Miscarriage: Disenfranchised Grief (from CAPA Quarterly Journal, March 2008)

Miscarriage: Disenfranchised Grief (Written in March, 2008)

“Miscarriage is bereavement, death and loss to the expectant mother.”

I am a Counsellor and Educator, and the mother of a two-year-old child (as a side note – on publishing this in 2021, I now have 3 children, ages 15, 12 and 9!). I have been working in counselling and the community sector for the past seven years and have been a Clinical Member of CAPA since 2004 (and PACFA member, since 2008).

In May of 2007, my world turned upside down. A happy family, that I saw, with “mum, dad and two kids” did not happen, at least not for me now. I had a miscarriage on 18 May, 2007. It was 36 hours in duration from start to finish. It was a terrible and harrowing experience, inclusive of labour, contractions and not much assistance from the hospital at the time I attended.

As a woman, I knew what was happening to me. The male doctor and female nurse from the emergency department could not confirm it was happening. Because my situation was not definite a miscarriage yet, I was sent home after been seen in the emergency department.

Some time later at home, I had labour pains. In severe pain, I made the decision to return to the emergency department. On return to the hospital, I had my miscarriage in the emergency department toilet. After a non-complete miscarriage happened, I required a Dilatation and Curettage (D & C) operation. A D & C operation is, as Better Health Victoria (2007) describes, a scraping of the womb lining and is virtually the same procedure as a termination or abortion.

Afterwards, I spoke to various people about my ordeal. It appeared to me that I had a contagious disease, or something that is just not spoken about. Something that is silenced. The majority of friends, extended family and acquaintances did not wish to speak to me about my grief or loss that I so wished to talk about. I believe it is hard to empathise with someone after miscarriage due to at least half the population never experiencing it. Even some therapists I have spoken to have been unsupportive.

I was 12 weeks pregnant. This was going to be a baby for me, since I already had one baby in the past and I expected this pregnancy to be our second baby. I found out that I was pregnant when I was less than 4 weeks pregnant. I therefore had two whole months prior to the miscarriage to get accustomed to the idea of being pregnant.

It was this second baby we had been hoping and praying for. These two months of knowing gave me a great deal of time to get used to the idea of being pregnant. I prepared a name, discussed options for the impending birth and considered where in our house the baby would be. At 12 weeks’ pregnant, it was almost time to discuss the pregnancy with friends and family. I somehow knew that it didn’t ‘feel right’ so I chose to keep my pregnancy news to myself until after the miscarriage.

Although cognitively, and through my counselling studies, I knew how I ‘should’ deal with this grief, the reality was extraordinarily different. Many that I have spoken to since have been dispassionate to my loss including close friends and some of my family. The barrage of statements like ‘just move on’ and ‘get back on the horse’ have been quite stressful and hard to bear. As a mother I just wanted that baby that I had lost and didn’t want to ‘get on the horse’ to just ‘get another one’.

Even well meaning friends who have trained in therapy or are usually compassionate have said extremely insensitive remarks. Therefore, I feel it is difficult to convey even to a fellow therapist, or in the therapy that I have received since, the actual pain after my miscarriage.

What I have as a result chosen to do is to complete my Masters and research this largely untapped area. Further on I will explain what I will be researching and why.

I believe that miscarriage is bereavement, death and loss to the expectant mother. It is the potential baby’s loss, a bereavement that is unrecognised, as well as being the death of the baby, even if it was not born.

It has been these beliefs that have led me to further studies. This means completing a Masters in Applied Social Science and as part of my research, I will be discovering attitudes of Social Workers working with women who have miscarried.

There are suggestions by Twemlow (1992) that perhaps miscarriage is often undiscovered in therapy. He intimates that therapists do not ask the relevant questions relating to whether or not a client has miscarried in the past, or whether therapists know what to do if the subject does come up. Perhaps it may also be that some therapists may not even recognise the importance of miscarriage as an event in a woman or couple’s life.

