by Donna Rothert, Ph.D.
Licensed Clinical Psychologist
A sudden gush of blood, a strange look from a doctor, or the words, “I’m sorry” might be a woman’s first clues that she has experienced a pregnancy loss. At whatever point in the pregnancy this loss occurs, this moment often starts a period of pain and searching as a woman struggles with the impact of losing the baby she had dreamed of bringing home. Since approximately 20 percent of all known pregnancies end in miscarriage or stillbirth, it is, unfortunately, an all-too-common experience that can be extremely difficult to bear.
Attachment in Pregnancy
“People didn’t seem to understand why I was so sad about my miscarriage, as if because I didn’t carry my baby very long, I wasn’t attached.”
Although some women might not become strongly attached to a baby prior to birth, the majority certainly do. It’s true that for many women whose pregnancy loss occurs later in the pregnancy, as in the case of a stillbirth, there are likely to be extremely difficult physical and emotional experiences as a result. These women may be at greater risk than those with earlier losses of having psychological trauma and a longer and more intense grief experience. These increased difficulties are associated with the deep sense of attachment formed during the pregnancy.
However, the assumption that women emotionally attach in proportion to the length of the pregnancy is not always true. Eighty percent of pregnancy losses are first trimester miscarriages. Women often don’t tell others about their pregnancy during the first trimester and may try to “keep from getting too excited” due to fears about a loss. However, a woman who miscarries at 8 weeks’ gestation may experience it as the loss of a child and grieve it as such, while someone else may have a later loss and experience it with less intensity.
A pregnant woman generally goes through a process of imagining the baby: guessing if it’s a boy or girl, wondering how the baby might look and behave and considering how this new being will likely enhance and alter the current family configuration. The developing feelings of hope, affection and attachment with a new and beloved family member are specific to this pregnancy and this baby. This holds true even if the pregnant woman has or expects to have other children.
Loss and Grief
“I had no idea, just no idea that anything could hurt as much as losing my baby. I thought I would never feel joy again; that I was somehow broken forever.”
A Silent Sorrow; Empty Cradle, Broken Heart; Unspeakable Losses—just looking at the titles of books on pregnancy loss evokes the enormity of the pain they attempt to address. Part of the poignancy of pregnancy loss is the loss of part of one’s future or the “death of dreams.” The dreams of holding, nursing, rocking and watching this baby grow are lost forever.
Of course, individual reactions, or grief response, to any loss can vary greatly. However, certain emotions are frequently shared by women after pregnancy loss. Shock, fear, loneliness, sadness, despair (often including suicidal thoughts), anger, and confusion are all common features of the grief process following pregnancy loss.
Paradoxically, some women also experience a sense of relief following pregnancy loss, especially if the pregnancy was particularly difficult or tenuous for an extended period of time. This does not mean that the pregnancy was unwanted or that the loss isn’t still enormously painful. A minority of women report only minimal emotional response to a pregnancy loss. These women might see the loss as simply part of life, rather than as a significant crisis.
Exhaustion, physical pain, and feeling a loss of control can intensify the painful nature of the early grieving period. Depending on the individual and her circumstances, an element of trauma can also be a part of a pregnancy loss, complicating and exacerbating the process of grief. Additionally, “anniversary reactions” are typical, meaning that the yearly anniversary of the loss is usually accompanied by a resurgence of feelings, often of an intensity not experienced since just after the loss. If the loss happens before the expected due date, the due date and subsequent anniversaries of it may bring about the same reaction. These anniversary reactions are an expected part of grieving.
“I feel like I waited forever for this chance-I always wanted to be a mother and it took us so long to conceive. Then nine weeks into it—poof—we lost everything. We’re back to square one.”
Defined as the spontaneous loss of a pregnancy prior to 20 weeks’ gestation, miscarriages make up 95 percent of early pregnancy losses and occur in 15–45 percent of all pregnancies (the variance is due to the difficulty in tracking early pregnancies). For many people, this is the word that comes to mind when they think of pregnancy loss.
There are many ways in which a person might experience a miscarriage. One common example of a miscarriage involves a woman using the bathroom and discovering that she’s bleeding. She then sees a doctor and is informed that the pregnancy has either ended or is in the process of ending.
Some women have no symptoms of a miscarriage until they have a sonogram and are informed that the pregnancy has in some way gone awry. At least half the time, there is no known cause for a miscarriage.
Often a D&C operation (dilation and curettage) is performed after miscarriage to minimize bleeding and risk of infection. Some period of physical recovery is often necessary and will occur alongside any emotional reaction.
Emotional reactions following miscarriage, as in the case of other types of losses, may include sadness, despair, relief, fear, anger, shock, and confusion. The woman and her partner may have strong feelings about the medical procedures or other medical treatment that were part of the process. The feelings of those who have experienced miscarriage are more likely to go unrecognized than they are for people who experience stillbirth or other late-term pregnancy losses. This may lead to a greater reluctance to express emotions or seek help, complicating the process of emotional healing.
