“Psychological challenge for couples in this time frame”

How do we mourn a child we did not really get to know, other people did not meet, and integrate this loss into our future family life?

How do you mourn the loss of a person who was in your life for only such a short while, but for whom you had such high hopes and dreams?

I have heard many women express their feelings concerning failing not only as a mother but also as a woman and as a wife. They feel they did not succeed at the task women are “made” for.

Daniel Stern proposes in his book “The motherhood constellation” ( ) that new mothers create a so-called motherhood constellation. When pregnant, mothers develop a new mental representation about themselves and their future child. A mental representation means that someone is able to symbolize an image of things that they have never experienced, as well as things that do not exist; in this case, it is the mental representation of being a mother (or father). This new mindset, which depends on culture, personality, and own upbringing, forms the so-called motherhood constellation. It develops during pregnancy and may last for many months or even years after birth. To be able to form this mindset, a mother’s sense of herself becomes largely organized around the presence of her future baby, the well-being of her child, and their mutual connection. The protection of her child becomes the mother’s first and main concern. Daniel Stern proposes four challenges within the constellation. One of the four challenges is for the mother to keep her baby alive, to protect her baby. When couples are confronted with the loss of their child through a termination of pregnancy, the mother did not “succeed” in this task. She was not able to prevent the baby from having anomalies—anomalies so severe that they resulted in a termination of pregnancy. And by “choosing” to terminate the pregnancy, she may even feel like she did the opposite of keeping her baby alive. Losing this child, therefore, does not only start a mourning process, but it also has a heavy influence on the mental image a mother has of herself ( ). One of the big challenges in the constellation is not achieved. This may not only lead to self-image problems but can also be seen as one of the causes of why women experience a termination of pregnancy as traumatic, and why this leads to anxiety, depression, post-traumatic stress disorder (PTSD), and complicated grief. In the time frame of aftercare, HCPs should be very attentive and observant how a mother copes with all of this. This can be done by asking how the mother is really doing, how is she coping? Does she eat, sleep, and get up in the morning? And by asking how would the father say the mother is doing? Asking the mother to change perspective can provide us with information about how she is coping. How are they coping together?

We need to know not only for the sake of the mother, but also in the case of a future pregnancy and the relationship that a mother will develop with her baby during and after the next pregnancy.

Mourning in men and women

Women and men deal with a loss such as this differently. Overall, women experience an intense level of grief and show more psychological consequences such as depression, anxiety, and PTSD (Korenromp et al., 2009, Jones et al., 2019; ). Mothers have a greater need to talk about their loss, hurt, and mourning (Dekkers et al., 2013). They fight for the existence of their lost child with their surroundings, and they are struggling and learning how to deal with other women being pregnant and seeing a baby (Dekkers et al., 2013). Men seem to take more comfort in distractions such as sports, meeting friends, and sometimes say “I don’t know what else there is to say about it….” Jones et al. also found that men reported less intense and enduring levels of psychological consequences than women, and that they show more avoidance and coping such as increased alcohol consumption (Jones et al., 2019). But there is a big task for the father to be able to support his wife post termination ( ). Low-level socioemotional support from partner to mother is found to be one of the significant high-risk factors for a high level of grief 1 year after perinatal death (Tseng et al., 2017). Couples who have lost a baby prior to, during, or shortly after birth often define this loss as highly traumatic and have a higher risk to develop PTSD ( , 2009 ). Couples need to find a way to accept, give room to, and support their different ways of coping. But that is not easy. It is one of the reasons why aftercare is so important.

Precisely 41% of women and 28% of the men sought professional aftercare outside the hospital after the termination of pregnancy (Dekkers, 2013). If couples know that acknowledgment of their lost child is needed to cope with this loss, if they are told by HCPs that many couples seek help from others, trying to integrate this loss into their future lives, they may not feel “incapable, weird, or not strong enough” to handle this themselves. Acknowledgment of the baby’s existence and of the couples’ suffering needs to be recognized by HCPs and the couples’ social network (Lafarge et al., 2014; Jones et al., 2017; Lou et al., 2020).

