The traumatic element of miscarriage

Miscarriage is defined by the World Health Organization (WHO) as the premature loss of a fetus up to 23 weeks of pregnancy and weighing up to 500 g [1]. Overall, about 12–15% of clinically recognized pregnancies end in miscarriage [2], with the frequency increasing with rising maternal age. Miscarriage is a difficult and stressful life event for a woman. Research on the psychological responses of women after a miscarriage shows that many of them suffer from grief, guilt, depression, and anxiety [3-5]. For some women, there is another important dimension to their response that must not be missed. That is the traumatic element, which is evident when the pregnancy loss is perceived as an unbearable and life-altering experience [6-8] and is related to overwhelming and disabling psychological stress [9,10].

Study on the psychological sequel after miscarriage found that one month after a miscarriage, 25%-39% of the women meet the diagnostic criteria for post-traumatic stress disorder (PTSD), and this prevalence reduced to 7% at four months [11]. Posttraumatic symptoms include re-experiencing (re-occurring of thought, images or nightmares related to the miscarriage), avoidance (e.g., not wanting to meet pregnant woman), hyper arousal (e.g., irritation, sleeping difficulties, anger) [12,13] and negative alterations in cognitions and mood (e.g., feelings of failure, guilt, shame) [14,15].

While the term “trauma” has been previously used to describe a broad range of life experiences, such as military combat, accidents, natural disasters, or violence, it may be less clear what exactly the traumatic aspect of miscarriage is. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [16], PTSD can develop in individuals who were exposed (directly or indirectly through learning about the event) to death, threatened death, actual or threatened serious injury, and actual or threatened sexual violence. Miscarriage, which only rarely threatens the women’s life, is therefore hardly acknowledged as a traumatic event. However, the physical and emotional losses involved in miscarriage are often experienced as profoundly as serious, life threatening event or even as the literal death of a child [17]. On the physical level, the woman is not only worried about the baby’s condition and the future of the pregnancy, but also experiences an extreme physical situation, involving pain, bleeding, weakness and anxiety. In a qualitative study, Kendall-Tackett [8] found that many women felt that the aftermath of miscarriage was actually one of the most traumatic parts. Women may be overwhelmed by the realization that their baby is gone when looking at a black ultrasound screen. Moreover, they often had to undergo invasive and painful surgical procedures, such as a D&C (dilation & curettage), that further promote feelings of powerlessness [18]. Echoing common symptoms reported by those experiencing other traumas, miscarriage often results in feelings of sadness, anxiety, loss of self-esteem, uncertainty, and vulnerability. Many areas of functioning, such as work or social interactions, are negatively influenced and sometimes avoided [9]. Taken together, these various aspects of miscarriage suggest that although miscarriage usually does not involve an actual life threat, its potentially traumatic sequel should always be considered.

Women vary in the type and magnitude of their responses to miscarriage. Previous studies have found several variables that were associated with increased risk for the development of PTSD after a pregnancy loss, including gestational age [19,20], planned versus unplanned pregnancy [21], type of pregnancy termination (miscarriage or induced abortion) [22], and feeling responsible for the miscarriage [23]. Other risk factors, such as perceiving the developing fetus as real (feeling fetal movement, naming the baby, purchasing items) [4], difficulties to conceive or give birth by 1 year after loss [24], and absence of living children [15] were associated with elevated grief levels but were not directly assessed in the context of traumatic responses.

The painful aftermath of miscarriage is further complicated by the insufficient support these women often experience [25]. Unfortunately, the care given to a woman focuses on the physical management while neglecting and dismissing her emotional part. Interviews with women who have undergone a miscarriage revealed that they felt that the emotional aspects of their circumstances were avoided by society [26]. They perceived that the common societal view was that a miscarriage is a result of a defected baby and that they could easily conceive again. Often, people in their surrounding failed to appreciate the impact of the miscarriage or minimized its consequences, making comments such as, “It was not meant to be” or “It is for the best” “it is better now than later” [5,27]. Because many early losses (i.e., miscarriage before 16 weeks gestation) are not acknowledged by society, some parents are surprised when they have feelings of grief or depression many weeks after the loss has occurred [28]. The secrecy that often accompanies the early stages of pregnancy and the absence of structured mourning result in miscarriage being a “unique form of loss” that can be difficult to overcome [29]. Nevertheless, research that explores the traumatic nature of pregnancy loss is still very much limited.

