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Although 50% of pregnancies end in miscarriage, it's rarely talked about and society tends to neglect the devastating psychological effects it has on both partners, writes GLYNIS HORNING. after an easy first pregnancy that produced a perfect son, I was breezing through my second until a 12-week checkup. "I'm sorry," said the gynae softly, after a pause in our usual banter, "I can't detect a heartbeat." A scan confirmed I had miscarried. In a trance, I heard the nurse book a D and C (dilation and curettage) for the following day. Driving home to tell my husband, anguish poured from me in wracking sobs that frightened me and passing motorists. Miscarriage is a complicated kind of loss. It's easy for those who haven't experienced it to underestimate it, especially in the first trimester, when the being you are carrying is barely bigger than a plum, and losing it is common (see box "causes of miscarriage"). But with today's advanced detection of pregnancy, an unborn baby can become part of our consciousness soon after conception, and the repository of our love, hopes and dreams. "With technology we can see ultrasound pictures and hear the baby's heartbeat very early, so attachment to the unborn baby begins early," says Joburg psychologist and bereavement counsellor Illeana Cocotos. Our bodies feed into this. As Rochelle Friedman and Bonnie Gradstein explain in Surviving Pregnancy Loss (Little, Brown & Co), the physiological and psychological processes of pregnancy start soon after conception. The levels of reproductive hormones in our system rise dramatically, our uterine lining thickens to sustain the new life, our breasts swell in preparation for feeding and our emotions change gear. A sense of attachment and "oneness" with the foetus can form even when the pregnancy is unplanned. Unless we're set against the pregnancy, and considering abortion or adoption, we can be left feeling empty and incomplete when a miscarriage ends it. "You need time to grieve your lost dreams, the psychological impact of miscarriage and the physical trauma of it," says Cocotos. "It's been found that even women whose pregnancies were unwanted were shocked by the physical process of miscarriage." Coping with miscarriage, she concludes, may be one of the most difficult processes a woman ever has to face. Yet levels of grief can range widely. "All loss follows the stages of denial, shock, bargaining, anger and depression, which We should not prescribe how a mother should mourn based on which stage of pregnancy she lost the baby, but rather allow her to mourn in the manner she feels is right for her. '45 you can cycle in and out of before acceptance begins and you can move on," says Dr Colinda Linde, another Joburg psychologist and author of Get the Balance Right (Metz Press). Cape Town teacher Nicole Masureik, 35, went into labour at 37 weeks, but was not worried as her firstborn, Janel, had arrived at 33 weeks. Besides, a scan the previous day had shown the baby was fine. By the following morning, however, labour had stopped and the baby was not moving. An ultrasound showed no heartbeat. "I was in such shock and denial that I couldn't accept that this meant she was dead until they brought in a paediatric specialist who confirmed it." Nicole was induced the following day. "(The) staff were wonderful, but there's no way to get your head around giving birth in circumstances like that." Afterwards, she and Graeme were encouraged to hold their daughter, take a lock of her hair, ink a footprint, and hold a brief naming ceremony. They called her Zoe, and the grief counsellor advised Graeme to bring in Janel, who was 18 months old, to see her sister. "They said to tell her straight that Zoe was dead, or she'd see how upset we were and think she was the cause. Janel gave Zoe a teddy, and when they wheeled her away she started crying. She knew Zoe was not going home with us. She completely got it. Children understand death in a way we don't." An autopsy and a battery of blood tests showed Nicole had a rare autoimmune blood disorder, APS, which produced too many clotting factors, and had blocked blood flow in the placenta. In the weeks that followed, Nicole retreated to her bed. "I fell apart - I couldn't make a decision about anything, even if I wanted a cup of tea. Graeme was forced to put his grief aside to cope with work, care for me, and get Janel to preschool each day. I couldn't bear to be with people, especially her, it was too painful. I lay with my nose in a book, unable to face reality." Next came anger and frustration. "I knew the medical staff had done what they should, but I was frustrated my APS wasn't picked up earlier, and hugely angry with God. It's only recently I've been able to say it wasn't his fault." A major help in getting there has been the birth of a third child, Nathan. "I got pregnant within 18 months of losing Zoe, but I was convinced we'd lose this baby too, even though doctors had me injecting myself daily to counter the APS and reduce the chances of another stillbirth. We bought our own foetal heart monitor and I used it constantly. I kept telling myself not to bond with ) how to support a friend who miscarries: Never underestimate the impact of miscarriage, however early. Don't be afraid to talk about the baby or her loss. Be there for her - simply hold her and listen. Encourage her to express her pain and anger. Don't try to minimise her loss ("you were just three months"). Don't offer platitudes ("it's for the best"). Don't offer your own war stories, except fleetingly to show you care. Don't say you know how she feels unless you too have had a miscarriage. Don't hurry her healing, but if it persists and tips into depression, suggest going with her to get help. Remember that the anniversary of her loss can awaken emotions - call or send a card of remembrance.

