MUCH ADO ABOUT NOTHING?

As part of my online searches to discover new information about pregnancy loss research, coping strategies and management I stumbled upon an interesting thread of comments.

This comments thread was in response to a news article in The Guardian online. The article was about a lady who, after suffering multiple losses, decided to organise across the United Kingdom different commemorative services where people could come to say goodbye to their unborn babies. An opportunity, if you may, to have a “funeral” for the pregnancy loss and hopefully leave with some form of closure.

What sparked the debate was someone wondering if services like this would just make too much about an issue no one used to talk about in the past. Women would have a miscarriage, be it early or late or even have a stillbirth and the healthcare team would just pretty much clean her up and send her home. It seemed that this person was pining for such simpler times when people did not talk so much about their feelings and go on and on about the babies they lost.

The responses to this comment ranged from vehement disapproval: “you have obviously never lost a pregnancy!” (It turns out the person commenting never had, go figure!) to guarded support: “some women do take it too far”.

I do think times have changed. I think that the inevitable consequence of a society where women have a voice is that women will speak. At a time when, in the Western part of the world at least, women are educated, enlightened and empowered, people have to deal with the fact that these women will highlight issues that are important to them.

I have written already about the disenfranchised grief of pregnancy loss and so it should come as no surprise that I wholeheartedly support the idea of an avenue that permits women (and those close to them) to grieve.

I grant that there is a danger (in some circles) to talk this issue of pregnancy loss to death but from personal experience and from talking to others who have gone through it as well, there is a more present danger (especially where I come from) of not talking about it enough.

If, in Nigeria and other parts of developing society, we aspire to “promote gender equality and empower women” (MDG-3), then we need to find out and talk about the issues that are important to women – not just avoiding death but coping with life.

THE DISENFRANCHISED GRIEF OF PREGNANCY LOSS

Disenfranchised grief is defined as grief that is not socially supported, either because the relationship with the person lost is not recognised, the loss itself is not recognised or the griever is not recognised1. In the case of pregnancy loss, it is usually that the loss is not recognised making it difficult to grieve properly.
Across sub-Saharan Africa, death is traditionally perceived as the process by which a person becomes an ancestor2. With pregnancy loss, there was no opportunity for the foetus to become a person, not to talk of an ancestor; this makes it very difficult for a typical woman or couple to come to terms with what exactly has been lost and how to mourn that loss.
The mourning practices of Nigerians in particular stem from a religious perspective, due to Nigeria’s triple heritage of Christianity, Islam and Traditional religions1. There is, however, no mourning practice for a pregnancy loss. A change to this should be considered as it has been reported that unacknowledged loss and a lack of grief rituals for the loss can challenge healing after pregnancy loss3.
In Nigeria, obituaries and memorials are used to celebrate a person’s life achievements and position in society2; it is an opportunity to list out all the family members that will miss that person. After a miscarriage, there are people that are affected by the loss, people who already loved this tiny foetus and were dreaming of the day the child would be born and the changes he/she would bring to their lives. But the very nature of first trimester loss is that there is a sense that one has lost someone so loved but has nothing to show for it; there is no actual visible person to mourn.
There is a need for an accepted approach to the process of dealing with a pregnancy loss. Without this, there is the risk that the accompanying grief, which goes unacknowledged, may be too much for the woman to bear, especially if she does not have the essential social support or the empowerment that comes from education to deal with it in her own way.

REFERENCES
1. Eyetsemitan F, “Cultural interpretation of dying and death in a Non-Western society: the case of Nigeria”, Online Readings in Psychology and Culture, Unit 14, Chapter 1. ©International Association for Cross-Cultural Psychology, 2002.
2. “Death, Mourning and Ancestors”, accessed from http://www.novelguide.com/a/discover/aes_01/aes_01_00107.html on 29/04/11
3. Douglas K I, Fox J R, “Tears of blood: understating and creatively intervening in the grief of miscarriage”, Compelling Counselling Interventions: VISTAS 2009, pp89-100, ©American Counselling Association, 2009.

THE TRIPLE-R MODEL: RESILIENCE

Just as there are red flags that suggest that a woman may find it difficult to cope after the experience of a pregnancy loss, there are encouraging aspects of her history that can foster healing, both physically and emotionally, after the loss.

·         Spousal/Social Support: it has been established that the support of the spouse, family and friends is a vital coping strategy. It is important to the woman to have her loss recognised and validated, to have a listening ear when she needs to talk and to have practical help (with chores for example) (1). When one considers that it is the cumulative impact of everyday hassles related to dealing with the loss that may have a detrimental effect on her health (2), it becomes apparent that at such a time, a woman who possesses a strong and supportive social network will fare much better than one who does not.

