Fetal loss and the psychological trauma that it can entail is an area that has received insufficient attention so far. Patients now are demanding more understanding and help from their doctors in overcoming this difficult situation which for some amounts to a life crisis.1 The fact that self-help groups are springing up in this field also testifies to a need that is not yet fully acknowledged and satisfied by the medical profession.
It has always been true that when a woman delivers a stillborn child, everyone understands and sympathizes with her grief, but the same understanding and sympathy has not been available to women who have miscarriages. It was only in the 1970s that attention was given to the emotional trauma of miscarriage experienced by so many women.2
Clearly, the intensity with which a woman will experience her loss will depend on many elements. The loss of a long-desired pregnancy will be different from the loss of an unplanned one.3 A sudden, unexpected miscarriage will usually cause more distress than when there were warning signs throughout the entire pregnancy. Age, a living child, and the number of previous miscarriages all will play a role,4'6 and so will the duration of the pregnancy and the degree of attachment formed. Bonding in a woman starts quite early in pregnancy, often enhanced by the visualization through sonogram long before she feels life. She forms a mental image of the child composed of fantasies, expectations, and hopes, with an intense emotional investment, and makes concrete preparations for changes in her lifestyle. Then, all her physical and emotional preparations are unexpectedly interrupted by bleeding, cramps, and a rush to the hospital. Generally her physical needs will be appropriately met, but what about her emotional needs? Until recently, a fetus was a nonperson and a miscarriage a nonevent.
Early pregnancy loss was and often still is treated by society as a taboo subject, too embarrassing to be touched upon. There are no rituals or rites that give comfort, and the usual platitudes offered to the woman for consolation are "next time it will be all right."
For the many women who feel an intense and excruciating sense of loss after a miscarriage, such remarks are taken as a trivialization of what they are experiencing. What they consider to be an incomprehensible lack of empathy and support in their time of need makes them feel isolated, thus further compounding their emotional distress.7
Although the woman goes through all the grief stages which parallel those that occur after the loss of a loved one, there are definite unique features of grief and mourning after a miscarriage. Lack of community support is one of them. Other features have to do with the effect this loss has on her as a person and on the relationship with her partner. In the majority of cases the cause of the miscarriage is unknown. As our thinking is conditioned to seek a relationship of cause and effect, she frequently blames herself. Self-blame can become torture. Any remark, well-meant as it might be, about what the woman should do or not do during her next pregnancy, will be heard as a reproach and will nurture her guilt. Also, many women initially may have been ambivalent about their pregnancies; if such a woman then miscarries, her guilt and selfblame is further increased.8
Her reproductive mishap may be experienced as a blow to her femininity and she may view herself as a "failure." Her other achievements become unimportant to her because she did not succeed in what other women seemed to accomplish so easily. This perception damages her sense of self-worth and makes her feel more vulnerable and in need of reassurance. She may feel she disappointed her husband by being unable to carry their child to term. She may even be afraid that he will leave her as she is not living up to his expectation of her as a woman and as the mother of his child.
Some women feel that their bodies have betrayed them. As one put it, "My body killed my perfectly healthy baby." This split of the normal experience of unity of mind and body, another form of turning against oneself, creates a potentially devastating conflict. Unresolved guilt feelings may be dredged up from the past, and the miscarriage may be regarded as a deserved punishment feeding into the already existing self-blame.9
Some women also experience a feeling of shame for having failed in their reproductive capacity, and this may be coupled with an intense envy of other women who go through pregnancy easily. But as envy is often regarded as shameful in itself, so these additional feelings of shame may feed into the lowered self-image.
Anger occurs generally in the grief process, but is often heightened after a miscarriage due to the disappointment of the joyful expectations, the lack of explanation for the event, the perceived or real absence of understanding and support, and the projection of guilt and self-blame onto others. This projected self-blame and guilt creates additional anger against the person who she feels is blaming her. Some of the anger is displaced, for instance, on the obstetrician or significant others, resulting in further isolation.
It is difficult for many women to go through a painful experience which is beyond their control. This is especially so for those women who have postponed pregnancy until they had established a career. They had become conditioned to set a goal, work hard toward it, and succeed. Being faced with a goal that may be beyond their reach creates a feeling of bewildered helplessness and may lead either to withdrawal or a neediness which does not fit their self-image. Such women also regard crying spells after the miscarriage and a decreased level of work performance as a loss of control. Some complain of a pervading feeling that "something is wrong" and of "falling apart." Others who had made plans to give up their profession while raising the child find themselves suddenly having to reorient their life situation.
The thought of another pregnancy is anxietyprovoking and therefore sometimes rejected. On the other hand, some women will obsessively try to conceive again immediately to replace the lost child and avoid the grief process. Both the "never again" approach or the "right away again" approach are undesirable. Furthermore, when the next pregnancy occurs, the woman often has initial difficulties in bonding as a self-protective measure.
