By Krista Cline
“Is anyone even thinking about the mental health of women in these situations?”
The psychological and emotional effects and implications of pregnancy loss are frequently downplayed by healthcare professionals and greater society. The psychological trauma that women may experience after a pregnancy loss can not only negatively affect them but can indirectly affect other close relationships within families and friendships. Without understanding how pregnancy loss can impact women, opportunities for providing care are greatly diminished, perpetuating the norm of silence surrounding pregnancy loss. This leaves many women questioning the multitude of emotions they endure during and after a pregnancy loss.
Previous research has found that health care professionals across many settings are unable to provide adequate physical, mental, and emotional care to women who are going through a pregnancy loss, in large part due to the prolonged norm of silence implicated in the medicalization of pregnancy loss. In addition, it is common for many women to hold off on announcing their pregnancies until after the first trimester in hopes of reducing chances of a false alarm. This delayed announcement may seem beneficial in the short term, but can actually become harmful in the long term as it reduces the odds of people understanding the situation of the pregnancy to the full extent. Thus, many women experience feelings of isolation almost immediately after the loss as healthcare workers are unable to provide emotional support or resources that could benefit women or help them manage their grief. Many women may choose not to disclose their pregnancy until after the first trimester for several reasons: they are unaware of the pregnancy, they realize the risk for a loss lessens after the first trimester, or for family or work reasons. The announcement of a pregnancy only after the first trimester is over can deprive women from support as many outsiders were unaware of the pregnancy in the first place. This may cause feelings of grief to grow as close friends and family of the parents are unable to provide support.
The psychological distress experienced after a pregnancy loss derives from a multitude of factors, but societal influences such as the norm of silence further reduces opportunities for care to be provided and a greater understanding to be achieved. Understanding the emotional issues that occur during and after a pregnancy loss can promote new approaches in how pregnancy losses are handled in the medical field. Minimizing the psychological damage after having a pregnancy loss requires efforts from multiple, different individuals, including healthcare workers, support systems such as family and friends, and the women experiencing the loss.
Healthcare providers are typically the first people that women work with after a pregnancy loss, which emphasizes the importance of their role in providing aid. The medicalization of pregnancy loss has promoted the norm of silence as it inhibits healthcare workers from understanding the emotional impact on the mother of miscarrying. Many women report negative encounters within the healthcare setting including insensitive comments from healthcare workers, general lack of empathy and support, lack of information, lack of planning follow-up appointments, dishonesty, and overall carelessness (Bellhouse 2019). Acknowledging the emotions emerging from the loss a woman is experiencing can provide them with a sense of understanding and of being seen.
In addition to acknowledgement, validating the grief of patients reduces perplexity surrounding how and what should be felt. Offering mindfulness training within hospitals can help alleviate the trauma not only for women, but also healthcare workers themselves (Cacciatore 2013). Nurses specifically are one of the most encountered hospital staff, so offering such training could greatly benefit their approach in treating and understanding a pregnancy loss (McLean 2012). While nurses were among the most encountered by patients, social workers were also noted to be among the least encountered healthcare professionals by women. The lack of social worker presence within the healthcare setting may nullify the knowledge of programs and emotional support that could benefit the women in need (McLean 2012). Medical counseling can be helpful for women in understanding what physically happened to cause the pregnancy loss, if a cause is indeed known, thus reducing feelings of self-blame, grief, and anxiety (Nikčević 2007). This can also potentially reduce fears of many women facing loss again in subsequent pregnancies. Providing healthcare professionals with adequate direction in how to best help patients who have miscarried can not only reduce feelings of isolation, but facilitate better communication regarding follow up appointments and referrals to counseling.
Mothers who experience pregnancy loss are more prone to develop Post Traumatic Stress Disorder (PTSD) or depression (Lloyd 2015). PTSD and depression related to pregnancy loss have long lasting impacts even if one has a successful pregnancy and gives birth to a healthy child following their loss. If such psychological disorders are not evaluated, they can result in worsening emotional and mental states, so understanding how to best provide for these patients is imperative. Harmful trends such as not recognizing the presence of taboos regarding pregnancy loss within therapy settings, focusing on internal causes of grief as compared to external causes, and lacking awareness of the confusion mothers may face can all undermine the effectiveness of therapy (Markin 2018). Offering validation for any and all emotions the women may be experiencing is the first step in providing a safe environment.
