Miscarriage and grief
Miscarriage and grief are both an event and subsequent process of grieving that develops in response to a miscarriage. Almost all those experiencing a miscarriage experience grief. This event is often considered to be identical to the loss of a child and has been described as traumatic. "Devastation" is another descriptor of miscarriage. Grief differs from the emotion sadness. Sadness is an emotion along with grief, on the other hand, is a response to the loss of the bond or affection was formed and is a process rather than one single emotional response. Grief is not equivalent to depression. Grief also has physical, cognitive, behavioral, social, cultural, and philosophical dimensions. Bereavement and mourning refer to the ongoing state of loss, and grief is the reaction to that loss. Emotional responses may be bitterness, anxiety, anger, surprise, fear, and disgust and blaming others; these responses may persist for months. Self-esteem can be diminished as another response to miscarriage. Not only does miscarriage tend to be a traumatic event, women describe their treatment afterwards to be worse than the miscarriage itself.
A miscarriage can often be "heart-breaking". A miscarriage can affect the women, husband, partner, siblings, grandparents, the whole family system and friends. Almost all those experiencing a miscarriage go through a grieving process. Serious emotional impact is usually experienced immediately after the miscarriage. Some may go through the same loss when an ectopic pregnancy is terminated. In some, the realization of the loss can take weeks. Providing family support to those experiencing the loss can be challenging because some find comfort in talking about the miscarriage while others may find the event painful to discuss. The father of the baby can have the same sense of loss. Expressing feelings of grief and loss can sometimes be harder for men. Some women are able to begin planning their next pregnancy after a few weeks of having the miscarriage. For others, planning another pregnancy can be difficult. Organizations exist that provide information and counselling to help those who have had a miscarriage. Some women have a higher risk of developing prolonged grief and complicated grief than others.
Miscarriage has an emotional effect and can also lead to psychological disorders. One discorder that can develop is primary maternal preoccupation. This is defined as a " ...'special psychiatric condition' in which the pregnant woman identifies with her baby, highlights the crisis a woman faces when the baby with whom she is preoccupied and identified dies..." Grieving manifests itself differently for each woman after miscarriage. It may often go unrecognized. The grief that follows a miscarriage resembles, but is not the same as, the grief experienced after the loss of a family member. Disbelief, depression, anger, and yearning, are described as being a part of the normal grieving process. These reactions remain from three to nine months after the loss. Forty-one percent of parents experience a normal, expected decline in grief in the first two years while 59% were delayed in the resolution of their grief.
Grieving can create feelings of loneliness. This grieving has been called a type of psychological trauma. Other serious consequences can develop including depression, anxiety disorder, post-traumatic stress disorder, and somatoform disorder. These responses all are associated with grieving after a miscarriage. Some women are able to complete the grieving process a few weeks after the miscarriage and start anticipating their next pregnancy. Planning another pregnancy is traumatic for others. The impact of a miscarriage can be "crippling" psychologically. Anger can be directed toward those who have had successful pregnancies and children. A woman can grieve the "loss of a future child" and question her own role as a mother. They may blame themselves or their partner for the miscarriage.
Unsuccessful attempts to become pregnant through in vitro fertilization (IVF) can also illicit a similar grief response in women. Those experiencing a late miscarriage may have more significant distress compared to those who have experienced a miscarriage in the first trimester. Even depression can occur.
"Women today...are aught in a unique historical moment: technology encourages them to form emotional attachments to their pregnancies, but society has not developed traditions to cushion the shock when those attachmets are shattered."
Descriptions of the miscarriage are expressed in non-clinical terms by those who have experienced the event.
- Lack of acknowledgement
- Not socially acceptable
- Pregnancy loss
Miscarriage has been found to be a traumatic event and a major loss for women. Pregnancy loss, including induced abortion is a risk factor for mental illness. The impact of miscarriage can be underestimated. The trauma can be compounded if the miscarriage was accompanied by visible and relatively large amounts of blood loss. Bipolar disorders are associated with miscarriage. Depression and bipolar disorder becomes evident after a miscarriage in 43% of women. Some women are more likely to experience complicated and prolonged grief than others.
