Private loss visible

Though an estimated 10 to 25 percent of all known pregnancies don't make it to a live birth--a figure that includes miscarriage and stillbirth--a lost pregnancy almost always comes as a shock.

The event can be physically and psychologically traumatic, and it's often followed by several months of grief, sometimes extending into a subsequent pregnancy. Less commonly, miscarriage brings on episodes of clinical depression and certain anxiety disorders.

Adding new complications, some psychologists believe, are recent cultural shifts, such as more women putting off childbearing until their 30s and 40s, when miscarriage rates go up. Then there are home pregnancy tests, heartbeat monitors and other medical technologies that can only increase couples' attachment to an unborn baby, making a pregnancy loss harder. But a growing body of psychological research and anecdotal data reveals several predictors of particularly problematic reactions to miscarriage and also offers clues for treatment.

Lost dreams

Most women who miscarry respond to the loss with grief--not only for the loss of the baby they'd been carrying but also for dashed expectations of a particular future. "When a miscarriage comes, a dream is lost," says Joann Galst, PhD, a psychologist in private practice in New York City who specializes in reproductive health.

Researchers define miscarriage quite broadly, usually as unintended pregnancy loss ending in fetal death any time before 28 completed weeks of gestation, though the gestational age varies across the literature. A miscarriage midway through the second trimester is undoubtedly a different experience than one at four weeks, even on a purely physical level, but the two go by the same label. In fact, research shows that grief following miscarriage tends to increase with the length of the pregnancy. In a study published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing (Vol. 27, No. 5, pages 547-555), researchers who developed the Perinatal Grief Intensity Scale (PGIS) found that how real the pregnancy and the baby seem is one of the strongest predictors of parents' grief intensity.

"It's the individual's perception of the event, as opposed to the actual reality of the events associated with the loss, that has the greatest impact on grief reactions," says Pamela Geller, PhD, an associate clinical and health psychology professor at Drexel University in Philadelphia.

Giving the developing fetus a name, preparing the nursery and the like increases the level of yearning for the lost baby, according to a study published in Assessment (Vol. 9, No. 1, pages 31-40). In fact, yearning for the lost baby distinguishes perinatal bereavement from depression, according to the same study.

Miscarriage raises the level of psychiatric symptoms in women. But whereas gestational age intensifies grief, the length of pregnancy seems to have no bearing on major depression, says Geller, who's co-authored a comprehensive review of the literature on affective disorders in the aftermath of miscarriage, published in 2002 in the Archives of Women's Mental Health (Vol. 5, No. 4, pages 129-149).

What does lead to depressive symptoms after miscarriage? A big risk factor is childlessness. The relative risk of major depressive disorder among childless women who'd had a miscarriage was 5 percent, as compared with 1.3 percent for miscarrying women with children, according to a 1997 report in the Journal of the American Medical Association (Vol. 277, No. 19, page 1517).

According to the same report, the other risk for major depression is past psychiatric problems: Among miscarrying women with a history of major depression, 54 percent experienced a recurrence following the miscarriage.

Researchers know much less about anxiety disorders, but Geller says that miscarrying women are at increased risk for anxiety symptoms immediately and for about four months following miscarriage. And research on women with obsessive compulsive disorder showed an increased risk of a recurrent episode following miscarriage. There's also some evidence that miscarriage sometimes leads to post-traumatic stress disorder (PTSD), but the research is preliminary, with a lack of comparison groups making the data hard to interpret.

Whether or not someone meets the clinical criteria for PTSD, some psychologists find it helpful to think of miscarriage as a trauma, much like a car accident. Deborah Rich, PhD, coordinator of pregnancy and newborn loss services at Fairview Health Services in Minneapolis, notes that after miscarriage, thinking and judgment are often impaired. The woman and her partner go over and over what they could have done differently, and they respond strongly to certain triggers. Knowing all this, a therapist can, for example, offer "anticipatory guidance," teaching the client to avoidtriggering events.

Changing roles, heightened expectations

One group that miscarriage--particularly repeated miscarriage--hits especially hard is women over 35 attempting to have children. This group is still relatively small, consisting mainly of well-educated, non-Hispanic white women, according to U.S. national health survey data. Even women in their 20s jump to catastrophic conclusions after miscarriage, says Galst.

But for older women worrying over whether they'll ever have a baby, these fears are not entirely unfounded. "The time pressure is far greater for a woman approaching 40 or in her 40s, and she feels she has no time to grieve," Galst says.

Shifting gender roles can also create problems. Although many women still tie up their identity with motherhood, there's been a rise in women's expectations that leaves some angry, frustrated, or guilty after things don't go as planned. Galst believes that many women in the past few decades "have become set on what their goals are, and think, 'If I work hard I will get it.'" But early miscarriage, she says, is "not at all under their control." (It turns out that getting medical answers helps both men and women cope, some research shows.)

Although the research is mixed on whether repeated ultrasounds heighten grief, Geller believes that technological advances have changed the miscarriage experience. Thanks to home pregnancy tests, women can learn about their pregnancy earlier than previous generations. And the heartbeat monitor and sophisticated hospital ultrasounds can certainly make the pregnancy more vivid. Expectant fathers, who these days tend to be more involved in the pregnancy in general, also see the baby earlier--and therefore feel a greater sense of loss. "That's a chief change," says Rich.

But Rich adds that the man's grief experience comes later than the woman's, often just when his partner is feeling better and ready to get pregnant again. What's more, men tend to have a narrower repertoire of coping strategies, Rich says, often leading to deeper despair. While women seek out social support from many sources--an approach Rich says helps women heal--men are more likely to withdraw, work harder and resort to substance abuse. While it's a myth that couples who've experienced pregnancy loss are more likely to divorce, Rich says that differences in male-female grief response do strain the couple relationship, and psychotherapists must treat the whole family, not just the woman.

Marina Krakovsky is a writer in the San Francisco Bay Area.