HCPs should point out that the need for professional psychological help is common. It is not up to us to decide if the case of the couples is “bad enough” to seek counseling, it is up to us to inform couples of the possibilities, and make sure that they know how to receive proper professional psychological aftercare.

Support and network

Parents appreciated it if they were given professional aftercare and missed not having received it as a standard offer from the hospital. Support from a partner, family, and friends in this time frame was valued greatly—as was a memorial service organized by the hospital where the baby was delivered. In this memorial service the names of all the children are read out loud, music is played, and one of the parents who had lost a child tells the story of their loss. Parents find great comfort in being among other parents who have also lost a child, as it allows them a chance to recognize their loss and pain in others. It also helps tremendously in the acknowledgment of their child. Reading books with similar stories also helps parents, and many of such books have been written by parents. In short: people feel less alone when exposed to peers.

Parents missed having been able to talk about coping with their surroundings and the way they deal with the loss of their child. Parents typically are in a life stage in which many friends, brothers, and sisters become pregnant and have babies. And no matter how much they grant others the joy of having a child, they also feel very sad and pained about witnessing other (future) parents’ anticipation and happiness. Some even say they cannot bear seeing their loved ones being pregnant or visiting them after birth.

All in all, HCPs and their network should keep a good eye on parents who have been through a pregnancy with prenatal decision-making or a termination of pregnancy. Dare to ask how parents are doing, talk about their loss and grief, and do not avoid it. You cannot hurt parents by asking about their loss—the hurt is already there. Not talking about their loss and their lost child makes parents more alone and tormented.

Eva Pajkrt and Liesbeth van Leeuwen

“Support for the whole family around loss after prenatal diagnosis of fetal anomaly”

At Antenatal Results and Choices (ARC), we recognize that the emotional impact of loss due to termination for fetal anomaly or expected loss after a diagnosis of a fatal condition affects the whole family. While the woman bears the brunt as she is carrying the baby and ultimately has to make the final decision about how to proceed after a prenatal diagnosis, we should not underestimate the psychological needs of the partner. They themselves can neglect their own need to grieve as they concentrate on looking after their partner ( ). Men have not always been encouraged to express their feelings or seek emotional support and for some their coping style is to suppress their own needs to be of maximum support to their partner. ARC seeks to address this through its downloadable booklet “Help for Fathers,” a forum for men and trained male peer support volunteers. At the time of writing, we are preparing materials to support same-sex partners.

The parents of women and men facing bereavement after prenatal diagnosis can also be profoundly affected. They must watch their offspring go through a painful and often harrowing experience and feel powerless to “make things better” which will often be their first parental instinct. They also have to deal with the loss of their potential grandchild. Furthermore, the more recent technological changes in prenatal diagnosis may be unfamiliar to them. Some “grandparents” contact the ARC helpline to find out what kind of help might be available to their son or daughter. The helpline team will always encourage them to use ARC as a source of support for themselves and point them toward the downloadable PDF on our website, “Help for Grandparents.”

Parents who opt to terminate an affected pregnancy often express anxiety around how to talk to their other children, living, or prospective about what happened. The conflicted feelings they have about actively choosing to terminate can sometimes cause them to believe they have to “admit” the truth of what happened and face what they believe will be an inevitable judgment. The ARC booklet, “Talking to Children,” prompts them to consider what other children actually need to know. Children do not need all the details (it could be argued that this is part of the parents’ story and sharing all may overburden their children). However, at the time of the termination, children will need to be told something age appropriate to explain their parents’ distress. If they are aware of the pregnancy, they need to know the younger sibling they were anticipating is not to be.

Iris: Noud

After 6 years, I noticed that I was always scanning my environment, scanning for people who had more than two children. If people had more than two children (which I had after having given birth to my son, Faas), I would condemn that. If people said they had two children, I would inquire whether they desired a third child. And if they did, I would lecture them on the risks of anything going wrong and I would interrogate why they would be willing to take that risk when their two children were healthy. In my opinion, wanting a third child was greedy and ungrateful. I felt angry when people had more than two children, and I just could not get my head around people willing to take the risk of having their life changed forever like I experienced, when in my view “they had it all.” I had an amazing life, a wonderful partner, a healthy boy, and fantastic job and great friends. I just wanted what is so common among people with one child: a healthy brother or sister for Mats, and my life changed forever because of it. The scanning became an obsession and I had to do something about it. I needed the help of a psychologist because I was so angry at the entire world but it was so difficult to actually take the step. Would a psychologist really think that my problem was big enough to address? I had my second child, what was I complaining about. I decided to approach the same psychologist I spoke 5 years before about this.

