Responding to loss in pregnancy

Every one grieves the death of an infant. Parents who have tragically lost their baby to cot death or illness find that others grieve with them. Immediate family and extended family, friends and acquaintances all recognise the heartbreaking nature of what has occurred. There are funeral rites which aid the grieving process; there are photographs to reflect upon. Even the sad, sad task of packing up baby clothes is a means of coming to terms with the reality of the distressing loss. In contrast, the experience of those who suffer loss during pregnancy can be very different. In this paper I want to reflect on the grief occasioned by the loss of a baby to miscarriage, stillbirth or abortion and suggest ways in which we might respond with heightened awareness and compassion to them.

Some general comments on grief and loss

After the publication in 1970 of the ground-breaking work of Elisabeth Kübler-Ross, On Death and Dying, her five stages of grief entered into the lay-psyche.[1] We read that grieving people regularly go through a stage of denial. The painful truth is often too much to handle in the immediate after-math of learning of a present or potential loss. This can be a constructive coping strategy in the short-term and it requires that the support person respects the need to process the news at a rate that is manageable. Similarly, we need to appreciate that people often become angry at their circumstance, displacing it onto immediate others, the medical establishment or God. Anger is another means of dealing with pain, distancing the sufferer from the interior grief that is too much to handle. Bargaining and a period of depression may follow but, if support has been adequate and patients have been allowed to process their feelings and thoughts in the context of compassionate others, eventually there may occur the healing process of acceptance. Ultimately, our understanding of Kübler-Ross’ work was more nuanced and we came to realise that these stages were not linear, for people may well revisit a stage that they had previously encountered.

These observations have certainly been helpful insofar as they have enabled us to respect the range of emotions which grieving people may experience. More recently, however, the process of grief that Kübler-Ross articulated has been questioned. George Bonanno’s evidence-based research challenges the notion that there are differentiated stages of grief. Instead Bonanno identified three common patterns of grief reaction: people who manifested resilience, people who demonstrated a recovery pattern, and people who suffered chronic grief. [2] Those in the resilient category struggle with emotional pain that is often acute but they are able to meet the everyday demands of their lives, putting the grief aside when required. Those in the recovery pattern find that grief seriously impinges on their present quality of life but they are nevertheless moving towards their pre-grief state. The remainder experience prolonged grief that is enduring and extreme, frequently requiring the help of mental health professionals.

It is this latter group with which I am primarily concerned in this paper. Societal as well as personal factors contribute to the depth of suffering experienced by these women and, frequently, by their partners. It is my hope that a presentation of these factors will help us in our compassion and support for those whose loss, whether acknowledged or unacknowledged, conscious or unconscious, dominates their lives and frequently impacts the lives of those around them.

The grief of miscarriage and stillbirth

In Australia the loss of a baby before the first twenty weeks is called a miscarriage; after twenty weeks the loss is a stillbirth. The grief occasioned by a miscarriage for both the woman and her partner is often underestimated with both anxiety and depressionbeing possible consequences of the distress following miscarriage.[3] A stillbirth is even more devastating; the intensity of grief has been found to be greater when gestational age is longer.[4] Parents are seldom prepared for the possibility of the loss of their baby in antenatal classes, intended as they are to provide support for a healthy live birth. Baby magazines do not engage with it; friends do not know how to react. The woman and her partner are often left alone to deal with the pain of loss, unaware that there are many other like sufferers.

In fact pregnancy loss is quite common with twenty-five percent of women experiencing a loss of some kind during their pregnancy and one percent of couples suffering recurrent losses.[5] Nevertheless, the woman often encounters emotional isolation as she struggles to come to terms with her grief, often feeling that even her partner does not understand her experience. The agonising search for an answer to the question “Why?” can be compounded by feelings of failure and frustration, and sometimes by guilt and shame, particularly for those with repeated losses. Both miscarriage and stillbirth generate a unique set of complex emotions which insensitive responses from family, friends and professionals can exacerbate. For example, a well-meaning comment of “You’ll get pregnant again” or “It was only a miscarriage” or “It was probably for the best” will just increase the grieving mother’s disappointment and sense of isolation.