Women experiencing miscarriage are at risk for grief reactions, anxiety or depression. Obsessiveness regarding the miscarriage can develop.[medical citation needed] Primary maternal preoccupation is also considered a consequence of miscarriage. This condition can occur if a woman who develops a close bond "with her baby" experiences the loss of the pregnancy.[medical citation needed]
Different grieving "styles" can exist and vary between individuals. There can be a complete avoidance of dealing with the memories of the miscarriage and there can be an "obsessive" concentration on an event in the miscarriage. This is in contrast with the expected ability to "reminisce about the loss of a loved one". Complicated grief differs from the more common form of grief that occurs after a miscarriage. The grieving process associated with other events such as the loss of a spouse or parent is expected to decline in predictable and steady rate. This not true for those experiencing grief after a miscarriage because only 41% follow the expected decline in grief while most, 59% do not fit this pattern.
Stress and posttraumatic stress disorder
Miscarriage is associated with posttraumatic stress disorder. Risks for developing PTSD after miscarriage are: emotional pain, expressions of emotion, and low levels of social support. Even if relatively low levels of stress occur after the miscarriage, symptoms of PTSD including flashbacks, intrusive thoughts, dissociation and hyperarousal can later develop. The effects of stress can complicate miscarriage. Miscarriage is a stressful event and because stress is a risk factor for subsequent miscarriage, its presence can become part of cycle that continues. Lower stress levels are associated with more favorable outcomes in future pregnancies while higher stress levels increase the risk.
Physical recovery from miscarriage can have an effect on emotional disturbances. The body has to recover from the sudden pregnancy loss. In some instances fatigue is present. Insomnia can be a problem. The miscarriage is very upsetting to the family and can generate very strong emotions. Some women may feel that the miscarriage occurred because they somehow had caused it. Others may blame the father or partner for the miscarriage. Coping with a miscarriage can very greatly between women and families. Some find it difficult to talk about the miscarriage. The narratives of women tend to coincide with quantified and measurable effects. Some women engage in activities that are believed to aid in recovery such as therapy, religion and art. Counseling can be offered but effective interventions to assist in recovery have been difficult to identify due to the reports of efficacy and ineffective counseling. Comparisons are hard to make. Despite the lack of studies that describe effective interventions for those with grief after a miscarriage, some clinicians still offer counselling and follow-up to help women recover and adapt to the loss.
Recommendations to help recover from the event include:
- Turning to loved ones and friends for support. Sharing feelings and asking for help when needed.
- Talking to the partner about the miscarriage.
- Keeping in mind that men and women cope with loss in different ways.
- Making good choices for health and well-being such as: eating healthy foods, keeping active, and getting enough sleep to help restore energy.
- Joining a support group. A support group might help with feelings of being alone in the loss.
- Doing something in remembrance of the baby.
- Seeking help from a grief counselor, especially if the grief doesn't ease with time.
Generally, the impact of experiencing miscarriage is underestimated. Other methods used to promote recovery are be relaxation techniques, guided imagery, and "thought-stopping". Even Gestalt role-playing has been used. Some women can "emotionally relocate the child", redefine a relationship "with the missing child", and engage in "continuing the bond" to incorporate the loss into their life experiences.
Women who have miscarried report that they were dissatisfied with the care they received from physicians and nurses. One observer highlights the insensitivity of some health care providers when they approach the grieving mother "...by playing down her emotion as somehow an irrational response..." Clinicians may not recognize the psychological impact of the miscarriage and can "expect parents to move on with their lives."
Since the experiences of women can vary so widely, sensitive nursing care afterward is appropriate.
