By Norman Brier
Miscarriage--defined as an unintended ending of a pregnancy before the twentieth week of gestation--is a relatively frequent event that often produces a strong sense of bewilderment and marked feelings of distress. A woman who miscarries experiences several losses: the special attention and care she had been anticipating or receiving as a pregnant woman; the feeling of being one, a unity, with the developing fetus; the feeling of bodily adequacy related to the ability to bringing a pregnancy to term; and, especially, the times that were to be spent with the expected child.
Most people have a great deal of difficulty coping with a miscarriage. The experience is often sudden and unexpected, so that there is little time to prepare. Often it is also highly ambiguous; unlike the loss of a friend, parent, or partner, there is no person to bury or actual memories of shared time to treasure and grieve. Instead, only an imagined future can be mourned, and usually without any clear rituals to help the person structure and express her grief.
The frequent lack of adequate emotional support is likely to add to a woman's distress as well. Many of the people who might have been supportive during prior times of stress may be unaware of the pregnancy and miscarriage. Those who are aware often fail to recognize the extent of a woman's distress, or make comments that seem to minimize the experience, such as, "You'll have another," or "It wasn't meant to be."
In the support groups I conduct for women who have experienced a miscarriage, the following are some of the questions asked most frequently.
How common is miscarriage, and what causes it?
Currently, 15 to 20 percent of known pregnancies end in miscarriage. The percentage is likely to be even higher in the future, for at least two reasons. First, pregnancies are being detected earlier and, as a consequence, couples are becoming aware of unviable pregnancies that they might not have known about in the past. Second, women are postponing childbearing to a later age, when miscarriages are more frequent. The rate of miscarriage roughly doubles from age 20 to 30, and then doubles again from the early to late 30s. More than 80 percent of miscarriages occur during the first trimester, with 75 percent of these occurring before the eighth week.
A miscarriage is caused most frequently by problems in the fetus, usually chromosomal abnormalities, and by problems in the maternal environment. The latter includes uterine and placental problems, progesterone deficiency, and less commonly, infections and systemic disease. Exercising, having sex, or lifting heavy objects do not cause a miscarriage. A fall or a blow is also unlikely to cause a miscarriage unless it was life threatening. No reliable evidence exists to show that emotional distress causes a miscarriage.
Why do I feel such an intense sense of loss when I never even saw my baby?
Most women form an emotional attachment with their developing baby very early on. By about the tenth week of pregnancy, it is usual to have a distinct and definable mental image of the baby and detailed daydreams of his or her arrival. Procedures such as sonograms and amniocentesis greatly facilitate the formation of these mental images, and the pictures produced by these procedures tend to be the images most frequently imagined after the loss has occurred.
Is what I am feeling normal?
Immediately following the loss, most women experience a great deal of emotional distress. It is usual to feel a profound sense of grief, guilt, and anxiety, and a depressed mood. It is also usual to have sleep and appetite problems, little energy, concentration difficulties, and strong feelings of discouragement.
For the majority of women, these feelings peak and begin to lessen between the fourth and sixth week after the miscarriage and are almost fully gone by the third or fourth month. A minor but still sizable group of women, however, continue to be distressed for a much longer period of time. The likelihood of having a prolonged period of distress increases the more the following conditions apply:
(1) The pregnancy had been planned for a long time and very high expectations were attached to the birth of the baby
(2) A long time and/or much effort (e.g. infertility treatments) were needed to conceive
(3) Guilt over prior abortions is present
(4) The miscarriage occurred relatively late in the pregnancy
(5) There is a history of prior losses
(6) Social support is lacking
(7) An unhappy relationship exists between the partners to the pregnancy
(8) There is a history of poor coping, especially prior periods of depression.
A sense of not being oneself or of being in shock is often experienced at the time of the miscarriage. This feeling may be an attempt to adapt by "stepping out of time" until it is tolerable to "catch up" to the distressing reality of being pregnant one day and not pregnant the next. As the shock fades, there tends to be a preoccupation with thoughts about the lost pregnancy, and feelings of self-blame and anger are common. The anger is often especially strong towards health providers for failing to prevent the loss.
Typically, there is also a strong desire to find a reason for what has happened, along with a belief that the miscarriage is unfair. Probably as a result of this sense of unfairness, feelings of envy are frequently felt toward pregnant women and mothers of infants. With the passage of time, sad feelings often begin to be replaced by anxious feelings, as concerns about conception and the ability to bring a baby to term tend to become central.
Why does my husband seem to feel so differently about the miscarriage than I do? Are these differences likely to harm my marriage?
While fathers are likely to be strongly affected by a miscarriage, they tend to experience a less intense and prolonged grief reaction than mothers. A mother's distress is usually independent of the gestational age of the fetus, whereas the intensity of the father's distress seems to depend a great deal on the length of the pregnancy. A father's reaction also seems to depend on the degree of attachment he feels toward his partner, and the opportunities he has had to experience the pregnancy as a reality. For example, a father is more likely to be distressed if he has seen the fetus during a sonogram and has felt fetal movement.