Some facts

Miscarriage touches more people than we, as therapists, may truly be ever able to grasp. Miscarriage is the loss of a foetus before it is viable (Macquarie Dictionary, 1995) and around one in five women who know they are pregnant, experience a miscarriage (Overs, 1995). It is the spontaneous loss of an embryo or foetus prior to 20 weeks’ duration (DHS, 2007). After 20 weeks, it is deemed a stillbirth or neonatal death (DHS, 2007).
There are suggestions by ABC (2007), that as many as one in three women will experience a miscarriage during their reproductive lives. This doesn’t include women who haven’t had their pregnancies confirmed, or women who may have not realised that they may have had a miscarriage.

In my literature review for the Masters, I discussed the importance of maternal grief and recognising that maternal grief is a unique and individual experience (McDonald, 2007, Written 30.11.07). There is also important information illuminated by Nichol about maternal grief (Nichol, 1989). Nichol suggests that it is in the first trimester, where a baby is felt to be an integral part of a woman and that the loss of a baby during such time is actually a loss of part of herself. A large majority, or approximately 80%, of pregnancy loss occurs in this first trimester (birth.com.au, 2004). If Nichol’s theory is correct, there are many women who feel that they have lost a huge part of themselves post-miscarriage.

Being a woman in my thirties I am well aware of the proverbial ‘clock ticking’ in my body. What appears to be encouraged currently in popular culture is to have children at an older age. According to Fox (in The Australian, 2007), “the way you look and feel does not determine your reproductive age”. Additionally, Fox describes how many believe ’40 is the new 30’ and ‘30 is the 20’. This could be the case in terms of how someone may think and feel, though the body appears to remember in a reproductive sense.

There are some staggering figures that Fox (2007) mentions. Potential mothers and fathers trying for a baby over the age of 40 have a 50% chance of miscarriage and over the age of 45 the chance of miscarriage is up to 55% (Hughes, Steigrad, Persson & Costello, 2005).

With the age of mothers steadily increasing since 1995 (NPSU: UNSW, 2005), we need to be aware of the risks of miscarriage for advanced maternal age. The chance of conception problems and miscarriage increases with age, after around the age of 35 (Hughes et al, 2005).

Hughes, et al (2005) also make mention that the growing trend for women to delay childbearing requires more women to be on assisted reproductive technology (ART), e.g. In Vitro Fertilisation (IVF) and other assisted reproduction techniques. It is important to note that Hughes, et al, highlight that there is a direct correlation between increased maternal age and any form of pregnancy loss. Even as Fox (2007) outlines, she was indeed lucky to achieve a child through the IVF process at 43 and that many couples do not, especially over the age of 40, even if they go through IVF. So the myth that if you cannot fall pregnant naturally you could just try IVF may be incredibly misguided.

Women in their 30s and 40s could be therefore forgiven for being confused on when they need to start trying for children. Popular culture presents a false picture as these statistics show. It is therefore a psychological minefield if a woman is trying to conceive after the age of 40, often with little success. Add this to the pro-life (anti-abortion) and pro-choice (those for abortion) debate that has been described as a ‘social taboo’ by many religious fanatics and argued against such taboo status by feminists (Pregnancy Advisory Centre, 1998), let alone the guilt and moral dilemma a woman faces if she chooses to have an elective abortion for any reason. The choice whether or not to conceive is fraught at every turn no matter the age of the woman.

Women at any age, though especially over the age of 40, now have more chance at deciding whether or not to keep a pregnancy if there are genetic abnormalities due to the introduction of many new forms of genetic testing and ultrasounds. There is often then the need to induce a miscarriage if there are chromosomal abnormalities. Hughes, et al, 2005 explain that chromosomal abnormalities, including Down Syndrome, are only increased with maternal age.

In context

What does this mean for us as therapists working with women?

Although not all women have children, as mentioned above, you may find that about one in three, or one in four of your women clients may have had a miscarriage. It appears that these statistics may expand as the numbers of women delaying childbirth increase.

Information that a woman has miscarried in the past may never be mentioned to you even if you are the therapist. Some women may not think this is relevant years later, even if it was an extraordinarily traumatic event. It will depend on the reactions of friends and family to a pregnancy loss as to whether a woman may entrust you with such information. Those women who may have been silenced may further silence themselves because of a lack of trust even if you are a trusted person.

Twemlow (1992) indicates that “even sophisticated psychoanalytic clinicians rarely obtain details on abortions and miscarriages” (p.113). Therefore it could be surmised that counsellors and psychotherapists may not ever ask the question: “How many miscarriages have you experienced?” to any woman of childbearing age.

Recently, the debacle at Royal North Shore Hospital (RNSH), led a father-to-be, Mr Dreyer, to speak out to the media about the appalling treatment of his wife after she suffered a miscarriage (Smith in SMH, 2007). Male clients can therefore be impacted by any miscarriage that their partner has had. It may therefore be wise for a therapist to ask if there has been any childbearing loss experienced by an individual, or a couple in therapy.

Even as I write this paper, there appears to be more blunders in hospitals relating to miscarriage. According to Channel Nine News (Ninemsn.com, Feb 10, 2008), a woman in Ballarat, Victoria, was given her dead baby in her hospital bag. Although in some circumstances women may wish to bury a baby after miscarriage, this is very unusual to receive a baby in a hospital bag along with your belongings. In this instance it would be extraordinarily distressing for a woman, who may have just lost a baby, to find her dead unborn baby along with her personal items. It appears that the Victorian Health Minister Mr Andrews will be investigating the matter (Ninemsn.com, Feb 10, 2008). And not a moment too soon. The question now is – how many further blunders have to happen before there is a complete overhaul of the Australian public hospital system as to treatment post-miscarriage loss?

As Women’s Health Week (2003) explains “one year after the miscarriage, 32% of women interviewed said their interpersonal relationships were more distant than before”. This is a significant proportion of women who have miscarried. Women, as I found, can feel that their partner does not know the true extent of their grief because they did not carry the pregnancy. Women can feel completely at fault and guilty as it was their body that let them down. It is my belief that guilt plagues many women post-miscarriage and this can lead to feelings of isolation and separation from their partners.

How is miscarriage grief disenfranchised?

To be disenfranchised means that you do not have the right to vote, or that you have had a right taken away (Cambridge Dictionary, 2008). Disenfranchised grievers are therefore denied and deprived of their rights to mourn. Disenfranchised grief, as suggested by Doka (2002) is a type of grief that is not socially acknowledged or publicly mourned.

Disenfranchised grief is a type of loss or bereavement that is unacknowledged by society and the griever is someone who is not afforded the right to grieve. It is my belief that miscarriage grief quite clearly falls into this category of grief as there is no public mourning. In miscarriage, the baby, foetus or embryo did not exist outside the womb of the mother. There is no funeral granted, there is no ceremony or any official recognition of the loss in our society.

Based on the statistics here, two-thirds of women experience successful pregnancies. This could leave the other one third of women who have been pregnant and suffered a miscarriage feeling isolated, especially if no woman around them has had a miscarriage. It is only after seeking out and speaking to other women of childbearing age that I have found some women who have experienced miscarriage and felt able to openly discuss my grief.

Women who have experienced miscarriage or abortion need to be afforded this right to grieve. Often there may be no other place but in a counselling room that it could be recognised as a need and a right to grieve. It is incredibly important that such allowance is made to a woman in this circumstance.

Support services for miscarriage

Women who have miscarried are also disenfranchised by their choice of support services. In New South Wales, the main support service on offer for women who have miscarried is SIDS and Kids (SIDS and Kids, 2007) and in Victoria it is SANDS – Stillbirth and Neonatal Death Support Inc (SANDS, 2007). There is no group specifically supporting miscarriage, only those that includes peri- or neonatal (post-20 weeks gestation), e.g. SANDS, SIDS and Kids and Bonnie Babies, these services additionally support parents who have lost full-term babies. In my circumstance I did not want to compare my grief to someone who had lost a living baby.

After my loss I wished to find a support group for miscarriage alone. There appears to be none that are run by a counsellor, therapist or support worker supporting miscarriage. I know I did not lose a baby, I lost a potential baby. My baby would probably have never have survived outside the womb and I didn’t get to keep the baby in my uterus to full term. Therefore I see my loss as not at all the same as someone who has lost a full-term baby. It is a different experience.

