Miscarriage and stillbirth: causes and outcomes

Miscarriages

Sadly, miscarriages occur in approximately one out of four pregnancies. Of the 4.4 million confirmed pregnancies in the U.S. each year, over 500,000 end in miscarriage and 26,000 are stillbirths. Just as unfortunate, many people do not know how to cope with this experience and believe they are to blame. It is therefore important for parents to have a knowledgeable and comforting source in which they can confide at this time of grief, such as a support group, bereavement professional or pastoral care.

After a baby's death, parents grieve for their loss and for all that this new life would have brought. They mourn for the future they would have shared together as a family and for the happiness and joy they expected. Many also lose hope. Grief brings an overwhelming feeling of emptiness, sadness and longing for the loss. Parents desire to hold, care for love their new infant.

Many believe that this intense longing and need will never be fulfilled. Coming to terms with loss is extremely difficult; and once it becomes a reality, there is much pain. With time, grief brings other feelings that come and go, such as guilt, anger, bitterness or resentment at life in general, oneself or the doctors. With such emotional anguish come physical problems as well, including exhaustion, headaches, breathing problems and stomach pain. Depression is common, as is loss of self-confidence. A parent questions, "What could I have done so this would not have happened?" Many grieving parents believe that life no longer has meaning and that life -- their own life in particular -- has lost its ultimate purpose. As one grieving parent said about her experience, "Like many others, I lost all sense of worth, felt useless and had no confidence in anything I did. Most of all, I now know, I never felt worthy of giving myself any praise. I felt a failure, and I tried to carry on as normal to compensate for failing everyone else" Some parents believe they have failed others, such as their partner or family. Often they believe they multiply such failure by not smiling and coping with their situation. However, holding in emotions can make their problems all the worse.

According to Church, coping with miscarriage entails recognizing the myths that surround pregnancy loss. When a grieving mother blames herself for a miscarriage or stillbirth, she suffers a tremendously heavy burden that cannot be carried alone. It is important to dispel untruths to alleviate undue feelings of guilt. Some myths, for example, blame the loss on a woman's physical pursuits. Misinformed individuals believe that activities such as exercise, sexual intercourse, horseback riding, and airplane trips can cause a miscarriage. However, the truth is that during a healthy first-trimester, women may continue with their normal physical activities without the risk of losing a developing child. The source of the myth is that exercise may cause contractions in the uterus and help expel an already unhealthy pregnancy that was going to end sooner or later.

When a couple loses their child, they feel very much alone. Friends and family can sympathize and care for the grieving parents, but they cannot empathize unless they have gone through a similar situation. Professionals emphasize the social isolation parents experience due to the lack of recognition of their grief by others, especially if the loss occurs early in pregnancy. Most hospitals and the majority of society do not perceive the fetus as a living entity. Similarly, others rather than the parents find it difficult to appreciate the existence of a stillborn baby as a person. They cannot feel the emotional impact of the death for the parents. In fact, because stillbirth has so seldom been acknowledged in western culture, it has been called "the forgotten grief" as a result, the parents will not talk about their loss, which may prevent or delay resolution. Some mothers become very attached early in their pregnancy and feel they have truly lost a living person, regardless of when the loss occurs. Other women do not experience this personal attachment, but are distressed by the physical and medical aspects of the experience.

It takes considerable time to get over the grief from a stillborn child. Boyle et al. conducted a study on grief with mothers who had a stillborn child. They had a much higher risk factor for depression than those who had healthy deliveries -- 5.5 at two months after the loss, falling to 1.7 at eight months, and then slightly increasing again to around 2.7 at fifteen and thirty months. DeFrain et al. measured perceived happiness among mothers, six months before a stillbirth, right afterwards, and over the next four years. Happiness was highest beforehand, fell to near the lowest possible level after the loss, and gradually increased to near the previous high point after four years. The grief lasts longer than miscarriage, as expected, due to the further development of the infant and the pregnancy attachment. The same study by Defrain et.al found a comparable decline in happiness for fathers after the loss, but a slightly more rapid increase over the next two years.