For many, pregnancy loss is a topic that is hard to discuss and is largely disregarded for this reason as people are unsure how to address it appropriately. Interactions with friends and family have a substantial impact on how women are able to cope with their pregnancy loss. Many women report receiving insensitive comments from those within their support and social circle. While these comments may have been made in an attempt to lighten the mood, they are often seen as insensitive (Bellhouse, 2018). Without full understanding of how one may be feeling about a pregnancy loss, assumptions may be made. With increased awareness of the condition of a pregnancy people around the mother who has experienced loss can offer comprehensive support. Overall improvement in societal understanding may also promote families disclosing their own experiences with pregnancy loss which could aid in providing support and reducing the sense of isolation for others. Women who don’t have the opportunity to share their experiences through other relationships found it helpful to discuss their pregnancy loss with their mothers as they can offer general counsel (Gerber-Epstein 2008).
Evaluating life after a pregnancy loss can also be crucial for a mother in order to promote a better psychological state. Some women found returning to “normal life,” such as work, was helpful in distracting them from the grief, however others found it difficult to return to normalcy while dealing with the mental struggles they were facing (Gerber-Epstein 2008). While having control over whether or not one returns to working life after a pregnancy loss is ideal, it is not always the reality many face. To best manage their psychological well being, women, or couples, should try to find ways to prioritize making time for themselves. Conducting a ceremony or ritual to honor their child was found to be beneficial to many women and couples (Rowlands 2010). Many women found that one root cause of their grief was from the absence of a tangible item or event with which to identify their grief with (Gerber-Epstein 2008). Thus, memorializing the loss provided a tangible event with which to remember their child, rather than an intangible fantasy of the life they could have had with their child. Introspection of how to continue after a pregnancy loss is essential for women and couples to best understand how to provide themselves while grieving.
With all of this information available regarding pregnancy loss, there was a dearth of research examining the actual emotional experience that women who were currently experiencing, or had recently experienced pregnancy loss, were going through. The current study seeks to fill that gap in the literature by examining the following research questions:
- During a pregnancy loss, how do doctors and staff handle the emotional needs of their patients?
- What should doctors, nurses, and other office and hospital staff do in an effort to help manage the emotional needs of their patients?
Materials and Methods
The current study is an exploratory study of women and pregnancy loss. Sixty face-to-face or virtual semi-structured interviews were conducted by the researcher between August 2023 and December 2023. Interviews were conducted either at a coffee shop or virtually via Zoom or Google Meet, and were recorded for transcription. Identifying information was removed from transcripts prior to analysis. Interview respondents included women who had experienced a pregnancy loss within the past five years or were currently experiencing a pregnancy loss and were identified via an online message board. An ad was placed on the message board in August 2023. Convenience sampling methods were selected. As such, it is possible that the volunteer nature of sampling rejected positive bias into our findings. This study was approved by the IRB of the author’s institution. The author reports that there are no competing interests to declare.
Transcripts were thematically analyzed using NVIVO software. Analyses were guided by an inductive content analysis approach. Themes were not developed prior to analysis but instead were allowed to emerge from the data. Although in some cases, probes were utilized to follow-up up on responses, the interviews did not substantially deviate from the interview guide. The interview guide centered on the timing of the respondents’ most recent pregnancy loss, the emotional aspects of the pregnancy loss, and suggestions for doctors, nurses, and other staff in regards to treating pregnancy loss.
Results
The most prominent finding was the suggestion that doctors’ offices and hospitals have separate waiting rooms and examination rooms for women who are experiencing pregnancy loss.
India Batson, a YouTuber, went viral in March 2024 after making a video suggesting that OB/GYN offices should have separate waiting rooms for women who are experiencing a pregnancy loss. Participants of the current study, from which data was collected before the viral video, almost unanimously agree. Three main themes emerged from the respondent interviews: (1) Descriptions of what doctors, hospitals, and staff did well during pregnancy loss; (2) Descriptions of what doctors, hospitals and staff did not do well during pregnancy loss; (3) Suggestions about what should have been done differently by the doctors, hospitals, and staff.
