Miscarriage

Early perinatal loss or miscarriage is increasingly being given its full significance as not only the loss of a pregnancy but the untimely death of an individual person who has to some extent been part of a family (see Conception). In the eyes of society miscarriage often occurs unnoticed. The lost child is unseen, unnamed and unacknowledged through an obituary. There are often no physical remains to bury with the rituals that usually afford comfort to a grieving family. It can be a lonely vigil described by a spectrum of evolving emotions—shock, ambivalence, guilt and anger. Unfortunately, it can also be a time of alienation, rejection and shame. The premature death of these unbeheld children confronts us with our own mortality and provokes us to wrestle with the meaning of human suffering.

Multifaceted Loss

Kowalski notes that “perinatal death encompasses each type of loss—loss of a significant person, loss of some aspect of the self (reproductive health), loss of external objects, loss of a stage of life, loss of a dream inherent in the parents’ desire to have a child and loss of creation” (cited in Ney, p. 1193). Fortunately, there is a growing trend to encourage couples to realize the full extent of their loss by, if they so choose, holding, naming, blessing and saying farewell to their stillborn children and by keeping mementos: footprints, a hair lock, photographs or ultrasound images.

Parents’ involvement in a memorial service when there is no body may be helpful for the completion of mourning even if only “two or three come together” and informally share their feelings (Matthew 18:20). The value of rituals cannot be underestimated. They represent “a rope bridge of knotted symbols strung across an abyss” (Grimes in Van Biema, p. 8). We use them to navigate the passages of birth, initiation, marriage and death. Live children are blessed and welcomed after birth by passing through water (in many Christian traditions) or being held up through smoke or sunlight (Native American). A stillborn child can by ceremony be recognized to be a person, now deceased, but with a soul properly commended to God, making the grieving completable.

In the case of early pregnancy loss, the “unfinished baby” more likely than not has been completed and claimed by the mother even if there is no body to weep over. Because the fetus or embryo who dies early in pregnancy through spontaneous miscarriage, ectopic pregnancy or even elective termination (see Abortion) may not have been seen and known, the death may not be considered worthy of recognition and mourning. “Such ignorance of the significance of the loss on the part of society, friends, and even the woman herself impedes the bereavement process and may interfere with bonding to future children” (Ney, p. 1193).

Although each person responds individually, medical research has delineated stages as described by women who experienced recovery from a miscarriage. These dovetail with accepted patterns and tasks of grieving. Initially uncertainty progresses to shock and denial. Parents may express anger outwardly as injustice or inwardly as guilt as they actualize and accept the reality of the loss. During the stage of searching and yearning they identify and release their distress, sorrow and pain. Disorganization occurs as they are adjusting to life without the thoughts and plans for the new baby. Confronting or avoiding painful reminders of the miscarriage occurs when having to tell others the news, seeing the nursery, pregnant women or other babies, marking the first menstrual period, sexual intercourse, the baby’s due date and the anniversary of the loss. During the stage of reorientation parents successfully withdraw emotional energy from the loss and reinvest it in other activities and plans for the future.

The degree of prenatal bonding and grief may vary considerably. Each woman’s experience is uniquely influenced by what the pregnancy meant to her and her family. Some factors that influence the perceived value of the pregnancy include the ease of becoming pregnant, the perceived age of the mother and pressure to conceive, and whether the pregnancy was planned. An experienced mother may have a deeper sense of loss, having endowed the unborn child with specific characteristics and perhaps even a name. Alternatively they may sense some relief if the pregnancy had come sooner than planned. Women who have not successfully carried a child to term may feel more profound doubt of their reproductive health. If an ultrasound examination has been done, the images add to the reality of the fetal existence, as do hearing fetal heartbeats and perceiving movements internally or even externally that may have been shared with a spouse and other children. Also, the duration of the anticipatory time during the warning symptoms of bleeding and cramping can influence how deeply she may have begun to attach herself.