Children and concerns about future pregnancies
One emotional response to miscarriage is the strong apprehension that can develop anticipating a subsequent pregnancy. Procreation abilities may also be questioned by the woman. Significant distress can develop in the other children in the family when they think a sibling has died. They may regard this as a baby they did not get to meet. They can also experience grief and guilt find it difficult to express these emotions to their parents. The siblings may feel a need to act as if everything is the same and that they are unaffected in an attempt to protect their parents from their own feelings. Children can also need help, understanding and the ability to make sense of the event.
Memorials and burial
Rituals that recognize the loss can be important in coping. Family and friends often conduct a memorial or burial service. Hospitals also can provide support and help memorialize the event. Depending on locale others desire to have a private ceremony. The religious faith of the woman and family impacts the grief process. Conversely, the lack of recognition that the miscarriage has occurred by family and friends can be troubling and add to the trauma of the event.
Grieving after the loss of a child through miscarriage in other cultures can vary from western culture. An individual's culture plays a large role in determining an inappropriate pattern of grief, and it is appropriate to take into account cultural norms before reaching a complicated grief diagnosis. There are cultural differences in emotional levels, how these are expressed and how long they are expressed. External symptoms of grief differ in non-Western cultures, presenting increased somatization. Narratives by Swedish women include their own perception of losing a child. Investigations describe their grief over their miscarriage: "When miscarriage occurs it is not a gore, an embryo, or a fetus they lose, it is their child. They feel that they are the cause of the miscarriage through something they have done, eaten, or thought. They feel abandonment and they grieve for their profound loss; they are actually in bereavement." Native American women have cut their long hair following the death of a family member. The narratives of women tend to coincide with quantified and measurable effects. In women who are induced to have an abortion, an identical grieving process can occur. The emotional responses to a spontaneous abortion (miscarriage) and an elective abortion are sometimes identical. Spanish women experience grief in much the same way in the rest of Western culture. Some women find online forums helpful.
- Robinson, GE (January 2014). "Pregnancy loss". Best Practice & Research. Clinical Obstetrics & Gynaecology. 28 (1): 169–78. doi:10.1016/j.bpobgyn.2013.08.012. PMID 24047642.
- "13 Things To Know About Grief After Miscarriage or Loss". Postpartum Progress. May 16, 2013. Archived from the original on September 9, 2017. Retrieved September 9, 2017.
- "Grief Issues Special to Miscarriage – the broken bond". www.miscarriagesupport.org.nz. Archived from the original on July 4, 2017. Retrieved September 9, 2017.
- "Hospice Foundation Of America - Grief". hospicefoundation.org. Retrieved 2017-09-13.
- Lok, I. H., & Neugebauer, R. (2007). Psychological morbidity following miscarriage. Best Practice & Research Clinical Obstetrics & Gynaecology, 21(2), 229-247.
- Bellieni, Carlo V.; Buonocore, Giuseppe (2013-07-01). "Abortion and subsequent mental health: Review of the literature". Psychiatry and Clinical Neurosciences. 67 (5): 301–310. doi:10.1111/pcn.12067. ISSN 1440-1819. PMID 23859662.
- Nelson, S. Katherine; Robbins, Megan L.; Andrews, Sara E.; Sweeny, Kate (2017-03-01). "Disrupted Transition to Parenthood: Gender Moderates the Association Between Miscarriage and Uncertainty About Conception". Sex Roles. 76 (5–6): 380–392. doi:10.1007/s11199-015-0564-z. ISSN 0360-0025.
- Some thesauruses consider 'sadness' to be a synonym for grief. See
- Beutel, M.; Deckardt, R.; von Rad, M.; Weiner, H. (November 1995). "Grief and depression after miscarriage: their separation, antecedents, and course". Psychosomatic Medicine. 57 (6): 517–526. doi:10.1097/00006842-199511000-00003. ISSN 0033-3174. PMID 8600477.
- Choices, NHS (2017-12-07). "Miscarriage - Causes - NHS Choices". www.nhs.uk.
