Miscarriage: The loneliest grief of all.

Kate Evans has had six miscarriages. To her, each felt like a bereavement – yet she mourned in silence. So how do you deal with the loss of someone who never lived?

Tuesday, 27 January 2009

The doctor's silence tells me everything I need to know. Eventually, he clears his throat, and says in a voice deliberately gentled, "I'm very sorry". And so am I. There on the screen before us, I can make out the form of a tiny curled foetus and, where a few weeks earlier, its heart was thumping with life, it now lies still in the cavernous vacancy of my womb. This is no longer a baby. It is a miscarriage. 

It surprises me how surprised I am. This is the sixth baby we will have lost; you would think that I would be used to it by now. But maybe it's not surprising that I had to believe in this baby, as though by investing in it some hope, and some love, I could will it into being.

They have run all the tests. Like the majority of women with recurrent miscarriage, they have found nothing wrong with me. They don't know why this is happening. 

In my mother's generation, there were no early pregnancy tests, and you weren't officially pregnant until you had missed three periods. These days, it's different. The very first day of absent menstruation can find you racing to the chemist, and then fumbling with instructions and collection pots and testing sticks until that tell-tale blue line makes its announcement.

The next step is a visit to your GP, where you are told the day your baby is due. You are handed a free book on pregnancy containing photographs and descriptions of your developing baby. It confidently states that, by 12 weeks, the foetus is fully formed. (It doesn't warn you here that only five out of six pregnancies make it this far). The book suggests that you make an early appointment with your midwife and begin thinking about where you want your baby to be born. So you do. 

And you discover the unmistakable differences that pregnancy brings – the signs that women have never needed testing kits to tell them. A visit from the tit-fairy brings you newly enlarged and extra-sensitive bosoms. You have a vastly increased need for food and for sleep. You feel more squeamish, more nauseous, more emotional and more hygienic. The hormone rushes make you feel like you're stoned. Lack of food makes you violent. You feel the glow of life inside you. You begin to plan and to dream. You probably chat to your baby. You consider its sex and its name. 

And then you begin to bleed. 

So you've lost your baby. And it's such a massive thing to lose. You, me, everyone reading this, we all started out as a little smudge of amniotic cells. My children would be 18 months old, or four months old, or I would be five months pregnant. I've lost a good friend because her baby was born on the day that mine was due and I have never been to see him. It hurts too much. 

I have never known depression like the cloud that descends every time I lose a baby. I can compare it with the death of a close friend and I can honestly say that it's worse. When a friend of mine died suddenly, we viewed the body, we buried him and we were able to say goodbye. I had the company of others who were as grief-stricken as I was. My mind replayed moments with him – a ceaseless video stream of memories, which was part of the way that my brain processed the loss. 

With a miscarriage, I'm left battling through the layers of euphemism to even recognise that I have been bereaved. What is this that has happened? "Pregnancy loss"? The word "baby" was never mentioned by the staff in the Early Pregnancy Advisory Unit. When the scan revealed that my baby was no longer viable, I was referred for an operation with the horrendous name of "Evacuation of Retained Products of Conception". My child, described as clinical waste. 

If there's no body, how can I grieve? I feel as though I must be kidding myself, wallowing in a morass of grief over a person who never even lived. Every time my mind trips back to this death, this loss, it strikes on empty, because there's nothing there to miss. This jellybean, lying forlornly on some toilet tissue – how can that sum up all my hopes and dreams for this child? How can it contain all my love? 

I almost welcome the pain and blood that happens when I miscarry. It seems more real to me than opting for an operation under general anaesthetic. There is pain involved. I want to feel it. 

When a friend dies, you can seek solace in the company of other mourners. Miscarriage, by contrast is an entirely private grief. There's me and my partner, and he's generally so intent on protecting and comforting me that it's hard for him to make space for his emotions. "How are you?" a friend will ask, in a conversational tone, and I wonder, do they really want to know the blackness of my mood? Every time it happens, I find it harder to struggle through, and yet I fear that, for my friends, this drama has become repetitive and boring. With each miscarriage I need help more, yet I feel I can ask for it less. 