Adding to the complexity of the recovery and contributing to the distress, a D&C (surgical dilation and curettage) may be required to remove remaining placental and decaying fetal tissue that has not passed spontaneously, preventing ongoing bleeding and infection. The operation itself may be perceived as a possible threat to the mother’s health, and despite ultrasound confirmation of the fetal death, in periods of uncertainty or denial she may feel that they are taking her baby. In later stages of gestational death, when a D&C is not possible, induction of labor after a brief but agonizing waiting period is often recommended for the protection of the mother’s health. A marathon of labor and birth ensues with no reward of a child’s cry (see Birth). During this delicate interfacing between patient and caregivers, the quality of the support greatly alters the woman’s experience, for better or worse.

Unfortunately, physicians may be vulnerable to frustration when they cannot cure. They may be paternalistic, indifferent, impatient and unfamiliar with grief. Physicians and hospital staff need to treat the patient compassionately as a person hurting and not a “body bleeding.” Giving permission to express a range of feelings, providing explanations and information, checking back for understanding, giving specific directions about what to expect and do during recovery, adequate pain control and compassionate listening are all valuable ways to assist a woman through this difficult time. Specific reassurances include the fact that miscarriages are common and represent an inevitable process that often cannot be prevented or arrested by maternal or medical efforts. It is nature taking its course.

Specific concerns may arise about the cause of death, requiring many follow-up visits to unravel all the nagging questions and worries. It is particularly valuable to address and appease unnecessary guilt for causing or failing to prevent the loss. Scientific evidence suggests that physical activity, vomiting, sexual intercourse, stress and ambivalent feelings toward the pregnancy do not cause miscarriage. There may be more involved questions concerning the contributions of possible maternal infections or disease, exposure to medications and toxins, smoking and alcohol. These are rarely implicated in early pregnancy loss. As science unravels the mystery of conception, evidence points to a staggering degree of naturally occurring loss from perhaps half of all fertilized ova failing to implant to many pregnancies that are lost during late menstrual flow before their presence is even surmised. A significant number of examined embryos and fetuses that have spontaneously miscarried have microscopically evident chromosomal abnormalities. It remains to be fully demonstrated that genetic errors detectable on a molecular level and immunologic rejection will likely account for the balance. Although this may provide reassurance that the pregnancy “wasn’t meant to be,” many families feel the additional blow of failure and guilt that an abnormality has occurred and ambivalence toward losing something “less than what was intended.” Disappointment in God’s lack of intervention on behalf of their child can be difficult to express.

Response of the Family

Partners grieve but often express themselves in different ways from their wives. A man may keep his sorrow to himself so that his wife will not know his grief and thus double her own. Paradoxically, his silence adds to the apparent silence of God. The range, intensity, duration and progression of responses are not usually synchronous between partners. A delicate balance alternating between intense communication and the guarding of each other’s solitude is necessary for couples to respect and support one another at this time. The pregnancy may have meant more to one of the parents. Faith and hope may ebb and flow unpredictably. The loss of a lifetime of plans, dreams and aspirations leaves a void that may be filled by a small glimpse of eternity. Couples who share intimately can enlighten each other’s darkness and carry faith for one another at a time when hope seems lost. We must, however, ultimately trust that God himself will answer us in places of deepest questioning and doubt, strengthening the mortar of our faith through adversity.

Siblings are not to be forgotten. A young child can perceive his parents’ grief but is incapable of fully understanding or relieving it. Excluding children by withholding news of what has occurred or failing to share feelings does not reduce pain. In the absence of age-appropriate explanations children are prone to fantasy and a correspondingly greater degree of distress. “Magical thinking,” whereby children imagine they have caused the death of a sibling, is common and needs to be addressed, especially with later gestational loss. Children who are born after a pregnancy loss can become “replacement children” and may experience increased parental expectations and confusion of their identity. Ideally, the deceased sibling is neither forgotten nor replaced, and the parents in healing and health can embrace the new child fully and uniquely.

Response of Friends and Encouragement from Scripture

Family and friends who are not sure what to say but attempt to be supportive should not underestimate their significance. Phone calls, cards, flowers, meals, quiet visits and prayers are palpable expressions of love that buoys and balances a family in the midst of deep waters.