- Lloyd Jones, Sarah (2015). "The Psychological Miscarriage: An Exploration of Women's Experience of Miscarriage in the Light of Winnicott's 'Primary Maternal Preoccupation', The Process of Grief According to Bowlby and Parkes, and Klein's Theory of Mourning". British Journal of Psychotherapy. 31 (4): 433–447. doi:10.1111/bjp.12172. ISSN 0265-9883.
- Robinson, Joanne (March 2014). "Provision of information support to women who have suffered an early miscarriage (review)". British Journal of Midwifery. 22 (3): 175–180. doi:10.12968/bjom.2014.22.3.175.
- Wen-Yi, Marianne; Ka Shun, Lam; Ling Ho, Priscilla Jia; et al. "The impact miscarriage on women's psychological well being and interventions: A literature review". Singapore Nursing Journal. Cite journal requires
- American Academy of Family Physicians (2007-11-01). "Pregnancy Loss: What You Should Know". American Family Physician. 76 (9): 1347–8. PMID 18019879.
- Hunter, Amanda; Tussis, Lorena; MacBeth, Angus (2017-12-01). "The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: A meta-analysis" (PDF). Journal of Affective Disorders. 223: 153–164. doi:10.1016/j.jad.2017.07.004. ISSN 1573-2517. PMID 28755623.
- Robinson, Gail Erlick (2011). "Dilemmas Related to Pregnancy Loss". The Journal of Nervous and Mental Disease. 199 (8): 571–574. doi:10.1097/NMD.0b013e318225f31e. ISSN 0022-3018. PMID 21814082.
- Daniel Goleman, Emotional Intelligence (London 1996) p. 271
- Jeve, YadavaB; Davies, William (2014-07-01). "Evidence-based management of recurrent miscarriages". Journal of Human Reproductive Sciences. 7 (3): 159–69. doi:10.4103/0974-1208.142475. PMC 4229790. PMID 25395740.
- Garrido-Gimenez, Carmen; Alijotas-Reig, Jaume (March 1, 2015). "Recurrent miscarriage: causes, evaluation and management". Postgraduate Medical Journal. 91 (1073): 151–162. doi:10.1136/postgradmedj-2014-132672. ISSN 0032-5473. PMID 25681385. Archived from the original on September 10, 2017.
- Johnson, Martin P.; Baker, Sarah R. (June 2004). "Implications of coping repertoire as predictors of men's stress, anxiety and depression following pregnancy, childbirth and miscarriage: a longitudinal study". Journal of Psychosomatic Obstetrics and Gynaecology. 25 (2): 87–98. doi:10.1080/01674820412331282240. ISSN 0167-482X. PMID 15715032.
- Rosenthal, M. Sara (1999). "The Second Trimester". The Gynecological Sourcebook. WebMD. Archived from the original on December 1, 2006. Retrieved December 18, 2006.
- Choices, NHS. "Miscarriage - Afterwards - NHS Choices". www.nhs.uk. Archived from the original on September 5, 2017. Retrieved September 5, 2017.
- "Thinking About Another Pregnancy" (PDF). Miscarriage Association. 2013. Archived (PDF) from the original on September 5, 2017. Retrieved September 4, 2017.
- Meredith, Pamela; Wilson, Trish; Branjerdporn, Grace; Strong, Jenny; Desha, Laura (2017-01-05). ""Not just a normal mum": a qualitative investigation of a support service for women who are pregnant subsequent to perinatal loss". BMC Pregnancy and Childbirth. 17 (1): 6. doi:10.1186/s12884-016-1200-9. ISSN 1471-2393. PMC 5217635. PMID 28056861.
- "Pregnancy loss". womenshealth.gov. 2016-12-14. Retrieved 2017-09-18. This article incorporates text from this source, which is in the public domain.
- Kulathilaka, Susil; Hanwella, Raveen; de Silva, Varuni A. (2016-04-12). "Depressive disorder and grief following spontaneous abortion". BMC Psychiatry. 16: 100. doi:10.1186/s12888-016-0812-y. ISSN 1471-244X. PMC 4830021. PMID 27071969.