This paper explores the trauma of miscarriage from a temporal view. By temporal, I mean relating to time. The main assumption presented here is that because the concept of time carries an extraordinary meaning for pregnant women, a sudden loss of a pregnancy causes a painful breach in the continuity of being that might explain the complex, and sometimes traumatic emotional reaction.

The meaning of time in pregnancy and childbirth

Despite the paucity of research regarding time experience during pregnancy, it is clear that the dimension of time has a unique importance for the pregnant woman [30,31]. The pregnancy period is a time of intensive and frequent changes in the body and mind of the woman. Hopes for the future, early attachment to the unborn child, establishing a maternal image, and the expectations of one's partner and family, are all factors that contribute to the complex emotional response to pregnancy [6,32,33]. The psychological and physical development of the pregnant woman is closely related to time. For a pregnant woman, the passage of time serves as a positive indicator to the healthy development of the baby and herself. In addition, time has a dramatic effect on pregnant woman because it represents a gradual progress towards something irreversible and inevitable. Giving birth is the ultimately “one way ticket”, which for some women could also involve fear and anxiety [34]. Time is also a framework that women consciously and unconsciously rely on, in order to prepare themselves to motherhood. They organize their perceptions, feelings and expectations regarding their stage of pregnancy. A hermeneutical study [34] of pregnant women described typical transitions in the mother’s phenomenology as the pregnancy progresses. While women in their first trimester were pre-occupied with realizing and processing their new life situation, women in their second trimester were dealing with the inevitable future of having a child, and women in their last trimester were mentally and practically busy with preparations for the unknown future.

However, in order to draw a possible connection between pregnancy loss and time experience, it is important to understand how pregnancy and childbirth are embedded in time in Western societies. The medicalization of childbirth and the technological advances dictate a linear, rigid timelines that dramatically affect time-perceptions of pregnant women. In a society that values precision, assessment and certainty, there is a focus on medical timelines, milestones and increments, all indicate a linear perception of time. In particular, development of new surveillance technologies as prenatal diagnosis technologies and monitoring dramatically affected the notion of time and the importance given today to the first three months [35]. Ultrasound has made it possible to determine gestational age, to follow the growth of the fetus and to detect fetal abnormalities. The motto in prenatal services in many Western countries is “the sooner, the better”, so pregnancy has been medicalized earlier and earlier [35]. The prevalent use of ultrasound seems to have a positive effect on personalizing the baby and increasing prenatal bonds [36,37]. Ironically, these same effects make miscarriage more difficult to contemplate. The contrast between life and death seemed to be more marked and violent in cases where the miscarriage followed a scan during which the baby’s heartbeat had been seen or after first movement of the fetus have been felt [38]. Like facing the news of a death of a baby that is already born, the moment of negative ultrasound result represents the collapse of all dreams and hopes for the future of the child and the family [39]. Detecting early pregnancy via ultrasound before any bodily cues are experienced also creates the risk of placing more value on objective reassurance of the pregnancy [40,41]. Thus, women may suspend or even ignore the recognition of a pregnancy [42] or feel as if it is “tentative” [43] until such reassurance could be given to the existence of normal pregnancy.

It should be noted that the aspect of time is a crucial element in giving birth. Medical evaluations of risk in childbirth are linked closely to time schedules and deviations are linked to interventions [44-46]. Frequently asked time-related questions, such as ‘How long between contractions?’; ‘What time did your waters break?’; or ‘How long was your labor?’, shape medical and social discourses about labor and delivery. Several authors propose that the linear time of Western societies, in which the clock guides expectations of progression through labor and delivery, might be at odds with life cycle events like birthing that are guided by women's embodied experiences and physiological changes [47-51]. However, Maher [52] found that women developed their own timelines to manage birth, which reflected a combination of medical time, clock time and their own sense of time passing, suggesting that the role of time might be more complex than a simple conflict between medical clock and some other organic birthing time.

