Multiple miscarriage: Psychosocial implications

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Multiple miscarriagePsychosocial implications

• Uschi Van den Broeck
• Master in Psychology
• University Hospital of Leuven, Belgium
• Department of Gynaecology/Fertility Center

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About me

• Clinical psychologist
• University Hospital of Leuven, Belgium
• Fertility Center fertility counsellor
• Department of Gynaecology
• Phd-research
• Psychosocial determinants of continuing or
  discontinuing fertility treatment a
  psychological analysis
• Funded by Leuven University Fertility Center and
  Department of Gynaecology

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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1. Psychology of pregnancy

• Pregnancy begins psychologically, long before it
  occurs physically.
• Growing towards motherhood fatherhood
• Fantasies and dreams about life with future child
• New goal

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Psychology of pregnancy

• Pregnancy unique experience
• Influenced by
• Cultural factors
• Personal history family of origin
• Personality
• Relationship
• Expectations and beliefs
• Social environment

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1. Psychology of pregnancy

• PREGNANCY POINT OF NO RETURN
• CRISIS

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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2. Psychology of pregnancy loss

• A crisis within a crisis (Leon, 1990)
• Conflicting emotions
• Sometimes first experience with death for couples
• Elation of pregnancy followed by despair of
  pregnancy loss

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2. Psychology of pregnancy loss

• Sense of loss in different areas
• Loss of a baby
• Loss of self-esteem as a parent
• Feelings of failure as a women
• Loss of pregnant status
• Fear of loss of reproductive capacity
• Fear of loss of health
• Fear of loss of control
• MULTIDIMENSIONAL LOSS

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• Christmas has always been a special time in our
  family. I miscarried on December 23rd and I
  didnt feel like my family was there for me. I
  devoted all my time and energy into the Christmas
  preparations but I felt like I had lost
  something that was mine and nobody
  acknowledged that. I had a hard time saying
  goodbye to the feeling of being pregnant. I
  couldnt get myself to eat red meat at the
  Christmas dinner. To them, it was nothing but to
  meit was already my baby.
• N.C., 35

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2. Psychology of pregnancy loss

• Loss is multi-layered
• Individual loss
• Family loss (parents, siblings, grandparents,
  etc.)
• Impact on relationships
• Impact on life conditions
• Impact on future plans, goals

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• After the second miscarriage, it got harder for
  me. I realized that I was going to be an older
  parent, and even more, that my own parents,
  might never get to be grandparents. I feel
  pressured into trying againbecause the clock is
  ticking, but I can see that my wife cant take it
  anymore right now. Its getting harder on both of
  us.
• J.E., 42, husband of N.C.

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• Between something
• and nothing

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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3. Common feelings when confronted with multiple
miscarriage

• Multiple miscarriage?
• World Health Organization (WHO)
• At least 3 or more consecutive pregnancy losses
  before the 22nd gestational week
• 1 of couples (Bagchi Friedman, 1999)

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Video Clip 1 Tori Amos
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3. Common feelings when confronted with multiple
miscarriage

• Miscarriage and multiple miscarriage
• unrecognized loss
• GRIEVING
• Normal, healthy, dynamic, universal and
  individual response to loss
• Healing process surviving and continuing to live

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3. Common feelings when confronted with multiple
miscarriage

• Major life-event individual differences

Tidal Wave
G S R H I A E D F O
w
Longing Despair Out of control
Sadness Regret Shocked Confused
Angry Guilty Responsible Emptiness
Panicky Loneliness Stressed Lack
of self-confidence
Unpredictable and repetitive pattern
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3. Common feelings when confronted with multiple
miscarriage
PHYSICAL SYMPTOMS Headache Stomach
achees Shortness of breath
constipated Tightness in the chest Problems
with sleeping Lack of appetite .
TRIGGERS
SOCIAL SYMPTOMS Isolation Withdrawal ..
COGNITIVE SYMTOPMS Dreams
Worrying Decision making
Expressions of grief
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3. Common feelings when confronted with multiple
miscarriage

• Unique aspects of perinatal grief in MM
• Psychological videotape
• Possibly traumatic event
• At risk for post-traumatic stress disorder,
  anxiety, depression, etc.

