden in its physical onset, leaving the mother with the sense that something terrible has happened (Keenan, 2007). Denial is a means of coping with the loss and this may last hours, days, weeks or even months in some cases.
- The acute mourning period, is the time in which the very raw emotions are felt. Sadness predominates – it’s not unusual to find oneself bursting into tears, crying often or being aware of a general and persistent underlying sadness that colours one’s whole being. There may also be an increase of feelings of anger, guilt, blame and jealousy – emotions that tend to cause feelings of discomfort.
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.
Women often feel a sense of “oneness” with their foetuses in early pregnancy and see the baby as an extension of themselves. Therefore the ensuing grief and loss is experienced as the loss of a person (Gray & Lassance, 2003). Women usually show the same range of feelings spoken about in other significant bereavement situations.
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. In addition, the process also requires a mind shift, as letting go of these thoughts and plans and allowing oneself to grieve can be hard.
Parental self image
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.
It’s important to help parents to understand that a miscarriage is a situation beyond their control.
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. There can be feelings of inadequacy or being “defective” in some way (Jelovsek, 2015). Women often put themselves under the microscope in search of a reason why the miscarriage has happened. Blaming oneself and wishing things were different is normal.
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.
Quite often these thoughts become a part of looking for an answer for the miscarriage but, all too often, there is no answer.
Anger is also a common reaction – when a significant loss occurs anger, guilt and physical are often felt within the deeper tissues of the body (Broquet, 1999). Anger 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. Platitudes like “Well, it was probably for the best” or “there may have been something wrong with the baby” only resulted in her feeling angry and wanting to withdraw and lick her wounds. 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 but we need to remember that men’s grieving style can be different to the mother’s and they also may not show their grief, not wanting to add to their partner’s grief. However we know that women want their partners to show their grief, to show they care and value the loss of their child also.
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.
Some fathers can feel left out when their partner miscarries because the woman has experienced the physical loss of the baby and people often think of her needs first. He may not want to express his feelings in front of other people and can feel powerless in comforting his partner. (See Men and Pregnancy Loss)
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.
The hospital experience
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. This can be accompanied by feelings of great emotional discomfort – it’s not unusual for women to believe that they’re going crazy whereas what happening is a perfectly natural response that’s been suppressed for a long time. It’s a time of trying to get used to what’s happened and the longer grief is put on hold the longer it will take to process the loss.
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.
Most Prevalent Symptoms Reported by Bereaved Mothers
A study of women following stillbirth or neonatal death showed the following symptoms (Nichol, 1989).
Fear of a nervous breakdown17%
Feelings of Panic14%
Repeated unusual thoughts13%
These symptoms are observed when counselling women who have experienced other pregnancy losses e.g. miscarriage and surgical abortion.
Psychiatric consequences of pregnancy loss if the grief process does not progress to resolution
The most common problems are depression and anxiety when grief has, for whatever reason, been put on hold. The general rate of depression in women is about 10-15%. After miscarriage, this rate is reported to be 22-55% and takes 12 months to return to the baseline rate of depression in the general community. The highest risk time for depression is the first 12 weeks after a pregnancy loss. Risk factors for developing clinical depression include previous depression, the further along in pregnancy that the loss occurred, a history of substance or alcohol abuse, a poor support system and a history of poor coping skills.
In the first 12 weeks after a pregnancy loss, 22-41% of women demonstrate generalized anxiety or panic disorder. The rate for men is about 3-5%. As with depression, these rates tend to return to baseline community rates within 12 months. Compulsive behaviours may increase during this time and women who have had a previous pregnancy loss are at greater risk of developing depression and anxiety in subsequent pregnancies (Jelovsek, 2015).
Psychological effects of miscarriage
- Feelings of disbelief
- 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
- 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.
Often the lead up and anticipation can be worse than the actual date involved and many women say they feel a sense of relief knowing why they feel the way they do.
Marking the loss
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, even if the loss occurred many years ago. 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. (see Creating Memories of Your Baby for further ideas.)
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”. However, she can’t forget even though she pushes down her thoughts and emotions and tries to get on with her life. What we do see is the rush of grief when there has been a significant trigger.
I remember Jane, who phoned in great distress. Her daughter had just announced her first pregnancy and this had triggered Jane’s memory of hers when she was 18 and had aborted. Jane cried for a long time before she was able to talk about her loss and what that meant for her.
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 had occurred 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 ‘Janes’, ‘Sues’, ‘Elaines’ and ‘Nancys’ 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.
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.
(Names and other identifying details used in this article are fictitious to protect client confidentiality.)
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