- Brier, Norman (2008-03-17). "Grief Following Miscarriage: A Comprehensive Review of the Literature". Journal of Women's Health. 17 (3): 451–464. CiteSeerX 10.1.1.473.673. doi:10.1089/jwh.2007.0505. ISSN 1540-9996. PMID 18345996.
- Kersting, Anette; Wagner, Birgit (June 2012). "Complicated grief after perinatal loss". Dialogues in Clinical Neuroscience. 14 (2): 187–194. ISSN 1294-8322. PMC 3384447. PMID 22754291.
- Kinsey, Cara Bicking; Baptiste-Roberts, Kesha; Zhu, Junjia; Kjerulff, Kristen H. (2015-02-01). "Effect of Previous Miscarriage on Depressive Symptoms During Subsequent Pregnancy and Postpartum in the First Baby Study". Maternal and Child Health Journal. 19 (2): 391–400. doi:10.1007/s10995-014-1521-0. ISSN 1092-7875. PMC 4256135. PMID 24894728.
- "Grief After Miscarriage". WebMD. Retrieved 2017-09-14.
- Scheidt, CE (2007). "Trauerverarbeitung nach Prä- und Perinatalverlust ( Mourning processing after pre-and perinatal loss)". Psychother Psych Med. 57 (1): 4–11. doi:10.1055/s-2006-951906. PMID 17357028.
- Christiansen, Dorte M. (2017). "Posttraumatic stress disorder in parents following infant death: A systematic review". Clinical Psychology Review. 51: 60–74. doi:10.1016/j.cpr.2016.10.007. PMID 27838460.
- Seftel, p. 62.
- Seftel, p. 58.
- Softel, p. 57.
- Chritiansen, p. 87.
- Seftel, p. 60.
- Daugirdaitė, Viltė; Akker, Olga van den; Purewal, Satvinder (2015). "Posttraumatic Stress and Posttraumatic Stress Disorder after Termination of Pregnancy and Reproductive Loss: A Systematic Review". Journal of Pregnancy. 2015: 646345. doi:10.1155/2015/646345. ISSN 2090-2727. PMC 4334933. PMID 25734016.
- Bowles, Stephen V.; James, Larry C.; Solursh, Diane S.; Yancey, Michael K.; Epperly, Ted D.; Folen, Raymond A.; Masone, Maryann (2000-03-15). "Acute and Post-traumatic Stress Disorder After Spontaneous Abortion". American Family Physician. 61 (6). ISSN 0002-838X.
- Christiansen, p. 92.
- Hale, B. (2007-01-01). "Culpability and blame after pregnancy loss". Journal of Medical Ethics. 33 (1): 24–27. doi:10.1136/jme.2005.015560. ISSN 0306-6800. PMC 2598085. PMID 17209106.
- Seftel, p. 57.
- Neugebauer, Richard; Kline, Jennie; Bleiberg, Kathryn; Baxi, Laxmi; Markowitz, John C.; Rosing, Mark; Levin, Bruce; Keith, Jessica (2007). "Preliminary open trial of interpersonal counseling for subsyndromal depression following miscarriage". Depression and Anxiety. 24 (3): 219–222. doi:10.1002/da.20150. ISSN 1091-4269. PMID 16988939. This article incorporates text from this source, which is in the public domain.
- Evans, Rachel (Jun 20–26, 2012). "Emotional care for women who experience miscarriage". Nursing Standard. 26 (42): 35–41. doi:10.7748/ns2012.06.26.42.35.c9160. ISSN 0029-6570. PMID 22908762.
- Sawicka, Maja (2017-05-01). "Searching for a Narrative of Loss: Interactional Ordering of Ambiguous Grief". Symbolic Interaction. 40 (2): 229–246. doi:10.1002/symb.270. ISSN 1533-8665.
- Radford, Eleanor J; Hughes, Mark (2015-06-01). "Women's experiences of early miscarriage: implications for nursing care". Journal of Clinical Nursing. 24 (11–12): 1457–1465. doi:10.1111/jocn.12781. ISSN 1365-2702. PMID 25662397.
