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.

BREAKING BAD NEWS

As a House Officer, while on call we had a lady rushed into theatre for an emergency CS due to foetal bradycardia diagnosed on the CTG (i.e. the heart rate of the baby was reading about 80bts/min when a normal heart rate for a baby in the womb should be between 110 to 160bts/min). It turns out that the CTG (an out-of-date model compared to what is used in UK and the developed world) had been picking up the mother’s pulse and we delivered a macerated foetus (i.e. the baby had been dead for a while and was already decomposing – sorry for the graphic details).
It was left to the consultant paediatrician to leave the theatre and tell the father how a baby would not be coming out and why (the mother was under general anaesthesia and so was unaware of what had occurred).
Different guidelines on the management of pregnancy loss suggest that the most senior member of the team should break the news to the woman/couple wherever possible.
However, this raises a question for more junior doctors on the frontline of care. If, for example, you are the Medical Officer on NYSC (national service in Nigeria) posting and you are the first and only person most patients would see, how do you effectively deliver bad news? What qualifies you to deliver bad news? Can empathy only be gained with experience? Is that why the more senior health professionals should deliver bad news? If yes, does this mean that we will inevitably bungle up the delivery of bad news until we learn how to do it properly?
Personally, I was always uncomfortable with miscarriage and pregnancy loss. I am ashamed to admit that when I went in to see the mother the next day on my House Officer ward round, I could not look her in the eye, I did not offer my condolences for her loss; I just said, “good morning” and checked her vital signs. It wasn’t till I had experienced a loss myself and conducted the survey that I realised how lonely and scary such an experience could be. Empathy can really go a long way to make a difference in such instances.
While preparing for my PLAB exams (in order to be registered with the General Medical Council in the UK), breaking bad news was one of the skills I had to learn. It is also a module in BMJ Learning for continuing professional development. This is a topic that was never discussed while I was in medical school in Nigeria.
I don’t claim to know the answers to the who, how, when or why of the delivery of bad news. But I know that no matter what level you are at as a medical student, doctor, nurse or midwife, “I’m so sorry for your loss” is easy to say: there’s no law against that.

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.

SARAH’S STORY

Sarah* was basking in post-wedding euphoria. The excitement of finally marrying the man she loved had been heightened by her discovery that she was already pregnant with their first child. They were off to their honeymoon and life seemed perfect.

One morning, three days into the honeymoon, she woke up with a strange feeling. “I just felt kind of empty”, she later shared, “I wasn’t feeling pain, I wasn’t having any pain, I just felt alone”.

This feeling was really strange to her. It was as if the baby inside of her had left her. She was terrified and asked her husband to book an ultrasound scan appointment as soon as possible.

She was booked in for a 3-D ultrasound scan. She could see all the features of the baby on the scan but the doctor performing the scan simply informed her that no foetal heart rate could be detected. She was looking closely at the face on the screen as she tried to digest the news; the baby looked just like her husband. How could there be no heart beat? How could this pregnancy be over?

“I just started screaming when I found out”, said Sarah. “I couldn’t hold it in anymore. Two nurses had to come in to the room to talk to me; but I couldn’t comprehend anything they said because I was just too hurt”.

“It was horrible! I was utterly devastated”, Sarah shared, and “it was just awful. I wouldn’t wish it on my worst enemy. I told them to just put me to sleep and do the procedure; I didn’t want to know what was happening. So I just woke up and it was done”.

This was the beginning of a very difficult time for Sarah. She had expected a period of bliss as she adapted to married life and prepared for motherhood. Instead, she was struggling with devastating feelings of grief. Feelings that she wasn’t prepared for; feelings she could not handle.

“My family helped me to pull through because I was just shattered. It was really, really hard; really trying times”.

Sarah remembers the day that a tiny spark of hope was rekindled in her heart. Her husband had suggested that she indulge in some retail therapy and while they were out she met a lady in the changing room. This lady was heavily pregnant and she struck up a conversation with her.

It turns out that this lady had experienced a late miscarriage at twenty weeks. Talking to someone who had been through this experience did something to Sarah.

“I finally saw someone who had been through what I went through. Here she was, with child and positive about the future, telling me how things would be okay.”

For Sarah, it was like group therapy in the changing rooms. All the soothing, placatory words the nurses had said to her that fateful day, the words that did not make any sense to her at the time, finally made sense. Sarah finally realised that there was hope. By hearing the story of another woman, she no longer felt so alone in her experience. And that gave her the strength to carry on.

As of the time I spoke to Sarah, she has gone on to have two healthy children. However, “there is no day that goes by that I don’t pray for him or her and hope that one day we will meet again someday”.

*not her real name.