Grieving the Loss of a Baby in the Womb
By Meredith Resnick, LCSW
Social Work Today
Vol. 21 No. 2 P. 16

When working with these grief-stricken patients, social workers face a unique set of challenges.

Perinatal loss encompasses various traumatic events that can occur any time during the gestational period. About 1 in 4 pregnancies ends in miscarriage; approximately 1 in 160 ends in stillbirth. Perinatal loss includes first- and second-trimester miscarriage, missed (silent) miscarriage, ectopic pregnancy, stillbirth, neonatal death, and complications from molar pregnancy, blighted ovum, and preterm delivery.

These clinical terms define the medical aspect of loss yet fail to address the grief-filled psychological space a woman inhabits after the body has recovered.

In a 2006 study, researcher Lynn Clark Callister, PhD, writes, “Perinatal loss engenders a unique kind of mourning since the child is so much a part of the parental identity. Societal expectations for mourning associated with perinatal loss are noticeably absent.”

This concerns both how to grieve the baby and one’s identity relative to that baby.

Intersectionality
A concept first coined by Kimberlé Crenshaw in 1989, intersectionality examines how race, class, gender, and other individual characteristics “intersect” with one another or overlap. Huong Diep, PsyD, recommends clinicians utilize an intersectional lens to heighten their awareness and sensitivity to discern the myriad ways in which these and other social identities converge to create unique forms of oppression and disparity that the clinician may not be familiar with (Wilson et al., 2019).

Diep, a board-certified psychologist who specializes in the intersection of gender, language, and culture and is an ally to the LGBTQ+ community, cautions this “means not to assume, even if you have significant experience working with this population, because each person has a unique story and grieves differently.”

For example, if a person identifies as part of the LGBTQ+ community, they may find that their unique challenges are overlooked or misunderstood. According to Craven and Peel, “Lesbian, gay, bisexual, transgender, and queer … communities have a long history of memorializing loss—The NAMES Projector AIDS memorial quilt, the Transgender Day of Remembrance, and art and fiction memorializing the Stonewall riots.

“Yet, as Heather Love cautions in Feeling Backward, ‘queer losses are frequently hard to identify or mourn since many aspects of historical gay culture are associated with the pain and shame of the closet.’”

Begin with awareness and acceptance of the potential underlying social, economic, political, financial, familial, cultural, gender, and religious layers that the clinician may know less about than they would prefer. “Since the social worker may not know how a patient self-identifies ethnically, culturally, racially, [or] religiously, utilizing an intersectional lens is vital,” Diep says.

Cultural Humility
In White Fragility, Robin Diangelo, PhD, writes, “While implicit bias is always at play because all humans have bias, inequity can occur simply through homogeneity; if I am not aware of the barriers you face, then I won’t see them, much less be motivated to remove them.”

Cultural humility shifts the focus to the clinician’s self-humility rather than achieving a state of knowledge. It is the “ability to maintain an interpersonal stance that is open and oriented to the other person, about aspects of cultural identity that are most important to the individual” (Hook et al., 2013).

“Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician [in this case, patient-clinician] dynamic, and to developing mutually beneficial and nonpaternalistic [authoritarian] clinical and advocacy partnerships with communities on behalf of individuals and defined populations” (Tervalon et al., 2016).

Generational and collective trauma of being marginalized and denied services and care amplifies the grief associated with pregnancy loss, says Nicole Alston, MSW, an associate at the Columbia Center for Complicated Grief. “African Americans were already dealing with a racial pandemic before COVID hit. So, that part is nothing new. However, once COVID hit, we were dealt a new pandemic,” she says.

Alston, who specializes in perinatal loss and its subsequent grief, says that the loss of a baby in the womb may exacerbate the present-day and ancestral pain for a person who is Black, a pain that has been exacerbated by pandemic-related stressors.

When visiting clients, Alston recommends social workers “listen to what's being said, listen to understand. If there was ever a time to check your ‘clinical temperature,’ it is now.

“In addition to dealing with racial trauma, as a [health care provider] or social worker, you could very well be working with someone who has had to bear witness to the deaths of multiple family members who died in a short period of time, or on the same day,” she says.

However external events constellate, including the loss of a baby, each person’s experience is unique. “One person's story cannot be used as a gauge to help understand the next client,” Alston says.

