The Angel Baby is Gone – Supporting Parents with Pregnancy Loss through their Grieving Journey

Figures provided by the Department of Health1 show that, in 2018-2020, there were over a hundred still births and close to 15,000 abortions each year. To address the difficulties faced by parents of abortuses, in the 2018 Policy Address, the Government has proposed to examine the provision of burial facilities to aborted foetuses while additional facilities were introduced in 2019. Apart from improving burial facilities, the needs of families experiencing miscarriages, especially the emotional state of expectant parents facing pregnancy loss, deserve more attention. Therefore, we have invited Ms. Agnes Tin, who has been involved in life and death education and grief counselling training for many years, to share her extensive professional knowledge and clinical experience with us. Some relevant community resources are listed at the end of this article for medical and other professionals to introduce to families in need of professional intervention.

The following article was originally written in Traditional Chinese and translated into English. Readers who are proficient in Chinese are encouraged to refer to the Chinese version. In case of any discrepancy between the English version and the Chinese version, the Chinese version shall prevail.

Tin Fong, Agnes
Honorary Lecturer, Centre on Behavioral Health, The University of Hong Kong

When do "life" begins? Does it start when a sperm fuses with an egg? The moment of implantation? When the fetal heart has formed and starts beating? Or until the baby is born? Ask your friends and you may find that different people have different points of view on "life". For some couples, "life" may even begin with an "anticipation of the future": while snuggling up to each other on their dates, they may warmly share about each other's vision of their future and at some point pictured how would their family be like even before their marriage, and come up with a name for their child between jokes...

    

What is "life"? It is more complex than one might think. It can be interpreted differently by different people, and "life" needs not be restricted to physical existence that can be seen by the naked eye. Therefore, people may have different reactions when a "life" is lost. For some, the experience of pregnancy loss is facing an invisible loss and silent grief, while mourning for the child whom they could never see, kiss or touch; a loss of not just a foetus, but a chance to conceive and give birth; a dream to become a parent, and a wish to build an ideal family. In our society, women usually do not announce their pregnancy to others in the first three months for fear that the baby will get "offended". Hence, when a miscarriage occurs, the parents are inevitably the only ones facing the suffering, and no one may be able to provide timely support and companionship. Healthcare workers and various helping professionals can support these parents with empathy as they cope with their grief.

What parents with pregnancy loss need is the patience to process the grief of losing a baby. If the journey of those who have experienced pregnancy loss could be understood, they may have more strength to rebuild their life:

(1) Acknowledging the Death: Understanding the Cause of Death

When faced with sudden bad news, very often our initial reaction is to find a reason for the incident2. The first question that comes to parents' minds is "Why?" when they experience a pregnancy loss. They need to get to the bottom of it and understand why it happened. Therefore, providing relevant objective information, such as the prevalence of miscarriage, factors that may contribute to miscarriage (miscarriage can occur without a known cause), available medical options, subsequent medical procedures and body reactions, etc., in addition to the empathetic listening and understanding of the parents' confusion by the healthcare professionals, is an important step in supporting them to digest the facts of the pregnancy loss.

(2) Understanding "Disenfranchised Grief"

Disenfranchised Grief3 is a socially unacknowledged experience of loss where the bereaved person is neither able to grieve publicly nor receive the social support they need, thereby denying them the right to grieve. Some people may think that a foetus that has not fully formed is not considered as a "life", as a result they may underestimate the impact of pregnancy loss on parents; the classic reassurance from family and friends such as "Don't be upset, you're still young, you can always have another baby...", all denied parents with pregnancy loss the right to grieve. Actually, parents may grieve and miss the foetus with different levels of intensity, regardless of the gestational age of the foetus or the length of the pregnancy. When parents share their thoughts of the foetus, we can follow the parents' way of referring to the foetus, such as "Baby", or use the baby's name (if the parents have chosen a name for their baby) when we respond; or take the parents' wishes into consideration before handling the dead body. All of these could help affirm the personhood of the foetus and the grief of the parents. For many parents who have lost a baby, the thoughtful and considerate arrangements made by the healthcare professionals, such as keeping the body as clean and neat as possible, dressing the child in appropriate clothes if feasible, and allowing ample time for the parents to say goodbye to their child etc., can make them feel that their child's life is respected, and that their grief is understood and recognised, bringing great support and comfort.

(3) Understanding the Experience of Grief

In the journey of grief, many people want to "fix" the issue or "recover" from grief as soon as possible. But grief is actually a tremendous "change" in life, and we cannot "fix" a change or "recover" from it. What we need instead is to "adjust" to the change. Grief is a normal and natural reaction to miscarriage. Parents with pregnancy loss need a process to adjust to a life without their child, to cope with the emotional distress of the pregnancy loss, and to reconstruct their perspectives on life, family, and other matters.

(4) Coping with Grief

According to the Dual Process Model of Coping with Bereavement proposed by Margaret Stroebe and Henk Schut4, bereaved families would experience two categories of stressors: loss-orientation refers to the family's experiences of grief, yearning for the loved one, inability to concentrate on work, social withdrawal, etc.; restoration-orientation refers to the stressors experienced when the family tries to carry on with everyday activities, such as looking after young children, managing household chores, going to work, etc. For parents who have lost their baby, we may support them to grieve, mourn, weep, or spend time alone to miss and reminisce (loss-oriented); at the same time, encourage them to gradually engage in parts of ordinary life and resume their daily functioning (recovery-oriented). As the family members repeatedly alternate between loss-oriented and restoration-oriented coping, the intensity and frequency of the oscillations between these two types of responses gradually become more moderate and balanced than in the early stage of bereavement, indicating that the family members are gradually adapting to life after the loss.