During the sessions, it became clear that I had not grieved properly. I had to grieve my loss, the loss of my son Noud, 6 years after I lost him. But why was I so angry with people wanting or having a third child? I did not even want a third child myself? Why did that trigger me at all? And then came a moment when my psychologist said: “Do you hear what you are saying, Iris? You say that you do not want a third child, but you have three children: Mats, Noud, and Faas.” And that was it. I have three children. This realization opened a door to reconnect to my grief again. It was intensely painful, and it diminished my obsession.

I wish I would have done things differently. I wish that I would have held him in my arms, that I would have given him a name straight away, I wish that I would have talked about him much more, and that I had not felt ashamed, because for years, shame is what I felt. I had given birth to a baby with multiple congenital anomalies and we decided to end the pregnancy. I tried to perceive that as something small, to simply move on. But that is not something small. It is big. It is huge and something that I carry with me for the rest of my life. I carry Noud in my heart forever, with all my heart. Deep in my heart and that feels so right, nobody can touch that.

What helps according to Iris:

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  Aftercare initiated by the hospital. A phone call, a note, a moment of attention for the intense situation you went through.

  
  
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  Offer advice regarding emotional processing. Recommend to take time for this processing and counsel toward talking to someone who has experience with this.

Sam Riedijk

Giving birth turns the couples into parents, and whether or not the child is alive, and whether or not couples decided to end the pregnancy, it makes no difference. Mostly the mother will be most strongly attached to the child, and the father will be mostly concerned with caring for the mother. Sometimes couples feel as if having made the decision to end the pregnancy deprives them from the right to grieve. However, all couples grieve when they lose a child, regardless of whether the loss was due to the decision to end the pregnancy or a natural cause ( ). Having to carry the weight of this decision does weigh heavily on parents. In congruence with scientific literature (Korenromp et al., 2009), most parents I speak with, even years after, even if they have no regrets, still find carrying the responsibility of this decision to be traumatizing. It is important to recognize that on top of this psychologically normal response, some individuals may require more psychological support to move through their grieving process. Having used antidepressants, being younger or more highly educated are some of the risk factors associated with complicated grieving ( ). In addition, the choice whether or not to see the baby may be a difficult one for parents, as they often state fearing that they may become overly attached or traumatized by the image of their deceased baby. Sometimes it takes some time to become strong enough or ready to see the deceased baby. In my experience, I have rarely met parents who, in hindsight, regretted seeing their baby, but I have met couples who, in hindsight, regretted not seeing their baby. Understanding that couples may be in doubt is important, giving space to express their ambivalence is also important ( ). Couples need compassion, sensitive care, and validation of their emotions (Peters et al., 2016). Couples are often reassured by hearing about the experiences of other couples, as it normalizes their responses and elicits trust that they too may come to experience the delivery and period after as something not only sad but also special.

Saying farewell

Parents in our hospital are offered a choice to either take care of the funeral or cremation themselves or leave this up to the hospital. In my experience, roughly as many parents decide to take care of the funeral themselves, whereas the other accepts the offer of the hospital cremation service. A minority of parents leave the hospital and never see their child again, while a minority of parents bring their baby home before the funeral. In most instances the time between birth and farewell is no more than 3 days. Most parents, irrespective of choice, organize a small farewell ceremony with a few of their closest loved ones. It is only after this ceremony that for parents, the grieving for the lost child begins. Grieving ceremonies are psychologically beneficial ( ).