Time and trauma

Research on the association between time and trauma suggests that traumatic incidents have the potential to effect and distort the normal time experience both in the short and the long terms [53,54]. Traumatic experiences interrupt the linear process of the complete psychological development throughout the persons’ life. They split life in two parts: before and after the event. This dividedness may markedly interfere with the person’s sense of continuity as well as with his emotional and cognitive capacities. When the traumatic experience is not processed, the trauma may be partially avoided, but the persons’ cognitions about the world begin to change. Life is no longer expected to be predictable, logic or complete [55].

Narratives of traumatized individuals often contain extreme disturbances in time perception (e.g., prolonged traumatic incidents may be experienced and remembered as foreshortened, whereas instantaneous episodes are experienced as prolonged). It has been suggested that these distortions reflect the need to process unusually large amounts of non- perceptual mental activity during a short period [56,57]. Terr [58,59], who analyzed stories of traumatized children and adults suggested that time sense is a relatively new evolutionary acquisition and, as such, is easily disrupted by trauma. Hence, disturbances and distortions in time experience are reliable indicators of psychic trauma. According to Terr [60], time disturbances play a defensive and protective role against trauma and aimed to reconstruct the sense of mastery that was undermined by it. For instance, the shortening of prolonged events makes it psychologically more possible to tolerate physical and mental pain and to hold off hopelessness, premature collapse, and death. Similarly, the prolongation of short-lived episodes may protect the individual by creating a larger number of potentially effective actions within a very short time [59]. In the most extreme forms of trauma, the traumatized individual loses his sense of time. He is alienated to time and cannot differentiate past, present and future. This detemporalization is the hallmark of alienation and dissociative processes [61], such as those seen in patients with dissociative identity disorder [62,63].

In summary, the association between time and trauma is complex and two-fold. On the one hand, time distortions serve to protect the individual from the unbearable consequences of trauma. As time stands still, the trauma remains distant and the mind is protected from its unbearable implications. Nevertheless, as long as the trauma is “frozen” in time, it cannot be processed and digested, eventually leading to psychological inadequacy and dissociation [64].

Temporal view on the trauma of miscarriage

The dimension of time has a unique importance in pregnancy. It is a period of “transition to the unknown” [65-67], which involves changes in fundamental life patterns [68]. Mental construction of the unknown baby is influenced by internalized relations and interactive patterns since the woman's own infancy [69]. In many terms, pregnancy can be considered as a developmental process, consisted of several tasks [70], such as accepting the pregnancy, acknowledging the baby, establishing the relationship between the mother and the baby, and working through separation issues [71]. However, when a pregnancy is abruptly terminated, the sense of development, coherence, and continuity is compromised. The vital movement towards the future is replaced by feelings of atrophy, emptiness, and 'freezing'. Although the normal tasks of pregnancy are not completed when a baby dies, the pregnancy did create a baby and left behind a mother and a father, whose parental needs to feed, to care and to love are not met [72]. Instead of going forward, developing, and growing, time moves backwards, to the beginning point. One of the reasons for the undermining of time experience after a miscarriage is the sudden confrontation with death. In the woman’s inner experience, miscarriage is a brush with death not just close by but inside her own body [39]. Miscarriage involves an overwhelming merge of the beginning of life with their end [73]. Two points on time, that were supposed to be distanced by many years, and contain a complete cycle of life, are condensed into one moment, which encompasses the tragedy of the family [74]. This intimate encounter with death shatters the parents’ most basic assumption about the world, causing them to see the world as dangerous, unjust, and uncontrollable [75,76].

Because the feelings of continuity and development are suddenly perforated, changes and distortions in time experience following miscarriage could be considered as indicators of traumatic occurrence. A careful examination of miscarriage stories reveals that women’s narratives often include preoccupation with time-related issues, echoing common experiences of those who have undergone other traumas [77]. Many of them would still monitor the age of the pregnancy as if it still exists, while others may report a feeling that time has stopped moving on the day of the miscarriage. They could also feel that they went back to the beginning point, indicating that time became sterile and meaningless.Therefore, listening to women’s stories through time lenses, may provide us important information regarding what is insufferable for them. To illustrate this point, I would present themes and vignettes of women who participated in a support group for pregnancy loss. These issues reflect the traumatic influence of miscarriage on time experience.

