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Pregnancy After Miscarriage

One of Leah's niches is to provide support and inspiration in the face of miscarriage and pregnancy after loss. Below you will see a link to her blog on this topic, as well as a published article on the grief of miscarriage. 

Inspire After Blog Weekly inspiration for women who are pregnant and have previously suffered a miscarriage



A Silent Grief: The Loss of Miscarriage
Leah M. Niehaus, LCSW

Determining the prevalence of miscarriage is a challenge, as some women miscarry before they may even know they are pregnant and others miscarry at home and do not become part of the statistics.  However, in general it is believed that 10-25% of all pregnancies are miscarried in the first fourteen weeks of pregnancy (www.americanpregancy.org).  Miscarriages can occur from chromosomal miscombination, due to infections, lifestyle and environmental conditions, auto-immune problems, or hormonal problems (Lerner, 2003).  Many more women are delaying motherhood today to focus on career and education—and the research shows that advanced maternal age (over 35 years old) also increases one’s chances of miscarriage.  Many couples struggle with infertility, the inability to get pregnant, and thus turn to In Vitro Fertilization (IVF)—these women are implanted with a fertilized egg and often the pregnancy still doesn’t take, which likely feels similar to miscarriage.  Thus, miscarriage is extremely common—yet, it is still a taboo topic in our culture and often overlooked in clinical settings.  With so many women and couples affected by the loss of miscarriage, it is important for therapists to be sensitized to the grief and loss issues associated with miscarriage and the common depression, anxiety, and isolation that accompany this particular kind of loss.

Why is this topic often overlooked clinically or within society?  Throughout history, infertile women or women who have struggled to carry a baby to term were often outcasts in society.  These women were made to feel responsible for their inability to get pregnant or maintain a pregnancy.  Though we have more medical knowledge today and hopefully more empathy, many women still carry around a sense of shame if they have endured a miscarriage and suffer silently.  Miscarriage is a complicated loss—there is no birth or death certificate and it is hard for outsiders to fathom the loss of a presence we did not know or had not touched.  Often, miscarriage survivors do feel a profound loss—they had already attached to their unborn baby, had possibly felt it move, had possibly seen ultrasound images, and had likely begun experiencing changes in their body as a result of the pregnancy.

As therapists, we are attuned to the significance of death and loss in the lives of our clients.  We know that individuals can have a myriad of responses to a loss and understand that people commonly experience depression and anxiety symptoms.  We know that recent losses often remind us of previous losses—and bring up unresolved trauma and hurts.  We recognize the different stages of the grief cycle and can assist an individual process loss at their own speed.  However, in my experience and in talking to colleagues, we often forget to assess for reproductive losses in a woman’s or couple’s history.  Either we forget, do not think reproductive losses are as important as other losses, or we are uncomfortable discussing this somewhat off-limits topic.  Today it has become increasingly more important to assess for reproductive losses and deal with their ramifications in therapy—more women and couples are presenting with miscarriage loss or infertility problems at the core of their pain.

The Experience of Miscarriage:

The experience of miscarriage affects one both physically and emotionally.  Each woman’s physical experience of miscarriage is unique—for some it is quick and painless and for others it can feel quite frightening and traumatic.   Some women have a natural miscarriage, where the pregnancy is lost at home with heavy bleeding and cramping—like a heavy menstrual period.  Some women do not know that the pregnancy has ended until they visit the doctor and there is no heartbeat present.   Women can chose to have a natural miscarriage or chose to have a D & C Procedure (Dilation and Curettage), which is a surgery that removes the fetus.  In medical terms, this is called an “abortion,” and it is common for doctors and nurses to call it such during a        D & C Procedure.  This can be especially upsetting to a woman who very much wanted this pregnancy and does not want the term abortion applied to her loss.  Sometimes there are medical complications with natural miscarriages or D & C Procedures that have to be dealt with as well.

For many women, the physical experience of miscarriage was extremely upsetting and would be useful to discuss in therapy.  Often family, friends, and loved ones may not want to hear the physical details of miscarriage—and how the experience made the woman feel—and this can add to the woman’s sense of shame and isolation.  In addition, many women feel that the medical professionals are insensitive to their loss.  It is common for doctors to be concerned about the physical details of miscarriage—that is their job—however, many are less familiar with the emotional fallout of miscarriage and the woman’s need for comfort and hope at a critical time.   Some women suffer recurrent miscarriage, defined as three or more miscarriages, and often they feel objectified by the medical professionals.  After multiple losses, a woman goes through many uncomfortable diagnostic tests, spends much time detailing her losses, has had D & C procedures, often has had surgeries on her uterus, and has had constant attention focused on her most private body parts; this can all make the woman feel like a medical chart or specimen and not a woman who has suffered multiple losses.  The miscarriage survivor is not comforted as if someone close to her passed from a disease, nor is she comforted as she receives treatments as a cancer patient might be.  It is important to help normalize these feelings for women, help them gain confidence to speak up for themselves, and help empower them to find new practicioners when appropriate.

