Miscarriage and grief

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Inconsolable grief by Ivan Kramskoi Inconsolable grief.jpg
Inconsolable grief by Ivan Kramskoi

Miscarriage and grief are both an event and subsequent process of grieving that develops in response to a miscarriage. [1] Almost all those experiencing a miscarriage experience grief. [2] [3] This event is often considered to be identical to the death of a child and has been described as traumatic. [4] [5] [6] "Devastation" is another descriptor of miscarriage. [7] Grief is a profound, intensely personal sadness stemming from irreplaceable loss, often associated with sorrow, heartache, anguish, and heartbreak. [8] Sadness is an emotion along with grief, on the other hand, is a response to the loss of the bond or affection was formed and is a process rather than one single emotional response. Grief is not equivalent to depression. [9] Grief also has physical, cognitive, behavioral, social, cultural, and philosophical dimensions. [10] Bereavement and mourning refer to the ongoing state of loss, and grief is the reaction to that loss. [1] [11] [12] Emotional responses may be bitterness, anxiety, anger, surprise, fear, and disgust and blaming others; these responses may persist for months. [13] [14] [15] [16] [17] Self-esteem can be diminished as another response to miscarriage. [13] Not only does miscarriage tend to be a traumatic event, women describe their treatment afterwards to be worse than the miscarriage itself. [18]

Contents

A miscarriage can often be "heart-breaking". [19] A miscarriage can affect the women, husband, partner, siblings, grandparents, the whole family system and friends. [20] Almost all those experiencing a miscarriage go through a grieving process. [1] [2] [3] [13] Serious emotional impact is usually experienced immediately after the miscarriage. [1] Some may go through the same loss when an ectopic pregnancy is terminated. [10] [21] In some, the realization of the loss can take weeks. Providing family support to those experiencing the loss can be challenging because some find comfort in talking about the miscarriage while others may find the event painful to discuss. The father of the baby can have the same sense of loss. Expressing feelings of grief and loss can sometimes be harder for men. Some women are able to begin planning their next pregnancy after a few weeks of having the miscarriage. For others, planning another pregnancy can be difficult. [22] [23] Organizations exist that provide information and counselling to help those who have had a miscarriage. [22] [24] [25] Some women have a higher risk of developing prolonged grief and complicated grief than others. [26] A factor that can affect grief for men is finding help in an environment that is traditionally women-focused for maternity care and support. [27]

Psychological impact

Miscarriage has an emotional effect and can also lead to psychological disorders. One discorder that can develop is primary maternal preoccupation. This is defined as a " ...'special psychiatric condition' in which the pregnant woman identifies with her baby, highlights the crisis a woman faces when the baby with whom she is preoccupied and identified dies..." [11] Grieving manifests itself differently for each woman after miscarriage. It may often go unrecognized. [11] The grief that follows a miscarriage resembles, but is not the same as, the grief experienced after the loss of a family member. [28] Disbelief, depression, anger, and yearning, are described as being a part of the normal grieving process. [29] [30] [9] These reactions remain from three to nine months after the loss. Forty-one percent of parents experience a normal, expected decline in grief in the first two years while 59% were delayed in the resolution of their grief. [29]

Grieving can create feelings of loneliness. [31] This grieving has been called a type of psychological trauma. [11] [5] Other serious consequences can develop including depression, anxiety disorder, post-traumatic stress disorder, and somatoform disorder. These responses all are associated with grieving after a miscarriage. [32] Some women are able to complete the grieving process a few weeks after the miscarriage and start anticipating their next pregnancy. Planning another pregnancy is traumatic for others. The impact of a miscarriage can be "crippling" psychologically. [13] Anger can be directed toward those who have had successful pregnancies and children. [5] [10] A woman can grieve the "loss of a future child" and question her own role as a mother. [5] They may blame themselves or their partner for the miscarriage. [1] [31] [16] [33]

Unsuccessful attempts to become pregnant through in vitro fertilization (IVF) can also illicit a similar grief response in women. [16] Those experiencing a late miscarriage may have more significant distress compared to those who have experienced a miscarriage in the first trimester. [32] Even depression can occur. [11]

"Women today...are aught in a unique historical moment: technology encourages them to form emotional attachments to their pregnancies, but society has not developed traditions to cushion the shock when those attachments are shattered." [34]

Descriptions of the miscarriage are expressed in non-clinical terms by those who have experienced the event.