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3. Common feelings when confronted with multiple
miscarriage

• Injustice Why is this happening to me?
• Feelings of helplessness
• Need to blame someone
• Desire to bring a sense of control to the event
• Hope that if a cause can be identified, a
  recurrence can be prevented
• SEARCHING FOR A CAUSE
• ? premonitions
• ? little anticipatory grieving thief in the
  night

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3. Common feelings when confronted with multiple
miscarriage

• Self-blaming possibilities
• Feeling that theyve disappointed themselves,
  their partners, their family
• Doubts about reproductive competence
• Anger towards their own body
• Each loss magnifies the pain every loss is
  followed by a new period of grieving
• Impact on self-image
• Body becomes ambivalent object
• Uncertainty rules increasing ambivalence about
  each consecutive pregnancy

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3. Common feelings when confronted with multiple
miscarriage

• No or little public acknowledgement
• Absence of visible object to mourn, no rituals
  prospective grieving ? few memories
• Few socially acceptable avenues for mourning
• Lack of social support
• Reassurance resulting in minimalizing the loss
• It was for the best Itll work next time
• Conspiracy of silence
• Designed to protect loved ones
• Has the effect of further isolation
• Not a reality to anybody else
• Social environment taboo

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3. Common feelings when confronted with multiple
miscarriage

• Accepting the reality of the loss and
  experiencing the pain and loss
• When you are in the trenches
• Adjusting to life without your babies
• Time (gestational age) alone is not necessarily
  an indicator of the level or degree of
  attachment, nor is the physical presence of the
  baby after birth. (Moulder, 1994)
• Trying to make sense of it
• Give life meaning again
• Choose the wisdom out of the wound

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3. Common feelings when confronted with multiple
miscarriage

• Gender differences mothers and fathers
• Loss is equally important but different ways of
  experiencing feelings at different times
• Its a journey, not a destination.
• Dance of closeness and distance (Rosenblatt,
  2006)
• Fathers are often overlooked, feel ignored or
  excluded have to deal with organisational tasks
• Sexual relationship can be difficult for a while
• ? physical reminder of the pregnancy

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• It hurt me so much when people called or ran
  into J. on the street and they always asked how I
  was doing it never occured to them that J. had
  lost a baby too. I was so angry at everyone for
  not realising we were both in this thing, wed
  both lost our baby. It made it so much harder on
  J.
• E.T., 25

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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4. Coping with grief and loss

• There is no right or wrong.
• No typical response to loss, there is no typical
  loss its individual
• There are no rules.
• No single pathway through grief it comes and
  goes
• There is only one way,
• and that is your way.

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4. Coping with grief and loss

• How long will I feel like this?
• Expectations from environment
• Bad times even when you feel better (process of
  grief!!)
• Shadow grief special events and dates will
  remain triggers

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4. Coping with grief and loss

• Risk of more intense or longer lasting distress
• Pregnancy strongly desired
• Waited a long time to conceive
• No living children
• Elective abortions
• Other losses in history
• Few warning signs that a loss might occur
• Experienced the loss relatively late in pregnancy
• Little social support
• History of coping poorly

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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5. Infertility and recurrent pregnancy loss

• Infertility and miscarriage are both devastating
  experiences
• Together larger impact, which can complicate
  grieving
• Infertilitycan create a life of its own
• A lot of focus on pregnancy and childwish
• Repeated cycles of hope and sadness etc.
• Time consuming and emotionally consuming
• Impact on a couples relationship and marriage
  can be considerable

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• I just kept thinking why is this happening to
  me? A miscarriage is horrible to happen to anyone
  but we had been trying to get pregnant for so
  long. That made it so much worse I kept lying
  awake at night not knowing wether Id be able to
  conceive ever again
• B.C., 32