Those couples who have had trouble conceiving and suffer a miscarriage or early infant death naturally have even a greater strain. They need to decide whether or not to try again, maybe through assisted reproduction, or giving up on their wish for a child all together. Some of these individuals may have had several other miscarriages, also making the next one even greater in terms of grief.

Since death is so poorly handled in the United States, there are no widely accepted rituals marking this particular occurrence. Even close friends, family, medical professionals, and clergy can be so disconcerted by a pregnancy loss that they may not be able to provide the simplest consolation to grieving parents. Instead, they rely on such platitudes as it was "God's will" or "It happened for the best."

Why is it so difficult for individuals to offer compassion following a pregnancy loss? The Rev. Vienna Cobb Anderson, who for many years served a congregation in Washington, D.C., believes that this gap is related to a newly distant relationship with death and its main expression, grief. She recalls that it was not that long ago when social customs surrounded death. People wore special clothing and put a purple wreath on the door to let people "know that a family was in need and required special attention and care. People knew about the death and cooked meals, or called and just came by." By relying on the telephone to spread the news, Anderson believes people feel even more removed from the event. "So often I hear members of my congregation say they didn't bother to visit people in mourning because they would probably cry and upset everybody, without realizing that this is exactly what should happen, that people are more upset if they don't see their friends and relatives crying with them."

Over the past decade, the need to provide support for grieving families has improved, with increased numbers of books and support groups, online chat rooms and resource lists. Many hospitals have developed pregnancy loss bereavement committees with obstetricians, maternal-fetal specialists, ethicists, labor and delivery nurses, chaplaincy and social workers. Medical centers are sponsoring memorial services and gardens for babies lost to miscarriage, stillbirth, and newborn death. Despite these changes, however, considerable lag times exist between medical care and bereavement support. Since obstetrics is geared toward bringing new life into the world, many healthcare professionals are not trained in responding to a family's sorrow or feelings of loss. Few medical schools offer bereavement courses as part of their core curriculum or obstetrical rotation.

Obstetrician Stanford Bourne found that physicians tended not "to know, notice, or remember anything about the patient who has had a stillbirth." Staff members untrained in bereavement may avoid the grieving parents, because they do not know what to say or are afraid the parents will become more upset, not realizing this is what is actually needed. The American Academy of Pediatrics and the American College of Obstetrics and Gynecology have jointly created hospital protocols to enable healthcare professionals to help parents after a loss. These guidelines for care recognize that parents need support and assurance from the hospital staff to express love for their baby and say goodbye. If they suffer a midterm or late pregnancy loss, parents may want reminders, such as photographs, footprints, or a lock of hair. Couples who suffer an early miscarriage may wish to have positive pregnancy tests or copies of sonograms as keepsakes. Parents should have the opportunity to see their baby and, depending on the gestational age, hold on to it as well. With any pregnancy loss, bereaved parents should have access to grief counseling, pastoral care, and options for rituals, as well as information on medical information. Many grieving parents blame themselves for not requesting these services after the fact. Proper care makes a major difference in the family's ability to engage in a healthy grief response.

Along with this changing ability to help parents deal with their loss have come various rituals. Increasing numbers of parents are recognizing how such rituals provide connection to their community, a sense of the sacred and an outlet to do something about their grief. Some of the rituals actually come from other cultures that are much more open about the subject of death. In Japan, for example, the traditional Jizo ritual has grown considerably over the last couple of decades, since in Japan little distinction is made between pregnancies lost to miscarriage and those to abortion. The ceremony recognizes the need for the mother to apologize for whatever guilt she may be carrying about the pregnancy loss. She may light a candle, make offerings, or tie a red knitted bonnet or bib on a small stone statue. or, the grieving Japanese woman may write the name of a lost pregnancy or child on a paper and send it down the river. It is believed that this paper will float to the mythical River of Souls. Here, the loss spirit will be watched over by Jizo, a benevolent and nurturing caretaker who tends to these loss children.

In the United States, increasing numbers of parents are recognizing how rituals provide connection to their community, a sense of the sacred and an outlet to do something about their grief. Ascher notes, "Grieving is physical as well as spiritual. It is an inner journey but its restlessness demands movement." Pregnancy is a rite of passage in culture, and when completed, such rituals bring one back to the world with a new identity. With pregnancy loss, it is an incomplete rite of passage, so there are much fewer rituals.

When doctors and nurses begin to utilize bereavement interventions, they learn to tolerate patients' intense emotions and their own closeness to death. The gratitude of bereaved parents usually convinces hospital staff that their training is effective and worthwhile. "Most bereavement specialists also encourage medical professionals who come in contact with grieving parents to be willing to show their own vulnerable and human side. One mother recalled how important it was to have her physician and midwife present when her baby's death in utero was confirmed. "My doctor got teary-eyed when she saw the ultrasound, and the midwife was visibly moved, too," she remembers. "It meant a lot to me for them to be there and to show that kind of feeling." In one study, a mother felt that the care surrounding her second trimester pregnancy loss at a large metropolitan medical center had been handled poorly -- both medically and emotionally. In addition to other things, she did not see or hold her baby girl when she was born, and initially the hospital staff told the mother that it would not release the baby for burial because it weighed less than 500 grams. When she did not receive an answer to her letter to the hospital's administration and the board of trustees, the mother asked to meet with the obstetrical nursing supervisor. The nurse listened to the story, verified it by checking hospital records and agreed that the mother's experience had been unsatisfactory. As a result, she discussed the issue with the head of obstetrics and the hospital board. The mother was pleased by the positive result of her efforts. She recalls that many changes took place, including the purchase of a camera. Also, pictures and footprints are now kept on record and a social worker is called whenever a loss occurs. Parents are encouraged to see their babies and private burial is offered as an option.

If parents sense that their needs are neglected during their hospital stay, it can be both therapeutic and effective for them to write a letter to a patient representative, social work department, director of obstetrical nursing, or hospital chaplain with a copy to the chairman of the hospital's board of trustees, requesting a follow-up meeting to discuss their experiences. The results of these efforts can be gratifying.

Not every hospital responds so quickly and positively to suggestions for enhancement to their bereavement services, but when patients' criticisms are taken seriously, these institutions can alter their policies in time to provide better care for bereaved parents in the future. Responding can help grieving parents find a way of honoring their baby's memory. As one mother relates, "My work on the hospital bereavement policies gave meaning to a life that never had a chance. It changed my grief and anger into positive action. It was a very, very good feeling to be productive in our baby's name."

Of course, it is not only hospitals that need to respond to the needs of these patients. The clergy are also expected to have a means for helping their parishioners. According to Thomas Moe, author of the book Pastoral Care in Pregnancy Loss: A Ministry Long Needed, who has studied grieving rituals, "for too long the church has lived in the myth of successful American healthcare, by not entering into a deliberate style of ministry to those who are suffering pregnancy loss because of not understanding the magnitude." The church must move out of the world of mythology and into reality and help those people who are really hurting. Another reason for the church not acting quickly is its ignorance that victims of pregnancy loss may truly be grieving. Pregnancy loss includes emotional grief and suffering and, as a result, increases many spiritual problems.

In this day and age, the need to understand and provide caring ministry is very obvious. This service introduces the religious community to the issue of pregnancy loss and describes how to help those who experience such tragedies. Effective ministry in pregnancy loss necessitates a person develop basic life theories to prepare for such in-depth care. With the help of pastoral care, the public and the faith community can develop strategies for individuals who are victims of pregnancy loss.

Recently, the ministry in the U.S. has more closely addressed this bereavement issue. One example is the book Hope Deferred: Heart-healing Reflections on Reproductive Loss. It states, for example, that any kind of death challenges theological assurances, but especially those dealing with the loss of infertility, miscarriage, and stillbirth. Saying that God knows best is actually saying that God doesn't want someone to have children. Or to be told that this is being done by God as a test is to be told that God is a sadist. Such standard reasons do not assure anyone of God's deep love and care during a loss. Encouraging people who are facing the death of a loved one to transcend their situation in order to see the larger good denies the very nature of grief itself.