·         Hardiness: this is an attitude and an approach to life that can be protective in times of stress such as a miscarriage. A woman with hardiness would view the miscarriage as a challenge and an opportunity for personal growth with a strong belief in her ability to overcome this adversity and continue to enjoy a good life (2). She believes that everything happens for a reason and works out what it is. This may be due to the coping repertoire that she may have developed as a result of prior life experiences. Past life experiences can equip the woman with the emotional strength she needs to reach a state of resolution and healing after the miscarriage (3).

·         Spirituality: after a miscarriage, there is a struggle on the part of the woman to make sense of what often has been an inexplicable train of events (4). So she may seek spiritual guidance in order to make meaning of the miscarriage on a spiritual level so she can attach value to what happened (5). The complex narrative she develops in order to give religious meaning to her experience is an effort to draw positives out of a negative experience (4) and as she turns the loss over to God (5), there is a strength and peace that may follow, which overrides scientific explanation.

These factors protect against the impact of the stress of pregnancy loss and can be identified from a well-focused family and social history.

REFERENCES

1.       Abboud L, Liamputtong P. When pregnancy fails: coping strategies, support networks and experiences with health care of ethnic women and their partners. Journal of Reproductive and Infant Psychology,  Vol. 23(1) pp. 3-18, 2005.

2.       Gross R, Rolls G. Biological Psychology: Stress. In AQA (A) Psychology for AS. London, Hodder Education, Hachette UK, 2008.

3.       Swanson K M, Connor S, Jolley S N, Pettinato M, Wang T. Contexts and Evolution of Women's responses to miscarriage during the first year after loss. Research in Nursing and Health, Vol. 30. pp2-16, 2007.

4.       Frost J, Bradley H, Levitas R, Smith L, Garcia J. The loss of possibility: scientisation of death and the special case of early miscarriage. Sociology of Health and Illness, Vol. 297, pp 1003-1022, 2007.

5.       Douglas K I, Fox J R. Tears of blood: Understanding and creatively intervening in the grief of miscarriage. In Bleuer J C, Yep R K, Walz G R. (Eds) Compelling Counselling Interventions. Alexandria, VA, VISTAS: American Counselling Association, 2009.

THE TRIPLE-R MODEL

This is a model I developed to explain the factors that influence the response of a woman to miscarriage.

A miscarriage could hardly be described as a life-threatening condition but its effects on the woman, both physically and emotionally, are significant (1). This significance of the miscarriage experience on her mental health and emotional wellbeing is unique to the woman: miscarriage, though very common is extremely personal. The women differ in needs and expectations as well as their actual experience of the miscarriage (2).

A woman’s appraisal of her miscarriage is typically in terms of what being pregnant meant to her and what was at stake for her in losing the pregnancy (3) (4). The attribution of meaning to the pregnancy may be responsible for observed clinically significant negative reactions to miscarriage. Reports exist of up to 51% of women developing clinical depression after a miscarriage with a minimum of 22% developing clinically significant levels of depression and/or anxiety (5). It is also understood whatever meaning is attributed to the miscarriage affects the woman’s view of medical care received (versus medical care desired) in the course of the miscarriage experience (3). 

There are strict, established and concise guidelines on the management of the medical features of a miscarriage but little guidance is offered as to how health care professionals are to manage the psychological or social aspects of this loss (6). Gynaecologists and midwives may not be familiar with the diagnosis or management of depression (5). It is therefore pertinent that comprehensible insight into the factors that surround clinically significant mental and emotional responses to a miscarriage is made available.

The Triple-R Model is simply an academic discourse of the evidence already in existence about the factors that influence the grief response to a miscarriage, either by attenuating it or by aggravating it. The three R’s stand for the factors that may pose a Risk, the factors that provide Resilience and the Role of the health care professional in caring for the woman/couple after a miscarriage.

In other words, Risk+ Resilience+ Role àResponse

By expanding on these factors, a clear picture of the role of the health care professional in the management of the woman’s response to the miscarriage will emerge.

REFERENCES

1. Abboud L, Liamputtong P. When pregnancy fails: coping strategies, support networks and experiences with health care of ethnic women and their partners. Journal of Reproductive and Infant Psychology,  Vol. 23(1) pp. 3-18, 2005.

2. Smith L, Frost J, Levitas R, Garcia J. Women's experiences of three early miscarriage options a qualitative study. British Journal of General Practice, Vol. 56(524) pp198-205, 2006.

3. Swanson K M. Research-based practice with women who have had miscarriages. Journal of Nursing Scholarship, Vol. 31(4) pp339-345, 1999.

