Approximately 20% of confirmed pregnancies end in loss. The most common cause of miscarriage is chromosomal abnormalities, followed by genetic mutations. Combined they cause the overwhelming majority of first trimester miscarriages. Our species is particularly chromosomally unstable, as many as 70% of all conceptions are not viable. Many conceptions are lost – the fertilised ovum fails to implant or is actively rejected by the maternal body – before pregnancy is even confirmed. Sometimes the fertilised ovum succeeds in implanting and passing the maternal body’s initial screening process, but is nevertheless not viable. This is the cause of most miscarriages within the first trimester. Other common causes of miscarriage include immunological problems, infections, thyroid disorders, polycystic ovary syndrome, exposure to toxins, and an incompetent cervix and some of these factors play a role in second trimester miscarriage in particular.
Miscarriage can be, and often is, a devastating experience. I myself have experienced this devastation. Each pregnancy loss is unique and there is great diversity in the healthy and normal ways that women may react to the experience. Pregnancy loss, even early pregnancy loss, may trigger a profound sense of grief.
The first thing to understand about grief is there is only one rule: there are no rules. Each person grieves differently. If you experience pregnancy loss more than once, you may find that you grieve differently each time. There are many ways to grieve, so grieve in the way that makes sense to you. Grief doesn’t have stages and there isn’t an endpoint to be reached. You don’t need to ‘get over it’. With time, if you honour your grief, the raw intensity of your pain will lessen or will become easier to live with. This doesn’t mean that the hole in your heart will heal, that your grief will go away. It does mean that you’ll learn how to live with a hole in your heart. You’ll find a way to live with this loss, and live a rich, meaningful and happy life too. This will take time.
Living in limbo
Depending on how your pregnancy loss unfolds you may find yourself living in ‘limbo’ for a time. That is, you may experience a period of time during which you know are at risk for miscarriage, or even know that miscarriage is highly likely, but the possibility of pregnancy loss is still not certain. Living with this kind of excruciating ambiguity, even for a short period of time, is an incredibly difficult experience. While you live in ‘limbo’ your top priority needs to be treating yourself with love and compassion. Don’t put pressure on yourself to do anything other than live through each day. At the same time, until miscarriage is confirmed with absolute certainty, it is best to continue to adhere to basic health advice for pregnancy, such as avoiding alcohol. Stay in regular contact with your doctor and follow your doctor’s advice.
Again, depending on how your pregnancy loss unfolds, you may find yourself needing to choose how you want to manage your miscarriage medically and physically – choices between surgical (D & C, curette) management, medical management (medication to induce miscarriage) or expectant management (waiting for natural miscarriage to begin if it hasn’t already). There is no one right choice, only the choice that’s right for you. Talk to your doctor about the options that are available to you where you live and given your exact situation. Ask your doctor to explain to you clearly the advantages and disadvantages of each approach in your specific situation.
The physical experience
Physically, the experience of miscarriage varies between feeling similar to a period, to feeling like a particularly painful and heavy period, to feeling more like a ‘mini-birth’, to feeling similar to giving birth at term, depending on the timing of the miscarriage and the exact circumstances. You have the right to make informed choices about pain relief options at this time. Talk to your doctor about the most appropriate pharmacological options in your particular situation and draw upon non-pharmacological options for pain relief too, from hot-water bottles, to abdominal breathing, to mindfulness practices. Relieve pressure in every other area of your life that you can. Miscarriage can be not just an emotional ordeal but a physical ordeal as well. If this is true for you ensure that you take this into account and give yourself the time to rest and recover just as you would from any physical ordeal.
The emotional crisis
In the immediate aftermath of the loss, again, the top priority must be taking care of yourself. All you need to do is live through this crisis one day at a time. In my opinion, in the midst of an immediate crisis, all bets are off. If you want to stay in bed all day in your pajamas, eat a whole block of chocolate, hurl crockery about your kitchen, or weep for hours on end, go right ahead. You have every damn right.
The only caveat I would add to this is that if you have older children do ensure that your children are provided with a loving and emotionally safe space at this time. It is okay for your children to know that you are feeling sad, even to see you cry, as long as the basic emotional safety of their world doesn’t appear to be at threat. Make it as easy as possible for yourself as you provide this loving and emotionally safe space by calling in support from family and friends and by making any time you have with your children easier on you while being emotionally safe and enjoyable for your children at the same time. For example, enjoy movie marathons together, get out favourite activities, and indulge in a bit of takeaway or easy meals. During the immediate emotional crisis, your goal as a parent to your older children should simply be to maintain that loving, emotionally safe connection. You can go back to stimulating their cognitive development and encouraging healthy eating next week!