A pregnancy loss has an impact on interpersonal relationships.10 The prospective father generally has not developed a similar early attachment to the fetus, and thus does not experience the same intensity of loss.11 If he will not discuss his own sadness she may think this indicates a lack of emotional involvement in the lost child. His attempts to help her to overcome her grief are shaped by notions of what he would find helpful for himself. Therefore, many action-oriented men will try to distract the wife or companion and become exasperated if unsuccessful. She, on the other hand, will often not clearly express her own needs to talk about her feelings over and over again, to hear about his, to have them acknowledged, and to be reassured of his love and understanding. When these needs are not met and his attempts to console her are futile, he may feel helpless. The resultant anger finds overt or covert expression by blaming her for allegedly overreacting, or by withdrawal into work. Then he may feel guilty and become even more angry. This in turn makes her feel more alone, misunderstood, and desperate. The end result is a breakdown of meaningful communication. In other words, a pregnancy loss often creates a crisis which can either make a relationship closer, split a couple apart, or remain as a festering, unresolved conflict for the future.12
For the woman, this emotional turmoil of selfblame, lowered self-worth and self-confidence, and unsupportive and threatened interpersonal relationships may make the task of working through her grief overwhelming and lead to a variety of psychopathological reactions.13 These include a delayed grief reaction on the anniversary of her miscarriage or when she finds herself pregnant again, an aimless overactivity, or an inability literally and figuratively to bury the lost child. More frequently the unaccomplished grief expands and imperceptibly transforms itself into a clinical depression.14-15
Mrs. H, a 35-year-old married lawyer, gravida 3, had two voluntary terminations of pregnancies, and one early spontaneous abortion in the past ten years. She had had the two voluntary abortions because the pregnancies came at a professionally inconvenient time. She and her husband decided together to start a family and she became pregnant immediately and never thought she would have problems. She did not feel well during the early pregnancy, and resented her husband's lesser involvement.
At eleven weeks she bled and miscarried. A D&C was performed, and the postoperative course was uneventful. She felt that nobody, including her husband, took the miscarriage seriously, and became resentful, angry, and isolated. Not knowing the cause of the miscarriage made it even harder to accept the loss, and she was plagued by the question "Why me?" In her career she had always achieved any goal she set for herself, and to have something so crucial be beyond her ability to control was devastating. Her very high-powered job lost its ability to engage her full interest, and her level of performance declined severely. She felt guilty and her self-image as a high achiever was threatened. She was reluctant to try another pregnancy and decided to adopt. Her husband wanted to have a biological child. His lack of understanding made her intensely angry, they had bad arguments and hardly spoke. She developed a sleep disorder, had nightmares of crying babies and lost a considerable amount of weight. Mrs. H was seen with her husband. He related feeling very excited about the pregnancy but could not do much for her when she was not feeling well . He felt his wife used the pregnancy to tell him what to do, which he resented. When the pregnancy was lost he felt "a big void and emptiness" but wanted to put the experience of the miscarriage behind them and not "wallow in the grief." He found himself ineffectual in helping his wife come out of her depression, unsure as to what kind of reaction he was supposed to have, and he felt that she blamed him for not knowing what would help her. He wanted to recreate a future, and his wife's angry refusal to try another pregnancy made him feel frustrated, resentful, and angry. Both were very angry at the obstetrician whom they felt was very unsympathetic and unhelpful.
This case is a typical example of what happens so frequently after a pregnancy loss: préexistent marital problems, in this case an unresolved power struggle and a lack of willingness to negotiate, are aggravated by the crisis. His perception of helping her does not meet her needs. Although he felt very sad about the loss he thought it would be an additional burden for her if he shared his feelings with her. As happens so frequently, their respective ways of working through their grief were of a different kind and a different pace. His idea of overcoming the miscarriage by attempting another pregnancy was unacceptable to her because she had not detached herself yet from the previous experience. His insistence drove her into a hardened position of refusal, and the resulting manta] tension prevented her from accomplishing the grief work. The result was a clinical depression.
The only remaining meeting ground is their shared anger at the obstetrician. Why is this so often the case? Clearly part of the anger is displacement. But are there perhaps some ways in which obstetricians contribute to becoming the focus of that anger? Some, as mentioned before, are unaware of the depth of emotional distress a woman can experience after a miscarriage. At other times, the obstetrician may feel uncomfortable and avoid the emotional aspect altogether. Death, except in gynecological oncology, is not frequent in this specialty which might therefore attract a special kind of physician who would rather not deal with death. Some might have an uneasy feeling regarding the miscarriage, as if it were a personal failure.16 But the most basic factor seems to be that gynecologists and obstetricians are trained to become diagnosticians, surgeons, and healers, and not counselors and consolers. Many patients require these latter roles after a miscarriage. Empathy shown by the physician allows the patient and the couple to ventilate their feelings, thereby facilitating and beginning their grief work. A short statement on the part of the obstetrician such as "There is no evidence whatsoever that anything you did or didn't do could have prevented the miscarriage" can forestall countless hours of pain or self-blame. Marital tension can be abated by pointing out that each person goes through grief in a very individual way and that this trying time will bring the couple closer through sharing, if each of them will only express his or her needs and be considerate of the different needs of the other.
Comprehensive care means attending to both the physical and the emotional needs of the patient. This is clearly illustrated in the continuing treatment of pregnancy loss.
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