Multiple miscarriage:Psychosocial implications

Uschi Van den BroeckMaster in Psychology

University Hospital of Leuven, BelgiumDepartment of Gynaecology/Fertility Center

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

1. Psychology of pregnancy

‘Pregnancy begins psychologically, long before it occurs physically.’

Socialization: imaginative play ‘playing house’

Society has certain expectations for women and men: motherhood is often placed on a ‘pedestal’

1. Psychology of pregnancy

Sense of control:Women have multiple roles (career, family, social,…)

Birth control: freedom to decide when ‘not’ to get pregnant

Illusion of control

Couples talk about their plans for the future

Pregnancy is ‘planned’, ‘timed’

1. Psychology of pregnancy

Bonding and prenatal attachment starts sooner because of modern technology Ultrasounds 3D images …

1. Psychology of pregnancy

Pregnancy = unique experience

Influenced by: Cultural factors Personal history: family of origin Personality Relationship: ‘early days’, ‘long term’, ‘single’, .. Expectations and beliefs Social environment

1. Psychology of pregnancy

Growing towards motherhood fatherhood

Fantasies and dreams about life with future child

Experiences with parenting in family of origin are evaluated

‘New goal’

1. Psychology of pregnancy

Social event:

Grandparents and changing family structure: a new generation

Work-related issues: maternity leave, part-time work etc.

Psychology of pregnancy

PREGNANCY = POINT OF NO RETURN = CRISIS

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

1. Psychology of pregnancy loss

‘A crisis within a crisis’

Conflicting emotions: Sometimes first experience with death for

couples Elation of pregnancy followed by despair of

pregnancy loss Loss of a baby, a part of yourself, your health,

control, potential, reproductive capacity etc. …

1. 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

GRIEVING

1. Psychology of pregnancy loss

Expectations and beliefs about future life are destroyed

Idea of ‘controllable world’ challenged

Confrontation with ‘sterile’ medical world is often painful ‘Unrecognized loss’ Miscarriage is ‘normal’

‘Between something…and nothing’

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

3. The grieving process

Grief is a normal, healthy, dynamic, universal and individual respons to loss

Kaleidoscope

Healing process: surviving and continuing to live

3. The grieving process

Grief (Covington, 2000) ‘Tidal wave’:

growing and cresting with time

Intense feelings of shock, disbelief, anger, self-blame, rage, guilt, anxiety, depression unpredictable and repetitive pattern

Expressions of grief: physical/somatic, psychological, social, emotional, cognitive

‘Triggers’: reminders and rekindlers

‘Shadow grief’: it’s always there

3. The grieving process

Unique aspects of perinatal grief

Prospective: few memories

Multidimensional: individual’s unique experience

Little anticipatory grieving: sudden and without warning

No or little public acknowledgement

Absence of visible ‘object’ to mourn

Few socially acceptable avenues for mourning

Lack of social support

‘Pain of not ever knowing’

3. The grieving process

Mourning characteristics

Parents’ expectations and attitude towards the pregnancy: influences respons to the potential or actual loss

Personal beliefs: ideas, hopes, dreams and dreads about the pregnancy

Cultural background

Gestational age/postnatal age affects the grief process

Attachment to the pregnancy and future baby or babies is formed prenatal

time alone is not necessarily an indicator of the level or degree of attachment (Moulder, 1994)

3. The grieving process

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted

with multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

4. 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) Recurrent pregnancy loss:

Traumatic event Symptoms of depression, anxiety, lowered self-

esteem, …

4. Common feelings when confronted with multiple miscarriage

Every loss is followed by a new period of grieving

Increasing ambivalence about each consecutive pregnancy

Protective mechanism: distancing from a new pregnancy, beginning bereavementprocess and seperation before an actual loss occurs

Degree of attachment is a better predictor for severity of grief reactions than gestational age

4. Common feelings when confronted with multiple miscarriage

Major life-event: individual differences

Sadness Regret

Shocked Confused Angry

Guilty Responsible

Emptiness Panicky

Loneliness Stressed

Lack of self-confidence

Longing Despair

Out of control

4. 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 …….

Video Clip 1: Tori Amos

4. Common feelings when confronted with multiple miscarriage

Physical and emotional lossdifferent for women and men

Self-blaming possibilities

‘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

4. Common feelings when confronted with multiple miscarriage

Feeling that they’ve disappointed their partners, their family

Doubts about reproductive competence

Marital strain: differences can be misinterpreted

4. Common feelings when confronted with multiple miscarriage

Gender differences: mothers and fathers:

Loss is equally important but the experience can be very different

Different ways of experiencing feelings + at different times

It’s 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

4. Common feelings when confronted with multiple miscarriage

Risk of more intense or longer lasting destress: 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

4. Common feelings when confronted with multiple miscarriage (Cuisinier, 1996)

Recurrent miscarriage = recurrent disappointment

In general couples cope fairly well

Already having children >< no live children Thoughts about a future pregnancy Will I ever conceive? Will I be able to keep the pregnancy? Need for a succesful pregnancy becomes

overwhelming Secondary childwish: often incomprehension of

environment ‘Why do you need another child?’

4. Common feelings when confronted with multiple miscarriage

‘How long will I feel like this?’

Expectations from environment

Bad times even when you feel better (process of grief!!)

‘Shadow’ grief

4. Common feelings when confronted with multiple miscarriage

Social environment Many different expectations Confrontation with pregnancy: painful, often

avoidance or trying to be brave People often don’t know how to respond:

minimalizing Reactions can be hurtful Seek out supporting contacts No matter what people ‘recommend’, seek what

is right for you and feels right for you. Grandparents and other relatives have lost a

‘family member’ too.

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

5. Coping with grief and loss

There is no right or wrong. ‘There are no rules.’

‘I think I should be over it by now.’ ‘Some people go through worse things.’

There is only one way, and that is your way.

Video Clip 2: Grey’s Anatomy

5. Coping with grief and loss

Accepting the reality of the loss

Experiencing the pain and the loss in your life

Adjusting to a life without the pregnancy and without your babies

Trying to make sense of it and give life meaning again

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

6. Infertility and recurrent pregnancy loss

Infertility and miscarriage are both devastating experiences

Together: larger impact

Physical component of treatment can become more invasive and traumatic with each repeated reproductive failure

Impact on partner relationship

Impact on social relationships

‘Invisible loss’

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

7. Trying again…

Timing? Too soon Not soon enough

Sexual relationship can become pressured

‘Careless’ pregnancy is gone

Rituals and superstition

Sharing the good news with friends and family

Extra check-up and honest reassurance from the medical team can help reduce anxieties

Overview

1. The psychology of pregnancy 2. The psychology of pregnancy loss3. The grieving process4. Common feelings when confronted with

multiple miscarriage5. Coping with grief and loss6. Infertility and pregnancy loss7. Trying again…8. Helpful interventions

8. Helpful interventions

Reality reinforcing interventions

Decision making is up to the couple but ‘informed’ choice

‘Joining’ the couple

Creating a safe ‘holding environment’

Listening without judging

8. Helpful interventions

Creating mementos

Memorial activities

Self care

Keeping a journal: writing things down

Reaching out: talking with friends, support groups, etc.

Multiple miscarriage:Psychosocial implications

Thank you for listening

Uschi Van den BroeckMaster in Psychology

University Hospital of Leuven, BelgiumDepartment of Gynaecology/Fertility Center

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