I am a mother. I have a child, conceived after my third miscarriage. In an earnest attempt at consolation, I am repeatedly told "Well, at least you have got him". And it's true, and I love my son dearly: he is perfect, wonderful and amazing. I am aware that the pain of other women who never carry a child must be greater than mine. But that doesn't mean that I'm not hurting. Having had a baby, I know exactly what it is I've lost. I know what it feels like to give birth, to breast-feed and to raise a child. The stack of baby clothes that I have in the attic is slowly diminishing, pragmatically distributed to women who are actually having babies, not ghosts. 

And alongside the helplessness and hopelessness there is another, even darker emotion. It could be politely described as bitterness. How it actually feels to me is hatred. I hate pregnant women. This is nuts. I have been heavily pregnant myself and I know it's no fun. What I should feel is sympathy. Envy would be understandable, but hatred? What's going on here?

There's generally no point trying to bury your emotions. It's only by feeling them and naming them that you can get through them. And if you try to run away from them, they have a habit of catching up with you. Jealousy and hatred are impolite, socially unacceptable emotions, but they could serve a purpose. Throughout the animal kingdom, there are examples of bereaved mothers attempting to steal babies. Maybe I'm just part of a bigger picture here. The survival of the species is best achieved if there is a mechanism for matching up thwarted parents with unwanted babies. And I have reached the point where I've thought, "She's got my baby. That's my baby that she's growing." Insanity, I know, but possibly evolutionarily useful insanity. 

So where does this leave me now? 

The stakes keep rising but we have to keep playing the game. Maybe another baby will arrive to heal the hole in my heart. Or maybe my life will continue, trapped into this loop, like a needle that lands on a record but hits a scratch and lifts off again before the song even starts playing. 

On a practical level, we don't seem to have much problem conceiving, which isn't entirely a blessing. I am sincerely grateful that we haven't spent thousands of pounds on IVF to walk this difficult road. But it does mean that any time we want to step off the roller-coaster, to gather our energies for the next ride, we have to avoid trying to conceive a baby that we desperately want. Which makes our lovemaking very poignant. The only fixed point that I can see ahead is the eventual end of my child-bearing years. Either we will have had another baby, or we will have tried. I won't be so sentimental as to say that these unborn babies will stay with me, because they never really lived, but these scars will have made me part of who I am. And I am proud of that. 

Our society conspires to render miscarriage invisible. There is an unwritten rule that a woman should never announce her pregnancy until she reaches three months "just in case". Just who is this helping? The first trimester is when a woman does the work of creating the baby. Every organ in the baby's body is formed, and the mother experiences worse fatigue and nausea than at any other point of gestation. Women need to be supported through this vulnerable period and, with no outward sign that they are pregnant, how are they going to access that help if they can't ask for it? 

And if they miscarry, as one in six early babies will, women need even more support through their trauma. "Not telling" leaves women stranded with their grief. How can they begin to explain that they are mourning the loss of something whose existence was kept secret in the first place? 

Pregnancy is a superstitious time and I can see why women don't want to tempt fate by announcing their news too soon. But fate has dealt me that blow, the one people don't talk about, and I can tell you that the fact that people don't talk about it makes it a whole lot worse. 

So talk. Tell. We can be proud of our pregnancies, no matter how "successful" they are. A hurting heart is a sign of a loving heart. The only thing that has really helped me through this is knowing other women who have been through the same thing. Miscarriage is such a common trauma – there is no reason for us to be alone in our grief. 

When it all goes wrong: The facts about pregnancy loss

 

* Miscarriage is common. Between one in five and one in eight pregnancies ends in miscarriage. Most miscarriages occur during the first 12 weeks of pregnancy.

* About half of miscarriages are thought to be due to the fact that the foetus is not developing normally because of chromosomal, genetic or other problems. The causes of the other half are not known.

* The risk of miscarriage increases with age, rising to about one in four pregnancies in women over 40.

* Following one miscarriage, a woman has the same chance of a subsequent pregnancy being successful as a woman who has not miscarried. Even after three miscarriages, there is a 70 per cent chance that the next pregnancy will be successful if no cause for the miscarriage has been identified.

* If a woman has three consecutive miscarriages, this is known as recurrent spontaneous miscarriage and doctors will want to investigate any possible causes. But often no cause can be found. 

www.independent.co.uk/life-style/health-and-families/features/miscarriage-the-loneliest-grief-of-all-1516750.html 

The Stages of Grief After a Miscarriage.