“The whole hospital experience felt surreal. People were asking me about an autopsy and whether I wanted a cremation or a burial. I hadn’t delivered yet and I felt like yelling ‘Look at me, I have a baby inside and she’s supposed to be born in a couple of months.”
A stillbirth is a fetal death after 20 weeks. Although only 14 percent of pregnancy losses occur during the second trimester and just 6 percent during the third trimester, these losses are still not infrequent. The causes are numerous, including umbilical cord accidents, premature birth, and birth defects.
Shock and disbelief are likely to be present in late-term losses. The woman involved may feel that after successfully completing the first trimester, discovering whether she was carrying a girl or a boy and receiving positive news from prenatal testing, she is fairly assured of a healthy baby. She has had many months to fantasize and plan what life will be like with this baby. The shift from these happy expectations to the reality of the death of her baby is an enormous one to make.
Despair is very common in these losses. The attachment phase has been lengthy and the woman may have come to know her baby through his or her kicks, rolls, hiccups, and sleep cycles. She may have seen multiple sonograms and spoken to her baby for months, referring to the baby by name.
Labor and delivery, challenging for most people expecting positive outcomes, can be torturous for someone who knows her baby has already died. If the labor has to be induced, especially if the loss occurs significantly before term, the process is likely to be slower than a typical labor, and may even last for days. Interactions at the hospital tend to take on extreme importance to the parents involved, not only because of the loss itself and the difficult delivery procedures taking place there, but often because this is the only setting in which they will ever see their baby.
Because of the need to see and nurture the baby, hospitals now encourage parents to spend time with the baby after he or she is born, and will routinely take pictures of stillborn babies for the parents to take home. Babies are cleaned after birth and wrapped in blankets or dressed. Additionally, the practices of naming babies and creating ceremonies to acknowledge them are recommended. Although this is an extremely difficult time to be making decisions, there may be a number of them to be made, including whether an autopsy will be performed and whether there will be a burial or cremation.
Physical recovery from a stillborn delivery is often similar to the regular post-partum experience. Even if delivery happens months before the expected due date, a woman experiencing a stillbirth will still have her breast milk come in. This usually occurs a few days after labor and is particularly uncomfortable and upsetting. These early days at home may be an especially vulnerable time for a woman.
Other Types of Losses and Complicating Factors
“We felt so elated that the IVF worked. Then the doctor told us that there were four babies and we would have to do a reduction of two to save the others. I was in shock—it seemed like a sentence for us, not a choice.”
A number of additional factors may intensify the pain of pregnancy loss. Such factors include medical issues such as ectopic or molar pregnancies, and “crisis pregnancies” that involve significant medical intervention and/or drastic behavioral changes such as constant bed rest. Infertility issues and repeated pregnancy losses or losses in a multiple (twins or higher order) pregnancy can also complicate the grief experience. Medical terminations for impaired pregnancies and selective reductions in pregnancies of multiples pose significant additional challenges. Lastly, a history of depression, anxiety, or other mental health issues is likely to complicate a woman’s experience of pregnancy loss.
What Can Help
The Grieving Mother: What You Need
As odd as it sometimes sounds to people, experiencing your grief intensely, fully, and with minimal concern about outside judgments is generally the most effective way to deal with it. Grief that is denied or avoided is likely to continue to resurface, sometimes in very troubling ways. Addressing grief allows you to learn how to bear it and incorporate the experience of your loss into your life. If your baby has died, whether recently or years ago, here are some ways to help yourself through the grieving process.
*If, like many women, you feel that this loss was the loss of your baby, acknowledge yourself as a mother. Even though your baby has died, you are a parent and specifically a parent to this child. It may be helpful for you to accept this in your own thinking and in your interactions with others.
*Pay attention to healthy eating, sleeping and other physical care. Be careful to avoid numbing substances such as alcohol and other drugs. Exercise, as physically appropriate to your current health, can be a useful release during this stressful time.
*Find someone with whom to share your feelings, preferably someone who won’t judge them. People may need guidance on how to helpful. It’s okay to tell them that you don’t need advice, just someone to listen. Talk about your feelings—good and bad—about the pregnancy and the outcome.
*A number of books and Web sites about pregnancy loss are now available. Some are comprehensive and cover a variety of types of losses, while others focus on particular experiences and needs. Reading others’ stories, whether in books or online, may reassure you that you’re not alone.
*Consider writing down your thoughts and feelings, whether in a journal, poems, stories, or online blog. Naming your feelings in some form is an important step to being able to bear them.
*Try not to put expectations or time limits on what you should be feeling. The feelings are likely to come in waves and vary in intensity.
*Religious and spiritual practices can provide support and peace to you. Rituals, whether religious or secular can be extremely useful as ways of signaling to yourself and others that the pregnancy and loss had meaning. Focusing on memories of the pregnancy and baby, rather than making yourself “wallow” in grief, is actually an important step in incorporating the loss into your life. Although rituals and the sharing of memories tend to be recommended more often for those experiencing later pregnancy losses, they are just as relevant for early pregnancy losses, including first-trimester miscarriages.
