Psychological effect

Early in miscarriage, as women begin to develop cramps or bleeding, they may experience anxiety, fear, helplessness and feelings of loss of control . The actual incidence of grief after miscarriage is unknown. Beutel et al. found that 48% of the 125 women they studied had no change in their emotional reactions; however, most studies agree that many women experience sad feelings or grief in the first days after the loss. This grief may be intense and similar to that experienced after any other significant loss . The distinctive quality about miscarriage grief is that the focus is on the anticipated future and what might have been rather than on memories . It also commonly includes feelings of guilt or self-blame. Most studies show a gradual decline in grief over the first 6 months after loss .

A number of studies have reported an increase in depressive symptoms after miscarriage. Neugebauer et al. found that, in the early weeks after a loss, 36% of women had moderate to severe depressive symptoms that gradually decreased but still were elevated by 6 months. Robinson et al. found levels of depressive symptoms at 6 months that were lower than reported just after the miscarriage but still elevated (10.9% v 4.3% for controls) and remained high at one year. It was not clear whether the elevated levels at 1 year represented a sustained level of distress or an anniversary reaction. Some women experience an actual major depressive disorder. Neugebauer et al. reported that 10.9% of his miscarrying group experienced a major depression in the first 6 months after loss, a relative risk of 2.5 compared with a comparable community group.

Women at highest risk of having depressive symptoms are those who have a history of major depression ; are childless ; are highly invested in the pregnancy ; or are concerned about being infertile. Women who were already pregnant at follow up were less depressed than those who were not . No relationship has been established between intensity of grief and maternal age, social class, or previous therapeutic abortion . Reports of the relationships between symptom intensity and length of gestation , partner support, marital or family problems, and history of previous miscarriages are inconsistent .

Anxiety can also be a major reaction to miscarriage. A significant number of women report elevated levels of anxiety up to 6 months after miscarriage, and may also be at increased risk for obsessive–compulsive and PTSD . Nikcevic et al. found the anxiety is largely focused on concerns about the cause of the miscarriage and risks in future pregnancies. Robinson et al. found that the anxiety experienced often seemed worse than the depression. A total of 41.2% of the women who had miscarried felt the loss was partly their fault, and 22.6% felt others blamed them; 85.3% felt stressed; 77.6% found the miscarriage was as great as any previously experienced stressor. Many felt dissatisfied and angry with the care they had received from medical personnel.

Many women have little support for dealing with the results of a miscarriage. Health professionals may fail to acknowledge the effect of the loss, treating it as a medical event only and minimising the psychological effect. Lack of investigation into the cause of the miscarriage may leave women feeling insecure and anxious about a subsequent pregnancy.

Women often avoid telling friends about their pregnancy until the end of the first trimester when they feel it is more secure. As a result, if they suffer a loss, they may have little support as no one knows they were pregnant. Even if friends know, they may incorrectly assume that early losses are insignificant as there was no ‘real’ baby. Women, therefore, may not understand why their sad feelings do not go away in a few weeks.

This misunderstanding may be exacerbated by the differences often seen between the way men and women grieve . Kong et al. found that 43.4% of men whose wives had miscarried scored high in both the General Health Questionnaire-12 and the Beck Depression Inventory immediately after the loss, although the women still had higher initial scores. Although the women’s scores decreased gradually over 12 months, male scores decreased sharply within the first 3 months, reaching a plateau level. Many theories account for this difference. Men may not feel the same attachment to the fetus at this early stage. On the other hand, men may just cope differently, trying to distract themselves with activities rather than talking about feelings. Men may also think they will exacerbate their partners’ distress by talking about their grief. This reticence on the part of their partners may make the woman feel her grief is excessive.

Gold et al. found that, even controlling for other known risk factors, the rate of marriage dissolution increased in couples who had experienced a miscarriage (hazard ratio 1.22), most of this effect being seen between 1.5 and 3 years after the miscarriage. Improving communication between the two can help them better adjust to the miscarriage and diminish their grief.

Other family members may also be affected by the loss. The reaction of siblings varies with their age and developmental stage . Some parents may try to protect their living children from grief by not telling them about the loss or giving a vague message such as ‘the baby stayed at the hospital’. Even if children did not know their mother was pregnant, they can sense that their parents are sad and something is wrong. They may become sad, confused, fearful and guilty, wondering if they are the cause of the distress.

Grandparents may also experience distress after a miscarriage . They may feel grief at the loss of a potential grandchild and sadness for what their son or daughter is experiencing. They can be supportive and helpful. Other parents, however, may ignore the needs of their children and act as if the loss was theirs. They may be angry and judgmental, blaming the parents for the loss.

