Miscarriage and loss

The tragedy of miscarriage has traditionally been private, an event grieved largely by the mother, on her own. Health-care professionals advised these women that the sadness would grow less pronounced over time, especially following a successful pregnancy.

But new research suggests that some women may mourn for much longer than expected, even after the birth of a healthy child, although the range and severity of the symptoms may vary. That's also true for men, as new studies have found that men grieve over a miscarriage more than once thought.

"Because it is medically common, the impact of miscarriage is often underestimated," says Janet Jaffe, PhD, a clinical psychologist at the Center for Reproductive Psychology in San Diego and co-author of the 2010 book "Reproductive Trauma: Psychotherapy with Infertility and Pregnancy Loss Clients." "But miscarriage is a traumatic loss, not only of the pregnancy, but of a woman's sense of self and her hopes and dreams of the future. She has lost her ‘reproductive story,' and it needs to be grieved."

A woman who has a miscarriage is at risk for depression and anxiety symptoms in subsequent years, says University of Rochester Medical Center psychiatry professor Emma Robertson Blackmore, PhD. In addition, even after having a healthy child, women who miscarry have a higher risk of postpartum depression, Robertson Blackmore has found. In a paper published in 2011 in the British Journal of Psychiatry, she followed more than 13,000 women for three years post-birth. Of the 2,823 who had miscarriages, about 15 percent experienced clinically significant depression and/or anxiety during and after pregnancies for up to three years.

Mothers may also struggle to manage the needs of a healthy child after a loss. For example, research by Sherryl S. Heller and Charles H. Zeanah looked at mothers who had delivered a child within 19 months after a perinatal loss. When the child was a year old, the researchers assessed the mother-child attachment relationships and found that 45 percent of the infants had disorganized attachments to their mothers (Infant Mental Health Journal). A 2001 study also found evidence of disorganized attachment behavior in infants born subsequent to stillbirth (Journal of Child Psychology and Psychiatry).

Robertson Blackmore says such findings may mean miscarriages have psychological implications for future children. "This raises the important issue of how and whether previous perinatal loss and associated mood symptoms may alter a child's outcome," she says.

Early loss

Another common misunderstanding about miscarriage is that a woman will experience less grief if she loses the baby early in her pregnancy. But most researchers have not been able to find an association between the length of gestation and intensity of grief, anxiety or depression (Research in Nursing & Health). A woman who has lost her child at 11 weeks may be as distraught as a woman who has lost her child at 20 weeks, says Jaffe's co-author, Martha Diamond, PhD.

"While the medical experience might vary, it depends on the meaning of the pregnancy to that person," Diamond says. "By labeling it a traumatic loss, we validate the experience."

While reproductive technology is a blessing for many expectant parents, it might also increase grief when the pregnancy fails, says Kristen M. Swanson, RN, PhD, dean of the School of Nursing at the University of North Carolina, who has extensively studied miscarriage and early pregnancy loss. She says historically, a woman may have miscarried and never even known she was pregnant. That is much less likely today.

"Take ultrasound — that window into the womb is more common," Swanson says. "We are paying more and more attention to the early phase of pregnancy. [These days,] you can know within hours of conception if you are pregnant. We are much more attentive."

Still, for women who miscarry early, their grief is less socially acceptable than the anguish of someone who miscarries later in their pregnancy, says Jaffe. "With later losses, people can have a funeral or memorial service. When it's an early miscarriage or even a failed IVF cycle, it is often unacknowledged by others, [yet] these are invisible losses that feel disenfranchised and not validated."

For some women, Diamond says, anxiety after a miscarriage can stem from experiencing a seemingly inexplicable trauma. Women will engage in what she calls "retroactive bargaining" in an effort to feel less out of control.

"They will spend enormous amounts of emotional energy trying to explain why it happened," Diamond says. "They often blame themselves, even when it is inaccurate, to help make sense of it. Women may torment themselves with guilt and blame, rewriting the story, so to speak: ‘If I hadn't gone to the grocery store' or ‘If I didn't stay up so late.' It's a way of coping with the loss. I've come to see this as part of the grief process."

Such feelings can be particularly difficult for women who were ambivalent about the pregnancy to begin with. That can create feelings of guilt, Diamond says.

