Research in the United States finds that miscarriages affect approximately 10% to 25% of all recognized pregnancies (Robinson, Baker, & Nackerud, 1999; Shreffler, Greil, & McQuillan, 2011). Despite this statistic, the emotional needs of women following this event do not often get the attention and care necessary for healing (Speert, 1992). The physical trauma of a miscarriage in combination with the unexpected loss can amount to a traumatic event (Zucker, 1999). A meta-analysis on pregnancy loss and mental health suggests between 20 to 30 percent of women experience a deterioration in psychological functioning and general health following their loss (Brownlee & Oikonen, 2004). Miscarriages can happen from genetic problems, infections, drugs, cigarettes and alcohol, exposure to chemicals or pesticides, multiple pregnancies, abnormalities of the reproductive organs, hormone imbalance and ectopic pregnancy although there are still miscarriages for which the cause is unknown (Hey, Itzin, Saunders, & Speakman, 1989). The experience of a miscarriage is often minimized by those who have not been through a lost pregnancy, when in actuality most couples genuinely grieve for their unborn (DeFrain, Millspaugh, & Xie, 1996).
Many individuals are under the impression that the relationship with an unborn or newly born infant and its parent is one that will develop and exist essentially in the future (Doka, 1989). This notion is entirely unfounded for the parents as they have been bonding with their unborn since they knew of his or her existence. In lieu of the aforementioned assumption, many individuals will discount or be unresponsive to the loss (Doka, 1989).
For many couples the standard hospital response to miscarriage or perinatal death is in the form of crisis intervention (Brownlee & Oikonen, 2004). These interventions are provided by a multidisciplinary team of professionals and offer practical support as well as information regarding the loss and emotional support (Brownlee & Oikonen, 2004). While the crisis intervention model validates the loss and meets the immediate needs of the mother, it is brief and cannot address the grief and mourning that will ensue (Brownlee & Oikonen, 2004).
The loss of a pregnancy can have a significant emotional impact on a woman, her partner and her family. Not only is she losing her unborn child, but she will be losing her role as a mother, her hopes for a family and expectations around the future of her baby (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). For some, motherhood is considered a central piece in a woman’s lifetime, one that is integral to fulfilling her role as a woman, adult and partner (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). In western culture, the myth of motherhood, where childbearing is the defining role, idealizes women who become mothers (Zucker, 1999). Potentially losing this experience can have a devastating impact on a woman’s emotional and mental health (Gerber-Epstein, Leichtentritt, & Benyamini, 2009).
During the first trimester of pregnancy, women often experience their growing baby not as a separate being, but as a part of, or extension of themselves; this is identified as the narcissistic stage (Gray & Lassance, 2003). Considering almost three-quarters of miscarriages occur within the first 12 weeks of pregnancy, the early miscarriage implies a loss of a part of oneself, in addition to the loss of the maternal role and the dreams of building a family (Gray & Lasance, 2003).
The literature regarding reactions and behaviours following a miscarriage find grief patterns similar to those of other types of significant losses (Brier, 2008). Although this research and information regarding grief following a miscarriage is helpful in understanding a woman’s experience, there are unique aspects of this loss that must be considered and identified when working with this population (Brier, 2008). Depression is also of concern when working with the responses to a pregnancy loss. Research on depressive symptoms in women following their miscarriage indicated up to half of the women in the study reported elevated levels of depressive symptoms within the first few months following their loss (Shreffler, Griel, & McQuillan, 2011).
Shock is the most common initial response (Peppers & Knapp, 1980). When a mother has been focused on ideas and expectations of a normal delivery, finding out about a miscarriage is devastating, and has been described as “unreal” or a nightmare from which they will awaken (Peppers & Knapp, 1980, p. 32).
Feelings of guilt are often present and related to blaming the self for failure to protect and nurture the developing baby (Brier, 2008). The sense of failure can instill feelings of uncertainty around future fertility and physical ability to carry a pregnancy (Zucker, 1999).
