Motivation and emotion/Book/2024/Pregnancy loss and emotion

Pregnancy loss and emotion:
What are the emotional consequences of pregnancy loss for parents?

Multimedia presentation (3 min)

Overview

Scenario Mrs. E, a 30-year-old professional woman with no prior psychiatric history, miscarried 8 weeks into a planned second pregnancy. No surgical or medical intervention was required. She had a strong support system. She experienced sadness and disappointment following the miscarriage but had no other symptoms until presenting to her obstetrician’s office for a follow-up visit 3 weeks following the loss. Triggered by the presence of several visibly pregnant patients, she began crying uncontrollably in the waiting room. The crying eased with support from her physician and did not recur. She conceived again 2 months later and in the years following reported only some recurrent sadness around the anniversary of the expected delivery date. Miscarriages can cause profound emotional distress, and the way individuals process and handle these experiences often fluctuates over time. People may experience a range of emotions, including grief, sadness, anger, guilt, and confusion. Each individual's reaction to a miscarriage is unique, and these emotions can shift unpredictably as they navigate their healing journey - healing is not linear.

Figure 1: Baby's food in hand of parents

Pregnancy loss, also known as miscarriage or spontaneous abortion, refers to the unexpected loss of a pregnancy. A miscarriage can happen for many reasons. These include hormonal imbalances, health issues, age, and lifestyle choices. The emotional toll of pregnancy loss can be significant. Women and their partners may experience a range of emotions including grief, guilt, anger, and depression. It is important and necessary to understand the emotional consequences the loss can have on both parents to be able to arrange proper support and help.

Focus questions: What are the emotional responses to pregnancy loss? How does Kübler-Ross' stage theory of grief apply to individuals experiencing pregnancy loss? How do emotions differ between medically intervened pregnancy loss and late pregnancy loss? How do male and female partners experience grief and process emotions following pregnancy loss?

What are Emotions?

Emotions describe complex psychological states. They connect our physical and mental states and have subjective, physiological, and behavioural elements.

• Subjective experience is the internal aspect of emotion, how one feels inside.
• Physiological response explains how emotions often trigger physical reactions in the body. For instance, fear might cause an increased heart rate, while happiness might lead to a feeling of warmth or lightness.
• Behavioural response indicates the way emotions are expressed externally. This might include facial expressions, body language, and actions. Smiling, crying, or shouting are examples of behavioural responses to emotions

Primary vs secondary emotions

Emotions can be broadly categorised into primary (basic) emotions and secondary (complex) emotions. The six basic emotions present from birth are sadness, happiness, fear, anger, surprise and disgust. Secondary emotions are more complex and often involve a combination of primary emotions. Examples include shame, guilt, pride and jealousy.

Figure 2: External signs of the passions from Le Brun. J. Pass

Why do emotions happen?

The expression of emotions occurs for each person multiple times a day for a number of reasons:

• Survival: Emotions can trigger quick responses to danger (e.g., fear triggering a fight-or-flight response).
• Communication: Emotions help convey how we feel to others, facilitating social interactions and relationships.
• Decision Making: Emotions can influence choices and behaviour, often providing a gut feeling or instinctual guidance.
• Motivation: Emotions can drive actions, such as the pursuit of goals or avoidance of harmful situations.

Ekman and his proposed criteria for emotions

Paul Ekman is an American psychologist known for his work with emotions. Ekman and Keltner (1970) claimed that basic emotions are discrete categories of emotional states with distinguishable characteristics. The criteria included distinctive signals (facial expressions), specific physiology (brain region activated), specific antecedents (events leading up to the emotion) and distinctive subjective experiences (needs to feel different).

Locationist View

The locationist view relies on consistency and specificity of brain activity for the duration of an emotion. Consistency in terms of the same brain region is active every time you experience a specific emotion and specificity, meaning each emotion has a unique pattern of brain activity.

Working with Ekman's Criteria, disgust has unique facial expressions attached to the emotion such as scrunching out noses and curling our lips. Additionally, in regards to the locationist view, the anterior insula is suggested to be specifically and consistently involved in the experience of disgust. This is because the anterior insula is involved in awareness of internal body states.

Quiz

For an emotion to be recognised it has to what:

	Be in relation to human motivation
	Show consistent activity in the brain when experiences
	Cause the individual to feel happy
	Has to be also experienced by other animals

What is a pregnancy loss?

Pregnancy loss, also known as miscarriage, refers to the spontaneous loss of a pregnancy before the fetus can survive outside the womb, typically before the 20th week of gestation. It is a relatively common experience affecting 15-20% of known pregnancies, with 80% of these occurring during the first trimester. In Australia, it is estimated to occur in up to one in four confirmed pregnancies (Bellhouse, C., Temple-Smith, M., Watson, S., & Bilardi, J. 2019).

Early vs Late Pregnancy Loss:

A miscarriage can happen both early into the pregnancy, within the first 12 weeks, or late into the pregnancy, usually occurring between 13 and 20 weeks old pregnancy (Broquet, K. 1999) .