Going back to square one

One of the commonly identified issues among women who have undergone a miscarriage is the feeling that time went back to the point where the pregnancy has started. In a qualitative study of eight women, who experienced miscarriage in the midst of treatment for infertility, women reported feeling like they were going back to “square one” [78]. That is, that the time they invested in their efforts to conceive and in the pregnancy was now meaningless. It is like the miscarriage violently erased the passing weeks, months or even years (no matter how productive they were in other areas of life), of intensive emotional and physical investment and turned time to a sterile, meaningless and sometimes even a cruel dimension. Feeling this way, no wonder they also felt that time became an enemy that they had to fight against its flow.

Feeling as if the pregnancy continues- The feeling as if the pregnancy continues is a common theme among women who have undergone a miscarriage. Probably it is related to the unique time experience during pregnancy. Most of the women in Western societies keep a precise schedule of their gestational age [35]. After a miscarriage, women find it very hard to immediately return to the normal experience of time, which is quite different from the weeks/days accurate counting of pregnancy age. These feelings are increasing around the date of planned delivery or when encountering pregnant woman with the same gestational age. For many women, the transformation to “normal” time experience actually means that time has become meaningless. There is nothing more to expect, to hope for, and sometimes even to live for. For example, Amira, who was a 27 years old woman, lost her first pregnancy during the 8th week. On the surface, it seems that she was successfully coping with the miscarriage. She went back to work immediately and had plans for her next summer vacation, which she ironically described as “unexpectedly child-free”. When the group tried to encourage her to talk about her pain, she usually dismissed it with common clichés such as “everything is for the best” or “it is better to lose it now than later”. However, it was clear that she was still monitoring the pregnancy course as if it still existed. In her mind, she kept a very precise record of the pregnancy, and sometimes said “I was supposed to be 21 weeks now”,” I was supposed to deliver next week”, etc. For some time, this was the only hint that something painful is going on inside her. When one of the women mentioned it to her, she was surprised, but suddenly said: “I may continue like this forever. I would always carry this pregnancy with me”.

When a woman continues to monitor her pregnancy, she protects herself from the intolerable realization of trauma. If time goes on, then nothing really happened. On the other hand, if the trauma is somehow denied, its necessary processing is also impaired. Following her work with second –generation holocaust survival, Gorden [79] indicated that traumatized individuals could not create a coherent narrative because of a failure to mourn their loss. She suggested that when the traumatic past is denied and the need to mourn is unmet, people are unable to establish a feeling of continuity in life and to acknowledge that time is finite. Thus, Amira could not gain a genuine living experience but only by using extensive protective mechanisms.

Freezing of time - For some women, time is not going on, but rather stands still after they miscarry. They feel as if the flow of time has been hindered and find themselves surprised by the fact that life is normally continuing around them. As Anna, a participant of the group described: “On Monday nine weeks pregnant I came excited to the first ultrasound check. The gynaecologist laconically announced that there is no heartbeat and that the fetus stopped developing 10 days ago. Suddenly, I felt a terrible, painful vacuum exactly in the same point where my life seemed to end when I learned about my mother’s cancer. The doctor immediately gave me forms to fill and said: you have to finish with it, D&C or pills. Make your decision fast and make an appointment because you would not want to waste your time. I was completely dizzy, I had to get out there and get some air. I did not have any time to waste now, because my time has completely stopped”.

The freezing of time after a traumatic event has probably a protective role. The feeling that time stopped creates a sense of numbing, that wards off external excitations and blocks all memories and emotions related to the traumatic experience [80-82]. However, this “freezing” of trauma and placing it out of time is exactly the mechanism that keeps the traumatic content still active [62]. If the traumatic content cannot be processed and assimilated into pre-existing inner models [83], traumatic memories remain unrepresented and dissociated [84]. These disintegrated parts of one's history remain frozen in time, waiting and pressing to be recognized as part of his subjectivity [85].

The infiltration of the past into the future - Like survivors of other traumas [86], women who miscarried express deep concerns and uncertainty about their future [26]. Often the experience of pregnancy loss undermines the mother’s trust in her creative abilities and raises high anxiety regarding her capacity to become pregnant, to keep the pregnancy and to give birth [38]. Although the traumatic event belongs to the past, the woman experiences the present time as infiltrated by the trauma due to intrusion of unresolved elements, that she may even not be aware of [87]. The infiltration of the trauma from the past into the future indicates that the trauma was not processed and placed in space and time. It would be carried from the past into the woman’s future affecting her emotional, social, and parental state of mind. Interestingly, women who had a miscarriage in their first pregnancy are indeed at higher risk for many adverse outcomes (such as pre-eclampsia, miscarriage, bleeding, early birth, complicated birth, and low birth weight) in their next pregnancy compared both to women who had a successful first pregnancy and women pregnant for the first time [88]. The question to which degree this vulnerability is affected by psychological factors remains open.