There are several theoretical perspectives that explore miscarriages and how they can lead to more complicated grief. The first theory suggests grieving a perinatal loss is similar to grieving the loss of a loved person, but in this case the loved one was never a actual, physically present being (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). This absence of a concrete being can aggravate the mourning process and potentially lead to complicated grief (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). The literature on this theory suggests that women may have a difficult time understanding their loss as it was for ‘someone who did not exist’ (Gerber-Epstein, Leichtentritt, & Benyamini, 2009, p. 23). Although this theory is relevant to understanding complicated grief, I find this description of the embryo to be insensitive to the woman’s individual ideas about her pregnancy and the relationship she may have had with her developing baby.
The notion of the narcissistic stage of pregnancy is central to the second grief theory for miscarriage (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). As mentioned, during the first trimester a woman may perceive her developing baby as a part of herself, as opposed to a separate being. This “narcissistic loss” (Gerber-Epstein, Leichtentritt, & Benyamini, 2009, p. 4) can complicate the normal grieving process and may be experienced as a betrayal by the woman’s own body (Gerber-Epstein, Leichtentritt, & Benyamini, 2009).
Lastly, the third approach focuses on the traumatic nature of a miscarriage and examines studies that identify significant traumatic symptoms. Research looking at the psychological reactions following a first trimester miscarriage suggests approximately 70% of participants experienced anxiety, fear, helplessness, sleep difficulties and repeated recollection of the experience (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). This theory suggests that not only does a woman need to mourn her loss, but she may also need to deal with the effects of trauma, which can in turn complicate her grief process (Gerber-Epstein, Leichtentritt, & Benyamini, 2009).
The impact a miscarriage has on a woman’s mental well-being and the way in which she grieves will vary based on each woman’s unique experience, mainly history, culture, beliefs and ideas around her pregnancy. Other influential factors include investment and meaning in the pregnancy, fertility history, relationship quality, age of the mother, previous pregnancy losses, number of children, time and energy involved in conception and external expectations and influences around childbearing (Shreffler, Griel, & McQuillan, 2011).
The degree of planning and anticipation before and in the early stages of a pregnancy can affect the level of distress experienced by the woman. Studies exploring this relationship found that women who lost planned pregnancies endured greater distress than those of unplanned pregnancies (Shreffler, Griel, & McQuillan, 2011). The level of attachment and commitment to the developing baby are also influential in how much distress a woman may experience following a miscarriage (Shreffler, Griel, & McQuillan, 2011). Mother-infant attachment starts to develop before the baby is even conceived; planning the pregnancy, confirming the pregnancy, and preparing for the baby are just the initial steps in forming a mother infant attachment and they all occur prenatally (Shreffler, Griel, & McQuillan, 2011). Brownlee and Oikonen argue that technology has increased the opportunity for forming stringer attachments to the foetus with 3D imaging, foetal monitoring and ultrasounds (2004). Commitment and attachment can also contribute to the meaning of the pregnancy for a woman, which will affect her levels of distress in the instance of a miscarriage (Shreffler, Griel, & McQuillan, 2011).
Women experiencing their first pregnancy may also show greater distress in the case of a miscarriage. The first pregnancy symbolizes a significant transition into motherhood, and also entails emotional and psychological growth (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). A developing maternal identity, and anticipatory thoughts, fantasies, wishes, hopes and anxieties about the developing baby have great personal significance for first time mothers (Gerber-Epstein, Leichtentritt, & Benyamini, 2009). These developments and processes are well under way throughout the first trimester; losing them or having them abruptly terminated will cause greater distress for women experiencing their first pregnancy, than for those already with children (Shreffler, Griel, & McQuillan, 2011).
Hormones and chemicals during pregnancy have prepared the mother to nurture and care for her baby (Doka, 1989). This fluctuation of hormones combined with the emotional intensity of the loss can further impede the grieving process (Doka, 1989).
Views and beliefs on motherhood and the importance of motherhood are additional factors which will affect the psychological response to miscarriage. Infertility research suggests women who place a great amount of importance on child-bearing experience greater levels of distress (Shreffler, Griel, & McQuillan, 2011).