- Quagliata, Emanuela (2013). Becoming Parents and Overcoming Obstacles : Understanding the Experience of Miscarriage, Premature Births, Infertility, and Postnatal Depression. City: Karnac Books. p. 64. ISBN 9781782200185.
- Women's reproductive mental health across the lifespan. Lynn-Barnes, Diana. Cham. ISBN 9783319051154. OCLC 880941778.CS1 maint: others (link)
- Cowchock, F. S.; Ellestad, S. E.; Meador, K. G.; Koenig, H. G.; Hooten, E. G.; Swamy, G. K. (December 2011). "Religiosity is an important part of coping with grief in pregnancy after a traumatic second trimester loss". Journal of Religion and Health. 50 (4): 901–910. doi:10.1007/s10943-011-9528-y. ISSN 1573-6571. PMID 21861239.
- Keefe-Cooperman, Kathleen (2005-06-01). "A Comparison of Grief as Related to Miscarriage and Termination for Fetal Abnormality". OMEGA - Journal of Death and Dying. 50 (4): 281–300. doi:10.2190/QFDW-LGEY-CYLM-N4LW. ISSN 0030-2228.
- Klass, Dennis (2015). "Book Reviews of Narratives of Sorrow and Dignity: Japanese Women, Pregnancy Loss, and Modern Rituals of Grieving". OMEGA - Journal of Death and Dying. 70 (4): 454–457. doi:10.1177/0030222815573931. ISSN 0030-2228.
- "Hospice Foundation of America - What is Grief?".
- Shear, MK; Simon, N; Wall, M; Zisook, S; Neimeyer, R; Duan, N; Reynolds, C; Lebowitz, B; Sung, S; Ghesquiere, A; Gorscak, B; Clayton, P; Ito, M; Nakajima, S; Konishi, T; Melhem, N; Meert, K; Schiff, M; O'Connor, MF; First, M; Sareen, J; Bolton, J; Skritskaya, N; Mancini, AD; Keshaviah, A (February 2011). "Complicated grief and related bereavement issues for DSM-5". Depression and Anxiety. 28 (2): 103–17. doi:10.1002/da.20780. PMC 3075805. PMID 21284063.
- Horwitz, A. V., & Wakefield, J. C. (2007). The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. Oxford University Press.
- Adolfsson, Annsofie; Larsson, P. G.; Wijma, Barbro; Berterö, Carina (June 2004). "Guilt and emptiness: women's experiences of miscarriage". Health Care for Women International. 25 (6): 543–560. doi:10.1080/07399330490444821. ISSN 0739-9332. PMID 15354621.
- Seftel, p. 59.
- Ridaura, Isabel; Penelo, Eva; Raich, Rosa M. (February 2017). "Depressive symptomatology and grief in Spanish women who have suffered a perinatal loss". Psicothema. 29 (1): 43–48. doi:10.7334/psicothema2016.151. ISSN 1886-144X. PMID 28126057.
- Leveno, Kenneth (2013). Williams manual of pregnancy complications. New York: McGraw-Hill Medical. ISBN 9780071765626.
- Seftel, Laura (2006). Grief unseen : healing pregnancy loss through the arts. London: Jessica Kingsley Publishers. ISBN 9781843108054. OCLC 153919942.
- Barnes, Diana (2014). Women's reproductive mental health across the lifespan. Cham: Springer. ISBN 978-3-319-05115-4.
- Christiansen, Ole (2014). Recurrent pregnancy loss. Chichester, West Sussex, UK: John Wiley & Sons. ISBN 9780470672945.
- Kohn, Ingrid (2000). A Silent Sorrow : pregnancy loss : guidance and support for you and your family. New York: Routledge. ISBN 978-0415924818.
- Lothrop, Hannah (1997). Help, comfort, and hope after losing your baby in pregnancy or the first year. Tucson, Ariz: Fisher Books. ISBN 9781555611200.