Although pregnancy loss is similar to other traumatic occurrences, it is somewhat distinct from psychological distress following other events in the preponderant emphasis on the future rather than the past. Thus, after a miscarriage, the woman is preoccupied with images of an anticipated future rather than on adverse past experiences [4]. This unique characteristic of pregnancy loss adds a considerable amount of ambiguity and confusion to the aftermath of miscarriage: is it the past or the future that are mourned? Some women are surprised by the feelings of longing, love and grief they feel for a fetus in very early pregnancy stages [89]. Unless the reality of loss is recognized by the woman herself and by her social network, the trauma could not be resolved [90]. With no acknowledgment of the past trauma, the links between past, present, and future are disintegrated [91]. Thus, the trauma is still active; present everywhere and anywhere, merely waits for the appropriate moment to reappear. Instead of mourning the traumatizing past, the future becomes the source of horror.

An important, less known impact of unresolved trauma of pregnancy loss on the future of the woman is her relationship with her future children [92,93]. Although the common belief is that the birth of a healthy child would mark the end of the painful experience for the family, a pregnancy or birth following a miscarriage are not helpful in processing the grief [94]. Pregnancy loss leaves parents feeling that life is fragile [95], and vulnerable to another loss as reality cannot be trusted to be logical, predictable and understandable [55]. Thus, a new pregnancy becomes a psychologically traumatic event [28] that evokes traumatic memories, thoughts and feelings surrounding the previous loss. Sometimes, the pregnancy itself is an avoidant behavior which is aimed at reducing the emotional pain stirred by the trauma, thus inhibiting the mourning process [96]. Several studies of the relationship between mothers who lost a pregnancy and their subsequent child suggested that attachment disorders between the mother and subsequent child one year postpartum may be due to unresolved grief [97-99]. For instance, in a prospective study, Hughes et al. [100] followed mothers who had experienced a traumatic loss through pregnancy and the first years of the child life. This study confirmed the association between unresolved status in relation to the miscarriage and disorganized attachment of the child. Moreover, there is also evidence that siblings born after stillbirth or other perinatal loss are vulnerable to psychological problems [93,101]. To understand why women are so worried even if they have a healthy subsequent child, it is fruitful to use the term of the paediatrician and psychoanalyst Donald Winnicott “fear of breakdown”. According to Winnicott, a traumatic experience of primitive agony cannot get into the past tense unless the ego can first gather it into its own present time experience and into omnipotent control. The fear of something that has already happened indicates that the ego integration is not able to encompass something. Therefore, the search for a traumatic past that has not been fully experienced or acknowledged would reduce the anxiety from future occurrence [102]. Research has confirmed the idea that addressing the past trauma helped to enhance and make fuller the present and future [9,103], especially in regard to intergenerational effects of grief and trauma after pregnancy loss.

Although miscarriage is almost always a meaningful loss, for some women it is also a traumatic one. As miscarriage abruptly interrupts the psychological and physical developmental processes of pregnancy, it creates a painful breach in the continuity of life, affecting the present as well as the future.

Echoing narratives of those who experienced other traumas, stories of women following miscarriage are marked by changes, preoccupations or distortions in time experience. These themes often indicate that the trauma has not been resolved, but rather is kept frozen outside of time. The cases presented here suggest that for many women, time carries the traumatic element of the miscarriage, as they find it difficult to integrate the experience into their lives.

As with other reproductive losses, miscarriage is often accompanied by a conspiracy of silence, and is often treated by others and sometimes by the woman herself as a “non-event” [39]. Minimizing the loss involved in miscarriage further complicates the emotional reaction and increases the chances for future agony [104]. Recognizing the personal loss for the woman could help in processing the trauma and placing it in time and place. Addressing the parental relationship with the unborn child and keeping a connection to the baby who died within the family story [105,106] may help parents to move forward as changed mothers and fathers[8].