The first few days, most parents describe feeling closer to each other as partners. They go through child birth together, name their child, invite a few important others to share a moment with their baby with them, and organize the farewell ceremony. To couples, this feels like a safe bubble in which they are synchronized and are truly in it together. As long as the partner stays at home, the bubble remains warm and intact. However, as soon as the partner leaves for work again, the bubble bursts and the parents each starts to write a different chapter in the book of grieving. This relationship dynamics phenomenon often causes tension between parents. It is not even a male–female difference, but in my experience a pregnant–nonpregnant issue, as I have seen the exact same dynamics in lesbian couples. Here, I will call it woman and partner for readability.

Woman

After giving birth, women often describe feeling exhausted and proud and overwhelming love for their child. The time spent looking at the baby and cherishing it are essential for creating memories that mothers will hold onto tightly the rest of their lives. Any pictures taken in this moment are also important for creating a footprint for the baby. It is important that she codesigns a farewell for her baby that suits her, that does justice to her motherhood. It is the only way in which she can care for her baby. It is good to encourage parents to each contribute to the farewell ceremony, to make it their own, as it has the potential of comforting them in their most difficult grieving moments. A farewell that feels good, that was made their own, is something that couples will look back on in acceptance.

When the moment of farewell has passed, women describe feeling numb for a few weeks. They wake up thinking it was a dream. They find themselves talking about what happened as if they described something that happened to someone else. The reality of the loss takes some time to surface, and it tends to wash over them in waves.

Many of the women I spoke expected their grief to follow a linear curve. Starting at the bottom and then gradually climbing back to normalcy. What they experience is actually much more comparable to waves or labor contractions. Pain that suddenly sets in, intensifies, peaks, and then resides. Waves of sadness, broken-heartedness, anger, and despair were alternated with moments of calm, of feeling okay, and of feeling guilty for not experiencing grief. In my counseling sessions, I always find myself explaining this pattern to couples, or women, and see it resonate. The recognition of this experience is comforting and provides reassurance and a frame of reference. When parents seem to be in doubt of what they are experiencing or when they are trying to resist, be strong, or find distraction, it is extremely useful to provide an explanation for what they are feeling and to validate that what they are experiencing is normal. For most parents, this is their first encounter with intense grief. Normalizing can be done in many words. Mine tends to be something like:

Most people I have met who were in a situation similar to yours have told me they felt exhausted, they did not recognize themselves, in the sense that they did not enjoy what they normally enjoyed, they did not care for things they would usually find important, their bodies felt different, they could not concentrate, or make decisions. Deciding which yoghurt to choose in the supermarket was impossible. People would come home from shopping and put their keys in the refrigerator and the cheese in the closet. Even sleep is affected. I am wondering what it is like in your situation?

Every time people express relief, to hear that this is normal and that they are not losing their sanity. Such small efforts to offer some frame of reference actually provide a lot of comfort.

It seems that grieving is something that happens in each cell of your body, each piece of your psyche.

I have noticed that women grieving by cocooning seem to recover more quickly from their loss. Some women make their world very small, stay at home, only let those people in who feel safe and bring something that benefits her. These women seem in close contact with their pain and describe in some sense embracing their grief. They cry when it happens, they laugh when they feel it, they know that work is for later, and they spend their time on the couch, writing down their memories, creating a photo album, or choosing a symbolic piece of jewelry. In a symbolic way, they are exerting their motherhood, creating existential right for their baby, creating a footprint.

Sometimes women feel that they should not give into their emotions, feeling that they should seek distraction and be strong. It may be that I have a bias in my experience because only those women come to me for whom this does not work. But in my experience, it was often these women who had sleeping problems or who experienced delayed grieving, sometimes up to years later. I am not judging this, because I think that it can take time to get ready for grieving. I do think that all grieving needs energy and attention. Distraction can help to recharge and it can also take away the energy and mental capacity that is necessary to grieve.

Grief is invisible though and, therefore, can be difficult to acknowledge or even recognize. Using metaphors may provide a powerful tool to visualize grief. The metaphor that I like to use is one of a broken leg.

Imagine your leg is broken in three places. To you it would probably seem entirely valid to sit on the couch all day and rest, to have others care for you for a while. Of course at some point your leg will need to learn to move again, starting with some small exercises and gradually building up, adding more burden to your leg. In fact your grief is something like a severe wound to your psyche and requires the same care as your leg. If your leg was broken in three places, you would probably not train for the marathon. Likewise, you should not ask yourself to get back to work and function like you are used too when you are grieving.