pregnancy news the new baby - impossible, of course. Poor Graeme just disconnected." It was only when a healthy Nathan was born some two years after Zoe's death, that they realised how stressed they had been. "Graeme burst into tears. And I was so exhausted and overwrought that the instant he'd assured me Nathan was breathing and had all his fingers and toes, I passed out." ways to cope The effects of miscarriage or stillbirth (when you lose a baby in the third trimester) are individual and most women would benefit from counselling, says Cocotos. "It can help you identify feelings and reduce the risk of emotional problems months, even years, later." acknowledge your loss The usual social rites of death are normally absent after a If you don't feel like talking, keep a journal or express your feelings by painting, making music, and when you're ready for it, by getting physical - dancing, running or exercising, which also releases feel-good hormones. Don't be tempted to escape with alcohol or drugs, or rush into another pregnancy before you are ready. And don't be hurried by well-meaning people who tell you to "get over it - you can always have another baby." Everyone takes a different amount of time to heal, and you will get there. In one study, 55% of women who miscarried presented with "significant psychological distress" immediately afterwards, 25% at three months, 18% at six months, and 11% at one year after the miscarriage. Should you seem stuck, get counselling. We don't work through the grief cycle in a linear way, and are often at different places in it from our partners, and deal with it in different ways. 4) miscarriage, and this often prevents parents accepting the reality of the loss," says Cocotos. Holding a small ceremony (lighting a candle, planting a tree) can help bring closure, however early the miscarriage, and if the pregnancy is advanced, naming your baby, holding it and having a burial ceremony. "We should not prescribe how a mother should mourn based on which stage of pregnancy she lost the baby, but rather allow her to mourn in the manner she feels is right for her," she adds. Talk through your loss with your doctor once you are over the shock, to establish the reason for the miscarriage. "In most cases the cause is a chromosomal defect in the foetus," says Cocotos. "Knowing this may help you realise you could have done nothing to prevent the miscarriage and that you didn't contribute to it." let yourself grieve Be aware of, and identify, the well-known stages as you experience them, says Linde. "Tell your story as much as you need to," she says. "Cry, scream or punch a pillow. The point is to feel the emotion enough to be able to process what happened, but not be so overwhelmed or cut off that you cannot move on. Sometimes the only way out is through." consider your partner In the initial shock it may be all you can do to keep yourself together, but spare a thought for your man. "Men and women grieve differently," says Nicole. "We are often at different places in the grief cycle from our partners, and deal with it in different ways. You need to be tolerant and very gentle with each other or it can tear a marriage apart." Friedman and Gradstein report a study showing women are more likely to see miscarriage as the loss of a person, while men often see it as a sad event, but not death. In general, men talk about feelings less, and feel they must take care of women by staying strong, so they delay their grieving, as Graeme did. Women can interpret this as not caring about the miscarriage, which can strain the relationship. "As men tend to get caught in the double bind, the impact a miscarriage can have on a father tends to go unrecognised," says Cocotos. "It's important to communicate your feelings, and try and stay connected." If you struggle, get help. "Instead of blaming each other and harbouring resentment, use what has happened to bond through shared grieving," advises Linde. offload with others Nicole found solace unburdening not just to family and friends, but with the online community she found in chatrooms, and with contacts she made through the British chapter of the Stillbirth and Neonatal Death Society (SANDS). When she and Graeme could find no equivalent in SA, they started a local version, Born Sleeping. It enables parents bereaved by miscarriage, stillbirth or neonatal death to share their experiences at meetings, through a Facebook group, by email or by phone (see useful contacts). "This is especially useful where emotional support is lacking in the existing family or social structure," says Cocotos. adjust to your new reality "Give yourself time to change your perception that you were a mom, and now you are not," says Linde. Understand that you have changed, even grown, through your grief. Take time off work if need be, and try a change of scenery. "Reinvest emotional energy in new relationships, as women recover and benefit from nourishing existing relationships and building new ties," says Cocotos. Finally, keep reminding yourself that most women who have miscarriages go on to have healthy babies. "It's a process," says Nicole. "On what would have been Zoe's birthday, I still cry. But the pain gets much less." You never get over something like losing a baby, but you learn to live around it, she concludes. "As someone said to us, it's almost like joining a secret club. It's painful, but you are not alone. Reach out and you will find others happy to help." causes of miscarriage First trimester One in four known pregnancies end in miscarriage, threequarters in the first trimester (many more happen before women even realise they are pregnant). Chromosomal abnormalities feature in more than half. Most happen by chance and are unlikely to recur, but chromosomal problems due to a parent's genes are also possible, especially in repeated miscarriages. Progesterone deficiency also causes early miscarriage and while progesterone supplements may delay it, they may not prevent it. Second trimester Some 15% of miscarriages are estimated to be caused by uterine malformation, uterine growths such as fibroids, or cervical problems, 20% by umbilical cord problems, and others by placental problems. Third trimester Causes of stillbirth include haemorrhage, maternal illness (such as uncontrolled diabetes), infection (such as measles), lifestyle (smoking, drug use, malnutrition, exposure to radiation or toxic substances), umbilical cord problems, and incompatibility between the mother's and baby's blood groups. Other causes at any stage can include incomplete implantation of the egg, maternal age, maternal health problems such as high blood pressure, certain medications, maternal trauma, hormonal problems and infections. For all this, nearly half of all miscarriages and stillbirths globally occur for no discernible reason, says Nicole. "In spite of all the advances in medical science and improvements in antenatal and postnatal care, the percentage of unexpected miscarriages and stillbirths has hardly declined since the early 1980s." useful contacts Born Sleeping Contact Nicole: 084 524 1541/2, This email address is being protected from spambots. You need JavaScript enabled to view it. or visit bornsleeping.wordpress.com or visit their Facebook page: Born Sleeping ZA The South African Depression and Anxiety Group (Sadag) If you battle with ongoing depression: 0800 567 567 or sms 31 393


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