Parents need to find ways to manage their grief, grief that can seem to tear them apart. These ways vary according to the circumstances and unique needs of the mother or couple. Frequently women who have had a miscarriage need to recognise that they have a right to grieve even if their loss seems considerably less than that of others who have, for example, lost a child at birth or in infancy. Karen Edmiston poignantly conveys the reality of such grief: “When does life begin? Conception. When does life begin to be important, memorable, meaningful, sacred, worth grieving over? Conception.”[6]

Women grieving the loss of their baby need to accept that little, often unidentifiable, things can trigger a recurrence of grief. They need also to find ways of coping with their grief. Strategies for coping with loss to miscarriage can be many and varied. Some mothers use online resources, blogging or creating an online memorial; others will decorate the Christmas tree with the child’s memory in mind. The family may acknowledge their dead child in the “count” of their children.[7] There are many other means of acknowledging the reality of the deceased child’s life.[8] Appropriate professional intervention can also make a significant difference. There is evidence that supportive hospital care can aid both physical and emotional recovery following a miscarriage.[9]

In giving birth to a stillborn child the mother is confronted with extremely complex emotions. Life and death converge.[10] There has been a birth but there is silence; instead of welcoming their child into the world the mother and father must farewell their baby. One woman observed, “I am angry, unbelievably sad. I feel lonely, lost and beg to wake up from this nightmare. My whole being has been ripped to shreds.”[11] Many mothers understandably report feelings of emptiness that touch them both emotionally and somatically.[12] Subsequent pregnancies are likely to generate much anxiety with the fear that failure may attend this pregnancy also. Mothers who have miscarried often lament that there is no body to hold and ultimately to bury. Those who have a stillborn child do have that option and many claim it is a help in their grieving process.[13]  

Whether the loss in pregnancy is due to miscarriage or to stillbirth, enormous sensitivity and compassion is needed to convey a felt sense of support to the grieving mother and her partner. The grief of loss due to miscarriage and stillbirth generates a range of distressing emotions.[14] However, the grief associated with an induced abortion is even more distressing because it has often to be hidden due to fear of societal judgement. Abortion can generate a complicated grief that impinges upon lives with disturbing and long-term consequences.

The grief of abortion

A preliminary reflection

The evidence regarding the psychological or mental health risks associated with an abortion supports the positions of neither the pro-life nor the pro-choice movements.[15] A study of 500 women to the age of thirty revealed that the majority of respondents reported that they had made the “right decision” in having an abortion.[16] The researchers comment that these findings call into question “strong pro-life positions that depict unwanted pregnancy terminated by abortion as consistently having devastating consequences for women’s mental health.”[17] On the other hand the results do not support the pro-choice movement either insofar as the movement argues that abortion is without any deleterious mental health consequences.[18] Certainly there is no evidence to substantiate the notion that abortion reduces the mental health risks associated with an unwanted and continuing pregnancy.[19]

Instead, it is claimed that there is justification for holding a “middle-of-the-road position” wherein  mental health problems do arise for those women who experience abortion as a “stressful and traumatic life event.”[20] Coleman goes further in insisting that “abortion is associated with moderate to highly increased risks of psychological problems subsequent to the procedure.”[21] Moreover, for those women with a prior history of abortion there is evidence that mood disorders and substance abuse significantly increase.[22] It is with those for whom abortion and its sequelae are traumatic and enduring that I am concerned.

The complicated grief of abortion

A range of circumstances may trigger the perceived need for an abortion. The woman approaching menopause may feel she simply cannot “do babies” again. The woman may suffer a disability. There may be migrant and cross-cultural problems that militate against a woman being pregnant outside marriage. The major group, however, that presents for abortion is the 15-25 year age group.