Heather Michelle, Yahoo! Contributor Network
Jun 27, 2007 

When a woman experiences I miscarriage, she is subjected to the same stages of grief that is associated with the death of a loved one. While different psychologists agree and disagree on these stages of grief, there are many common elements that everyone will experience, including a woman who has had a miscarriage. I went through these stages.

I was ten weeks pregnant when I was told I was going to miscarry. I went straight into denial. This is always considered the first stage of grief. Some call it denial and others call it disbelief. Either way, a woman will not believe it is really happening. She will hold out hope until the miscarriage is over. I refused any intervention and waited for my miscarriage to happen naturally, because I was in denial. It took two weeks before my miscarriage. I held onto my hope the entire time.

Anger is another stage of grief. Not everyone believes that this is always going to occur. When a woman experiences a miscarriage, she gets angry. She gets angry with herself thinking about things she could have done better during her pregnancy. She gets angry with nobody in particular, because she wants to know why this happened to her and her baby!

Another stage of grief is plea-bargaining. Everyone has done it at some point. Asking for one thing and promising another in return. While this may not occur after a miscarriage, women who have been in the same position I was are likely to experience this. She will beg for the life of her baby in exchange for something else. I did this.

The stage of grief that most people are familiar with is the stage known as depression. This is when the reality of the situation truly sinks in. Every woman will experience this after a miscarriage. She will think of the child that "could have been."

Finally, there is acceptance. We cannot grieve forever. Life must continue. This will happen eventually. It is different for every woman and depends a lot on how far along she was when the miscarriage took place. It is important to realize that every woman will experience the different stages of grief much differently. Some will skip a stage entirely. The length of each stage is never predictable. It is something a woman must

deal with before she is able to reach acceptance. It is vital that the people in her life allow for these stages of grief to occur. Too many people dismiss the feelings of a woman who has miscarried. They feel it is not comparable to losing a loved one.

It is comparable. While the child may have never breathed on his or her own, the mother will have already formed a bond. She will have considered names for her baby. She will have pictured what he or she would look like. She probably even bought things for the baby. 

She developed a relationship and her grief is valid.
 

Heartfelt : giving the gift of photographic memories.

Heartfelt : giving the gift of photographic memories from Gavin Blue on Vimeo.

About the movie "Birth in Nepal".

 "Birth in Nepal"

The film maker, Sabina Shrestha has captured the scene very well. This a very common childbirth practices in rural Nepal, especially western part of Nepal. This flim is taken in the mid-western region of Nepal, where sociocultural taboos and practices are deeply entrenched in the society. 

Childbirths and menstruating blood are considered polluting and childbirths is considered normal life event thus not required medical help. In Nepal, women are considered second class citizen so having a girl child is considered burden to the family, which is some how reflected in the video.

Apart from this, in Nepal we don't have a separate cadre of midwife, who assisted women during childbirths. In the film, Laxmi was said midwife but in reality she is not a midwife. She is a Auxillary Nurse-midwife (ANM), who had undergone 18 months pre-service course to become a ANM. Just because of their long exposure and practices in rural setting health facilities they are able to assist women for normal childbirths. Otherwise, they are not competent and confident in assisting women for childbirth. Only ANMs are the one in rural and peripheral health care settings who are responsible for helping women before, during and after childbirths. They are based in the health facilities and in the village level there is no such health personnel who can help women during childbirth except female health community volunteer as mentioned in the video.

There is lots do in Nepal to save the lives of women and newborns. So, through our recently established Midwifery Society of Nepal we are advocating with the government of Nepal to strengthen maternity care services in rural areas by bringining a separate cadre of midwife as crucial human resource for safe motherhood, which has also been acknowledged by the government of Nepal and incorporated in the national policy but has not yet implemented. 

Here is the link of our society www.midson.org

Ms. Laxmi Tamang,

RN, MPH, Founder Managing Director, Aadharbhut Prasuti Sewa Kendra  (Nurse-midwives led Independent Birthing Centre), Kathmandu

Birth in Nepal

http://english.aljazeera.net/programmes/witness

Stillbirths: missing from the family and from family health/.

Original Text

Gary L Darmstadt a

Stillbirth is a devastating occurrence for families, and women bear the brunt of the consequences.1, 2 Hopes and dreams are dashed, and expectant women might suddenly face scorn, isolation, and rejection. They can be pressured to become pregnant again soon, and hence face a shortened birth interval and an increased risk for themselves and for subsequent pregnancies. This cycle continues—unbroken and unvoiced—every day in homes and communities around the world, especially in poor families.

