By Rosemary Mander
Miscarriage and the grief which follows it have been widely ignored in the past. This may have been due to the western societal taboo on discussing loss, or due to it being regarded as a "woman's problem" or the frequency with which miscarriage happens. It has been estimated that about one third of pregnancies end in miscarriages, although the figure may be higher.
The term "miscarriage" includes a wide variety of conditions which result in the early end to a pregnancy, and/or the birth of a baby who is not mature enough to survive. The occurrence of miscarriage is spontaneous to the extent that it is unpredictable and happens without any apparent cause or intention.
While numbers explain to some extent previous and, perhaps, ongoing failures in care they are of little help to the woman who is going through or has been through the experience of miscarriage.
The woman's experience of miscarriage has been given little research attention, but studies which have been undertaken suggests that widespread assumptions may not be correct. These assumptions relate, first, to the importance of the experience, which has been shown to be somewhat more serious than the insignificant menstruation-like event, which is often assumed. One study  showed that the woman was surprised by the intensity of the pain of miscarriage; this was aggravated by the nature of the pain which, rather than being compatible with period pains, was more like the pain of childbirth or even of a termination of pregnancy . Equally surprising was the severity of the bleeding, which was sufficient to arouse in the woman the fear that she might he dying.
In terms of the woman's emotional reaction, the grief response may he deeper and more long lasting than she had previously thought likely. The resolution of her grief may be impeded by the sudden and unexpected onset of the miscarriage, which precludes any opportunities to begin the grief work through anticipatory grieving. The woman's grief is likely to be profound and to feature some elements of guilt, which may he due to her perception that her behaviour may have been inappropriate, such as undertaking; too much exercise. The woman may find that she feels anger towards her body for not supporting her pregnancy as she would have wished. Other emotional responses are likely to relate to the woman's future childbearing, and be associated with fears that this occurrence may repeat itself in future pregnancies. On the other hand, the woman may find some consolation in the reality of having actually conceived.
Similarly, the fact of her pregnancy may serve to convince her that she would be able to conceive again.
While the limited importance attributed by staff to the woman's experience of miscarriage may be in part the cause of her disengaged "care", there may be other factors involved. These may include the staff's own personal experiences or the organisation of the health system within which care is provided.
One aspect of care which gives rise to unhappiness among women who miscarry is the woman's perceived lack of control over the situation. The routinisation of care means that the woman's choices relating to her treatment may remain unexplained to her and unexplored with her. In response to these limitations, some changes in the woman's care have been introduced enabling her to assume some degree of control over the things which happen to her and which happen to the baby which she is losing or has lost.
The significance of pregnancy and birth to the individual woman may not always be the same as its meaning to the society of which she is a part. Because of this the meaning of the potential or actual loss of that pregnancy varies and may be given insufficient consideration by a health care system which may have other priorities. Thus the woman who experiences a miscarriage is likely, when she most needs caring support, to experience marginalisation. This is encountered first in the formal health care system. The woman may meet marginalisation again later in the informal support system which, for its own and different reasons, may have difficulty coping with this woman's loss.
Hence, in a range of supposedly caring and supportive relationships the woman is likely to have to face behaviour and comments which belittle her loss and denigrate its significance.
Although our understanding of some family members' grieving of miscarriage is increasing, there is still a general impression that families experience particular difficulty when a loss occurs before or around the time of birth. This finding was most apparent in the research by Linda Rajan  who found that all too often the woman found it necessary to put her own grieving "on to the back burner" while she provided support for other members of her family.
My personal experience leads me to believe that the sibling of the lost child faces particular difficulties due to others' underestimation of their understanding.
In order to allow grieving to proceed healthily, it is necessary to have memories on which we can focus. Ordinarily, when a person dies in old age, there is an abundance of memories, largely those which are stored in the memory banks of our brains. In the case of a baby, however, who has not had an independent existence, the woman needs to create her memories. Thus mementoes such as a photograph of the family after the birth or the picture produced by an ultrasound scan may serve to confirm the reality of the baby and provide a focus which may be used to begin the grieving.
An aspect of grieving which is increasingly being recognised as crucial is the mourning, which involves the more public or ritual aspects of coping with loss. These may include wearing appropriate clothing, sending flowers and letters, religious or other services and funeral arrangements. Mourning practices benefit the community by giving everyone an opportunity to recognise the loss of the one who has died, as well as allowing each individual to contemplate their own mortality. Of more significance for the bereaved and in the context of miscarriage is the community support which mourning demonstrates in terms of the sharing of the loss. In western society miscarriage is not yet widely recognised as a reason for mourning, so the support which it brings is not yet easily available to the woman and those close to her.
Increasingly, however, the woman is being encouraged to plan an appropriate ritual which may help her to take advantage of the support which mourning offers. These shared rituals may include religious or other memorial services, possibly the burial or cremation of the baby's body or the planting of a tree in memory. 
Other more private rituals may also be helpful on a more individual basis. The woman may be helped by writing a letter to the baby who was lost, or by composing a poem or a piece of music. As well as helping the woman to recognise the reality of her loss and, thus, to facilitate the beginning of her grieving, these compositions may serve other purposes. Letters, poems and music would provide the woman with an opportunity to contemplate the meaning of her pregnancy and, hence, the meaning of her loss.
Childbearing carries with it a multiplicity of hopes and aspirations. For many women and couples these expectations remain unspoken and possibly unrecognised. It may be that, even in a successful pregnancy, the hopes which it represents may not be completely fulfilled, but there is likely to be plenty of time in which the woman may adjust to the reality of the child who was born. For the woman who experiences a miscarriage, these hopes are dashed unexpectedly, suddenly and totally. Thus, she is left to contemplate and to try to work out the meaning of what has happened.
Ideally, those near to the woman who has miscarried would be able to help her to begin this contemplation but, for reasons which I have mentioned already, this may not be possible. The woman may be able to identify other ways of making sense of her experience and of completing her relationship with the baby who was lost. After miscarriage the woman needs to be able to find a safe way of communicating in order to explore the meaning of her loss. It is possible that a sympathetic listening ear may be found among family or friends, or in the secure environment which a self help group may offer, as mentioned below. In the absence of a human ear other means, such as pen and paper, may allow the necessary outpouring which helps her to make connections between this experience and the other strands of her life.
In this way the woman is able to begin the work which will eventually integrate her experience of miscarriage into her life. This work will help the woman to fit the earth-shattering experience which is miscarriage in to her "structures of meaning"; these are the beliefs which make up the individual's framework of understanding and which underpin her philosophy of life, in order to lend meaning to the ups and downs which we all face . As she begins to attribute meaning to this painful experience, the woman starts to assume some degree of control over the things that are happening to her. Thus, she is increasingly able to take control of the events which may have seemed uncontrollable and she begins to re-establish the continuity of her life.
Hey V, Itzin, C, Saunders, L ,Speakman, MA, Hidden loss: miscarriage and ectopic pregnancy, 2nd Ed, London: The Women's Press, 1996
c/o Clayton Hospital
W. Yorkshire WFl 3JS
(Staffed 9am-4pm, Mon-Fri.; Answering service at other times)
Dr Rosemary Mander MSc PhD RGN SCM MTD is a Senior Lecturer, Dept Nursing Studies, University of Edinburgh.
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