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5. Infertility and recurrent pregnancy loss

• Impact on partner relationship ? vulnerable
• Couples sometimes balance grieving
• Men and women experience infertility differently,
  inevitably pregnancy loss is experienced
  differently
• Important to take time to build the relationship
  again, remember why you are together both on an
  emotional level as well as on a sexual level

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• We dealt with it very differently. T. doesnt
  talk much at all and I felt so alone. Like I was
  the only person this had ever happened to. He
  didnt understand or he didnt want toit came
  close to splitting us up.
• A.V., 31

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5. Infertility and recurrent pregnancy loss

• Invisible loss is doubled
• Physical component of treatment can become more
  invasive and traumatic with each repeated
  reproductive failure

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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6. Trying again

• Timing? too soon versus not soon enough
• Importance of grieving each previous loss before
  trying for a new pregnancy
• Focus on pregnancy increases obsession
• Belief that it will make everything better
• Sometimes it does
• Sometimes it doesnt delayed grief reactions
• In general, no rules
• Each couple has a unique experience and situation
• Informing them about the risks
• Honest communication defenses have a function!!!

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6. Trying again

• Sexual relationship can become pressured
• Careless pregnancy is gone dealing with
  uncertainty
• Rituals and superstition having a sense of
  control
• Sharing the good news with friends and family
  when is the right time?
• Extra check-up and honest reassurance from the
  medical team can help reduce anxieties
• ? information and communication

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Overview

1. The psychology of pregnancy
2. The psychology of pregnancy loss
3. Common feelings when confronted with multiple
   miscarriage
4. Coping with grief and loss
5. Infertility and pregnancy loss
6. Trying again
7. Helpful interventions

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7. Helpful interventions

• Decision making is up to the couple but
  informed choice
• Joining the couple
• Creating a safe holding environment
• Listening without judging
• Stimulating creative outlets

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• The hours, the days afterwards I had to decide
  if I wanted to see you, hold you. The biggest
  dilemma in my life. I felt so weak and sad, felt
  like I couldnt deal with it all. Im so terribly
  sorry I left you there, in the cold, with
  strangers, without keeping you safe and warm. I
  would give everything to keep you in my arms,
  keep you safe with me, talk to you, give you an
  everlasting and warming kiss So quickly you left
  me, no longer a part of my life, taken away and
  never returned. You and me, without one another.
  I let the chance slip away to cherish you for the
  first and last time, to see you, feel you, smell
  you
• L.R., 29

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7. Helpful interventions

• Creating mementos pictures, clothes, teddy bear
• Memorial activities
• Keeping a journal writing things down ? taking
  control
• Reaching out talking with friends, joining
  support groups, etc.
• Providing information both medical and
  psychosocial
• If possible seeing, holding, touching, baby
  naming
• Reality reinforcing interventions
• Couple approach dont forget the husband!!!

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References

• Bagchi, D., Friedman, T. (1999). Psychological
  aspects of spontaneous and recurrent abortion.
  Current Obstetrics Gynaecology, 9, 19-22.
• Burns, L.H. Covington, S.N. (2000). Infertility
  counseling a comprehensive handbook for
  clinicians. Parthenon Publishing, N.Y.
• Leon, IG. When a baby dies psychotherapy for
  pregnancy and newborn loss. New Haven Yale
  University Press, 1990.
• Spitz, B., Keirse, M., Vandermeulen, A. (2004).
  Omgaan met een miskraam. Uitgeverij Lanno, Tielt,
  2004.

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Multiple miscarriagePsychosocial implications

• Thank you for listening
• Uschi Van den Broeck
• Master in Psychology
• University Hospital of Leuven, Belgium
• Department of Gynaecology/Fertility Center
• Contact 32 16 34 28 60
• Uschi.vandenbroeck_at_uz.kuleuven.ac.be