4. Swanson K M, Karmali Z A, Powell S, Pulvermakher F. Miscarriage effects on couples' interpersonal and sexual relationships during hte first year after loss: women's perceptions. Psychosomatic Medicine, Vol. 65, pp902-910, 2003.

5. Lee D T S, Wong C K, Ungvari G S, Cheung L P, Haines C J, Chung T K H. Screening psychiatric morbidity after miscarriage: application of the 30-item General Health Questionnaire and the Edingburgh Postnatal Depression Scale. Psychosomatic Medicine, Vol. 59(2) pp207-210, 1997.

6. Frost J, Bradley H, Levitas R, Smith L, Garcia J. The loss of possibility: scientisation of death and the special case of early miscarriage. Sociology of Health and Illness, Vol. 297, pp 1003-1022, 2007.

THE EFFECT OF MISCARRIAGE ON MENTAL HEALTH

A woman who has miscarried is at a higher risk of anxiety and depression than a woman who never miscarried¹. The response of a woman to a miscarriage is, however, dependent on the context within which the miscarriage happened. It is therefore important to recognise and treat each woman as an individual: expecting every woman who has a miscarriage to develop mental health issues is as remiss as assuming every woman who has a miscarriage gets over it easily and without help.

When assessing a woman after a pregnancy loss, it is important, as a health care professional, to be able to distinguish between a grief reaction (which is normal) and a depression reaction (which is pathological).

According to a study on grief and depression after a miscarriage, grief usually proceeds as shock à preoccupation with the deceased à resolution².

Central emotions in grief are sadness, loneliness and a sense of emptiness². Central emotions in depressions are dejection, guilt, discouragement, despair and the usual physical disturbances (i.e. sleep and appetite disturbances)².

Basically, if you talk to a woman who has just suffered a pregnancy loss and she reports feeling weepy all the time, thinking about the baby and wondering why it happened, with sadness increased any time she is faced with reminders of the pregnancy, she is going through a normal coping mechanism. She is obsessed with the baby she lost.

If, however, you talk to a woman after a pregnancy loss and she feels dejected, cannot cope with day-to-day tasks, feels irritable, restless and anxious, she may need professional help to deal with coping. She is obsessed with negative feelings.

This study also found that an ambivalent attitude towards the pregnancy usually resulted in a depression reaction to the loss of the pregnancy². This shows one cannot assume that just because the pregnancy was not planned or maybe not even wanted then the woman will be fine when it is over.

Multiple potential meanings can be attributed to a miscarriage¹. It is a part of our duty of care to ensure that the meanings attributed to the miscarriage by our patients do not result in an inability to cope with the loss. Health, after all, encompasses physical, mental and social wellbeing and we should strive for that.

REFERENCES.

1.       Swanson K M, “Research-based practice with women who have had miscarriages”, Journal of Nursing Scholarship, Vol 31(4), pp339-345, 1999.

2.      Beutel M, Deckardt R, von Rad M, Weiner H, “Grief and Depression after miscarriage: their separation, antecedents and course”, Psychosomatic Medicine, Vol 57(6), pp517-526, 1995.

COPING AFTER A MISCARRIAGE

A recent press release by researchers at the University of Michigan Health System confirmed an interesting fact: online forums can help women cope with pregnancy loss.

They surveyed over 1000 women on 18 different message boards and came to the conclusion that an important tool in dealing effectively with the loss is talking to someone who knows what you’re going through. A lot of family and friends are unwilling to talk about such matters: miscarriage, stillbirth and so on. It is an uncomfortable subject and many times, they do not understand the need to talk about it.

I personally know that the online forum specifically for women who had experienced a miscarriage on www.babycentre.co.uk was a lifeline for me. These women knew exactly how I felt and there was an abundance of cyber hugs and positive thoughts given and received freely between complete strangers united by loss.

In one of my posts, I shared Sarah’s story and she remembered that the first time she really felt like everything was going to be okay was when she was able to talk to a complete stranger that had also suffered a loss.

An interesting finding in this study was that the African-American population was significantly under-represented on these message boards even though they were statistically more likely to experience miscarriages and stillbirths than their Caucasian counterparts. I cannot assume to know why this is so but I am under the impression that in Africa, an online message board may also not work, even though there is internet access.

The key take home message for me is this: after a pregnancy loss, a woman will cope much better if she is able to talk to someone that understands what she is going through and is willing to talk about it with empathy and sensitivity.

SOURCE

Mary Elizabeth Dallas, “Online forums can help women cope with pregnancy loss”, November 4, 2011. Accessed from http://www.nlm.nih.gov/medlineplus/news/fullstory_118355.html  on November 22^nd 2011