Depending on the counselor and the person in front of you, many other metaphors can help people get grip on what happens to them.

On average, most women I have encountered tended not to feel ready for work for around 4 months after birth (Geerinck-Vercammen and Kanhai, 2003). However, my colleagues in fetal medicine indicate that they consider slowly returning back to work anywhere between 2 and 6 weeks after delivery as normal.

Often women have conveyed that the due date is an intensely painful moment. Only after the due date the true loss “starts,” because this is the date that the baby should have been there, and the discrepancy between what is and what should have been becomes tangible. The period before the due date is more of a twilight zone. This also means that all the first times after the loss start at the due date; the first summer holiday, first Christmas, your birthday, and other meaningful dates. Many women I have met told me that somehow in their minds their baby was growing up, one birthday at a time. In that sense, I see how the relationship these mothers have with their deceased child changes over time but never ends ( ).

Sometimes women wonder what is an appropriate time to get back to work. The answer has proven to be quite simple: when you feel like it. In my experience, women gradually enlarge their cocoon and increasingly feel like going out and letting the world back in, at their own pace. They will know they are ready because they get curious about how their colleagues are doing, they feel like contributing again. They feel that they can offer support to a friend in need again. This inner compass is very valuable. Feeling ready helps to face the challenges of the outer world, like facing women who are pregnant or had their baby around your due date. I have yet to meet the woman who has discovered how not to experience pain when confronted with other people’s pregnancies and baby happiness.

What is important for women is to find a way in which their baby has a place in their lives, a name that is mentioned not only by her but also by her loved ones. Gradually they develop their own ways of answering the question: When will you have a baby? Or how many children do you have? Questions that, during the first period of grieving, are extremely painful, after a while become uncomfortable, and eventually become part of life without causing imbalance anymore.

Partner

The partner has a different task in the grieving process. Throughout the pregnancy, he has become increasingly involved in caring for the pregnant woman. He has witnessed her changing body, her moods, what is on her mind. He has been there when the news devastated her and him, and he has felt the responsibility to be strong, to be there for her, to stay rational where she became emotional, and to manage appointments while she was struggling with feeling her baby kicks in her belly in the midst of bad news, in the roller coaster of hope and fear. When they decided to end the pregnancy, he probably believed that was the best thing to do for the baby, them, and their family. However, he also felt overwhelmed by her courage and his guilt that she had to give birth and he felt powerless when he was standing by while she was in pain. Once he sees his baby, he too feels pride and love, but often even more so of his wife. When she is grieving, he feels the responsibility to keep the world spinning. In this phase, woman and partner are writing different chapters in the same book, each fulfilling important tasks, but not the same tasks.

Therefore partners often resume work quite rapidly, ranging between 2 days and 3 weeks after birth. The woman tends to experience a great deal of anxiety when she is left home alone. This is the moment the safe bubble bursts and some tension rises between partner and woman.

Pregnant–nonpregnant differences

When the partner ensures that the world keeps on spinning, he might discover that he and his wife have conflicting needs (Ramdaney et al., 2015). While he needs distraction, she needs to introspect, while he needs action, she craves peace, he wants to meet his friends, while she is too anxious to discover the next friend has fallen pregnant. Often partners find themselves offering each other the support they need themselves, only to find out that this does not match the need of their partner at all. Without knowing anything about the couple in front of me, I have witnessed the relief of recognition when I tell them what often happens between couples during this phase.

Often the partner will say to the woman that she needs to get off the couch, leave the house, meet with friends, seek distraction. He does not realize that this is the last thing on earth she wants. Likewise, women often ask their partners how they are feeling, inviting them to introspect and talk about their emotions. She does not realize that he will have a hard time connecting with his pain, because he is creating space for hers. If both partners would give each other what the other person needed it would be something like this. She would tell him that he should definitely go out, get on his bicycle or meet up with friends, and that she will be fine in the meantime. He would be offering her support by sitting next to her, offer his shoulder and ask her to tell him what’s going through her mind. Embrace her, allow her time to repeat herself, and not offer any solutions. He is the solution. Her pain can dissolve in his attention, even if it is just for a moment.

