Miscarriage: The need for general discussion

Abstract

The experience of miscarriage, a common unpredictable early pregnancy loss, is shrouded in silence. The prevailing secrecy, misconceptions, and lack of informed social support may be harming those impacted and experiencing this loss. This editorial discusses some of the consequences of this silence and calls for purposeful public discussion at multiple societal levels with the aim of reducing the stigma, shame and unacknowledged individual responses felt after this loss.

Introduction

Pregnancy is often a time of mixed excitement and nervousness, as mental and physical preparations begin in anticipation of the arrival of a new family member. For women, whose bonds to the fetus may change or deepen over time,^1,2 this means adjusting their expectations of the future, their role as a parent, and imagining who their baby will become. However, in Canada, 15%–25% of these pregnancies will end in miscarriage, an early loss within the first 20 weeks of pregnancy. ³

While responses to miscarriage vary, from feelings of depression and grief to relief if the pregnancy and its side-effects were unwanted, the lack of support and recognition of those impacted by this loss is a significant issue. Researchers have associated miscarriage with a higher risk for mental health symptoms ⁴ – a significant concern since depression and stress have also been associated with adverse impacts on pregnancy outcomes. ⁵ Additionally, for some mothers, the experience of pregnancy was altered following a miscarriage by increasing their fear of another loss and reducing their attachment to the new fetus. ⁶ This indicates that miscarriage has not only immediate impacts for women who miscarry, but that it may also have longer-term effects and may influence the health of their future pregnancies. Despite these findings and how common it is, miscarriage is hardly talked about and is often considered a taboo topic.

Miscarriage as an individual loss; death as a societal loss

When a death occurs, common practices such as holding a funeral and allowing close community members to gather and commemorate the deceased provide a supportive network for those closest and may help the community come to terms with the loss. This social event and recognition are an important aspect of death, but how do we mourn a loss that was never born, that we never shared memories with?

Understanding what was lost and the meaning it holds in a miscarriage is difficult since the development and death all occur in the womb, hidden from view. The lack of formal burial practices and social recognition that occurs for typical deaths ⁷ may complicate how people grieve a miscarriage. Conversely, assumptions that the person must be distressed after miscarriage may make those who feel relief for the loss of an unwanted pregnancy to feel as though their response is socially unacceptable.

The secrecy of early pregnancy

Early pregnancy is often shrouded in secrecy. Waiting to tell friends and family of the pregnancy until the ‘high-risk’ threshold of week 10 – where the likelihood of miscarriage drops dramatically – has become the social norm. ⁸ Recent studies conducted in the United States and the Republic of Ireland found that the frequency of miscarriage in the general public is often underestimated^9,10 and that the assumed causes of miscarriage do not align with research findings. ⁹ These recent studies indicate that the lack of general discussion around early pregnancy may be allowing misconceptions about the cause and frequency of miscarriage to remain.

Increasing our discussion about miscarriage

Each woman has the right to decide to whom and when to divulge their pregnancy. However, telling a few trusted members may build a support network that could help navigate the joys and worries of pregnancy. When miscarriage does occur, having this network may help the people affected get the support they need and feel validated in their emotional response.

An opposing view may be that public discussion of miscarriage could increase women’s stress and worry during pregnancy, especially since not everyone will experience a miscarriage. Additionally, it may make people uncomfortable to talk about death during pregnancy, which is often seen as a time of life and hope. However, in the following paragraphs, I will outline reasons why the benefits of increasing our discussion about miscarriage far outweigh the harm.

The current advice for reducing the risk of miscarriage focuses on the health and lifestyle of the women, which may create the assumption that they have control over the success of their pregnancy. ¹¹ In many studies, women report feeling as if they failed their role as a woman, that their body failed them and blamed themselves for the loss.^12,13 Other studies found that family and community members blamed the women for the loss.^14,15 Additionally, pregnancy loss, from miscarriage to stillbirth, is shrouded in social silence. ¹¹ For many, this renders open discussion of emotional responses challenging. ¹⁶ Additionally, it may reinforce the public misconceptions on the frequency and likely causes, the social norm of keeping the pregnancy a secret – ‘just in case’, and the lack of social acknowledgment of the validity of both grief and non-grief responses. These factors may play a role in the considerable stigma and shame surrounding early pregnancy losses and may act as a barrier to women seeking support and resources.^13,17,18 They both highlight the urgent need to dispel these misconceptions and create room for purposeful dialogue with the aim of improving support for those experiencing this loss.

With the lack of discussion on this topic, those experiencing miscarriage rely on healthcare providers to explain the situation and choices they have. However, research into experiences of healthcare after miscarriage indicates that many participants felt unprepared to make decisions, and were confused and distressed by the medical jargon.^19,20 Guidance and support from healthcare centres after miscarriage were often limited for bereaved families seeking to know their options and next steps.^16,17,21 In some cases, the participants were not offered follow-up for their emotional needs ¹⁹ or wanted more choice in the mental health service they were referred to. ²¹ Discussion on how to address these unmet emotional and psychological needs is an essential first step in supporting patients as they navigate both the social expectations of their response and their actual response after the miscarriage.

An overburdened healthcare system means that it may be difficult to promptly implement new changes, yet altering social discussion, perceptions of miscarriage and acknowledgment of the potential psychological impacts can start through small changes inside and outside of the hospital setting. The lack of validation of miscarriage as a meaningful loss by society, including healthcare providers, friends and family, has been noted in research as a potential impact on women’s experiences of miscarriage.^12,14,15,20 Conversely, several studies report that seeing others’ stories or the disclosure of miscarriage by public figures and friends helped women to feel less alone and more validated in their grief.^9,13 This demonstrates how acknowledging the diverse, but equally valid responses to miscarriage and discussing how miscarriage is more common than general estimates may be an important step in reducing the isolation and stigma surrounding this type of loss.

While partners, family and friends were often identified as key sources of support,^16,21 the lack of discussion on how to provide support may leave these sources lost on what to say or how to approach the person who experienced a miscarriage. ¹⁷ Therefore, public health and education strategies should include topics of miscarriage to increase discussion ¹⁰ and provide tailored evidence-based resources informed by the needs of both general and targeted audiences to increase public engagement and dissemination of knowledge.^13,18 The efforts of the Miscarriage Association ²² in the United Kingdom are an excellent example of the type of resources and guides that the Canadian government could provide to those experiencing the loss, as well as the institutional and the general community interested in understanding the potential impacts and seeking to provide support.

Conclusion

Public discussion of miscarriage is necessary to reduce exposure to shame and stigma and improve the care and support experienced. Changes can be made at all societal levels. Friends and family can demonstrate understanding and support, healthcare providers can provide empathetic and continuous care, and public health strategies can distribute informed resources, such as digital grief guides and clinical training modules, to improve understanding and recognition of miscarriage. By improving public engagement and understanding of this hidden issue, we can advocate for this group and ensure policies and communities are supporting the countless people impacted by miscarriage.