The Loss Cycle:

The loss cycle is a helpful concept for practicioners when helping a woman process a miscarriage.  Typically we think of the five stages of loss:  Denial, Bartering, Anger, Depression, and Acceptance.  It is common for women to get stuck and vascilate between these stages from time to time, before they accept their loss and begin to move forward.  There are many unique factors to consider when assessing a client’s reactions.  First, how long did it take her to get pregnant?  If it took her a long time (over six months), this loss may feel more devastating for her than another client.  Does she have other children?  How far along was the pregnancy?  What was the nature of how she discovered the pregnancy had ended?  How do hormones play into her acute distress?   How much support does she have?  Is this her first miscarriage or has she had others?  What is the cultural significance of her loss?  Do women in her culture openly discuss miscarriage loss or are there myths/beliefs in the culture that make her feel ashamed?  How is her partner coping and does he blame her?  What is her age—how many fertile years does she have left?   What are her religious beliefs and how are these beliefs helping her or hindering her in her grief cycle?  Often, one’s faith may feel comforting after a loss; however, many women have existential questioning after loss as well.  Finally, how has she coped with loss in the past?

During the Denial stage, it is common for a woman to feel shock, disbelief, confusion, and fear.  Even though miscarriage is common, no one thinks that it is going to happen to them.  Their body may still feel pregnant and they may not have started their menstrual cycle yet, all of which may contribute to their denial.  During the Bartering stage, a woman may be replaying what went wrong or trying to find meaning in her loss.  In the Anger stage, a woman may feel embarrassed, ashamed, or angry at her body, self, partner, or God.  During the Depression stage, typically women experience feelings of overwhelm, helplessness, sadness, and a lack of energy.  In time, a woman will reach the Acceptance stage, where she can look forward at the options and come up with a new plan for the future.  It is important to note that many women grieve each month when they have their menstrual cycle—it is a reminder of her loss and that she is not pregnant again if this is what she desires.  In addition, many women feel a pressure to “try again” quickly, due to their age or other factors, often before they have thoroughly grieved their previous loss.

The Role of the Partner:

Pregnancy loss is often the first crisis in a marriage or committed relationship.  It can be devastating when it occurs and shake the foundation of the relationship.  It is common for women and men to have different responses to the miscarriage, which can be frustrating for them both.  Often men have a different attachment to the baby, as the baby was not growing inside of their body.  Some women express that men don’t feel the loss as profoundly and that they are able to move on more quickly.  Typically, the woman is still grieving the loss of the miscarriage and the husband moves on to being concerned because his wife is still angry or depressed.  The sexual relationship may also be strained, as sex has likely become more about baby-making than being close to one another.

Miscarriage can cause strained partner relationships.  However, many times it also offers the possibility of improved cohesion and unity for a couple.  Many women feel comforted by the fact that they have someone to grieve with and at least one person who shares their pain.  If a couple can weather the storm of miscarriage successfully, their resilience will likely serve them well on the path of parenthood.

Treatment Recommendations:

1.     Assess your own biases and feelings about miscarriage loss.  Realize your blind spots and why you may or may not be comfortable talking about the topic.

2.      Include reproductive history in the psychosocial assessment.  Ask the questions and invite the conversation, even if this is not a presenting problem.  Ask questions regarding the medical history as well as the emotional issues that surrounded any miscarriages.  The struggle with infertility, not being able to get pregnant, is likewise a loss and should be explored fully.

3.     Encourage the woman/couple to tell their story—to you, to loved ones for support, to other women and couples suffering.  Help them to bring more light into the world about this topic.

4.     Refer the woman/couple to a support group if desired (rare to find one, but becoming more common).

5.     Refer the woman to online support and blogs that can provide comfort and hope (http://babylossdirectory.blogspot.com; http://forums.delphiforums.com/mommiesofangels; www.angelfire.com/emo/miscarriage; www.hopexchange.com; www.MEND.org)

6.      Refer the woman for a psychiatric evaluation if extremely depressed or anxious.

7.     Help the woman integrate this loss into her life history.  Assist her to see herself as strong and resilient as a result of her loss and pain.

8.     Assist the woman/couple find ways to remember the lost child because the world will not “remember” this child as he/she hadn’t been born yet.  Planning a way to remember can be quite healing.  For example, planting a flower or tree in the child’s memory, writing a poem and reading it at private memorial service,  keeping the ultrasound pictures in a keepsake box, or wearing a necklace that keeps the child’s spirit close to their heart. 

9.     Support the woman/couple on their path of “trying again.”  This time period can be extremely anxiety-ridden for a miscarriage survivor—help her to cope and take one day at a time.  Instill hope and cautious optimism in herself and in future pregnancies.

10.  If she is a recurrent miscarriage survivor, help her to explore her options fully—help her to make decisions regarding surrogacy, foster parenting, or adoption if she reaches that point in her parenthood quest.
 

The Beauty of Miscarriage

There is one silver lining about a miscarriage, as opposed to other losses.  When a pregnancy ends, it is devastating…however, one is fortunate to have the chance to try again to get pregnant.  This is not something that a woman wants to hear directly after suffering a miscarriage.  Yet, it is a very hopeful option to explore in the future.  The vast majority of women have a successful pregnancy after suffering a miscarriage.  The statistics are in their favor; usually it is an emotional leap that needs to take place to try again.  The very thought of being pregnant is usually terrifying (yet desired)  to a miscarriage survivor—and a healthy pregnancy and baby can be especially healing for the couple who has experienced this type of loss.

Lerner, Henry M.,  Miscarriage:  Why It Happens and How Best to Reduce Your Risks, 2003.  

Leah M. Niehaus, LCSW works as a therapist in Hermosa Beach.  Leah is a recurrent miscarriage survivor and now has three healthy children.  Please feel free to contact her at (310) 546-4111, leahniehaus@me.com, or www.leahmniehaus.com.

 Published by the California Society for Clinical Social Work . Volume XXXIX Number 6 . January 2010

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