(5) Attending to the Needs of Men

Having gone through the pregnancy and subsequent miscarriage, the mother's mood is undoubtedly affected; yet the father's needs also deserve attention. Generally speaking, as the focus often rests on the mother's side, the most common advice for the partner is "take good care of your wife/ partner", offered while overlooking the emotions of the father. Although the dads do not get to experience the amazing journey of a baby growing inside their bodies, they still have a unique relationship with their children as they witness their partners' bellies grow in size day by day. The grief of losing a child, the feeling of inadequacy in face of death, the frustration of passively witnessing their partners' suffering, and the tendency to be less articulate in expressing themselves, all require understanding and support from closed ones for fathers to cope. Fathers may not be used to sharing their feelings but tend to deal with their grief with a problem-solving, functional approach (instrumental grief)5. Therefore, provide them with useful information (including information about miscarriage, common grief reactions and experiences, etc.), acknowledge their emotional needs, and encourage them to relieve their stress in ways they find comfortable (e.g. arranging some time alone to do relaxing activities such as exercising, photography, etc.) are all indispensable.

(6) Promote Communication between Partners

Chinese are generally not be used to expressing emotions. Besides, fathers may sometimes prefer suppressing their emotions, adopting a supportive role and focusing on solving everyday problems. Therefore, they may feel overwhelmed by the grief of their partner. At the same time, a woman in grief may not always have the emotional capacity to understand the feelings and stresses her partner is facing. Moreover, two persons in a relationship often differ in the way they express emotions and handle their grief (e.g. after suffering from the pregnancy loss, the mother may cry incessantly, while her partner may feel overwhelmed by grief and rush to get back to normal), which may sometimes leave each other feeling alienated and misunderstood. Encourage couples to communicate and express, so that they could better understand each other's way of grieving, needs and the expectations towards their partner. Their care and love towards each other will be an important source of strength to draw on when they cope with grief.

(7) Establishing Continuing Bond

Although death brings physical separation, we can still maintain psychological and emotional bonds with our beloved ones; this common phenomenon in the aftermath of bereavement is referred in research as "continuing bond"6. Women who have suffered miscarriage often feel a sense of emptiness as they have in a sudden lost the physical connection with their child. Through religion, symbolic rituals, accessories, ultrasound pictures of the child, handprints and footprints, handfuls of hair, the child's name (if applicable), memories of interactions with the baby over the belly during pregnancy, etc., the child becomes part of the parents' life and a company in their life journey ahead.

(8) Resuming Former Life

As parents gradually return to their former lives, they will have to face different practical issues, such as how to deal with concerns from family and friends? How to handle the baby items prepared? Share and discuss with parents their preferred options (e.g. invite a trusted relative or friend to explain the situation to people close to the family in private first, packing baby items at the parents' pace and preference – some may want to wait until they feel more settled before deciding what to do, others may choose to leave it to someone close to them, etc.) is an important part to help them rebuild their life.

(9) Rethinking Views of Life

All parents who have lost a baby experience some sort of shock and may reflect on their life following their experience of loss, e.g. family planning ("Is a family only complete with a child?"), future plans ("I always thought I had control over my fate, but it turns out I have no control over my life"), religious beliefs ("Why did God take the baby away? Do I still believe in God?"), and even self-perceptions ("Other women have children naturally, so why can't I? Do I fail as a woman?") and forth. They need a process of rediscovery. Encourage them to read books, share with others (including persons with relevant religious affiliations and those who had similar experiences of pregnancy loss), organise their views on life, and rebuild their perspective on life and values gradually.

(10) Planning for The Next Pregnancy

There is no universal timeline for getting pregnant after miscarriage, whether one is ready for another pregnancy depends on the physical and psychological condition of each individual7: some may want to get pregnant as soon as possible, others may experience feelings of doubt and anxiety, and some may need a longer time to transition through their grief. As parents prepare for another pregnancy, they have to be more aware of their physical condition and allow their partners and themselves reasonable and sufficient time to mourn for their loss, think about how to cope with the worries and nervousness of another pregnancy, to share their thoughts and support each other, so as to get prepared in the physical, psychological and relationship aspects for a subsequent pregnancy over time.

While adjusting to the impacts of pregnancy loss is not easy, it will be helpful if healthcare workers and other professionals can walk with these parents through grief.

Local Resources (listed in arbitrary order)

If healthcare workers and other professionals find that the parents are experiencing significant distress in need of professional support, you may approach the following community resources:

References

  1. Health Statistics Division. (2019). Tables on Health Status and Health Services 2019. Department of Health, the Government of the Hong Kong Special Administrative Region.  https://www.dh.gov.hk/english/pub_rec/pub_rec_lpoi/pub_rec_lpoi_thshs.html
  2. Rando, T. A. (1993). Treatment of complicated mourning. Champaign, IL: Research Press.
  3. Doka, K. J. (1989). Disenfranchised grief: Recognizing hidden sorrow. Lexington: Lexington Books.
  4. Stroebe, M. S., Hansson, R. O., Stroebe, W., & Schut, H. (Eds.) (2001). Handbook of bereavement research: Consequences, coping, and care. Washington, DC: American Psychological Association.
  5. Doka, K. J., & Martin, T. L. (2000). Men Don't Cry, Women Do: Transcending Gender Stereotypes of Grief. New York: Routledge.
  6. Klass, D., Silverman, P. R., & Nickman, S. L. (Eds.) (1996). Continuing bonds: New understandings of grief. Washington, DC: Taylor & Francis.
  7. Miscarriage Association (n.d.). Miscarriage Association. https://www.miscarriageassociation.org.uk/