In the aftermath
As soon as that immediate emotional crisis settles it is vital that you focus on good mental health care for yourself. You are currently at risk of developing depression and it is crucial that you support your mental health at this time. ‘All bets are off’ has a definite time limit: give yourself no more than two weeks of this, less if possible. Good mental health care means:
- Getting regular exercise. If you usually do exercise regularly you’ve probably had a break. Get back into it now. If you don’t usually exercise it is important to start. Regular physical activity supports good mental health. Find physical activity that fits in your lifestyle and is enjoyable for you. If fitting regular exercise in is difficult then try exercising flat out as hard as you can for three to five minutes a day (go absolutely flat out as long as you can then bring yourself back to a slow steady pace until you’ve recovered enough to go flat out again). This will, in minimum time, ensure that you are getting a mental health boosting endorphin hit.
- Living a rewarding life. Do things that you enjoy. Do them whether you feel like it or not. Read a good book, eat your favourite food, watch a favourite movie, get back into your hobbies, have a romantic night out with your partner or plan a fun family day together. Build a rich, rewarding life now and feelings of joy will gradually return.
- Be social. Connect with your friends, family and partner. Reach out for support. Miscarriage is not rare, it is common. It is highly likely that you already know a kind and compassionate woman who has been in exactly the same situation that you are now so consider sharing your experiences with supportive women in your life. If that feels too difficult consider accessing support through online chat rooms or by calling pregnancy loss support organisations.
- Be kind to yourself. Take care of your mental health and give yourself time to recover. Allow the thoughts and feelings that you have to come and go. Don’t pressure yourself into feeling better soon. It will take time. Compassionately give yourself this time.
- Honour your grief. Your grief isn’t a sign of being broken. It is testament to your strength, your love and your courage. Don’t fight your grief, instead allow the crashing waves to take you. Learn to surf them. This is what it feels like to heal.
Create your own meaning
Don’t let your miscarriage be defined in medical terms or by what your loss meant in the eyes of other people. Find your own personal meaning, drawing on your religious or spiritual beliefs if relevant or your own personal outlook on life. Create the memories you want to keep and acknowledge your loss in a way that holds meaning to you. You might like to: name your baby, hold a ceremony, make a keepsake, light a candle or write your baby a letter. There’s no right or wrong so do what feels right to you.
There is no specific time frame to wait before trying to fall pregnant again. You and your doctor only have to be confident that you have fully passed the remains of your current pregnancy (your doctor may confirm this with blood tests and/or a scan). Some doctors advise women to wait one cycle. Your doctor may have further advice depending upon your exact circumstances. Trying to fall again, and the timing of this, is your (informed) choice. In making that choice, do consider your full situation including your immediate emotional state and desires, as well as your age, fertility and life plans. For some women, waiting a few months before trying again may be the best action emotionally. However, don’t let other people talk you into waiting if it doesn’t feel right for you. It isn’t compulsory. For other women trying again as soon as possible is the best course of action emotionally, and some women may feel (due to age or fertility) that waiting is simply not an option no matter what their emotional state.
If you suspect that there was more to your miscarriage than a chromosomal abnormality or a genetic mutation, talk this through with your doctor. If you have experienced three or more consecutive miscarriages (recurrent miscarriage) ask your doctor for a referral to specialist healthcare and support.
If you want to have a child then every ovulation is a fresh roll of the dice. Even if you are playing with ‘loaded’ dice: every ovulation is a fresh roll. Even amongst women who have experienced three consecutive miscarriages, the majority will fall pregnant with a viable pregnancy and successfully carry the baby to term. As a general rule, sheer persistence, simply continuing to roll that dice, usually results in a living, newborn baby.
Grief into the future
Remember, you don’t have to ‘get over it’. You will always be a mother to your lost baby. You have every right to continue to mother your lost baby in whatever way makes sense to you. Your baby will always be with you, a part of you and your life’s story.
Apply it to your life: Have you experienced a miscarriage? What helped you to navigate this time?
Larsen, E.C. Christiansen, O. B., Kolte, A.M. & Macklon, N. (2013). New insights into mechanisms behind miscarriage. BMC Medicine. 11:154 doi: 10.1186/1741-7015-11-154
Cowchock, F.S., Gibas, Z., Jackson, L.G. (1993) Chromosome errors as a cause of spontaneous abortion: the relative importance of maternal age and obstetric history. Fertility and Sterility. 59 (5), 1011-1014.
Brier, N. (2008) Grief following miscarriage: a comprehensive review of the literature. Journal of Women’s Health. 17(3): 451-464. doi:10.1089/jwh.2007.0505.
To the children we know but briefly and to the parents who love them anyway