Trauma

Miscarriage has been found to be a traumatic event and a major loss for women. [18] Pregnancy loss, including induced abortion is a risk factor for mental illness. The impact of miscarriage can be underestimated. [37] [6] The trauma can be compounded if the miscarriage was accompanied by visible and relatively large amounts of blood loss. [38] Bipolar disorders are associated with miscarriage. Depression and bipolar disorder becomes evident after a miscarriage in 43% of women. Some women are more likely to experience complicated and prolonged grief than others. [29]

Mental health

Women experiencing miscarriage are at risk for grief reactions, anxiety or depression. [1] Obsessiveness regarding the miscarriage can develop.[ medical citation needed ] [38] Primary maternal preoccupation is also considered a consequence of miscarriage. This condition can occur if a woman who develops a close bond "with her baby" experiences the loss of the pregnancy. [11] [ medical citation needed ]

Complicated grief

Different grieving "styles" can exist and vary between individuals. There can be a complete avoidance of dealing with the memories of the miscarriage and there can be an "obsessive" concentration on an event in the miscarriage. This is in contrast with the expected ability to "reminisce about the loss of a loved one". [38] Complicated grief differs from the more common form of grief that occurs after a miscarriage. The grieving process associated with other events such as the loss of a spouse or parent is expected to decline in predictable and steady rate. This not true for those experiencing grief after a miscarriage because only 41% follow the expected decline in grief while most, 59% do not fit this pattern. [29]

Instrumental grief

Instrumental grief can be active and/or problem-focused. Examples include working on house-related projects, creative tasks, and more. Men experiencing the loss of a baby may go through this type of grieving. [27]

Stress and posttraumatic stress disorder

Miscarriage is associated with posttraumatic stress disorder. [6] [39] [29] [40] Risks for developing PTSD after miscarriage are: emotional pain, expressions of emotion, and low levels of social support. [39] Even if relatively low levels of stress occur after the miscarriage, symptoms of PTSD including flashbacks, intrusive thoughts, dissociation and hyperarousal can later develop. [38] The effects of stress can complicate miscarriage. [18] [15] Miscarriage is a stressful event and because stress is a risk factor for subsequent miscarriage, its presence can become part of cycle that continues. [18] Lower stress levels are associated with more favorable outcomes in future pregnancies while higher stress levels increase the risk. [41]

Recovery

Physical recovery from miscarriage can have an effect on emotional disturbances. The body has to recover from the sudden pregnancy loss. In some instances fatigue is present. Insomnia can be a problem. [13] [14] [10] The miscarriage is very upsetting to the family and can generate very strong emotions. Some women may feel that the miscarriage occurred because they somehow had caused it. Others may blame the father or partner for the miscarriage. [13] [42] Coping with a miscarriage can very greatly between women and families. [1] [14] Some find it difficult to talk about the miscarriage. [14] [13] The narratives of women tend to coincide with quantified and measurable effects. [11] Some women engage in activities that are believed to aid in recovery such as therapy, religion and art. [36] Counseling can be offered but effective interventions to assist in recovery have been difficult to identify due to the reports of efficacy [43] and ineffective counseling. Comparisons are hard to make. [1] [13] [32] Despite the lack of studies that describe effective interventions for those with grief after a miscarriage, some clinicians still offer counselling and follow-up to help women recover and adapt to the loss. [44]

Recommendations to help recover from the event include:

Generally, the impact of experiencing miscarriage is underestimated. [6] [37] Other methods used to promote recovery are relaxation techniques, guided imagery, and "thought-stopping". Even Gestalt role-playing has been used. Some women can "emotionally relocate the child", redefine a relationship "with the missing child", and engage in "continuing the bond" to incorporate the loss into their life experiences. [38]

Women who have miscarried report that they were dissatisfied with the care they received from physicians and nurses. [12] One observer highlights the insensitivity of some health care providers when they approach the grieving mother "...by playing down her emotion as somehow an irrational response..." [33] [42] Clinicians may not recognize the psychological impact of the miscarriage and can "expect parents to move on with their lives." [33]

Since the experiences of women can vary so widely, sensitive nursing care afterward is appropriate. [46]

Children and concerns about future pregnancies

One emotional response to miscarriage is the strong apprehension that can develop anticipating a subsequent pregnancy. [1] [13] [14] Procreation abilities may also be questioned by the woman. [13] [5] Significant distress can develop in the other children in the family when they think a sibling has died. They may regard this as a baby they did not get to meet. They can also experience grief and guilt find it difficult to express these emotions to their parents. The siblings may feel a need to act as if everything is the same and that they are unaffected in an attempt to protect their parents from their own feelings. Children can also need help, understanding and the ability to make sense of the event. [47] Some things that can help children process grief include allowing them to express themselves or ask questions, becoming involved in the memory process, and more. [48]

Memorials and burial

Rituals that recognize the loss can be important in coping. [49] Family and friends often conduct a memorial or burial service. [1] [22] Hospitals also can provide support and help memorialize the event. Depending on locale others desire to have a private ceremony. [22] The religious faith of the woman and family impacts the grief process. [50] Conversely, the lack of recognition that the miscarriage has occurred by family and friends can be troubling and add to the trauma of the event. [51]

In culture

Grieving after the loss of a child through miscarriage in other cultures can vary from western culture. [52] [53] An individual's culture plays a large role in determining an inappropriate pattern of grief, and it is appropriate to take into account cultural norms before reaching a complicated grief diagnosis. [54] There are cultural differences in emotional levels, how these are expressed and how long they are expressed. External symptoms of grief differ in non-Western cultures, presenting increased somatization. [55] Narratives by Swedish women include their own perception of losing a child. Investigations describe their grief over their miscarriage: "When miscarriage occurs it is not a gore, an embryo, or a fetus they lose, it is their child. They feel that they are the cause of the miscarriage through something they have done, eaten, or thought. They feel abandonment and they grieve for their profound loss; they are actually in bereavement." [56] Native American women have cut their long hair following the death of a family member. [57] The narratives of women tend to coincide with quantified and measurable effects. [11] In women who are induced to have an abortion, an identical grieving process can occur. [51] The emotional responses to a spontaneous abortion (miscarriage) and an elective abortion are sometimes identical. [1] Spanish women experience grief in much the same way in the rest of Western culture. [58] Some women find online forums helpful. [45]

See also

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event and can include triggers such as misophonia. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Miscarriage</span> Natural death and expulsion of an embryo or fetus before its independent survival

Miscarriage, also known in medical terms as a spontaneous abortion, is the death and expulsion of an embryo or fetus before it can survive independently. The term miscarriage is sometimes used to refer to all forms of pregnancy loss and pregnancy with abortive outcomes before 20 weeks of gestation.

<span class="mw-page-title-main">Postpartum depression</span> Mood disorder experienced after childbirth

Postpartum depression (PPD), also called postnatal depression, is a mood disorder experienced after childbirth, which can affect men and women. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleeping or eating patterns. PPD can also negatively affect the newborn child.

<span class="mw-page-title-main">Grief</span> Response to loss in humans and other animals

Grief is the response to the loss of something deemed important, particularly to the loss of someone or some living thing that has died, to which a bond or affection was formed. Although conventionally focused on the emotional response to loss, grief also has physical, cognitive, behavioral, social, cultural, spiritual and philosophical dimensions. While the terms are often used interchangeably, bereavement refers to the state of loss, while grief is the reaction to that loss.