Descriptions of what doctors, hospitals, and staff did well during pregnancy loss.
When asked to describe what doctors, hospitals, and staff did well when women were going through a pregnancy loss, about 50% of respondents said, “nothing.” This, in and of itself, is an important finding. This indicates that the experience was negative, not only because of what the women were experiencing physically, but because of the lack of care they believe they received. However, the other 50% said that their doctors were helpful during their loss. The following were viewed as helpful behaviors: “Reminded me that the loss had nothing to do with any choice I had made;” “Kept checking on me to see if I was OK;” “Offered me grievance therapy and told me if at any time I needed it, I could use it;” “Offered tests and referral to a specialist;” “Offered condolences and resources for grief;” “Explained everything in detail;” “Listened to me and helped to educate me;” “Scheduled an ultrasound so I didn’t have to wait on HCG results;” “I was discharged from the emergency room after the provider was so sincere and reassured me that I’m not a bad mom, it’s not my fault, I’m not alone and whatever I choose to do is ok. My care team couldn’t have been better. They let me lead the way, while also answering all my questions and reassuring me.”
If the loss happened in the hospital (as many stillbirths do), respondents identified what the hospital staff did well during their loss. Many women specified that the hospital staff were very helpful and caring. The following were seen as helpful behaviors by the hospital staff specifically: “My nurse had recently went through a pregnancy loss and told me what I could expect;” “The nurses were exceptionally kind;” “They provided resources for my loss and grief;”
“The entire hospital staff including the receptionist, nurses, techs were so kind, compassionate, and respectful. They gave us bereavement gifts including for our other children, honored our baby as a human being, and helped us figure out how to take the baby’s remains home for burial;”
“My doctor was very sympathetic as she had gone through a loss a few years before. She offered a hug, answered any questions I had, and had a nurse follow up with me in the following weeks. She was so sympathetic. I looked forward to seeing her again when I tested positive for a new pregnancy a few months later. Seeing her again wasn’t traumatizing because she showed how much she cared. I can’t imagine how differently I may have felt if she hadn’t responded with such care.”
Descriptions of what doctors, nurses, and staff did not do well during pregnancy loss.
For many of the women, the list of what was not done well during their pregnancy was very long. In fact, there were many more women who were dissatisfied with their care than those who were satisfied. This dissatisfaction did not vary by where the pregnancy loss or follow-up care took place. For many women who experienced loss before 20 weeks, the loss occurred at home and they followed up with their OB/GYN. For those who experienced a loss after 20 weeks, most found out about the loss at their doctor’s office and then transferred to the hospital to deliver the baby.
“My doctor when I said I thought I had an ectopic pregnancy. Then he yelled at me when I asked why my HCG was going up and down. He told me this happened because I have too much anxiety. He could have done tests afterwards to see if my tubes were functional (they weren’t);”
“While I was going through my loss, my doctor never asked about my mental health. I also felt like when I first started bleeding and called into my doctor’s office, I was ignored. I was told bleeding was normal in early pregnancy;”
“I understand that miscarriage is common for doctors and nurses, but it’s not common for me. I deserved compassion, not just clinical jargon;”
“My doctor’s office was so booked up that I had to wait several days for an ultrasound to confirm what the bloodwork was showing. That wait felt like a lifetime;”
“I wish it would have been explained to me how awful the medications to expel the baby would be. They made me feel so sick. My doctor said it would just feel like a period, but I’ve never felt that terrible during my period;”Suggestions on what could have been done differently.
Suggestions on what could have been done differently.
Overwhelmingly, women who experienced losses said the same things over and over. First, women felt that they should not have to sit in the same waiting room at their OB/GYN office as women are experiencing normal pregnancies. Seeing other pregnant women during that time of loss was extremely traumatizing for many of the women.
