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 HEALTHCARE PROFESSIONAL’S ROLE (2)

Positive contacts with health care professionals have an impact on how well these women can cope after the loss (7). The woman’s ability to experience wellbeing after a miscarriage is enhanced by her receiving care from a provider that is well informed about the common human responses to miscarriage (6). Even though first trimester miscarriage is under-researched and imperfectly understood (5), there is a lot the healthcare professional can do to maximise the health of his/her patient after a loss. This may be by simply recognising the uniqueness of each loss (3), even though the medical process is the same and the occurrence of miscarriage is very common. 

In addition to this, the health care professional needs to recognise that, to his/her patient, that miscarriage is more than simply a medical event and deliberately avoid the tendency to “medicalise” (and by so doing trivialise) her loss (5). Where the health care professional does not trust in his/her ability to offer appropriate counselling, by being observant enough to identify those who may need a referral, he/she will be delivering quality healthcare.

It is a well known fact that early miscarriage is a distressing experience (2) (4), involving a major disturbance of self-identity (5). Psychological reactions to stressful events can result in physiologic effects (8); the actual miscarriage could be a straightforward process with no risk of complications that may pose a source of concern to the health care professional, but the way the woman perceives and responds to the miscarriage may be dangerous to her health. Therefore, the manner in which the health care is provided in the aftermath has the power to influence her response to the health care system (7).

Most women know little about miscarriage until they experience it and the occurrence of miscarriage is usually shrouded in secrecy (5). Those entrusted with their care should know enough to empower these women (and their partners) to successfully navigate the journey of healing in order to maximise their health. 

REFERENCES

1.      Ekwegh U. Women and miscarriage: knowledge, attitudes and needs. Printed by the Miscarriage Support and Information Centre. 2008.

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.       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.

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.       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.

6.       Swanson K. Effects of caring, measurement, and time on miscarriage impact and women's well-being . Nursing Research, Vol. 48 (6) pp288-298, 1999.

7.       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.

THE TRIPLE-R MODEL: ROLE (1)

It is obvious that I believe it is our role, as healthcare practitioners, to identify the risk and resilience factors in our patients that present with a miscarriage. However, our role as healthcare professionals is not simply to identify those at high or low risk of a significant negative response to the miscarriage. In my study of women in Nigeria who had experienced a miscarriage, the doctors and nurses were identified as their second most important source of support, second only to their spouses (1). 

In order to identify the type of support required the healthcare professional needs to be able to distinguish between a normal grief reaction and a pathological reaction to the miscarriage. This can only be achieved if the woman is allowed to talk about the loss and her feelings about it. Essentially, a grief reaction will manifest as a preoccupation with and longing for what was lost plus painful recollections and reminders in everyday life (2) (3). A depressive reaction will manifest as symptoms in the woman: irritability, restlessness, lack of concentration, sleep disturbances and so forth (2); in other words, a preoccupation with herself.

Women will, more often than not, welcome any opportunity to discuss their loss (4). However, there are some that may find it difficult to do so, due to feelings of guilt and shame (5). It is therefore very helpful if the health care professional creates an opportunity for the woman to discuss the miscarriage and what it meant to her. Following a miscarriage, women may have a strong desire for recognition and validation of the loss, particularly from their health care providers, who can help them to explore the meanings of the miscarriage (3). 

It has been confirmed by empirical research that women who receive counselling sessions, which were simply sessions where the women talked about the whole experience of the miscarriage, were more likely to show a decline in overall emotional disturbance (6).

...To be continued

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.

MY MISCARRIAGE EXPERIENCE

Even now, after I have had successful pregnancies and healthy children, I can still go back to that day in March 2007 (when I had the miscarriage).
I can still remember: 

• The fear, the heart-sinking, gut-wrenching fear I felt when I first saw the fresh blood stain. 
• The panic, the heart-breaking panic that came over me when, about 15 hours later, I could feel contractions as my body prepared to expel my baby. 
• The sense of despair that completely weakened me physically as I was examined in the hospital.
• The grief of losing someone that I loved so much but was never going to meet (that is a kind of grief that is very difficult to explain).

That was a dark time in my life and remembering it still has the power to bring tears to my eyes. The miscarriage changed me forever; I will never forget the events and the emotions of that experience. And I hope, the next time you see someone going through a pregnancy loss, you will remember my story and be a little more compassionate with her.

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.