*Whenever possible, postpone or delegate big decisions after pregnancy loss. Of course, planning a subsequent pregnancy can be a difficult decision that may feel particularly urgent. Working to understand your feelings and sharing them with your partner and others is especially important when making the decision about trying again. Talking to others who have made this decision and reading about the experience of other women in similar situations can help you decide when and if you want to try again.
*Support groups can be found through many organizations and hospitals. Some groups are specific to particular types of losses (miscarriages, stillborn and early infant death, medical terminations). Finding and connecting with others who have had similar experiences can decrease the sense of isolation and help a woman to identify and make sense of her feelings. Additionally, psychotherapy can serve as an opportunity for support and a place to find meaning in what is typically a life-changing event.
*If you’re experiencing severe insomnia, depression, suicidal thoughts or any other distressing feeling or behavior after pregnancy loss, there are professionals who can be helpful to you. A psychotherapist can help you with assessment of your symptoms, work with you to process your experience and, when needed, make referrals to a doctor who can prescribe medication. Psychiatrists and primary care physicians can also assess symptoms and prescribe medication. Crisis hotlines are available for immediate help and referrals.
How Others Can Help
If someone you know has suffered a lost pregnancy, reach out to her, offer yourself as a listener, and then be a good one. Don’t shy away or assume that she doesn’t want to talk about it. Resist temptations to offer advice, give explanations for the loss, or minimize the event. Take your cues from the grieving person. If she identifies herself as a parent or states that she lost a baby, treat her as a mother who has lost a child, because that’s what she is. Don’t assume that her feelings will be short lived or removed by another pregnancy or new baby. Remember that you don’t have to say anything perfect or profound. Just saying, “I’m so sorry for what you’re going through,” and offering yourself as a listener, is doing a lot.
Help for the Partner
Of course, pregnancy loss doesn’t just affect one person. Although the focus of this article has been on the woman who physically experiences pregnancy loss, multiple other people are usually affected. Her partner is likely to have many of the feelings described above and may find different ways of grieving and coping. Different styles of grieving are almost inevitable as couples experience a shared loss. Support groups are typically open to, and often work best with, both partners. Additionally, partners have the same needs for practicing self-care and finding someone other than their partner with whom to share their feelings. Couples therapy may also be useful.
Help for Other Family Members
Children and grandparents also have their own needs following a pregnancy loss. Please see the following resource list of organizations and information for these family members.
Donna Rothert is a licensed clinical psychologist in private practice. She specializes in pregnancy loss, infant loss, depression, anxiety, grief, and life transitions. She can be reached at (510)273-9548.
Copyright 2005 Donna Rothert, all rights reserved. You may e-mail or reproduce and distribute provided the following: The article appears in full, without editing, including contact information and this notice.
Books for Adults
A Silent Sorrow: Pregnancy Loss: Guidance and Support for You and Your Family, 2nd Edition; by Ingrid Kohn, MSW and Perry-Lynn Moffit Routledge, 2000
When Hello Means Goodbye: A Guide for Parents Whose Child Dies Before Birth, at Birth, or Shortly After Birth; by Pat Schwiebert, RN and Paul Kirk, MD, Perinatal Loss, 1998
Trying Again: A Guide to Pregnancy After Miscarriage, Stillbirth, and Infant Loss
by Ann Douglas and John R. Sussman, MD, Taylor Trade Publishing, 2000
Miscarriage After Infertility: A Woman’s Guide to Coping
by Margaret Comerford Freda, RN and Carrie F. Semelsberger, Fairview Press, 2003
Book for Children
We Were Gonna Have a Baby, But We Had an Angel Instead
By Pat Schwiebert and Taylor Bills (Illustrator)
Perinatal Loss, 2004
Organizations (all have Web sites and newsletters)
Provides training in perinatal bereavement, news and updates, newsletters, group information, message boards and chat rooms
MISS (Mothers in Sympathy and Support)
Focused on helping families after the death of a baby or young child, bimonthly newsletter, information in English and Spanish, information for kids dealing with loss
CLIMB (Center for Loss in Multiple Birth)
International parent contact list for bereaved multiple birth parents, website and quarterly newsletter.
AGAST International (Alliance of Grandparents, a Support in Tragedy)
www.agast.org; (888) 774-7437
Responds to bereaved grandparents with information packets, personal contact, remembrance cards and quarterly newsletter
Local Support Groups (all are free)
SAND (Support After Neonatal Death)
For anyone experiencing a perinatal loss from early miscarriage to soon after delivery
1st and 3rd Wednesdays, 7–9 p.m.(drop-in OK)
3030 Telegraph Ave. in Berkeley, 204-1571
For anyone who has had a medical termination due to genetic abnormalities.
1st and 3rd Tuesdays, 7–9 p.m.(call first)
Oakland Kaiser, 845-4656
Miscarriage Support Group
For anyone who has experienced a miscarriage.
Every other Monday, 7–8:30 p.m.(call first)
1656 N. California Blvd. in Walnut Creek, (925) 941-7908