“I was informed early on that my baby had a genetic heart problem and we had set up specialist appointments with cardiologists at 20 weeks. I had set up a day of back to back appointments in a new city with specialists and in the first appointment we were told there was no heartbeat. They sent me home, the next day I spent 8 hours in the hospital L&D (Labor and Delivery) unit sharing rooms with happily pregnant people while I awaited for a dilation procedure and further scans. The following day I underwent surgery (D&E) and again was placed in shared rooms with people who had delivered live babies. Being with all of those happily pregnant women or women who had just given birth to live, healthy babies was very traumatic for me;”
“When in the hospital, those suffering losses should be kept separately [sic] from those who are happily expecting or had recently delivered;” “I don’t understand how there is not a separate area for women who are going through the loss of a pregnancy.”
Additionally, women believe that there should be a separate Labor and Delivery area for women who will not be bringing home live babies.
women who will not be bringing home live babies
“I had to deliver my baby in the Labor and Delivery unit. All around, I heard healthy babies crying and healthy parents and families celebrating;” “Would it really require so much to have a small, separate unit where moms who are going through a miscarriage can have their babies? It’s emotionally traumatizing to be around pregnant women and babies during this time;”
“It’s just amazing to me that no one has considered that women who have lost a baby might not want to be around women who have just given birth and are holding healthy ‘take-home’ babies in their arms. It’s like….who is designing these hospitals? Is anyone even thinking about the mental health of women in these situations? You would tell a person that they lost their husband or parent or sibling in car crash right in front of a bunch of people who survived a car crash. There are literally separate rooms where doctors tell people that their family member has passed. Why in the world is this different if you are pregnant? You’ve just lost a baby. And, not only a baby, but you feel like you’ve lost an entire future. What could have been. And you get to deliver your dead baby right in a room right next to someone who is gave birth and gets to live that future. It’s devastating.”
“It’s quite traumatizing going through a miscarriage. When you have a miscarriage at home, you come in to see your doctor to make sure everything has passed, and you sit in the waiting room with pregnant women. My partner even asked if there was somewhere else we could wait. Nope. Then, if you have a miscarriage further along and have to deliver your baby in the hospital, it’s the same thing. For my second loss, I was stuck in a room right next to the nursery. Seriously, why would you do that to someone. The whole system is like this machine where they just push people out and don’t consider the emotions of the people going through it…..like, at all.”
Discussion
The loss of a pregnancy can have a profound effect on women who experience it. Not only are there physical effects, but psychological and emotional effects as well. Recognizing these effects are important and may be a pathway to help women to heal through what can be a very traumatic time in their lives. There is a very noticeable gap in the literature concerning women’s perspectives on what their doctors, staff at doctor’s offices, and hospitals can do to make this difficult time easier for these women.
In the current study, women voiced very clearly what actions their doctors and the office staff took that were helpful during this time. This included things like reminding the women that they had not done anything to cause the miscarriage, checking in on the women, offering referrals to therapy or specialists, listening to their concerns, and explaining everything clearly. If the loss happened at the hospital, respondents identified that helpful and caring nurses and staff were beneficial. Also, explaining thoroughly any procedures or what was happening to the woman’s body, providing resources for grief, and providing resources for burial were also viewed as beneficial.
Women also were very clear on actions that were viewed as negative in both the context of the doctors’ office and hospitals. Women overwhelmingly had more negative experiences with doctors’ offices, hospitals, and staff than positive. Women spoke of not being heard, being blamed for their pregnancy loss, not being asked about their mental health, being ignored, feeling as if they were just another number to their doctor and not being made to feel like a human. Many women complained of receiving very little information about what was happening or what could happen to their bodies at this time.
The most valuable information provided was receiving information on things that could or should be done for them when experiencing a pregnancy loss. Overwhelmingly, the number one idea was that there should be separate waiting rooms in doctors’ offices and separate units aside from the Labor and Delivery units for women who are experiencing loss. It is unimaginable to think that women would have to experience a loss right next to women who are celebrating the birth of their healthy babies.