In addition, consider how ethnic and racial differences and differences in sexual preference and social status might inform a client’s experience and affect your perception and interaction.

Attributes of cultural humility, which include openness, self-awareness, egolessness, supportive interactions, and self-reflection and self-critique, can foster mutual empowerment, partnerships, respect, and more optimal, inclusive care (Foronda et al., 2016).

Countertransference
In The Myth of the Perfect Pregnancy, Lara Freidenfelds, PhD, writes that “early pregnancy losses are part and parcel of childbearing.” She notes that the majority of miscarriages are caused by chromosomal abnormalities that render the embryo incompatible with life.

While good information, it does not help with grief work, particularly during the earliest stages of loss. “Sometimes social workers try and remain purely clinical because it feels safer, but failure to witness suffering thwarts the capacity to be present,” says Traysi Chong, LCSW, an adjunct lecturer at the USC Suzanne Dworak-Peck School of Social Work at the University of Southern California, who urges clinicians to avoid clinical terminology, which can be cold and impersonal. “Say ‘baby,’ not ‘fetus.’ Use the baby’s name if one was given and especially if the mom does.”

Keisha Wells, LPC, calls the experience of pregnancy loss “altered motherhood,” noting that losing one’s baby in the womb is a “forced and out-of-order loss.” The pain can be stifling and hard to talk about. Having a clinician who can listen and be present is essential, she says.

Facing this loss can also be difficult and scary for some clinicians. Their unconscious memories, fears, biases, and beliefs build energy outside of their awareness and impact the therapeutic interaction. It may appear as anxiety, disgust, overidentification, or impatience with a client.

When complications from pregnancy initiate a visit to the emergency department and a loss triggers hospitalization, social workers should understand that “there is going to be a lot of grief in that room,’” Chong says. “Even if loss occurs early, say at six or eight weeks, do not discount the level of suffering just because it’s an early loss and do not try to fix it.”

Diep encourages clinicians to “examine their need to ‘fix’ a patient's emotions instead of sitting with and bearing witness to their pain without flinching, tempering, or trying to change it. Most of the time, a patient just wants someone else to say, ‘I see your pain, and I see how much it hurts you.’"

As mandated reporters—and given the suffering that follows the loss of a baby in the womb—mental health providers will be continually assessing for danger to self and others, Diep says. “For some providers, a checklist of sorts can help to ground and center the clinician, especially if they are new to the field and/or in training,” she says. “However, if I am constantly checking in with a checklist, I am not present to the emotions that the patient is sharing with me and the feelings that may arise during the interaction between the two of us.”

Research has demonstrated that the therapeutic relationship between the therapist and the client is the most important element in the process of change. “There may be some anxiety due to imposter syndrome or fears based on their pregnancy losses, or if they have never been pregnant themselves,” says Diep, who encourages clinicians to “continue to do their work through therapy, coaching, and/or supervision to recognize the potential countertransference in working in the field of pregnancy loss.”

In addition, sorting through one’s religious and political beliefs and biases helps create space for client-centered work.

In the Face of Grief
“People, social workers included, ask question after question when they are anxious,” Chong says. Allotting ample time for visits, particularly in the hospital at bedside, can reduce the pressure of trying to find the perfect thing to say. Allow the conversation to evolve organically. Be a witness to their pain—and the pain of their partner.

“Prepare for the level of grief,” Chong continues. Conference with the bedside nurse and read the chart to best understand family dynamics and assess the scope of the loss (first loss? in vitro fertilization loss? multiple losses?). “Never walk into the LDR [labor, delivery, recovery room] or ED [emergency department] unless you’ve talked to the nurse first to understand the patient’s unique situation. Do not reinjure a patient by asking questions that are already answered in the chart,” Chong says.

Become familiar with the effects of postpartum and comfortable with the educational aspect. Many patients do not understand what their body is going through between the physical trauma, hormones, and overall loss. This is natural and to be expected. When social workers understand the medical aspects of pregnancy loss, they can be extremely helpful in normalizing the grief a patient feels without being overly clinical.

Even clothing can be a trigger. Chong says that when visiting grief-stricken patients, somber tones worn by someone seeking to support recovery can subconsciously deepen sadness in a patient already in mourning. By being fully present, social workers model the sensitivity that the patient can then gift upon themselves in the days to come.

