Pregnancy loss, or fetal death, can happen at any stage of pregnancy. It is more likely to occur before 12 weeks, when it is referred to as miscarriage. After 20 weeks’ gestation, it is called a stillbirth. Stillbirths are rare, affecting fewer than one in a hundred pregnancies in the U.S.
Fetal loss can be caused by genetic problems like Down’s syndrome, maternal illness or physical difficulties with the uterus. In many cases, the cause remains unknown. Coping with pregnancy loss can be extremely challenging. Strong emotions, including grief, anger, guilt and fear are normal. Women and their partners manage in different ways, none of which is right or wrong.
Dr. Diana Carter of the University of British Columbia explains that pregnancy loss is a complicated psychological event. “Women who have experienced miscarriage often have common bereavement reactions and while the intensity and experience of these reactions diminishes over time for most women, a substantial minority will develop long-term psychiatric consequences,” she writes.
A team from New York State Psychiatric Institute interviewed 114 women at six to eight weeks after miscarriage. Their mean level of depressive symptoms was “substantially elevated” above that in the community. Twenty percent were “highly symptomatic,” as compared with 10 percent among community women.
Depressive symptoms were more likely for younger women and those with a prior pregnancy loss, but did not vary with number of living children, marital status, ethnicity or educational level.
Dr. Benjamin Hale of the University of Colorado says that after a pregnancy loss, women may feel a sense of responsibility or guilt for what happened. These feelings can lead to a host of unpleasant emotions that bereaved mothers and their partners carry for years.
Dr. Hale believes that the usual approaches, which seek to overcome the mother’s feelings of self-blame, “play down her emotion as somehow an irrational response to events outside her control.” But a mother who feels this sense of guilt has good reason to feel upset, even responsible for the life of the child, but not culpable for the unfortunate turn of events.
He says, “Women are the providers of a safe environment for their babies. They are autonomous selfâlegislators carrying the moral burden of another life. When disaster strikes, they have every reason to be confused about how their actions may have changed the destiny of their child.”
Relationships can also suffer in the aftermath of a pregnancy loss. One recent study looked at marriage and cohabitation outcomes. Researchers from the University of Michigan used figures from the National Survey of Family Growth. They found that, of 7,770 pregnancies, 82 percent ended in live birth, 16 percent in miscarriage, and two percent in stillbirth.
Women who experienced miscarriage or stillbirth had a significantly greater possibility of their relationship ending, compared with women whose pregnancies ended in live births. The team conclude, “Parental relationships have a higher risk of dissolving after miscarriage or stillbirth, compared with live birth. Given the frequency of pregnancy loss, these findings might have significant societal implications.”
Dr. Thomas C. Michels of the Madigan Army Medical Center in Tacoma, Washington, points out that family physicians are in an ideal position to address psychological factors in women who have had a pregnancy loss.
“After pregnancy loss, women experience the same emotional and psychological reactions as those who have experienced any type of death; however, the duration of the distress is typically shorter in early pregnancy,” he writes.
After a loss in the second trimester (13 to 27 weeks’ gestation), “patients initially go through recognizable emotions, including shock, searching, and yearning. Often, the patient will have intense preoccupation with seeing or hearing the infant, and there may be a period of disorganization, with features similar to those of depression, before she gradually adjusts and is able to move on.”
Dr. Michels adds that many patients must also cope with their emotional responses during their next pregnancy, because women who have had a pregnancy loss often have a strong impetus to become pregnant again. “During the next pregnancy, these patients may have intense anxiety and ambivalence, with little emotional attachment,” he writes. “They may also be overprotective of the child after birth.”
Awareness of common and expected responses to pregnancy loss can help the family physician to provide guidance to these patients, who need information, reassurance, and encouragement, he concludes.
Support groups for parents who have had a pregnancy loss can be invaluable. There are also many Internet resources available. Psychological support or counseling can be of benefit.
American Academy of Family Physicians. Pregnancy Loss: What You Should Know. American Family Physician, Vol. 76, November 1, 2007, pp. 1347-48.
Neugebauer, R. Depressive symptoms at two months after miscarriage: interpreting study findings from an epidemiological versus clinical perspective. Depression and Anxiety, Vol. 17, 2003, pp. 152-62.
Hale, B. Culpability and blame after pregnancy loss. The Journal of Medical Ethics, Vol. 33, January 2007, pp. 24-7.
Michels, T. C. and Tiu, A. Y. Second trimester pregnancy loss. American Family Physician, Vol. 76, November 1, 2007, pp. 1341-46.
Gold, K. J., Sen, A. and Hayward, R. A. Marriage and cohabitation outcomes after pregnancy loss. Pediatrics, Vol. 125, May 2010, pp. e1202-7.
Carter, D., Misri, S. and Tomfohr, L. Psychologic aspects of early pregnancy loss. Clinical Obstetrics and Gynecology, Vol. 50, March 2007, pp. 154-65.