The Lancet's Stillbirths Series is a landmark summation of the causes and global burden of stillbirths, along with a framework to deliver solutions within the context of reproductive, maternal and child health, and nutrition programmes, and a rallying cry for collective action. The Series builds on several recent reviews3—6 that have shaped the evidence base needed to address the problem.

This Series now authoritatively identifies stillbirth as one of the most shamefully neglected areas of public health. Although stillbirth is a universal problem, and exists along a spectrum of intrapartum stillbirths and intrapartum-related neonatal deaths (ie, birth asphyxia), the burden is woefully inequitable. Series authors J Frederik Frøen and colleagues1 point out that stillbirth rates in low-income countries are now where they were in high-income countries 50—100 years ago. They conclude that by simply addressing this inequity, bringing global stillbirth rates down to the average of low-burden settings, four in five stillbirths would be eliminated. The stillbirth burden, as enormous as it is with 2·6 million born dead after 28 weeks' gestation (an estimate from Simon Cousens and colleagues7 in another Series paper) is grossly underestimated. Such underestimation is due to under-reporting, inconsistent definitions, and the fact that stillbirths do not feature in major global or national health targets and commitments, in part because no global health constituency has taken full ownership of the problem.

This Series makes major strategic advances to show that the way to address the problem of stillbirth is to strengthen existing maternal, newborn, and child health programmes by focusing on a few key interventions, which also have benefits for mothers and neonates. If implemented, according to Zulfiqar Bhutta and co-workers8 in the Series, 15 proven antenatal and intrapartum interventions—ten of them also effective for averting stillbirths—could avert more than 2·7 million deaths of mothers and neonates, and stillbirths, each year by 2015. Tools are already available and a strong case has been made for their benefits for mothers and neonates;9—11 no new stillbirth-specific interventions, delivery platforms, or health-system elements are needed, a point made by Series authors Robert Pattinson and colleagues.12 What is needed, however, is a change in our framing of the continuum of care to include stillbirths.

The Stillbirths Series further emphasises the critical nature of the intrapartum period as a narrow window for intervention, when nearly half of stillbirths, three-quarters of maternal deaths, and one-quarter of newborn deaths occur (totalling 2·3 million deaths). If all we did was to provide good-quality care during childbirth, at a cost of less than US$1 per head, we could avert 1·4 million deaths of mothers and neonates, and stillbirths, each year. The stillbirths and newborn deaths that could be averted in addition to maternal deaths substantially strengthen the argument for childbirth care, which safe-motherhood advocates have been making for decades. In one of the more illuminating analyses in the Series, Pattinson and colleagues12 show that, if maternal deaths are only considered in deriving cost-effectiveness estimates of obstetric care, the figure of US$54 347 per death averted is not cost effective. When the stillbirths and neonatal deaths averted by these same interventions are also considered, the cost-effectiveness estimate improves dramatically to $3920 per death averted. Figures such as these show why advocates across all of women's and children's health should rally together to count and address stillbirth, and ensure integration of this issue into the continuum of care.

Antenatal care might play an important part in reducing the number of stillbirths in ways that current modelling does not take into account, for example, as a gateway behaviour associated with the uptake of other health-promoting behaviours. Family planning probably also has an important role, but its effect on stillbirth reduction was not modelled in this Series either. Selected nutritional interventions reduce stillbirths, but links between nutrition, infection, and susceptibility to hypoxic insults need further elucidation,13 as does the role of improved adolescent and maternal nutrition.

To improve women's and children's health, we need to optimise every interaction families have with the health system, particularly with frontline workers. Families should be empowered as producers of good health themselves, through the adoption of improved preventive and promotive practices, and care-seeking for complications. Simultaneously, frontline workers' capabilities, performance, and connections to the health system must be enhanced so they can provide more timely and effective counsel and care.14

Stillbirth is a major global public health problem and its day has come. New research is needed to improve our ability to prevent 60% of the stillbirth burden that cannot be averted with current interventions.8, 12 Meanwhile, inclusion of stillbirth when designing integrated family health programmes, and improving collection of stillbirth data, are important first steps to address this issue while also advancing the continuum of care.

Full-size image (20K) David Scott Smith/Stock Connection/Rex Features

I declare that I have no conflicts of interest.