Although there is a group for recurrent miscarriage in Sydney at the Royal Hospital for Women, this is specifically for clinical problems in pregnancy. It is also a required that you need to have had two or more consecutive miscarriages (RHW, 2007). This is additionally a clinical group only and although supportive it is run by a Gynaecologist, not a Psychologist or Social Worker (RHW, 2007).

My research

After starting my Masters, I made the hard decision to take on the challenge of researching miscarriage. I have had now a number of months of research and completed my literature review. The research topic that has subsequently chosen is ‘Miscarriage: Disenfranchised Grief and its Implications for Healthcare Professionals (Social Workers)’.

Over the next two months, I will be conducting a pilot research project with Social Workers in the South Eastern Sydney and Illawarra Area Health Service. There will be individual qualitative interviews undertaken initially with a follow up questionnaire for any Social Workers unable to take part in the interviews. Although a small project, I hope to shed light on Social Worker opinions and attitudes to women experiencing miscarriage. If there is anyone wishing to receive a copy of my research report I am happy to send one to you.

Conclusion
Miscarriage is disenfranchised grief. It is often a silenced experience and the numbers of women who experience miscarriage will continue to grow the more women delay childbearing years. As therapists we need to ask more of ourselves so we adequately support women with this growing need for therapy, both personally and professionally.

Women do bear all future children and forms of human life. We must afford the right of women to grieve the loss of both children and unborn children. We must continue to be non-judgemental in our attitudes with all forms of maternal and paternal grief. It is also incredibly important to afford ourselves, as fallible human beings, the right to grieve when we go through important grief-stricken events in our lives. We need to be models to others for integrating our own experiences to allow ourselves to be better therapists.

Post-script

Here is a list of helpful suggestions for a best practice way of working with anyone that has experienced miscarriage. I put this list together from both what I have found helpful and unhelpful, and what makes sense to me as a therapist.

Best practice ideas

Do’s

1. Be compassionate
2. Listen intently
3. Do your best with being empathic
4. Be non-judgemental
5. Acknowledge their pain and grief
6. Recognise the need for ‘grieving time’, however long that may need to be.
7. Encourage the client to have a grief ceremony of some sort. For example, lighting a candle every day for the unborn baby for a period of time, planting a tree, erecting a plaque or burying a box of some of the baby items.
8. Enquire with the client about ‘what did this unborn child mean to you?’ (The unborn child often means different things to different people.)
9. Acknowledge feelings
10. Ask if they wish to talk about it further (or in detail). If not, do not press the client for more information.
11. Ask about how traumatic it was
12. Ask is this your first miscarriage? (a) If it is their first miscarriage, explore further how they wish to describe it. (b) If the miscarriage is not their first, is it one of many? How do they see themselves now? E.g. Do they see themselves becoming a mother if it is really important to them? Could they achieve parenthood? If not, what else has this tragedy shown them?
13. Women need to be afforded the right to be asked how they wish to deal with their miscarriage. Not told how they ‘should deal with it’.

Don’ts

1. Don’t make assumptions
2. Never say ‘I know how you feel’
3. Never suggest for them to ‘move on’, ‘get over it’ or any such words. Your client will move on in their own time.
4. If they do not wish to talk about it in detail or much at all, just go with the client wishes.
5. Don’t suggest that the client is depressed, anxious or has an anxiety disorder of any kind, as this isn’t true. Grief and their pain needs to be acknowledged instead.
Some research links anxiety disorders and depression with miscarriage (McDonald, 2007, Written 7.9.07). My belief is that if a woman’s grief is unacknowledged, especially by therapists or well meaning health care professionals, it is more likely for a client to become anxious or depressed. It is the silencing of a woman’s right to grieve that only exacerbates a woman’s pain. Ensure that you do not label any client post-loss.