“I can do that,” is a frequent response. Understanding that both have different needs helps to build a bridge. Additionally, when the household takes over, and couples resume their normal daily rhythm, spending time together without a phone in the hand, a TV in the background, or other distractions help couples to bridge the differences in longer term grieving.

Guiding siblings through the termination of pregnancy

Often pregnant couples already have children during the pregnancy in which the abnormalities are detected. Depending on the age of the child, they are aware that their mother is carrying a baby. They know that the pregnancy will result in a little brother or sister. When expecting couples receive the devastating news that abnormalities are detected in their unborn child, and they go through the roller coaster described earlier, this also affects their other children. These children, irrespective of their age, sense that something is going on and that their mom and dad are sad.

A lot of parents struggle with how to inform their children about the abnormalities in the pregnancy ( ). This is especially the case when couples are full amidst the decision-making process themselves. What we have seen, however, is that it is important to inform children about what is going on and why their parents are sad. If children are not informed and stay in the dark, they might start to blame themselves ( ). They may believe that they are the reason their parents are sad. It sometimes seems that children, especially when they are under the age of five, resonate the feelings of their parents. In this case, children seem to be mirroring their parents’ inner turmoil.

Depending on the age of the child, the couple can inform them that something is wrong with the baby or the baby is sick. Parents can explain that this makes them very sad, and that is why they are acting different.

When couples have made the decision to end the pregnancy, their other children should also be informed about this ( ). We have experienced that including children in this process makes them understand better and helps children in their own grieving process. The effect of involving the child is that it stays part of the inner circle, where it is usually safest. When parents try to protect children by not involving them, they feel excluded. Being excluded is being out of the safe zone. When children sense tension and emotional turmoil, being excluded may be even more distressing. It helps to realize that young children may feel less burdened by the loss of their sibling, as they do not yet possess the cognitive capacities to feel the pain of missing “what should have been.” They experience what is, and for them there is no painful discrepancy with what should have been.

Depending on the age of the child, parents can explain that the baby is “broken” and cannot live or that the baby would be in a lot of pain if it would be born alive. When children are a little older, parents can explain that they give birth to the baby so that the baby will not have to suffer. In all cases, it is important to stress to children that the unborn child is severely ill. Otherwise, children may become deeply troubled when they have the flu or fear they might die when they fall ill.

While parents lose their child, children lose a brother or sister. Children grieve the loss of this brother or sister in their own age-appropriate way ( ). Therefore it is important to include the children in the process of saying farewell to the deceased child. We hear from a lot of couples that they struggle how to do this, that they worry it might be traumatizing for their child(ren). From what we learned from parents’ experiences in our clinic is that children took the situation with much more “lightness” than their parents. We have yet to encounter the child who was traumatized by being included in the farewell ceremony ( ). We must note here that in these families, there typically was no psychopathology or other problematic family dynamics issues.

Including children allows them the possibility to mourn the loss of their brother or sister. Ways of including the other children, depending on their age, are having the child see or hold their deceased brother/sister, having the child watch photos of their brother/sister, giving the child a role in the farewell ceremony, having the child make drawings for their brother/sister, or having the child buy a gift/stuffed animal for their brother/sister. Couples may feel anxious about talking about their deceased child or show their emotions when their other children are present. Most parents are aware of their responsibility as caregivers and do not want to stimulate their children to comfort them in their grief, as this would cause role reversal. Indeed, parentification has a negative impact on the psychological well-being and development of children ( ). However, allowing your child to hug you and give you a kiss to comfort you in your sadness does not equal role reversal. I often tell parents that there is a boundary indeed, if parents were to actually rely on their child to feel better and seek out their child to receive comfort, it would be crossing the boundary. But allowing your child to practice with comforting behavior that they themselves receive from their parents is adequate parenting. Most parents recognize this boundary when we discuss it this way and feel reassured.

Being transparent about your emotions when you feel overwhelmed sets the example for the children that they are also allowed to feel sad/confused/angry and that it is normal to talk about their brother/sister if they want to.