Quiz

1 What happens if a miscarriage occurs past the 20-week period?

	The baby is now able to survive with medical help outside of the womb
	The fetus has no chance of survival
	It will be known as a late pregnancy loss

2 Are complex emotions a combination of primary emotions?

	No
	Yes

Figure 3: Pregnant women and partner

Pregnancy loss and emotions

Basic and complex emotions with pregnancy loss:

After a miscarriage, shock and numbness may set in, this is especially true when the loss was unexpected. It can leave parents feeling detached and disoriented. Anger and frustration may arise, sometimes directed at oneself, a partner, or medical professionals. Guilt may follow with parents wondering if they could have prevented the loss. For parents experiencing loss, encountering pregnant women or newborns can trigger jealousy and resentment. Many women feel surprised and isolated at the intensity of their reaction, unaware of how common it is (Broquet, K. 1999).

Anxiety and depression:

Experiencing a miscarriage can bring overwhelming anxiety, as the emotional and physical loss is profound. The fear of what went wrong, concerns about future pregnancies, and the grief of losing a baby can create a spiral of distress. This anxiety often manifests in constant worry, sleepless nights, and even panic attacks, as the uncertainty of the future looms large. It's a time when many feel isolated, struggling with feelings of guilt or shame, despite these emotions being undeserved. Seeking support from loved ones or professionals can be crucial in navigating this challenging period. Women who experience miscarriages and then fall pregnant again can go their whole pregnancy still in disbelief they are pregnant and try not to 'get their hopes up'.

Depression is a very real experience associated with pregnancy loss. The loss and grief isn't just for the child that is lost, but for the expectations and hopes of that child's life and its impact in the parents life.

Kübler-Ross' stage theory of grief

Experiencing a pregnancy loss is an emotionally devastating event that can trigger a wide range of intense feelings. Grief and profound sadness are often at the forefront. Parents may grieve over their wishes, hopes, and dreams for their unborn child and family. Perinatal grief signifies a specific situation in which someone does not grieve for a consciously-known person, but for a fantasised child with whom a bond has been formed even before his or her birth.

The five stages of grief have been proposed by Elizabeth Kubler-Ross and David Kessler. While similar to Kubler's work on the stages of dying, these stages suggest that responses to feelings that can last for minutes or hours as we flip in and out of one and then another. We do not enter and leave each individual stage in a linear fashion. We may feel one, then another and back again to the first one

Denial

This first stage of grieving helps individuals to survive the loss. In this stage, the world becomes meaningless and overwhelming. Life makes no sense as the individual is in a state of shock and denial. This can look like disbelief and a struggle to adjust to the news. At this early stage, it is about simply getting through each day as the denial helps to pace feelings of grief.

Anger

Anger is a necessary stage of the healing process. The more it is felt, the more it will begin to dissipate, and the more healing can be done. There are many other emotions under the anger, but anger is the emotion we are most used to managing pain. Angry can extend to your friends, the doctors, your family, yourself and your loved one. Usually there is more know about suppressing anger than feeling it but the anger is just another indication of the intensity of love.

Bargaining

After a loss, bargaining may take the form of a temporary truce. There is a desire for life to go back to the way it was, when planning for a future family was at the forefront of both parents' minds. There is a desire to go back in time and change habits that would have impacted the pregnancy loss such as eating better, avoided exercising, took prenatal vitamins…if only, if only, if only. These questions and ruminations find fault in action or thoughts on what could have been done differently. There is a sensation of remaining in the past and feeling guilty.

Depression

In some cases, the empty feelings present causes the grief to continue a deeper level in which the individual/s begin to experience depression. This depression is not a sign of mental illness, but the mind and bodies response to intense emotions lasting 6+ weeks and in pregnancy loss, especially late pregnancy loss, this can be a valid emotion to losing someone who had not yet met but were connected to. When a loss fully settles in, the realisation that the child will never get to have the life experiences by the parents and the pregnancy is not coming back is understandably depressing.

Acceptance

This stage is about accepting the reality that the child is physically gone and recognising that this new reality is the permanent reality. Acceptance doesn't mean the loss is okay, it means the new norms is accepted. If the time comes when the woman becomes pregnant again, enjoying the joys of pregnancy again, she may feel she is betraying what can be considered her 'first child'.

Does a late pregnancy loss amplify associated emotions?

Having to cope with late pregnancy loss has increased due to medical advances in prenatal diagnosis that have made it possible to detect many fetal anomalies that will cause death in infancy (Hunfeld, J. A. M., Wladimiroff, J. W., & Passchier, J. 1997). For example, Potter Syndrone is a fatal Congenital Disorder where there is a lack of amniotic fluid and kidney failure in an unborn infant. When detected, due to the complications it brings on the child's life and low chances of survival, many parents will be advised medical intervention to miscarry the child.

