Miscarriage. A silent loss.

Early miscarriage is the most common obstetric complication. One in four women are said to experience miscarriage at some point of their reproductive lives. In recent years, research has highlighted that following a miscarriage many couples go through painful loss and a particularly complex grieving process.

Grief is a natural and healthy reaction to loss. The grieving process includes a shifting of emotions such as denial, anger, bargaining, depression and acceptance. Under typical life circumstances we mourn somebody we knew, somebody with whom we have memories and past shared experience. When confronted with the loss of a loved one, denial and confusion are typical reactions, but we are clear who this person was to us.

Grief following a miscarriage, or any form of perinatal loss is more complex. How is it possible for us to mourn someone we never knew? Someone who in some way never became real. Following a miscarriage couples do not only mourn the loss of the baby and the pregnancy.  They mourn hopes and dreams about how this pregnancy would have changed their lives, a future in which they were parents to a baby.

Up to as recently as the 1980’s, it was considered that a woman would experience less grief if the loss occurred early in her pregnancy. More recently, researchers have been unable to find an association between the term of the pregnancy and intensity of grief. A woman who experiences pregnancy loss at an early stage may be as distraught as a woman who suffers loss at a later stage of the pregnancy.  The intensity of the sense of loss seems to depend on the meaning of the pregnancy to the person in question.

Current medical technology allows women to know very early on when they are pregnant. The attachment and bonding process can begin as soon as the pregnancy is confirmed. Expectant mothers begin to fantasise about their baby. They anticipate their future lives and prepare for motherhood. The unexpected event of a miscarriage seems surreal to many women. One day they are pregnant future mothers, the next they have miscarried. Many women feel lost and disorientated, they feel like they have begun a journey which abruptly comes to an end before they reach their destination. They feel deprived of showing the world their mother-ness, and doing what seems simple for other women, carrying a baby to term.

At this early stage of the pregnancy physical modifications are not obvious to the world, foetal movement is absent. The future baby is very much in the mother’s imagination. A positive pregnancy test and an ultrasound scan may be the only evidence documenting that the woman “really was pregnant.”

After a miscarriage, many women describe a great sense of emptiness.  The body goes suddenly from being pregnant to not being pregnant.  The pregnancy loss involves a significant shift in hormones that can affect brain chemistry.   Leaving the woman to process through complex grief in a vulnerable hormonal position.

Grief after miscarriage takes time; and varies in degree.  Women report feelings of anger one day and deep sadness the next. Certain events can trigger the intensity of grief such as going back to work, monthly anniversaries of the miscarriage and the expected due date. Often waves of grief can be triggered by celebrations such as Mother’s Day or when a friend gives birth.

We live in an “information age”, we are used to getting answers, finding out why, as soon as we can.  When a couple can’t find out what has caused the miscarriage the questions seem to turn in on themselves. Many women engage in re retroactive bargaining, a process of rewriting the story, so to speak: ‘If I hadn’t gone to the swimming pool’ or ‘If I didn’t stay up so late.’ Men seem to express guilt, “If I hadn’t stayed so late at the office” This seems to be a way of attempting to regain control and cope with the loss.

Questions such as, “Why me?” may surface. It is common to want answers even though none may exist. Anger may be directed at the doctor, feeling that he or she could have done more or at least have been more concerned. Feelings of anxiety after a miscarriage can stem from experiencing a seemingly inexplicable event.

Georgia Witkin, PhD, director of the Stress Research Program at the Mount Sinai School of Medicine in New York advocates that “Stress goes up and anxiety levels increase when people lose control and their ability to predict what will happen next goes down, Pregnancy loss, which is often unexpected, and unexplained affects both perceived control and ability to predict”.

Following a miscarriage, women can be surprised by feelings of jealousy towards other women who are pregnant or parenting. These emotions that erupt from time to time, are simply an expression of grief and are a common response following a pregnancy loss.

Funeral ceremonies allow us to say goodbye to a lost loved one. Our family and friends rally around us. They offer us sympathy and warmth, validating our loss, allowing us to move towards grieving. Society has no rituals to address early pregnancy loss or to acknowledge the couple’s grief. Well-meaning family and friends unknowingly say all the wrong things to a couple who have recently lost a pregnancy.

Early miscarriage seems to spur awkwardness and avoidance, people seem embarrassed or uncomfortable, not knowing how to address the couple’s feelings of sadness. They seem to engage in a type of “remedy” like sympathizing, saying such things as, “you will have another”,  “better to lose it early on”, “it was nature’s way”. They may even tell the woman how lucky she was to get pregnant in the first place. None of these responses are helpful to the couple. They neither validate the loss, nor facilitate the grieving process after a miscarriage.

Men and woman often react differently to a miscarriage. Many men feel they must be strong and protect their wives from their own feelings of loss and sadness. Others are more concerned about the medical and emotional health of their wife and spend much of their energy trying to “find a solution to make it better.”

Society tends to reinforce this; often others only ask how the woman is doing, excluding the feelings of the expectant father. Following miscarriage some men tend to hold their feelings inside and deal with the loss on their own. They may feel the need to avoid the topic, and turn their attention elsewhere. In turn their partner may feel emotionally abandoned and alone. This can cause conflict and bad feeling between the couple. Grief stricken couples seem to react in individual ways; one may be actively grieving while the other gives support and later the roles may reverse.

Society expects those who have gone through a pregnancy loss to move on quickly and “to get over it” as quickly as possible. The couple can feel a certain “pressure”, an expectation to return to normality. Sharing the experience with a professional, in a safe non-judgmental environment can help couples to feel less isolated and provide them support in what they are going through.

SOURCES: Johnson,P.  British Journal of Medical Psychology, 1996. Blackmore, E.R. British Journal of Psychiatry, 2011.Georgia Witkin, PhD, senior psychologist, Reproductive Medicine Associates of New York.Sami David, MD, reproductive endocrinologist, New York City.Emma Robertson Blackmore, PhD, assistant professor of psychiatry, University of Rochester Medical Center.

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