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: RISK

I had mentioned in an earlier post that I had developed a model based on existing evidence that may help to predict how well a woman will deal with the effects of a pregnancy loss. The following are risk factors that have been identified that may influence one’s ability to cope.

·         Nature of spousal support and/or social support: the receipt of poor social support is a very strong predictor for low emotional strength, intense emotional feelings and high risk of depression in the woman (1). A study also found that dissatisfaction with the spouse’s caring after a miscarriage was significantly raised in women who had a depression reaction to the miscarriage as opposed to those who simply had a grief reaction (2).

Simply put, the husband is vital to the woman’s healing  and grieving process.

·         Pre-existing vulnerability to anxiety/depression: The physical manifestation of a miscarriage usually causes anxiety during and after the event (3) and women who have miscarried have an increased risk of anxiety and depression that could last for years compared to women who never miscarried (4). A past history of depression could trigger a depressive reaction to the miscarriage (2). Some women may also possess a temperamental vulnerability to anxiety (5) and this may make her more prone to an anxiety response to the loss. The tendency to go beyond the normal grief response to a miscarriage and exhibit a pathological inability to cope and/or a state of despair is exacerbated by poor social support (2).

Simply put, if the woman is naturally anxious and easily worried or has suffered depression in the past, she is more likely to find it more difficult to cope after the pregnancy loss

·         Gestational age at the time of the loss: As early as 10weeks gestation, there is a real emotional connection to the pregnancy (2). When the gestational age is less than 20weeks, then the age of the foetus at the time of the loss does not make a difference in the strength or the duration of the grief, anxiety or depression (4). For pregnancies older than 20weeks, there is a longer grieving duration and a greater chance of depression, impacting negatively on close relationships (1) (4).

Simply put, a loss at 10weeks can be just as painful as a loss at 16weeks but a loss at 20+ weeks is potentially more devastating.

REFERENCES

1.       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.

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

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

5.       S, Rachman. Anxiety. UK : Psychology Press Ltd, 2004.

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

THERE IS A STRONG BOND, NO MATTER HOW EARLY

Studies have confirmed that even at a gestational age of eight weeks, a strong connection already exists between a woman and her unborn baby. This is why your sensitivity to her loss, no matter the stage of the pregnancy, is essential. Healthcare professionals need to appreciate that a miscarriage is a real loss and, in most cases, the woman already feels love for and a bond with the baby being lost.

To further buttress this point, I want to share excerpts of my dairy written in the early weeks of my first pregnancy before it ended in miscarriage during the 9^th week of gestation. These are my personal thoughts and feelings, written at the time as letters to my unborn child, shared for the very first time.

·        At 5⁺⁶ weeks: “I’m so excited...it’s been a roller coaster ride of symptoms all week, but to be honest, I’m loving it!

·        At 6⁺¹ weeks: “I’ll be happy when we can feel you; even happier when we can hold you in our arms”

·        At 6⁺³ weeks: “Tried...stuffing a sweater in my trousers to see what I’d look like with a bump. The sweater looked silly (lol)”

·        At 7⁺⁴ weeks: “I think about you so much...you’re all I ever think of nowadays...I love you babe”.

·        At 8⁺³ weeks: “How are you feeling in there?...I love you babe”.

·        At 9⁺¹ weeks: “I’ve booked an appointment for my first scan...Woohoo!!! What a great time to be alive, in love and expecting a baby...I’ll be seeing you in a week’s time. Stay healthy, perfect, beautiful”

·        At 9⁺⁴ weeks: “This is the day that the pregnancy ended...I feel robbed, cheated, completely devastated...I don’t know why I can’t have you...I grieve for you and for my dreams that died with you”.

PREDICTING THE OUTCOME OF THREATENED MISCARRIAGE (1)

 Threatened miscarriage is a common problem that presents in early pregnancy. This clinical presentation usually results in a lot of different advice, investigations and interventions. However, more often than not, the only thing we as healthcare professionals are able to do is “wait and see”.

