The hidden grief of miscarriage

Holly Ann Abel first sought out therapy a few months after her daughter Magnolia was stillborn in January 2021 at nearly 32 weeks. Abel struggled with grief and depression, followed by panic attacks.

“I felt extremely isolated,” said the 29-year-old, who lives in Lawrence, Kansas. “I was surrounded by family members and friends who loved me and wanted to support me. But none of them could walk in my shoes.”

People are prone to seek therapeutic help more quickly if the loss involves a stillbirth, said Bindeman, who also serves as chair-elect for the Mental Health Professional Group of the American Society for Reproductive Medicine. When the baby is lost earlier in the pregnancy, particularly if the miscarriage occurs in the first trimester, friends or relatives may send subtle or overt messages as the months progress that the would-be parents should be on more of a recovery trajectory. Patients will say, Bindeman recounted, “I’ve been told that I shouldn’t be sad about it anymore. But I’m still sad. So what’s wrong with me?”

But research has shown that the intensity and duration of grief are not necessarily driven by the duration of the pregnancy but rather by the woman’s attachment to the pregnancy and to what extent she perceived the developing baby as a person rather than a fetus. One recent study, involving 227 women who had experienced miscarriages, found that three fourths of the women strongly perceived the pregnancy/fetus as a person (Freedle, A., & Oliveira, E., Traumatology, Vol. 28, No. 4, 2022).

Some patients might have suffered pregnancy losses many years before seeing a practitioner but didn’t work through their emotions at the time, said Dorienna Alfred, PhD, PMH-C, a psychologist and certified perinatal mental health therapist in Gahanna, Ohio.

She also has authored a book about her own experience, Pregnant With Promise: A Spiritual Journey of Pregnancy, Bedrest, and Childbirth (Works of Faith, 2019). Psychologists should routinely ask new patients about their reproductive history as part of the intake process, she said, even if they are coming in for seemingly unrelated reasons. In her intake forms, Alfred asks about any history of pregnancy, including the number of live births, as well as any infertility treatment. When patients do report a prior loss, psychologists should not move along without asking additional questions, Alfred said. These might include, “In what ways does your loss affect you now? What was your experience of grieving that loss and having support?”

Adopt a trauma lens when working with these patients, suggested Elia E. Villalobos Soto, PsyD, PMH-C, a clinical health psychologist in Tampa, Florida, who also is a board member of the Women’s Health Interest Group of APA Division 38 (Society for Health Psychology). “These experiences can be traumatic,” she said. “If it happened in a hospital setting, ask how did they feel in that moment. Maybe they felt like no one was listening to them.”

It’s also important for psychologists to gain a sense of the broader cultural context around pregnancy and parenthood, whether that’s rooted in religious faith or ethnic/racial heritage, Villalobos said. For instance, the Hispanic/Latino culture can place a particularly high value on child-bearing, she said. “That’s why it’s taboo sometimes to talk about the loss or infertility issues.”

The urge to “fix” the grief of pregnancy loss is a human tendency, even among psychologists, Alfred said. She pursued certification as a perinatal mental health therapist after her son Joshua was born too early at 19 weeks, followed by difficult pregnancies.

“And, quite honestly, if you’ve had a loss that really is unimaginable, you may not be OK,” said Alfred, who has two living sons. “As a psychologist, we have to learn to hold space for people who just are not OK.”

Abel said her first therapist tended to offer strategies that seemed to minimize her emotions. They were still meeting when Abel learned that she was pregnant again with her living daughter, Marigold (“Goldie”), who is now 2.5 years old. Her anxieties and fears ramped into hyperdrive. “I very much felt like it was my full-time job to keep this baby alive,” she said.

When Abel tried to share her acute pregnancy fears, the therapist suggested unrealistic strategies that Abel felt didn’t address the scale of her worry and grief. She stopped seeing the therapist after she realized that she was dreading the appointments.