Kathleen Nielson, as a grieving mother, describes the refuge she found in her faith. “At a time when I felt a terrible emptiness inside, I inhaled the breath of God by taking Scripture into myself. At a time when I did not know what to say to God, through his Word I was able to open myself to Christ, who in the beginning was the Word” (pp. 10-11). “I knew God had preserved my baby in His way that is higher than mine. In His priceless, unfailing love” (Psalm 36:6-9) he had taken her son to himself and would preserve him pure and holy forever. Her child was “in the shadow of God’s wings,” “feasting on the abundance of God’s house” and “drinking from his river of delights.” “Knowing my baby would be cared for and delighted by God himself comforted me immensely as I wept over a child I held but would never feed.”

From Despair to Hope

It is little wonder that in many cultures and previous generations pregnancy was kept secret until it was no longer concealable. Technology can now provide confirmation at earlier stages, chemically and visually, of the presence of this new individual. There are Scriptures that affirm our belonging and intrinsic value even in the womb (Job 10:8-11; Psalm 22:9-10; Psalm 139:13-16), and it is clear that pregnancy loss was mourned even in biblical times. A progression can be traced from Old Testament to New Testament that is analogous to the grieving process itself, leading us from despair to hope.

Jeremiah in profound depression cursed himself and the man who told his father of his birth (Jeremiah 20:14-18). Job cried, “Why then did you bring me out of the womb? I wish I had died before any eye saw me” (Job 10:18). “Why was I not hidden in the ground like a stillborn child, like an infant who never saw the light of day?” (Job 3:16). Scripture does not euphemize, gloss over or glorify death.

In David’s grief for the loss of his son conceived after adultery and murder we see premature death as an unalterable state associated with guilt. “Can I bring him back again? I will go to him, but he will not return to me” (2 Samuel 12:23). Premature death sometimes counts as death incurred through sin (1 Samuel 2:3; Job 22:15; Job 36:14). However, a careful look at Genesis 2 reveals that there is a distinction made between death that is deserved and threatened and death that belongs to the natural state of the creature. Death when it finally occurs is explained in reminiscence of man’s creation: “until you return to the ground, since from it you were taken; for dust you are and to dust you will return” (Genesis 3:19). Ultimately, one fate comes to all, to the righteous and the wicked, and to the clean and the unclean.

The psalmist gives us the new message that God’s hand reaches into the world of the dead (Psalm 139:8). The first heralding of the resurrection occurs in Isaiah 26:19: “Your dead will live; their bodies will rise.” The author of Revelation assures us that “God himself will be with them and be their God. He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain” (Rev. 21:3-4). God’s promise is that this time of anguish will pass, making way for the hope of ultimate healing and reconciliation. In contemplating the earthly tragedy of the Pietà—Mary cradling her dead son—we find ourselves full circle from the stable and relinquished is the hope shared by all parents that they will be the ones cradled in old age by their surviving children. The miscarried or stillborn child is a person whose development is interrupted by natural defects, an extinguished flame who awaits final consummation when they, with us, will be fully restored in the likeness of Christ himself.

» See also: Birth

» See also: Conception

» See also: Death

» See also: Grieving

» See also: Pregnancy

References and Resources

E. C. Hui, Questions of Right and Wrong (Vancouver: Regent College, 1994); D. Manca, “Women’s Experience of Miscarriage,” Canadian Family Physician 37 (September 1991) 1871-77; G. García Márquez, The Circle of Life: Rituals from the Human Family Album (San Francisco: Harper, 1991); P. Ney, “The Effects of Pregnancy Loss on Children’s Health,” Social Science Medicine 38, no. 9 (1994) 1193-1200; K. B. Nielson, “The Day the Heart Beat Stopped,” Focus on the Family, March 1993, 10-11; R. Smolan, The Power to Heal (New York: Prentice-Hall, 1990); R. W. Swanson, “Parents Experiencing Perinatal Loss: The Physician’s Role,” Canadian Family Physician 32 (March 1986) 599-602; D. van Biema, “The Journey of Our Lives,” Life, October 1991; H. W. Wolff, Anthropology of the Old Testament (Philadelphia: Fortress, 1974).

—Carol Anderson