Recurrent miscarriage or recurrent pregnancy loss (RPL) is the spontaneous loss of 2-3 pregnancies that is estimated to affect up to 5% of women. The exact number of pregnancy losses and gestational weeks used to define RPL differs among medical societies. In the majority of cases, the exact cause of pregnancy loss is unexplained despite genetic testing and a thorough evaluation. When a cause for RPL is identified, almost half are attributed to a chromosomal abnormality. RPL has been associated with several risk factors including parental and genetic factors, congenital and acquired anatomical conditions, lifestyle factors, endocrine disorders, thrombophila, immunological factors, and infections. The American Society of Reproductive Medicine recommends a thorough evaluation after 2 consecutive pregnancy losses; however, this can differ from recommendations by other medical societies. RPL evaluation can be evaluated by numerous tests and imaging studies depending on the risk factors. These range from cytogenetic studies, blood tests for clotting disorders, hormone levels, diabetes screening, thyroid function tests, sperm analysis, antibody testing, and imaging studies. Treatment is typically tailored to the relevant risk factors and test findings. RPL can have a significant impact on the psychological well-being of couples and has been associated with higher levels of depression, anxiety, and stress. Therefore, it is recommended that appropriate screening and management be considered by medical providers.  

False pregnancy is the appearance of clinical or subclinical signs and symptoms associated with pregnancy although the individual is not physically carrying a fetus. The mistaken impression that one is pregnant includes signs and symptoms such as tender breasts with secretions, abdominal growth, delayed menstrual periods, and subjective feelings of a moving fetus. Examination, ultrasound, and pregnancy tests can be used to rule out false pregnancy.

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Postpartum blues, also known as baby blues and maternity blues, is a very common but self-limited condition that begins shortly after childbirth and can present with a variety of symptoms such as mood swings, irritability, and tearfulness. Mothers may experience negative mood symptoms mixed with intense periods of joy. Up to 85% of new mothers are affected by postpartum blues, with symptoms starting within a few days after childbirth and lasting up to two weeks in duration. Treatment is supportive, including ensuring adequate sleep and emotional support. If symptoms are severe enough to affect daily functioning or last longer than two weeks, the individual should be evaluated for related postpartum psychiatric conditions, such as postpartum depression and postpartum anxiety. It is unclear whether the condition can be prevented, however education and reassurance are important to help alleviate patient distress.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

<span class="mw-page-title-main">Broken heart</span> Intense stress or pain one feels at experiencing longing

A broken heart is a metaphor for the intense emotional stress or pain one feels at experiencing great loss or deep longing. The concept is cross-cultural, often cited with reference to unreciprocated or lost love.

<span class="mw-page-title-main">Grief counseling</span> Therapy for responses to loss

Grief counseling is a form of psychotherapy that aims to help people cope with the physical, emotional, social, spiritual, and cognitive responses to loss. These experiences are commonly thought to be brought on by a loved person's death, but may more broadly be understood as shaped by any significant life-altering loss.

Memory and trauma is the deleterious effects that physical or psychological trauma has on memory.

Childbirth-related post-traumatic stress disorder is a psychological disorder that can develop in women who have recently given birth. This disorder can also affect men or partners who have observed a difficult birth. Its symptoms are not distinct from post-traumatic stress disorder (PTSD). It may also be called post-traumatic stress disorder following childbirth (PTSD-FC).