References

ABC, 2007, ABC Health & Wellbeing, Fact File: Miscarriage http://www.abc.net.au/health/library/stories/2006/11/08/1831383.htm [Accessed 16.1.08]

Better Health Victoria, 2007, Dilatation and Curettage
http://www.betterhealth.vic.gov.au/BHCV2/bhcarticles.nsf/pages/Dilatation_and_curettage?open [Accessed 16.1.08]

birth.com.au (2004) Miscarriage, http://www.birth.com.au/class.asp?class=6620&page=1 [Accessed 26.11.07]

Cambridge Dictionary, 2008, Disenfranchised, Cambridge University Press. http://dictionary.cambridge.org/define.asp?key=22261&dict=CALD [Accessed 4.2.08]

Channel Nine News, 2008, Baby’s Remains Left in Mother’s Bag, February 10, 2008 http://news.ninemsn.com.au/article.aspx?id=378079 [Accessed 10.2.08]

Doka, K. (ed), 2002, Disenfranchised Grief: New Directions, Challenges, and Strategies for Practice, Champaign; Illinois: Research Press.

Fox, A., 2007, IVF in Your 40s is a Long, Hard Road, The Australian from 14 July, 2007 http://www.theaustralian.news.com.au/story/0,25197,22069686-23289,00.html [Accessed 4.2.08]

Hughes, G., Steigrad, S., Persson, J., Costello, M., 2005, Fertility in the Over 35-year-old, The Australian Doctor, http://www.australiandoctor.com.au/htt/pdf/AD_HTT_029_036___JUL08_05.pdf [Accessed 4.2.08]

Macquarie Dictionary, 1995, Miscarriage, Macquarie Dictionary and Thesaurus. Macquarie, NSW: Macquarie Library Pty Ltd.

McDonald, R.T., 2007, Assessment 1: Research Proposal Essay, ‘Miscarriage: disenfranchised grief and its implications’, Written 7.09.2007

McDonald, R.T., 2007, Assessment 2: Literature Review, ‘Pilot Project – Miscarriage: Disenfranchised Grief and its Implications for Healthcare Professionals (Social Workers)’, Written 30.11.2007

National Perinatal Statistics Unit, University of New South Wales (NPSU: UNSW), 2005, Australias Mothers and Babies 2004, ps18 http://www.npsu.unsw.edu.au/NPSUweb.nsf/page/ps18 [Accessed 4.2.08]

Nichol, M., 1989, Loss of a Baby: Understanding Maternal Grief. Moorebank, NSW: Bantam Books.

Pregnancy Advisory Centre, 1998, The Abortion Decision: Making the Decision When You Have Moral Concerns, Adapted from the following work; Allanson,S, 1998, Fertility Control Clinic, Victoria, and Maguire & Maguire, Abortion-A Guide to Making Ethical Choices: How to Make a Moral Decision, Catholics for a Free Choice. http://www.pregnancyadvisorycentre.com.au/downloads/Moral%20Concerns.doc [Accessed 4.2.08]

Royal Hospital for Women (RHW), 2007, Recurrent Miscarriage Clinic, http://www.sesiahs.health.nsw.gov.au/rhw/default.asp?page=114&template=6&leftnav=5 [Accessed 4.2.08]

SANDS, 2007, Stillbirth and Neonatal Death Support Inc. (SANDS) website, http://www.sandsvic.org.au/ [Accessed 4.2.08]

SIDS and Kids, 2007, SIDS (Sudden Infant Death Syndrome) and Kids website, http://www.sidsandkids.org/ [Accessed 4.2.08]

Smith, A., 2007, Miscarriage Inquiry Called, Sydney Morning Herald (SMH) from 26 September, 2007, http://www.smh.com.au/news/national/miscarriage-inquiry-called/2007/09/26/1190486349136.html [Accessed 26.9.07]

Twemlow, S.W., 1992, Transactions of the Topeka Psychoanalytic Society: ‘Miscarriage and Abortion’, Bulletin of the Menninger Clinic; Winter ’92, Vol. 56, No.1, pp.113-115. New York: Guilford Publications Inc.

Women’s Health Weekly, 2003, One-Third of Women Feel Distant From Partner Post-Miscarriage. Oct. 30, 2003, p. 60. Custom Journal 25