References

1 Frøen JF, Cacciatore J, McClure EM, et alfor The Lancet's Stillbirths Series steering committee. Stillbirths: why they matter. Lancet 201110.1016/S0140-6736(10)62232-5. published online April 14. PubMed

2 Haws RA, Mashasi I, Mrisho M, Schellenberg JA, Darmstadt GL, Winch PJ. “These are not good things for other people to know”: how women's understandings of pregnancy loss and early neonatal death in southern Tanzania may impact survey data quality. Soc Sci Med 2010; 71: 1764-1772. CrossRef | PubMed

3 Lawn JE, Kinney M, Lee ACC, et al. Reducing intrapartum-related deaths and disability: can the health system deliver?. Int J Obstet Gynecol 2009; 107: S123-S142. PubMed

4 Bhutta ZA, Darmstadt GL, Haws RA, Yakoob MY, Lawn JE. Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand. BMC Pregnancy Childbirth 2009; 9 (suppl 1): S7. CrossRef | PubMed

5 Rubens CE, Gravett MG, Victora CG, Nunes TMthe GAPPS Review Group. Global report on preterm birth and stillbirth (7 of 7): mobilizing resources to accelerate innovative solutions (Global Action Agenda). BMC Pregnancy Childbirth 2010; 10 (suppl 1): S7. PubMed

6 Yakoob MY, Lawn JE, Darmstadt GL, Bhutta ZA. Stillbirths: epidemiology, evidence and priorities for action. Semin Perinatol 2010; 34: 387-394. CrossRef | PubMed

7 Cousens S, Stanton C, Blencowe H, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 201110.1016/S0140-6736(10)62310-0. published online April 14. PubMed

8 Bhutta ZA, Yakoob MY, Lawn JE, et alfor The Lancet's Stillbirths Series steering committee. Stillbirths: what difference can we make and at what cost?. Lancet 201110.1016/S0140-6736(10)62050-8. published online April 14. PubMed

9 Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis Lfor the Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save?. Lancet 2005; 365: 977-988. Summary | Full Text | PDF(147KB) | CrossRef | PubMed

10 Bhutta ZA, Ali S, Cousens S, et al. Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make?. Lancet 2008; 372: 972-989. Summary | Full Text | PDF(340KB) | CrossRef | PubMed

11 Campbell OMR, Graham WJon behalf of The Lancet Maternal Survival Series steering group. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006; 368: 1284-1299. Summary | Full Text | PDF(296KB) | CrossRef | PubMed

12 Pattinson R, Kerber K, Buchmann E, et alfor The Lancet's Stillbirths Series steering committee. Stillbirths: how can health systems deliver for mothers and babies?. Lancet 201110.1016/S0140-6736(10)62306-9. published online April 14. PubMed

13 Lee AC, Mullany LC, Tielsch JM, et al. Risk factors for birth asphyxia mortality in a community-based setting in Southern Nepal. Pediatrics 2008; 121: e1381-e1390. CrossRef | PubMed

14 Kumar V, Kumar A, Darmstadt GL. Behavior change for newborn survival in resource-poor community settings: bridging the gap between evidence and impact. Semin Perinatol 2010; 34: 446-461. CrossRef | PubMed

 

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Stillbirths: what difference can we make and at what cost?

Worldwide, 2·65 million (uncertainty range 2·08 million to 3·79 million) stillbirths occur yearly, of which 98% occur in countries of low and middle income. Despite the fact that more than 45% of the global burden of stillbirths occur intrapartum, the perception is that little is known about effective interventions, especially those that can be implemented in low-resource settings. We undertook a systematic review of randomised trials and observational studies of interventions which could reduce the burden of stillbirths, particularly in low-income and middle-income countries. We identified several interventions with sufficient evidence to recommend implementation in health systems, including periconceptional folic acid supplementation or fortification, prevention of malaria, and improved detection and management of syphilis during pregnancy in endemic areas. Basic and comprehensive emergency obstetric care were identified as key effective interventions to reduce intrapartum stillbirths. Broad-scale implementation of intervention packages across 68 countries listed as priorities in the Countdown to 2015 report could avert up to 45% of stillbirths according to a model generated from the Lives Saved Tool. The overall costs for these interventions are within the general estimates of cost-effective interventions for maternal care, especially in view of the effects on outcomes across maternal, fetal, and neonatal health.

pdf

www.thelancet.com