“People don’t get over the grief; they learn to live with it,” Chong says.

Social Media
More women are announcing miscarriage on Twitter. Research by Cesare et al, published in 2020 in the journal Paediatric and Perinatal Epidemiology, found that the online community can be useful in helping those who suffer feel less alone. As a result of celebrity disclosures and the #ihadamiscarriage social media campaign initiated by psychologist Jessica Zucker, PhD, following her own loss, the previous silence around perinatal loss is shifting. This online community has enabled voices to be heard, supported, and honored.

Social media can provide a global view of how individuals are talking about pregnancy loss, and how they are framing and entering the conversation. It also can act as a means of feeling part of a community while enduring what many describe as a lonely and isolated experience. This can help “lessen stigma, connect people to resources, and to quickly search through hashtags and other search engines to find other like-minded people,” Diep says.

Nevertheless, clinicians should “caution patients against using the internet and social media as their sole source of information,” Diep says. “Search engines control results, and a great deal of content has not been vetted by health or mental health professionals.”

Also, there is the risk that “if someone doesn't find what they are looking for or a pregnancy loss story that resembles theirs, the automatic belief may be, ‘I'm even further alone in this. No one else on the internet or in the world has gone through what I have gone through,’” Diep says.

“For some folks, reading through message boards and other blogs was enough. For others, they needed a group process session via video. Others required one-on-one counseling,” she continues. “I would encourage people not to judge themselves for being stronger or weaker than someone else based on their level of need. It is indeed a sign of self-trust to acknowledge what you need and then seek it.”

Clinicians can encourage their clients to be mindful of what they post online, knowing that once they hit “send,” their words will likely remain online in perpetuity, whether they delete them or not.

— Meredith Resnick, LCSW, worked in health care for two decades and maintains a strong interest in the expressive arts. She is the coauthor, along with Kim Hooper and contributor Huong Diep, PsyD, of All the Love: Healing Your Heart and Finding Meaning After Pregnancy Loss.

Facts and Figures About Pregnancy Loss
• Neonatal death is the loss of a baby less than 28 days old.

•  It’s commonly reported that nearly 1 in 4 pregnancies ends in loss. According to the National Center for Health Statistics, about 1 in 100 pregnancies ends in stillbirth.

• Miscarriage is when a baby dies in the womb before 20 weeks of pregnancy. Some women have a miscarriage before they know they’re pregnant.

• According to March of Dimes, most miscarriages happen in the first trimester before the 12th week of pregnancy. Miscarriage in the second trimester (between 13 and 19 weeks) happens in 1% to 5% of pregnancies.

• According to “Ectopic Pregnancy” by Tyler Mummert, DO, and David M. Gnugnoli, DO, the estimated rate of ectopic pregnancy in the general population is 1% to 2% and 2% to 5% among patients who utilized assisted reproductive technology.

• Approximately 1% to 5% of all pregnancies will result in a missed or silent miscarriage.

• Molar pregnancy occurs in 1 in 1,000 pregnancies, according to the National Institutes of Health.

• A blighted ovum causes about 1 out of 2 miscarriages in the first trimester of pregnancy.

• According to a 2018 article in Reproductive Biology and Endocrinology, the overall rate of pregnancy loss in in vitro fertilization/intracytoplasmic sperm injection clinical pregnancies is 12.5%.

• Bereaved mothers are four times more likely to experience depressive symptoms compared with nonbereaved parents, according to a 2016 study in the Journal of Women’s Health.

• Depression has been shown to affect up to 20% of women following a miscarriage, according to a 2018 article in BMC Psychiatry.

• According to the Archives of Women’s Mental Health, 10% to 15% of women who miscarry reach the clinical threshold for a major depressive disorder in the months after the loss.

• Separate studies have found that some women may experience depressive symptoms up to nine months after a loss, while others may not experience depressive symptoms until three to six months after their miscarriage.

References
Foronda, C., Baptiste, D., Reinhold, M. M., Ousman, K. (2016). Cultural humility: A concept analysis. Journal of Transcultural Nursing, 27(3), 210-217.

Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychology, 60(3), 353-366.

Tervalon, M., Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.

Wilson, Y., White, A., Jefferson, A., Danis, M. (2019). Intersectionality in clinical medicine: The need for a conceptual framework. American Journal of Bioethics, 19(2), 8-19.