Management

Protocols used for stillbirth have been adapted to miscarriage. Although there is no baby to hold or pictures to be taken, patients should be offered the opportunity to view the products of conception; seeing the products may help women to realise the gestational age of the pregnancy. Giving a name to the potential baby, holding a memorial service, preserving mementos such as the mother’s hospital identification band or buying something to signify the existence of that pregnancy may be helpful . Other things that might be helpful include involving the family in making decisions about disposition of the remains and planning memorial services, providing written information about the variability of normal grief responses with resources listed and following up with calls and contacts to assess whether the family needs extra support or referrals .

Although not all women have ongoing problems after a miscarriage, most women would benefit from some follow up in which they are given whatever information is known about the cause of the loss and the chances of becoming pregnant again. Nikcevic et al. found that this was helpful in reducing the level of stress in women who had experienced miscarriage.

Because of the risk of grief reactions, anxiety or depression, follow-up support and counselling has been recommended as a means of improving psychological well-being . A recent Cochrane review has raised questions about appropriate interventions. The reviewers studied six randomised-controlled studies of counselling after miscarriage. The following were compared: one counselling session with no counselling ; three 1-h counselling session with no counselling at 4 months ; three 1-h counselling versus no counselling at 12 months ; two counselling sessions compared with no counselling ; and combined caring, nursing caring and self-caring compared with no treatment . Only one study showed any significant outcomes, and these were based only on an author-designed measure, not on standardised tests. The Cochrane Collaboration review concluded that the current evidence is insufficient to demonstrate the superiority of counselling over no intervention.

Other family members can support their loved ones by reading books on grieving with the living children, assisting them in creating mementos, and having them attend memorial services. Roose and Blanford described the development of an intergenerational perinatal bereavement programme that addresses the needs of parents, siblings and grandparents. This may include involving the grandparents or siblings in counselling, providing advice from a child bereavement counsellor, and providing separate support groups for grandparents. Parents found that these services useful to the entire family. Grandparents found it to be useful in their own and their child’s coping.

Despite the lack of convincing research evidence, most healthcare professionals who work with women who have miscarried believe support and counselling should be offered. Some women will cope well and not feel the need for counselling, whereas others may suffer intensely.

Future pregnancies

A future pregnancy does not necessarily resolve all of these problems. Women with a history of miscarriages suffer more from pregnancy-specific anxieties in the first trimester of a new pregnancy than women with no history of miscarriage . This anxiety declines to some extent after the pregnancy passes the gestational age of the previous miscarriage. Anxiety symptoms are more marked in women who have had recurrent miscarriages. Blackmore et al. found that anxiety and depression could continue even after the birth of a subsequent healthy child. On the other hand, becoming pregnant again can be a healing experience for women who have experienced fears of infertility.

Psychological effect

Early in miscarriage, as women begin to develop cramps or bleeding, they may experience anxiety, fear, helplessness and feelings of loss of control . The actual incidence of grief after miscarriage is unknown. Beutel et al. found that 48% of the 125 women they studied had no change in their emotional reactions; however, most studies agree that many women experience sad feelings or grief in the first days after the loss. This grief may be intense and similar to that experienced after any other significant loss . The distinctive quality about miscarriage grief is that the focus is on the anticipated future and what might have been rather than on memories . It also commonly includes feelings of guilt or self-blame. Most studies show a gradual decline in grief over the first 6 months after loss .

A number of studies have reported an increase in depressive symptoms after miscarriage. Neugebauer et al. found that, in the early weeks after a loss, 36% of women had moderate to severe depressive symptoms that gradually decreased but still were elevated by 6 months. Robinson et al. found levels of depressive symptoms at 6 months that were lower than reported just after the miscarriage but still elevated (10.9% v 4.3% for controls) and remained high at one year. It was not clear whether the elevated levels at 1 year represented a sustained level of distress or an anniversary reaction. Some women experience an actual major depressive disorder. Neugebauer et al. reported that 10.9% of his miscarrying group experienced a major depression in the first 6 months after loss, a relative risk of 2.5 compared with a comparable community group.

Women at highest risk of having depressive symptoms are those who have a history of major depression ; are childless ; are highly invested in the pregnancy ; or are concerned about being infertile. Women who were already pregnant at follow up were less depressed than those who were not . No relationship has been established between intensity of grief and maternal age, social class, or previous therapeutic abortion . Reports of the relationships between symptom intensity and length of gestation , partner support, marital or family problems, and history of previous miscarriages are inconsistent .

Anxiety can also be a major reaction to miscarriage. A significant number of women report elevated levels of anxiety up to 6 months after miscarriage, and may also be at increased risk for obsessive–compulsive and PTSD . Nikcevic et al. found the anxiety is largely focused on concerns about the cause of the miscarriage and risks in future pregnancies. Robinson et al. found that the anxiety experienced often seemed worse than the depression. A total of 41.2% of the women who had miscarried felt the loss was partly their fault, and 22.6% felt others blamed them; 85.3% felt stressed; 77.6% found the miscarriage was as great as any previously experienced stressor. Many felt dissatisfied and angry with the care they had received from medical personnel.

Many women have little support for dealing with the results of a miscarriage. Health professionals may fail to acknowledge the effect of the loss, treating it as a medical event only and minimising the psychological effect. Lack of investigation into the cause of the miscarriage may leave women feeling insecure and anxious about a subsequent pregnancy.

Women often avoid telling friends about their pregnancy until the end of the first trimester when they feel it is more secure. As a result, if they suffer a loss, they may have little support as no one knows they were pregnant. Even if friends know, they may incorrectly assume that early losses are insignificant as there was no ‘real’ baby. Women, therefore, may not understand why their sad feelings do not go away in a few weeks.

This misunderstanding may be exacerbated by the differences often seen between the way men and women grieve . Kong et al. found that 43.4% of men whose wives had miscarried scored high in both the General Health Questionnaire-12 and the Beck Depression Inventory immediately after the loss, although the women still had higher initial scores. Although the women’s scores decreased gradually over 12 months, male scores decreased sharply within the first 3 months, reaching a plateau level. Many theories account for this difference. Men may not feel the same attachment to the fetus at this early stage. On the other hand, men may just cope differently, trying to distract themselves with activities rather than talking about feelings. Men may also think they will exacerbate their partners’ distress by talking about their grief. This reticence on the part of their partners may make the woman feel her grief is excessive.

Gold et al. found that, even controlling for other known risk factors, the rate of marriage dissolution increased in couples who had experienced a miscarriage (hazard ratio 1.22), most of this effect being seen between 1.5 and 3 years after the miscarriage. Improving communication between the two can help them better adjust to the miscarriage and diminish their grief.

Other family members may also be affected by the loss. The reaction of siblings varies with their age and developmental stage . Some parents may try to protect their living children from grief by not telling them about the loss or giving a vague message such as ‘the baby stayed at the hospital’. Even if children did not know their mother was pregnant, they can sense that their parents are sad and something is wrong. They may become sad, confused, fearful and guilty, wondering if they are the cause of the distress.

Grandparents may also experience distress after a miscarriage . They may feel grief at the loss of a potential grandchild and sadness for what their son or daughter is experiencing. They can be supportive and helpful. Other parents, however, may ignore the needs of their children and act as if the loss was theirs. They may be angry and judgmental, blaming the parents for the loss.

Management

Protocols used for stillbirth have been adapted to miscarriage. Although there is no baby to hold or pictures to be taken, patients should be offered the opportunity to view the products of conception; seeing the products may help women to realise the gestational age of the pregnancy. Giving a name to the potential baby, holding a memorial service, preserving mementos such as the mother’s hospital identification band or buying something to signify the existence of that pregnancy may be helpful . Other things that might be helpful include involving the family in making decisions about disposition of the remains and planning memorial services, providing written information about the variability of normal grief responses with resources listed and following up with calls and contacts to assess whether the family needs extra support or referrals .

Although not all women have ongoing problems after a miscarriage, most women would benefit from some follow up in which they are given whatever information is known about the cause of the loss and the chances of becoming pregnant again. Nikcevic et al. found that this was helpful in reducing the level of stress in women who had experienced miscarriage.

Because of the risk of grief reactions, anxiety or depression, follow-up support and counselling has been recommended as a means of improving psychological well-being . A recent Cochrane review has raised questions about appropriate interventions. The reviewers studied six randomised-controlled studies of counselling after miscarriage. The following were compared: one counselling session with no counselling ; three 1-h counselling session with no counselling at 4 months ; three 1-h counselling versus no counselling at 12 months ; two counselling sessions compared with no counselling ; and combined caring, nursing caring and self-caring compared with no treatment . Only one study showed any significant outcomes, and these were based only on an author-designed measure, not on standardised tests. The Cochrane Collaboration review concluded that the current evidence is insufficient to demonstrate the superiority of counselling over no intervention.

Other family members can support their loved ones by reading books on grieving with the living children, assisting them in creating mementos, and having them attend memorial services. Roose and Blanford described the development of an intergenerational perinatal bereavement programme that addresses the needs of parents, siblings and grandparents. This may include involving the grandparents or siblings in counselling, providing advice from a child bereavement counsellor, and providing separate support groups for grandparents. Parents found that these services useful to the entire family. Grandparents found it to be useful in their own and their child’s coping.

Despite the lack of convincing research evidence, most healthcare professionals who work with women who have miscarried believe support and counselling should be offered. Some women will cope well and not feel the need for counselling, whereas others may suffer intensely.

Future pregnancies

A future pregnancy does not necessarily resolve all of these problems. Women with a history of miscarriages suffer more from pregnancy-specific anxieties in the first trimester of a new pregnancy than women with no history of miscarriage . This anxiety declines to some extent after the pregnancy passes the gestational age of the previous miscarriage. Anxiety symptoms are more marked in women who have had recurrent miscarriages. Blackmore et al. found that anxiety and depression could continue even after the birth of a subsequent healthy child. On the other hand, becoming pregnant again can be a healing experience for women who have experienced fears of infertility.