Multiple miscarriage: Psychosocial implications

1. Multiple miscarriage:Psychosocial implications Uschi Van den Broeck Master in Psychology University Hospital of Leuven, Belgium Department of Gynaecology/Fertility Center

2. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

3. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

4. 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’

5. 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’

6. 1. Psychology of pregnancy • Bonding and prenatal attachment starts sooner because of modern technology • Ultrasounds • 3D images • …

7. 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

8. 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’

9. Psychology of pregnancy • Social event: • Grandparents and changing family structure: a new generation • Work-related issues: maternity leave, part-time work etc.

10. Psychology of pregnancy PREGNANCY = POINT OF NO RETURN = CRISIS

11. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

12. 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. …

13. 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

14. 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’

15. ‘Between something …and nothing’

16. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

17. 3. The grieving process • Grief is a normal, healthy, dynamic, universal and individual respons to loss • Kaleidoscope • Healing process: surviving and continuing to live

18. 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

19. 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’

20. 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

21. 3. The grieving 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)

22. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

23. 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, …

24. 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

25. 4. Common feelings when confronted with multiple miscarriage Major life-event: individual differences Longing Despair Out of control Sadness Regret Shocked Confused Angry Guilty Responsible Emptiness Panicky Loneliness Stressed Lack of self-confidence

26. 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 …….

27. Video Clip 1: Tori Amos

28. 4. Common feelings when confronted with multiple miscarriage • Physical and emotional loss different 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

29. 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

30. 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

31. 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

32. 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?’

33. 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

34. 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.

35. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

36. 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.

37. Video Clip 2: Grey’s Anatomy

38. 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

39. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

40. 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’

41. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

42. 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

43. Overview • The psychology of pregnancy • The psychology of pregnancy loss • The grieving process • Common feelings when confronted with multiple miscarriage • Coping with grief and loss • Infertility and pregnancy loss • Trying again… • Helpful interventions

44. 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

45. 8. Helpful interventions • Creating mementos • Memorial activities • Self care • Keeping a journal: writing things down • Reaching out: talking with friends, support groups, etc.

46. Multiple miscarriage:Psychosocial implications Thank you for listening Uschi Van den Broeck Master in Psychology University Hospital of Leuven, Belgium Department of Gynaecology/Fertility Center Contact: