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“So about how long had you been trying to get pregnant before this miscarriage?” the OB/GYN, whom I’d only met minutes earlier, asked me. He stared intently at me from across his desk in a cramped little office.

“Fifteen months,” I answered woodenly, trying my best to staunch the tears that had been flowing freely for nearly a week since we lost our baby at eight weeks gestation. It was almost more than I could handle, this impromptu meeting after waiting in the OB/GYN office, surrounded by heavily pregnant women, with posters of babies at various stages of gestation covering the walls. And I’d just been through yet another invasive exam—perhaps the fourth or fifth since the first signs of miscarriage began more than a week ago—this time with one very nervous intern, who needed to make sure I didn’t have any retained bits of placenta that could later cause infection.

“Well, you have what we would consider primary infertility. So we could discuss your options. Maybe IUI, IVF?”

“No, no. Those won’t be options for us,” I answered firmly, if not a little defensively, wondering why this conversation was necessary.

“Well, you know that there are ways we could do it right here at the hospital, right? I know the military says they won’t cover it, but there are ways around that.”

“No, no. We won’t be doing that,” I said again, this time, with a definite edge to my voice.

After all, I thought, who was this doctor to be jumping into this discussion with me, at this time? He wasn’t my doctor, just the OB/GYN who happened to be available that day to do my one-week-post-loss follow-up appointment. He had no idea who I was, what my medical history looked like, or the values that my husband and I held that guided how we wanted to grow our family.

Although the doctor was trying his best to be sympathetic, in offering in vitro fertilization (IVF) or intrauterine insemination (IUI) so quickly, like it would solve all my problems, and the deep, aching feeling in my heart, I felt . . . invisible. Unheard. Like my pain at the loss of this unique, unrepeatable child was somehow invalid; that this baby didn’t matter, or count, because look! Here was a shiny new technology sure to help me get pregnant again, don’t you worry.

The doctor looked flummoxed by my repeated refusals, but finally let me and my husband go. As we left his office, the tears rolled freely down my cheeks once more. And it struck me that in his rush to reassure me that one way or another, we could conceive another child, this doctor never once acknowledged the one we had just lost.

I’ve written before about my miscarriage. Two years ago, I wrote for Verily about why I send flowers to friends and family who experience miscarriage, after realizing that the gift of flowers in the wake of my own miscarriage acknowledged our loss in a real, tangible way.

It’s important to acknowledge it as a loss, for me.

Why does our culture still have such a hard time talking about miscarriage? Why do we find ourselves and those around us hesitant to acknowledge it for what it is: the loss of a child?

We’ve certainly made significant strides in destigmatizing miscarriage, and women probably feel more open to talking about pregnancy loss than ever before. But why did it seem that the OB/GYN who followed up on my miscarriage couldn’t—or wouldn’t—simply let me grieve, or even verbally acknowledge my loss? Why was a dear friend of mine who experienced two miscarriages in a row told by her OB/GYN that she merely “got unlucky twice?” Why are well-meaning friends and family still so quick to reassure us that “something must have been wrong,” “at least now you know you can get pregnant!” and “don’t worry, you’ll get pregnant again,” instead of sitting with us—grieving with us—in our loss?

We might be tempted to explain this discomfort as the discomfort that most of us experience with death—but perhaps it is the opposite. Perhaps we don’t count life in the womb as real anymore. Perhaps we have become too accustomed to overlooking life in the womb to the point where acknowledging the loss of it has become more difficult.

Miscarriage is a true loss, but abortion complicates our ability to acknowledge it

Perhaps abortion has so conditioned us to thinking about developing children in the womb as less than human, that we (and our doctors) have a difficult time openly discussing or acknowledging this loss for what it truly is. The competing narratives surrounding the mental and emotional health effects of miscarriage and abortion can further muddy the waters.

Planned Parenthood, the nation’s largest abortion provider, trumpets that “for more than 30 years, substantive research studies have shown that legally induced abortion does not pose mental health problems for women.” Yet evidence overwhelmingly suggests that women who miscarry are at heightened risk for depression, anxiety, psychological distress, and even Post-Traumatic Stress Disorder (PTSD). After a miscarriage, many women experience intense feelings of guilt that they themselves somehow caused the miscarriage (I can attest to this; even three years after my own loss, I still struggle with feelings of guilt). As one Swedish study put it:

When miscarriage occurs it is not a gore, an embryo, or a fetus they lose, it is their child. They feel that they are the cause of the miscarriage through something they have done, eaten, or thought. They feel abandonment and they grieve for their profound loss; they are actually in bereavement.

The truth about pregnancy loss

So what could be the reason behind the supposedly disparate reactions to pregnancy loss between women who have miscarriages and women who have abortions? To delve further into this seeming conundrum, I spoke to Michaelene Fredenburg, president and CEO of Life Perspectives. Based in San Diego, Life Perspectives is an organization that provides education, research, and expertise to health professionals and other care providers to offer support after reproductive loss, including both miscarriage and abortion.

The Life Perspectives program (and its anonymous, healing websites and grew out of Fredenburg’s own experience with abortion and was initially geared toward lending support to women (and men, as well as other family members) after abortions. But what Fredenburg soon realized was that women who had experienced miscarriage and stillbirth were also suffering alone in the aftermath of their losses, even though their losses happened quite differently from the loss of abortion.

What Fredenburg has found, and what she aims to educate people about, is that when someone experiences reproductive loss, whether through abortion or miscarriage, “there is this sense of isolation, a lack of acknowledgment and support.” She also notes that men are often left out of the picture, although studies and surveys have shown that they grieve after miscarriage and abortion, too.

Through an “evidence-based grief and loss approach,” Life Perspectives educates health-care professionals about the unique ways these emotions manifest in different individuals who have experienced pregnancy loss through miscarriage and abortion. Fredenburg notes that, for example, “what I may not consider a loss at [age] 20, I may consider a loss at 30 or 40, and that might be where we begin to see the struggle.”

“People’s responses to reproductive loss are as unique as fingerprints,” Fredenburg wrote in a press release for Life Perspectives. “Some people are fine, and adapt to the loss quickly, while others struggle.”

No matter how the grief manifests, overall, “there is often a sense of loss,” says Fredenburg, and the feelings following miscarriage or abortion can be very complicated.

“We often hear ‘I feel relieved and sad,’ or ‘I feel grateful and I feel guilty.’ And it’s obviously very confusing to experience these types of feelings,” says Fredenburg. These complicated feelings can make it difficult for women to open up about (and to process) their experiences with pregnancy loss, which can in turn impede healing from the loss.

Their confusion may be compounded by the lack of understanding by some health-care professionals that pregnancy loss—whether through abortion or miscarriage—can evoke such intense feelings of grief and loss in the women (and family members) who experience it.

“The longer that I do this work,” remarks Fredenburg, “the longer that I feel there is a profound misunderstanding about the impact of pregnancy loss” on the mental and emotional well-being of those struggling after an abortion or miscarriage. But through her work with Life Perspectives, Fredenburg has found reason to be hopeful that with better education and awareness, the tide can turn.

“When we talk to health-care professionals about pregnancy loss, one of the things we talk about is the concept of ‘disenfranchised grief’ which is grief in the wake of a loss that isn’t culturally acknowledged,” she explains. “And we explain to them that they are in a position to ‘franchise’ the grief of their patients, which validates what these women are feeling, and can start them on their path of healing. And when we put it this way,” says Fredenburg, “they really get it.”

According to an August 2020 press release, Life Perspectives has educated “5,000 healthcare professionals, including nurses, doctors, mental wellness experts, and community- and faith-based organizations . . . to offer reproductive grief care to patients and clients.” In a testimonial on their site, Michelle Freitas from Haven of Hope, San Diego Rescue Mission states: “We think it’s important for our staff to have Life Perspectives’ training to better respond and support clients. This allows us to reach them on a new level, leading them to a place where healing can begin.”

But there is more work to be done.

As the Life Perspectives press release states, “many healthcare professionals interact daily with people who have experienced reproductive loss. What do they say to these patients and clients? The right—or wrong—words could impact a reproductive loss experience for decades.” And as Fredenburg points out: “In the medical community, there is zero standard of grief care for reproductive loss.”

Why don’t we know more about miscarriages—about what causes them, and what might possibly prevent them?

Perhaps another factor that leads to the unintentionally blasé attitude toward miscarriage that some women experience from friends, family, and health-care professionals is that miscarriages are, in fact, quite common. Estimates for the percentage of clinically recognized pregnancies that result in miscarriage range from as low as 10 percent to as high as 25 percent—and this doesn’t include the number of pregnancies that are detected by an early pregnancy test but end before the baby can be detected via ultrasound (a phenomenon called a chemical pregnancy).

Disparities abound in miscarriage rates, as well: just as black women are at higher risk than white women for maternal death (and black children are more at risk for infant death), black women also experience miscarriage more often, too.

For something so common to the human experience, we don’t seem to understand much about miscarriages.