Experiencing loss during pregnancy, whether a miscarriage or stillbirth, is an extremely personal experience. However, one only needs to speak to those who have experienced these types of losses to see that there are commonalities amongst them. In order to produce the most effective approach to alleviating emotional distress after a pregnancy loss, effort from various groups such as doctors, nurses, office and hospital staff should be implemented. Healthcare providers can bridge the gap between not only the medical understandings of the pregnancy loss and physical health to understand the event, but should also provide a space for providing emotional support as they are typically the first encountered during and/or after the loss. Overall strengths of current research relate to the creation of options or methods to implement to reduce emotional distress faced by those who experience pregnancy loss, such as having separate waiting rooms for women experiencing loss. Understanding the weight and the significance of the experience of being pregnant as well as the implication that there is always a potential for pregnancy loss should also be further studied in order to provide a comprehensive portrayal of the emotional implications these situations carry. Further research should investigate experiences of doctors, nurses, and staff to discover how much and what type of training they receive, if any, in order to help women manage their emotional distress during a loss. Future research should also focus on learning the doctors, nurses, and other staffs’ perspectives on what they think they can do to minimize emotional distress for their patients during the time of a pregnancy loss.
In conclusion, doctors, nurses, and other healthcare staff need to know that while pregnancy loss may be a common issue that they see in their patients, it can be incredibly emotionally upsetting for women who are experiencing it, no matter what stage of the pregnancy they are in. Previous research suggests that healthcare professionals need to focus their attention on emotional care of their patients as a form of holistic healthcare. There are a variety of issues that should be taken into account when thinking about how to address the emotional aspect of pregnancy loss, including; culture, the number of previous losses, anxiety diagnoses, contact (or lack thereof) of the deceased child and support systems available to the mother (Furtado-Eraso, Escalada-Hernandez, Marin-Ferandez 2020). This is an area of study that is incredibly relevant given the number of women who experience pregnancy loss; however, we have only begun to scratch the surface of care for these women.
References
Bellhouse, C., Temple-Smith, M. J., & Bilardi, J. E. (2018). “It’s just one of those things people don’t seem to talk about…” women’s experiences of social support following miscarriage: A qualitative study. BMC Women’s Health, 18(1). https://doi.org/10.1186/s12905-018- 0672-3.
Bellhouse, C., Temple-Smith, M., Watson, S., & Bilardi, J. (2019). “The loss was traumatic… some healthcare providers added to that”: Women’s experiences of miscarriage. Women and Birth, 32(2), 137–146.
Cacciatore, J. (2013). Psychological effects of stillbirth. Seminars in Fetal and Neonatal Medicine, 18(2), 76–82.
Furtado-Eraso S, Escalada-Hernández P, Marín-Fernández B. Integrative Review of Emotional Care Following Perinatal Loss. Western Journal of Nursing Research. 2021;43(5):489-504. doi:10.1177/0193945920954448
Gerber-Epstein, P., Leichtentritt, R. D., & Benyamini, Y. (2008). The experience of miscarriage in first pregnancy: The women’s voices. Death Studies, 33(1), 1–29.
Lloyd Jones, S. (2015). The psychological miscarriage: An exploration of women’s experience of miscarriage in the light of winnicott’s ‘primary maternal preoccupation’, the process of grief according to Bowlby and Parkes, and Klein’s theory of mourning. British Journal of Psychotherapy, 31(4), 433–447.
Markin, R. D., & Zilcha-Mano, S. (2018). Cultural processes in psychotherapy for perinatal loss: Breaking the cultural taboo against perinatal grief. Psychotherapy, 55(1), 20–26.
McLean, A., & Flynn, C. (2012). ‘it’s not just a pap-smear’: Women speak of their experiences of hospital treatment after miscarriage. Qualitative Social Work, 12(6), 782–798.
Nikčević, A. V., Kuczmierczyk, A. R., & Nicolaides, K. H. (2007). The influence of medical and psychological interventions on women’s distress after miscarriage. Journal of Psychosomatic Research, 63(3), 283–290.
Rowlands, I. J., & Lee, C. (2010). ‘The silence was deafening’: Social and health service support after miscarriage. Journal of Reproductive and Infant Psychology, 28(3), 274–286.
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