The grief of abortion is complicated. The woman who has had an abortion is meant to be relieved that her “difficulty” has been resolved. She is not expected to grieve. Indeed, neither she nor her partner feel they have permission to grieve.[23] Grief may not surface until many years later. The impact of the abortion may only be revealed, for example, in the context of psychological help for difficulties in relating to her marriage partner. Or the repressed trauma of an abortion may trigger painful somatic memories, the meaning of which is only discovered with therapeutic support.[24] Karol Woytyla observed that abortion may cause “an anxiety neurosis with guilt feelings at its core, and sometimes even a profound psychotic reaction” and that sometimes decades later a depressed woman may “remember the terminated pregnancy with regret and feel a belated sense of guilt.”[25]

 In the immediate aftermath of an abortion it can be a shocking surprise to a woman when she finds herself grieving her lost child with no tangible means of remembering her baby. In this respect the grief of abortion can be similar to miscarriage. There are, however, additional factors that confound the grieving process.

Often significant others have exerted pressure upon her to have an abortion, with self-interest either consciously or unconsciously in mind: her partner, her parents, friends, the dearth of adequate counselling support at an abortion clinic.[26] Abortion is usually offered to a woman as a quick solution that can resolve the many social, economic and, for younger women, educational problems confronting her. Hence the choice to abort is typically a forced choice. These pressures and the ensuing shame and guilt create the circumstances for much more mental disturbance than that occasioned by miscarriage or stillbirth. The stress subsequent to abortion has been seen as so extreme that the notion of a “post-abortion syndrome” has been proposed.[27]

The literature presents a range of debilitating psychological problems that a woman may suffer subsequent to abortion: low self-esteem, guilt, depression, suicidal thoughts, broken relationships, nightmares, flashbacks, anger, drug and alcohol use, sexual promiscuity and dysfunction, phobias and compulsive disorders. She may also find an inability to express emotions and discover that events that remind her of her dead baby hinder her engagement with age-appropriate activities. So, for example, she may be unable to attend a friend’s baby shower, or rejoice in a friend’s pregnancy. Her interaction with children can become unhealthy, either fearing or abusing them.[28]

Abortion affects not just the woman. Men, too, can be affected by abortion. They can feel powerless and angry if the decision to abort was made independent of them. On the other hand, if they pressured the woman to abort, guilt and sorrow may surface months or years later. Families and siblings of the dead child are also affected. A child who has been told that “if the baby is not all right the doctor is going to send the baby back to God,” may worry that he or she also is not “all right.”[29] Such anxiety generates significant existential insecurity with behavioural consequences for the child.

Those who suffer the grief of abortion, whether the woman, her partner or others affected by the abortion, need understanding and compassion. They also need hope.[30] I turn now to consider the ways in which sufferers of loss in pregnancy can be supported.

Care for those suffering loss in pregnancy

Pope Benedict XVI called for an “attitude of merciful love” to those suffering the effects of abortion and divorce.[31] And, indeed, there is an increasing awareness of the need to support those suffering grief following a loss in pregnancy.

Women do ring up various agencies looking for support after an abortion. It is very important to receive them in a non-judgemental manner, respecting the person and conveying understanding and compassion.[32] In the case of an abortion, such a response does not negate the seriousness of what has occurred.[33] It does, however, demonstrate that the value and dignity of the person has primacy in the eyes of the support person. Empathic support will enable a woman to do the necessary work of grieving, which is a first and essential part of the journey towards healing.

Whether it is a miscarriage, stillbirth or abortion that is the issue, there is a particular type of listening that provides a healing space in which the person, woman or man, feels safe and hence able to open up to the painful depths within, as well as open out to the listening person. It is the empathic, reflective listening that occurs when the support person is fully present in spirit to the suffering individual. Such listening is fully engaged; the woman knows she has the full attention of the listener. Moments of silence are valued and not hurried over. Periods of crying are quietly accepted. The full range of emotions must be recognised as a normal part of the grieving process:

The dreadful despair must be accepted as such and must be regarded as appropriate to this particular life situation. In addition, the chaotic emotions, especially the anger, must be endured. This is made easier by an understanding that the emotional chaos represents the dismantling of the old patterns of relationship and the old habits and therefore also the creation of a new potential.[34]

In helping people recognise, acknowledge and accept their grief, the counselor is also helping to effect transformation of the personality. The way is being created for old habits of emoting and thinking to be replaced by new, more constructive ones. For this to happen it is essential that the grieving process is given expression.