It’s estimated that about half of first-trimester miscarriages are due to a chromosomal abnormality. In these sad cases, there is nothing to be done to avoid the loss. But the other 50 percent of miscarriages could be due to a number of known risk factors, some of which may be avoidable (such as smoking), managed (such as diabetes), or mitigated (such as hormonal issues), if a woman can get the education and help she needs to address them. A 2014 study from the University of Copenhagen found that 25 percent of miscarriages could be prevented due to lifestyle changes.

Further, a 2020 study from the U.K.’s Royal College of Obstetricians and Gynecologists found evidence that supplementation with progesterone, the “pregnancy hormone,” led to a higher birth rate among women with a history of miscarriage. Among women with at least one prior loss, the study concluded, progesterone supplementation resulted in 5 percent more live births; among women with at least three prior losses, progesterone support resulted in an astounding 15 percent more births.

If it is true that there are steps that women and their doctors can take to help lower the chance of miscarrying, why are so many women dismissively told that “nothing could have been done,” when they ask about the reasons behind their miscarriages?

A woman typically has to miscarry three times before most doctors will investigate a cause

It is understandable that doctors do not want to imply that the burden of guilt lies upon the women who have miscarried; after all, as we’ve already discussed, that is an all-too-common reaction for women, and one that can leave lasting, painful scars.

But perhaps one of the reasons we don’t know enough about miscarriage is the lack of investigation into their origins. The American College of Obstetricians and Gynecologists only recommends “a thorough physical exam and testing” after a woman has miscarried a clinically recognized pregnancy three times. In practice, this recommendation can leave women devastated by repeated losses—and especially if many of those losses have been chemical pregnancies—feeling like their worries are being dismissed, and that the lives of their lost children aren’t valued. And, when issues like a progesterone deficiency (which is identifiable with the help of fertility awareness charting) can be managed by progesterone supplementation, why are women made to endure the mental, physical, and emotional anguish of miscarrying three times before anyone will take their pain seriously?

Perhaps the hesitancy to dig deeper into miscarriage is another symptom of our medical system’s lack of willingness to dig deeper into women’s reproductive issues in general. When I asked, “Is Abortion Killing Maternal Health?” I learned that many doctors dismiss women’s reproductive health concerns, or opt for quick-fix solutions instead of investigating the root causes of an issue. Just as doctors attribute many of women’s issues to being “in their heads,” or prescribe pharmaceutical birth control to mask the symptoms of reproductive issues like Polycystic Ovary Syndrome (PCOS) and endometriosis, all too often, women with miscarriages are dismissed as being impossible to help. And when help is offered, the first suggestion is usually assisted reproductive technologies (ART) in an effort to circumvent the issue, rather than treat it.

For couples with a history of infertility and miscarriage, assisted reproductive technologies like IUI and IVF may be recommended to screen out embryos with undesirable chromosomal makeups that may be deemed “incompatible with life.” For others, even more drastic measures may be suggested, such as using a gestational surrogate. But while these may result in a child, these are not treatments for whatever health issue is causing miscarriage and infertility. And because the loss of embryos is common—even expected—with artificial reproductive technologies (not to mention the slightly elevated risk of miscarriage with IVF pregnancies, as compared to natural pregnancies), it can further complicate the sense of loss a women who already had a miscarriage experiences.

In recent years, there have been tragic stories of equipment malfunctions at fertility clinics that have resulted in the inadvertent destruction of thousands of embryos. “My first thought was, ‘There go my babies,’” remarked one woman who had two embryos frozen at an Ohio fertility clinic that experienced technical malfunctions in March 2018. “I’m not going to be able to have kids anymore.” These unfortunate events, and the very existence of hundreds of thousands of embryos “on ice,” frozen in time indefinitely, throw into sharp relief our culture’s complicated feelings about preborn life.

And what does that do to our ability to openly talk about and eventually heal from miscarriage?

There can be little doubt that our complicated cultural relationships with fertility, pregnancy, miscarriage, abortion, and artificial reproductive technologies make for rough waters for those navigating the storm of pregnancy loss. Although scientific evidence incontrovertibly proves that life begins at conception, it has perhaps never been more fraught or more complicated to process what, exactly, that means for those of us who have experienced pregnancy loss.

That is why I believe there is no greater gift that can be given to parents experiencing the trauma of miscarriage than the acknowledgement that their child not only existed, but that he or she mattered, and that their grief over the loss of their child is justified. Doctors who take the time to investigate the potential causes of miscarriage—and may prevent the needless deaths of more preborn children through their investigation and treatment—also give women and their families an invaluable gift. And those who advocate for women and a consistent ethic of life—recognizing the inherent, equal, dignity and humanity of all human beings—do more than anyone to franchise the grief of those of us who have lost our loved ones, no matter their size or stage of life.