<span class="mw-page-title-main">Prolonged grief disorder</span> Medical condition

Prolonged grief disorder (PGD), also known as complicated grief (CG), traumatic grief (TG) and persistent complex bereavement disorder (PCBD) in the DSM-5, is a mental disorder consisting of a distinct set of symptoms following the death of a family member or close friend. People with PGD are preoccupied by grief and feelings of loss to the point of clinically significant distress and impairment, which can manifest in a variety of symptoms including depression, emotional pain, emotional numbness, loneliness, identity disturbance and difficulty in managing interpersonal relationships. Difficulty accepting the loss is also common, which can present as rumination about the death, a strong desire for reunion with the departed, or disbelief that the death occurred. PGD is estimated to be experienced by about 10 percent of bereaved survivors, although rates vary substantially depending on populations sampled and definitions used.

Antenatal depression, also known as prenatal or perinatal depression, is a form of clinical depression that can affect a woman during pregnancy, and can be a precursor to postpartum depression if not properly treated. It is estimated that 7% to 20% of pregnant women are affected by this condition. Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Even after birth, a child born from a depressed or stressed mother feels the affects. The child is less active and can also experience emotional distress. Antenatal depression can be caused by the stress and worry that pregnancy can bring, but at a more severe level. Other triggers include unplanned pregnancy, difficulty becoming pregnant, history of abuse, and economic or family situations.

Emotional abandonment is a subjective emotional state in which people feel undesired, left behind, insecure, or discarded. People experiencing emotional abandonment may feel at a loss. They may feel like they have been cut off from a crucial source of sustenance or feel withdrawn, either suddenly or through a process of erosion. Emotional abandonment can manifest through loss or separation from a loved one.

<span class="mw-page-title-main">Effects of climate change on mental health</span>

The effects of climate change on mental health and wellbeing are being documented as the consequences of climate change become more tangible and impactful. This is especially the case for vulnerable populations and those with pre-existing serious mental illness. There are three broad pathways by which these effects can take place: directly, indirectly or via awareness. The direct pathway includes stress-related conditions caused by exposure to extreme weather events. These include post-traumatic stress disorder (PTSD). Scientific studies have linked mental health to several climate-related exposures. These include heat, humidity, rainfall, drought, wildfires and floods. The indirect pathway can be disruption to economic and social activities. An example is when an area of farmland is less able to produce food. The third pathway can be of mere awareness of the climate change threat, even by individuals who are not otherwise affected by it. This especially manifests in the form of anxiety over the quality of life for future generations.

Mental disorders can be a consequence of miscarriage or early pregnancy loss. Even though women can develop long-term psychiatric symptoms after a miscarriage, acknowledging the potential of mental illness is not usually considered. A mental illness can develop in women who have experienced one or more miscarriages after the event or even years later. Some data suggest that men and women can be affected up to 15 years after the loss. Though recognized as a public health problem, studies investigating the mental health status of women following miscarriage are still lacking. Posttraumatic stress disorder (PTSD) can develop in women who have experienced a miscarriage. Risks for developing PTSD after miscarriage include emotional pain, expressions of emotion, and low levels of social support. Even if relatively low levels of stress occur after the miscarriage, symptoms of PTSD including flashbacks, intrusive thoughts, dissociation and hyperarousal can later develop. Clinical depression also is associated with miscarriage. Past responses by clinicians have been to prescribe sedatives.

Reproductive loss, sometimes reproductive disappointment or reproductive grief, describes a potential emotional response to unsuccessful attempts at human reproduction or family-building. These experienced losses may include involuntary childlessness generally, pregnancy loss from all causes, perinatal death, stillbirth, infecundity and infertility from all causes, failed attempts to conceive, failed fertility treatments, failed gestational surrogacy procedures, and losses related to all dimensions of the adoption process. Responses to miscarriage, stillbirth, selective reduction and neonatal death are a subtype of reproductive loss called perinatal bereavement.

Perinatal bereavement or perinatal grief refers to the emotions of the family following a perinatal death, defined as the demise of a fetus or newborn infant. Despite the not-uncommon circumstance of miscarriage and pregnancy loss, and the recognized subsequent psychological impact, including potentially complicated grief, "very little research exists documenting the efficacy of different interventions."

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