"It's very, very important that clients know that their ambivalence did not cause the loss," she advises. Diamond remembers working with a 16-year-old who miscarried at 12 weeks. "Everyone around her was thrilled and relieved. It took three sessions for her to acknowledge that she was grief-stricken," she says. "Part of her was relieved, but she was already used to the idea. Nobody around her could validate her sadness."

Men and miscarriage

Another myth surrounding miscarriage is that it does not affect men, says Mark Kiselica, PhD, vice provost and interim dean of the School of Education at the College of New Jersey.

In "Helping Men with the Trauma of Miscarriage," published in Psychotherapy: Theory, Research, Practice, Training in 2010, Kiselica and Martha Rinehart, PhD, looked at case studies of men whose partners had lost a baby. They found that the fathers' sadness and grief were largely dismissed by others. Rinehart, who is completing her master's degree in counseling with a focus on marriage and family counseling at the College of New Jersey, became interested in men's reactions to miscarriage when she miscarried nearly 20 years ago. "My father-in-law had a reaction that was really wounding to my husband. It was all the clichés, like, ‘You'll have other children,'" she remembers.

Her father-in-law statement's reflected how miscarriage was seen by an earlier generation as having nothing to do with men, Rinehart says. She and Kiselica found that men may mask their grief over a miscarriage as anger. They recommend that health-care professionals learn how to determine whether a man is suffering from masked depression after a miscarriage, by doing a male-oriented mental status examination or obtaining a Perinatal Grief Scale score for those whose grief seems extreme.

Men also grapple with the physical loss of their wives after a miscarriage, Kiselica and Swanson say. "What I know from my own data, and working with support groups in counseling, is that miscarriage does a number on your sex life," says Swanson, who has conducted support groups for couples who have miscarried. "For men it was, ‘When can I go back to her? I miss her.' For women, it was, ‘If I never have sex again, I'll die a happy woman.'"

Not surprisingly, pregnancy loss among lesbian relationships can be just as devastating, Swanson says. One of her former doctoral students, Danuta M. Wojnar, RN, PhD, an assistant professor and chair at Seattle University, is researching lesbian couples' responses to miscarriage. Wojnar has found that the non-pregnant partner has a similar response to a man following the miscarriage. "The response tends to be, ‘I lost her and I don't know how to get her back,'" Swanson says. Lesbian couples may also face other stressors, she says. For example, they may face a lack of support from those who disapproved of their becoming parents in the first place.

Swanson advises couples consciously separate "sex for fun and sex for function." The first is to enjoy being intimate; the second is with the plan of becoming pregnant.

In addition, couples should be reminded that pregnancy hormones can continue to cause emotional turbulence, Swanson says. "Prior to the menstruation post-miscarriage, there is a physical component to the sadness where it almost feels like the sadness owns you," Swanson says. "After the hormones get resettled, there is a shift and it will start to feel like you own the sadness."

Support systems

Psychologists can help women access support services for miscarriage by encouraging obstetricians and other physicians to refer women to counseling and by acting as advocates to make discussing miscarriage less of a societal taboo. One resource for guiding health professionals was developed by Pamela Geller, PhD, a Drexel University psychology professor and director of the student counseling center, and her colleagues, Christof Daetwyler, MD, and Mark Woodland, MD, in the Drexel University College of Medicine. Their website is called "Psychological and Medical Aspects of Pregnancy Loss" (see "Further resources").

Another way to help women is to guide them to Web-based resources, Geller says. In a 2006 paper in the Journal of Obstetric, Gynecologic, & Neonatal Nursing titled "Web-based Resources for Health Care Providers and Women Following Pregnancy Loss," Geller highlights eight organizations with websites that offer everything from chat rooms to advice on creating memorials for lost children.

In addition to letting a woman choose what she is ready for, the forums can provide anonymity. "Not everyone gravitates to individual psychotherapy," Geller says. "When women go to good websites they can get information when they want it, even if that's at two in the morning."

But whether a woman engages in one-on-one therapy, group sessions or web-based forums, a key component of all communications to couples who miscarry is that they are not alone, says Robertson Blackmore.

"We've had some very touching emails from older women, even women who are now grandmothers," she says. "It's still very relevant and very sad for many women decades after a loss."

Elizabeth Leis-Newman is a writer and editor in Chicago.