Dr. Nuzhat Aziz, Consultant Obstetrician, Fernandez Hospitals, Hyderabad, talks about the totally unacceptable stigma and shame heaped on women post pregnancy failure and wishes to clear misconceptions surrounding miscarriage.
It is noticed that like many western countries, India too, is beginning to observe Pregnancy and Infant Loss Remembrance Day on October 15? What is the significance of the Day?
In the year 2002, Robyn Bear, Lisa Brown, and Tammy Novak campaigned for a movement to declare October 15 as an awareness day for pregnancy and infant loss in USA. The aim was to create awareness, to allow people to join in reflection, support and honour those who have suffered a pregnancy loss or infant death. Pregnancy loss may be a miscarriage, stillbirth, an ectopic pregnancy or sudden infant death syndrome. Loss of a baby is devastating to the woman, to her family and all connected with her. The grief they experience is very different and still not acknowledged as other forms of bereavement. Pregnancy loss and stillbirths are still a taboo in many cultures, we struggle to talk about it. Grieving is a part of healing and acknowledging a person’s grief helps them to recover. The concept of observing October 15th as a Pregnancy and Infant Loss day is to create public awareness on this very important social issue. A parallel concept of lighting candles, all monuments lit up at 7 pm was added as the Wave of Light in the year 2004, allowing every individual to take part and join in promoting the campaign.
What is the most common cause of loss of pregnancy?
The most common causes of pregnancy loss differs with the phase of pregnancy. Early miscarriages have genetic abnormalities as a major cause but late pregnancy losses are due to hypertensive disorders, diabetes, fetal growth restriction as major reasons. Neonatal deaths have decreased significantly in the past few years. In developing countries, we still find labour related causes, infection as the main cause of neonatal death.
What are the main causes of Sudden Infant Death Syndrome (SIDS)?
Sudden Infant Death Syndrome is a sudden, unexplained death of a baby. Limited to less than a year of age. The causes are not known, for it happens suddenly in a healthy baby. Few conditions that are found to be associated are baby sleeping on tummy face down position, too soft mattress or fluffy toys, overheating during feeding, previous history of SIDS, mothers who smoke. It is important for mothers to know the best sleeping position, in a place where they can keep a watch on the baby, not feed the baby lying down in bed (when the mother might fall asleep).
What is the rate of miscarriage in India?
The reported incidence in literature stands between 10 to 30% but 15% is the accepted miscarriage rates across the world.
What is the psychological and emotional impact of pregnancy loss, particularly faced by women?
Women are scarred for life by a pregnancy loss. The hope of a baby playing in her arms builds-up with a positive pregnancy test. Pregnancy failure at any point of pregnancy shatters that hope and they experience the worst emotional trauma of a baby’s death. This grief lasts for a long time, and depends on multiple factors and on the emotional support she receives.
There is plenty of shame, stigma and self-blame linked to failed pregnancy. To what extent is a woman responsible?
There is no way a woman can ever be responsible for pregnancy failure. Women blame themselves when a loss occurs- especially in the early weeks of pregnancy. They seem to link intercourse, work or travel as a cause of the miscarriage. It is the responsibility of healthcare workers, her family to negate these feelings. We need to keep reinforcing at every visit that it was NOT her fault.
What is the best way to manage negative symptoms surrounding a miscarriage?
Society has a huge role to play along with her family as she grieves through this loss. Training in bereavement counselling allows healthcare teams to be sensitive, to use appropriate words. Every woman, couple grieves differently. Giving them time, listening to them allows one to look for a need for specialist help. Some may require psychological support and may benefit from referral to psychologist or psychiatrist.
Why is it important to talk and have an open expression about pregnancy loss and miscarriage?
We humans need support, we recover faster when we have family and society support. Death of an adult is followed by emotional support from everyone around us. But when a stillbirth or a miscarriage occurs, its taboo, its hidden and not disclosed. I know several women who left their hometown to escape questions about pregnancy after a baby loss. We hope that having a day of remembrance on October 15 will open these issues, allow couples to talk about their pregnancy loss, educate all on how to acknowledge this grief and facilitate healing.
Why do you think women are not adequately informed and supported by health care professionals following pregnancy and infant loss?
During our training we were not taught how to help individuals who experience any form of loss. As a young obstetrician I know I was not sensitive to the emotions of women and couples as I am today. At Fernandez we invest in “bereavement counselling” and train our residents, nurses and midwives on how to work with mothers who experience loss. Many of us need to learn about silence too. Some women need that space before they start sharing. We need to learn the cues on when to talk and not plug the silence. We simply need to raise awareness on this – among the women and in our own fraternity.
Do you think psychiatric issues following a prenatal loss can be resolved with the birth of a subsequent healthy child?
Each woman grieves differently, has different coping mechanisms. Many have anxiety, depression for varied periods of time. Couples find it difficult to go through the next pregnancy. Many triggers keep stimulating these emotions. Grieving women experience flashbacks as they visit the hospitals again, or every time the fetal heartbeat in a subsequent pregnancy is heard. When they have a subsequent healthy baby, they do become occupied with baby care. The psychological trauma is lifelong. I remember my friend, who first visited us for a second pregnancy after a first stillbirth. She had a subsequent healthy baby. I can never forget her words. She said every time she sees a 4 year old baby she keeps thinking her baby would have been playing this way (she had a loss 4 years ago). “I always say I have two kids, one is with God” Hence all preventable pregnancy losses should be prevented, to create better families, better society.
How long is recommended a woman should wait following miscarriage before conceiving again?
We would advise women to plan after evaluating all preventable causes of miscarriage, when she feels she can go through another pregnancy. We suggest after two to three menstrual cycles, but it is absolutely fine if they conceive sooner. There is no scientifically proven time period that is said to be the most appropriate interval.
What are the chances of losing a baby after miscarriage?
After one miscarriage, the chances of a miscarriage do not increase. The risk increases if a woman has recurrent miscarriages (three consecutive pregnancy losses).
Could stress and lifestyle choices contribute to miscarriage and pregnancy loss?
Many times, stress is unavoidable. It is important we do not use this as a reason for pregnancy loss because women will experience incredible guilt. Lifestyle choices yes can have an impact; smoking, alcohol, risk behaviour can be modified. Obesity is one important association that can be modified through lifestyle change.
Is there any link of preventing miscarriage to pre-conception planning? In what cases is pre-conception planning advised?
Preconception counseling or consultation is very important. I would suggest all women to have pre-pregnancy counseling. It allows for a review of her medical history, to optimize medical conditions like thyroid or diabetes or hypertension, to change to safe medications if necessary. It is also used to screen for common medical conditions, and start preconception vitamin folic acid supplements. Folic acid deficiency is known to cause birth defects. We check for vaccination status like Rubella, Covid these days, as it’s always better to plan pregnancy after vaccination. All miscarriages may not be preventable, but those due to preventable factors can be.
What are 5 warning signs of a possible problem during pregnancy?
1.Bleeding in early pregnancy
2.Abdominal cramps which are rhythmic and regular
3.Decreased fetal movements
Disclaimer: This is a reposted article, originally published in *PatientsEngage, on 13th October 2021