The results of a study were recently presented at the 2011 European Society of Human Reproduction and Embryology at Stockholm. It had been conducted in St. Mary’s Hospital in Manchester, United Kingdom. Its findings are quite exciting and could make management of threatened miscarriage even easier.

Below is my summary of the presentation; it will be in two parts.

INTRODUCTION

There are two types of pregnancy loss and the prevalence of each is as follows:

·        Early pregnancy loss (loss before the woman even knew she was pregnant) – 11-27%

·         Clinical pregnancy loss (loss after pregnancy has been confirmed with an ultrasound scan) – 7.9-15%

It is very difficult to estimate the prevalence of threatened miscarriage as most are unreported. Observational studies have reported prevalence of 5.5-16.4% with institutional records reporting prevalence of as high as 20% of clinical pregnancies.

Off all pregnancies complicated by threatened miscarriage

3.4-20% result in pregnancy demise

while 71-95% of pregnancies continue

This shows that, more often than not, a pregnancy complicated by a threatened miscarriage will still continue to term.

Being able to predict which ones of the pregnancies complicated by threatened miscarriage will actually result in pregnancy demise will enable the following:

1.  Targeted counselling of women at risk of pregnancy demise with reassurance of those not at risk.
2. Reduction of unnecessary investigations into women who are already distressed by the symptoms.
3. Avoidance of harmful interventions (especially if one can predict that the pregnancy will continue in spite of the symptoms).
4.  Research into potential interventions to rescue at risk pregnancies.

Now that your appetite has been whetted, tune in for the details of the study and the results in the next blog post.

WHY SHOULD I BOTHER ABOUT THE EFFECTS OF MISCARRIAGE?

Miscarriage, the emotional response to it and the mental health risks following it are significant. But are they important?

One of the Millennium Development Goals (MDGs) is to improve maternal health. A lot of health ministers in the developing world seem to have interpreted this to be: to reduce maternal deaths. Of course, this is important but maternal health has to be more than surviving; the mother should be thriving. This focus of governments and NGOs on mortality ignores other health issues related to reproduction that cause significant distress in women’s lives¹.

First trimester miscarriage is classed under gynaecology. In general, there is a “culture of silence”¹ which prevents women from seeking healthcare for gynaecologic conditions.  Interestingly, there is no disease burden attached to miscarriage; it is not identifiable within the Global Burden of Disease. 
Women need the health services to respond to their perceived needs². After a miscarriage, they need their doctors and nurses to be a source of support to them. I confirmed this in the research I conducted among women in Lagos, Nigeria.

Fertility levels are very high in Nigeria, more than twice the accepted rate for population maintenance (accepted rate = 2, Nigeria = 5.2 according to UNICEF). If at least 15% of all recognised pregnancies result in miscarriage, then miscarriage is an even bigger problem in Nigeria than in the developed world.

Depression is chronically disabling³ and the WHO estimates that mental health disorders are the leading cause of poor health and disability globally⁴. Mental health, however, is another health issue with an “appalling lack of interest” from governments and NGOs⁴; this stigma makes it impossible to generate appropriate attention and support. All this is despite the fact that mental health disorders are very important to public health³.

Mental health affects progress towards achievement of the MDGs particularly the empowerment of women and improvement of maternal health³. The mental distress suffered as a result of a miscarriage needs to be widely appreciated in healthcare circles.

It is pertinent that the combined effects of stigmatised mental health and pregnancy loss do  not defeat the efforts of public health and maternal health advocates to arrest their effects on women’s lives. Dealing with mental health issues after a miscarriage and incorporating psychosocial support into antenatal care may seem like a waste of valuable resources (time, money and staff) but “there is no health without mental health”³.

REFERENCES

1.            Stones RW, Matthews Z, Gynaecological disease in developing countries: whose burden? Opportunity and Choices Working Paper, Reproductive Health Research, University of Southampton.
2.       Filipi Z, Ronsmanns C, Campbell OMR, Graham WJ, Mills A, Borghi J, Koblinsky M, Osrin D, Maternal Health in poor countries: the broader context and a call for action. The Lancet (published online) DOI:10.1016/S0140-6736(06)69384-7. September 28, 2006.
3.       Prine M, Patel V, Saxena S, Maj M, Maselko J, Phillips M, Rahman A, No health without mental health. The Lancet 370 (9590) pp859-877, 2007.
4.       Chambers A, Mental illness and the developing world, www.guardian.co.uk, Monday May 10, 2010. Accessed on September 17, 2011.

RECOVERY FROM MISCARRIAGE

Most women are stable enough to be discharged within a few hours of treatment for the miscarriage. The patient may bleed for up to two weeks and her menstrual period will return within four to six weeks.

Although a woman physically recovers from a miscarriage quickly, psychological recovery in general may take a long time. Miscarriage is a heart wrenching loss and emotions may range from anger to despair. How short a time the foetus lived in the womb may not matter for the feeling of loss. Reports include being overwhelmed with crushing, breath-taking grief and still others feel that they may be suffering punishment for something they did wrong or that they have failed as women. It has been determined that 7% of women four months after a miscarriage will have Post-Traumatic Stress Disorder and women who had a miscarriage were 2.5 times more likely than controls to develop a Major Depressive Disorder.

Apart from depression and anxiety, a study conducted in Norway compared the guilt felt by women who have an induced abortion with the guilt felt by women after a miscarriage. When confounding variables were taken into account there was no statistically significant difference between the two groups on the index of guilt/shame. This would give insight into the perception women have about themselves and their perceived roles where the termination of a pregnancy, whether planned or spontaneous, still results in feelings of guilt and shame.

Miscarriage therefore results in a myriad of emotions. However, frequently mismatches occur between how a miscarriage is experienced and how people think it ought to be experienced. Hence the actual emotional experience of the loss comes as a rude shock to the woman.

The biggest challenge facing women after a loss is the response or lack of response from others. Members of her healthcare team and of her social circle usually tend to avoid discussing the issue of the miscarriage. This may be because the subject is too painful or the people do not know what to say or are afraid of saying the wrong thing. However, the parents suffering this loss need to feel validated in their grief; they need to know that their babies, feelings and losses are real. For women, depression is one of the most common mental health problems they face when changes and losses become too difficult to bear. This makes a prompt and effective response by the healthcare provider essential as a preventive measure. The doctor should therefore consider a counselling session or at least an opportunity to discuss her feelings about the loss before discharge or at follow-up; this may facilitate healing.

SOURCES

1.       A. N. Broen, T. Moum, A. S. Bodtker and O. Ekeberg, “Psychological Impact of Miscarriage versus Induced Abortion: A 2-year Follow-up Study”, Journal of Psychosomatic Medicine 66:265-271, 2004.

2.       S. Dubovsky, “Predicting Severe Grief After Miscarriage”, Summary &Comment, Journal Watch Women’s Health, April 1^st 1997.

THE PERCEPTIVE PRACTITIONER

Clinical practice is constantly evolving and healthcare professionals are constantly finding themselves playing catch-up.

If you pride yourself on being the best you possibly can be, if you desire to deliver evidence-based and up-to-date clinical care, then you would have realised by now that there aren’t enough hours in the day to keep up with all you need to know and practice it as well.

Spontaneous miscarriage is the commonest medical complication of pregnancy and indeed the commonest medical complication in humans. Knowledge about all aspects of the management and healthcare of women after this event – physical, mental and social – is constantly evolving.

Empathy, by its very definition, requires the healthcare professional to be understanding and to be sensitive to the feelings and experiences of our patients, vicariously feeling what they feel without having actually felt it before. 

The questions that arise as a result include, "How do you empathise with a loss you have never felt before?" and "How do you provide holistic care when faced with a miscarriage?"

I hope, at least in this area of medicine, to be of great assistance to you. Evidence-based facts, news and advances in management, personal stories of miscarriage and pearls for practice will all be made available twice a month, every month.

I hope you will be able to find the time to read the posts. I hope you find this blog useful. I hope you tell others about it. I hope you will see the difference it will make to your practice.

Here’s to you: the perceptive practitioner.