In general, after the miscarriage, fathers cry, talk about the loss, and get depressed to a lesser degree than their partners and are usually able to return to their normal routines more quickly. As a result, a father sometimes questions why his partner continues to grieve for so long and with such intensity. When this incongruity occurs, the marriage can become strained; the woman may feel that her partner is not sufficiently caring, while the man may feel that his partner is overreacting and failing to appreciate what he does feel. Conflict, however, is avoidable for most couples. In fact, a fairly large percentage of couples report feeling even closer after the miscarriage than they felt before.
How will the miscarriage affect my other children and my own parents?
Children under the age of 5 or 6 do not usually understand that death is a final and irreversible event. Therefore, the reaction of children before this age is primarily determined by how they see others react, especially their mother. For older children, common reactions include confusion in the face of their parents' distressed behavior, anger and disappointment that the expected brother or sister will not be coming, and feelings of self-blame, as if something they did or thought may have caused the miscarriage. Self-blame and guilt are especially likely if there was resentment about the arrival of the new brother or sister. Finally, there may be feelings of anxiety about the possibility that more bad things might happen, particularly to a parent. As a result, children tend to have more trouble separating from parents after a miscarriage.
Grandparents also are often profoundly affected by the loss of their "baby's baby." They tend to worry about the well-being of their own child and to feel upset at the loss of the times they anticipated with their expected grandchild. In addition, in the case of a wished-for male child, they may also feel upset over the lost opportunity for the continuation of the family name
What can I do to feel better?
It is helpful to try to get the clearest and most complete answers possible to two questions: (1) Why did the miscarriage happen? And (2) Will it happen again? The obstetrician is usually the best person to ask these questions. While he or she may not be able to provide clear-cut answers, it is important to request sufficient time for the consultation to hear the explanations that can be offered and to express the strong feelings and worries associated with these concerns.
Grieving tends to be facilitated when the loss is made as tangible as possible. Thus seeing evidence of the baby's death, such as fetal material, helps concretize the loss, as does naming the baby. Rituals are also helpful in allowing the grief to be expressed. A candle can be lit, a tree planted, a letter or poem written that puts into words the love, hopes, and dreams that were held for the baby. Written statements have two additional benefits. They help couples share their thoughts and feelings, and they establish a permanent record of the couple's connection to their lost child. For example, the couple can write a letter using the following format: "Dear (name used to refer to the fetus and/or planned name), We are writing to tell you the hopes and dreams that we had for you. We were never able to tell you that..."
Learning about what other people experience after a miscarriage, by reading articles or attending talks, also tends to lessen distress. Such experiences help validate the normality of what is being felt and allow the individual to anticipate what lies ahead. Preparation is especially helpful in dealing with the undoing of the changes that were made in the house or the purchases made in anticipation of the baby's arrival. Preparation is also helpful in handling encounters with people who do not know about the loss as well as those who do, and who are likely to ask disturbing questions. The couple can discuss what they picture when they anticipate the circumstance they believe will be stressful, how they imagine they will feel at this time, what they see as the possible ways of responding, and the choice that they feel is best for them.
It has been more than a month since my miscarriage and I still feel awful. What should I do?
A support group of other women who have experienced a similar loss may be helpful. In such a setting, people usually benefit from feeling understood by others; they have an opportunity to acknowledge and express their feelings, and can learn how others cope. Most obstetric practices maintain a list of such groups that are held in the community.
Assistance may also be obtained from a mental health professional who has experience in the area of pregnancy loss. As part of such a consultation, the implications of the loss for the individual are examined, as are any irrational beliefs that may be present, for example that the miscarriage is a punishment for some prior, guilt-producing event. In addition, other sources of stress that may be affecting the individual's reaction to the miscarriage are identified, and the adequacy of the person's support system is looked at. Advice is then usually provided to deal with any problems that have been noted, followed by a three-month follow-up appointment to see if there is sufficient improvement or the need for additional help.
If a woman remains distressed for more than two months from the time of the loss, to the point where the demands of everyday life cannot be met, a mental health evaluation is necessary. The clinician will note the emotional difficulties that are present, review past problems with coping, and (usually in partnership with the person and someone they choose from their support system) establish and carry out a treatment plan.
It is important to remember that the majority of woman who try to conceive after a miscarriage go on to have normal pregnancies and deliver healthy babies, and that the distress and difficulties in coping experienced after a miscarriage tend to be relatively time-limited. Thus, while feelings of sadness and anxiety, accompanied by a strong sense of loss, are usual, these feelings ease appreciably in a relatively short period of time.
Norman Brier, PhD, is a psychologist with a special interest in pregnancy loss. He has a private practice in Bedford, Mew York, and is a Clinical Professor of Pediatrics and Psychiatry at Albert Einstein College of Medicine.