For those suffering the grief of an abortion the work done by the Project Rachel Ministry is particularly helpful.[35] In the context of a retreat for those who have had an abortion, spiritual ministry reaches deep into the wounded spirit of those who have felt condemnatory judgement from themselves, the church or the community. Again, listening and acknowledgement of the woman’s pain must be given priority as instanced by the following observation:

I have found that time taken to listen to the story in some detail is all that’s needed to help make the connection. Many people may have listened to the story – although usually it is only a few – but when the person is listened to by the priest something happens to connect the person with God, forgiveness and their need for spiritual healing. While God’s healing is not dependent on a priest, it is clearly important for some to hear the priest acknowledge the pain they suffer for this spiritual healing to take place. This is especially true for those who have felt rejected by a priest or the church.[36]

Towards hope: an existential reflection

One of the consequences of an abortion, or indeed of any form of pregnancy loss, can be an identity crisis.[37]People who have been subjected to extreme suffering frequently find that their usual modes of self-experience and of relating to the world have been stripped away.[38] They experience agitation and restlessness. They speak of feeling “lost” and of being separated from others in ways that are distressing to them. Their suffering challenges their previous felt-sense of presence to themselves. It also challenges their relationship with God who often appears painfully absent. They have been stripped of their previous roles and personas. Their self-concepts have changed and they have no new concepts with which to replace them. They are no longer able to make sense of who they are. Emotionally, socially, cognitionally, somatically and spiritually they are in new and unfamiliar territory.  They are exposed to a mysterious and disturbing void at the core of their being and a profound existential self-question arises from that experience, the question “Who am I?” Learning to accept their emptiness with equanimity can be foundational for significant transformational change.

By attending to the experience of emptiness, and to the existential question that subsequently arises, people can be led to a vocational exploration, answering the question of “Who am I?” with the discovery of what God is calling them to do.[39] Indeed, as Pope Benedict XVI has observed, in affirming the dignity of the human person and the human person’s capacity to love, “[P]eople are able to respond to the loftiest vocation for which they are created: the vocation to love.”[40] The question for the person on the way towards healing will be the unique form in which that vocation to love will be expressed. It is encouraging for those involved in the work of “healing of souls” that they are also contributing to the salvation of humanity for, as Pope Benedict XVI observed, “without the healing of souls, without the healing of man from within there can be no salvation for humanity.”[41]

Conclusion

Loss of a child in pregnancy, whether due to miscarriage or stillbirth or abortion, is a cause of great grief and suffering. Everyone recognizes that stillbirth is extremely painful, but people often underestimate the extent of the grief also occasioned by miscarriage. Both circumstances require compassion and sensitivity on the part of others. However while miscarriage and stillbirth cause significant grief, they have not been associated with clinically recognised mental disorders to the same degree that abortion has. Whereas the death of a baby in miscarriage and stillbirth happen to a woman, in the case of abortion a woman chooses to have her baby die. However, the choice is a forced choice, a factor which significantly complicates the grieving process. Pressures exerted by her partner, her family, her culture and her psycho-social needs can all combine to create a perceived need to abort. Mental disorders, substance abuse and relational difficulties can then impact on women’s lives for years. Increasingly organizations such as those mentioned above are becoming available to assist women and their partners to acknowledge and work through their grief. As women and men do so, they are afforded the opportunity to find God’s grace in their suffering and to see that God’s love can transform even the darkest experience, giving their lives meaning and purpose.

Meredith Secomb has a PhD in theology from the Australian Catholic University (Melbourne) and has worked as a clinical psychologist in both the public and private sectors, the latter specialising in the interface of psychology and spirituality. This paper was originally delivered in Melbourne at the 2013 National Colloquium for Catholic Bioethicists which explored the topic “Issues in Mental Health and Drug Addiction.”