During these difficult family times, it is, however, important for children to maintain their normal routines as much as possible ( ). Attending school, practicing sports, playdates, etc. are beneficial to help children in their grieving process. As children spend a lot of time in school, informing their teacher ensures that children also feel safe to talk about what is happening/what happened in the class. The parents could discuss with their child and the teacher what they would like to tell in the class about their brother/sister. Furthermore, the teacher could observe how the child is doing and whether additional support such as a school counselor or child psychologist would be necessary.

Children grieve different than adults do. Children can be very sad, wanting to snuggle up with mom and dad and want to talk about their brother/sister. The next moment, minutes, an hour or hours later they can be happy and joyful again and want to continue their daily activities such as playing or school ( ). This does not mean they do not mourn the loss of their brother/sister; this is just a child’s way of keeping it maintainable for him/herself. For parents it is important to stay available for their children, for their questions, concerns, and tears. By speaking about the deceased child among the other children, the children learn that it is okay to talk about him/her and that their brother/sister is part of the family.

Children develop quickly and learn more about life and death in school when they grow older. Therefore in each developmental stage, children will be able to perceive the death of their sibling from a new perspective ( ). Based on their growing knowledge and development children keep asking new questions, using the new insights they gathered. These questions remain for years after the termination of pregnancy has occurred. Some parents worry when in a new developmental phase their child is all of a sudden preoccupied with the loss of their sibling again. It is, however, a psychologically adequate reaction for children to attribute new meaning to their loss with their newly developed capacities. When parents understand this, they indicate actually liking these questions, because it shows that for their other children the child they have lost is also part of their life. By staying mentally available for their children, parents can guide and support their children through the grieving process.

Karin Diderich

When we discuss the termination of pregnancy, we also discuss the different ways of saying goodbye. We advise to include previous children in (part of) these rituals. They can draw a picture for their little brother or sister, they can come by in the hospital with, for example, a grandparent and say goodbye if they want to. Once I entered a room for a physical examination of the fetus and found the family gathered around the 4-year-old big sister who was cradling the fetus in her lap, a wonderful moment. In contrast, I have heard back of people who did not include their daughter in saying goodbye who found that the daughter was terrified for the empty nursery and had scary images in her head. Sometimes a couple has already decided—with the best interest of the child in mind—not to include the child in any of the rituals. I remember one father who was also a teacher and had a very strong conviction that it would be harmful for his child to include him. Having (read about) different experiences myself, I persevered in telling him about this which actually agitated him so much that I was in doubt whether that had been wise. When I saw the couple again, he told me that in the end they had included their son and that was the best thing to do. Sometimes, a couple feels their child is too young to understand any of it and thinks it is better not to include the child. I tell them that children sense much more than we as parents might comprehend. When a couple does not quite see that, I sometimes share an experience of my own.

My own mother died of cancer at a young age and a very good friend of mine was terminally ill with cancer. I used to visit her with my three-year old daughter to help out with laundry etc. At one point the nursery teachers asked me to come by at the day care center because my daughter was not her real self in their eyes. We sat down talking and came to the conclusion that this was most obvious the day after my daughter and I had visited my friend. I sat down with my daughter and it appeared that she had come to the conclusion that mothers, including her own, die at a young age. I told her I was not sick and from then on I informed the nursery teachers every time we had visited my friend and my daughter became her real self again.

In a short time, I can, thus, illustrate how much children can sense and imagine. Sharing the true situation with their parents seems to be the less harmful option. In addition, I offer couples an appointment with the psychologist who has far more experience in this field.

Main recommendations

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  Dare to ask how couples are feeling and coping.

  
  
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  Refer couples in time when you feel they are not coping well.

  
  
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  Be attentive to anxiety, depression, PTSD, and complicated grief symptoms.

  
  
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  Point out the high percentages of received professional psychosocial aftercare; it is common for couples to need psychosocial care.

  
  
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  Actively acknowledge the loss of parents and give room to mourning.

  
  
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  Advise parents to include their other children in the farewell of their brother/sister.

  
  
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  Discuss the wish for a new pregnancy.