Research by Hunfeld, J. et al. (1997) studies the psychological stability among 46 women regarding The grief of late pregnancy loss, those whose ultrasounds showed lethal fetal anomaly above the gestational age​​ 24 weeks.  Shortly after receiving an unfavorable prenatal diagnosis, 45% of the women exhibited severe psychological instability. This percentage decreased significantly to 22% three months later, suggesting an improvement in psychological well-being over time. Four years after the loss, 38% of the remaining participants showed a clinically significant level of general psychological distress, as measured by the General Health Questionnaire (GHQ-28) (Hunfeld, J. A. M., Wladimiroff, J. W., & Passchier, J. 1997). This indicates that while some women improved, a notable portion continued to experience significant distress years later. Despite the decrease in the number of women showing severe psychological instability, the intensity of grief, as measured by the Perinatal Grief Scale (PGS), did not show a significant decline over the four-year period. This suggests that while psychological instability may have improved, the emotional pain associated with the loss persisted. Overall, the study indicates that while some women may find relief over time, others continue to struggle with their emotional health long after the event.

To answer the question does a late pregnancy loss amplify associated emotions ... no, there is no direct correlation between time and emotions, rather it is still an individual experience.

Medically intervened pregnancy loss

Emotions associated with abortions are complex and can vary widely from person to person, influenced by individual circumstances, cultural and societal factors, and personal beliefs.

An abortion is a medical procedure that terminates a pregnancy. It can be performed in various ways, depending on the stage of pregnancy and the health of the woman. There are two primary types of abortion:

• Medical Abortion involves taking medication to end a pregnancy. It is typically used in the early stages of pregnancy (up to 10 weeks) and usually involves two different medications taken at different times.
• Surgical Abortion involves a medical procedure to remove the contents of the uterus. There are several methods of surgical abortion, including aspiration (suction), dilation and curettage (D&C), and dilation and evacuation (D&E). Surgical abortions can be performed at various stages of pregnancy, depending on local laws and regulations.

The most common reasons women provided for seeking an induced abortion included education or job difficulties, desire for a wished-for child, and financial reasons. Emotions depend on the situation and individual but common ones include relief that the right decision has been made, grief from the emotion impact of the loss associated with the abortion and emptiness (Broen, A. N., Moum, T., Bödtker, A. S., & Ekeberg, Ö, 2005). Guilt and shame are also prevalent, especially in environments where abortion is stigmatized or morally contested. Some individuals may experience anger, either directed towards themselves, their partners, or the situation that led to the need for an abortion. Anxiety and fear about the procedure, potential future fertility, and judgment from others can also play a significant role. Additionally, ambivalence and confusion are common, as conflicting emotions can coexist, making the psychological landscape surrounding abortion particularly intricate and deeply personal.

The emotions of abortions were tracked multiple times in a study by Broen (2005) of 80 women who had an induced abortion, who were each interviewed 10 days, 6 months and 2 years after the procedure. The answers in the study were reported using a Likert-type scale from 1 (not at all) to 5 (extremely). Participants rated their feelings and the importance of various reasons for their decision to have an induced abortion.

Figure 4: Table from related study

Figure 3 includes a table from the study that shows the results of emotions connected to the abortion. At 10 days, women reported a range of emotions, with many expressing feelings of relief and a sense of having 'made the right decision'. However, some also experienced a little bit of initial emotional distress, including feelings of guilt and grief.

At 6 months emotional distress was more pronounced at this stage, with some women reporting trauma responses. The study noted that women who felt pressured by significant others, particularly male partners, were at greater risk for emotional distress during this period.

By 2 years, many women reported lower levels of emotional distress compared to the earlier time points. Those who had chosen abortion due to having enough children showed significantly lower levels of avoidance and emotional distress. However, some women continued to experience feelings of loss and grief.

Quiz

Can late pregnancy loss be due to natural causes outside of medical intervention:

	No, medical intervention is the only reason that late pregnancy loss occurs
	Yes, a pregnancy can have multiple issues that result in a fetus being unable to survive

Men's emotions following a miscarriage

Men's experience with pregnancy loss, such as sharing their feelings and try to support their partners during a pregnancy loss has received little attention. The emotional struggles faced by a male partner most commonly include feelings of grief and depression. In comparison to women, men may face different challenges including expectations to support female partners, and a lack of social recognition for their grief and subsequent needs (Murphy, F. A., & Hunt, S. C. 1997). Many men feel profound sadness and grief over the loss of the baby, similar to what their partner experiences. They may also feel a sense of helplessness, as they cannot alleviate their partner's physical and emotional pain, which can be distressing and frustrating.

Figure 5: Fatigued man

Men's grief experiences are highly varied and can differ significantly from those of women. Men often face unique challenges and additional tasks that complicate their grieving process. These include feelings of helplessness, responsibilities such as caring for other children, and societal expectations to support their partners, which can lead to a sense of disenfranchisement. Many men experience a form of double disenfranchisement, where their grief is not only unrecognized by society but also overshadowed by the grief of their partners. This lack of recognition can hinder their ability to process their emotions effectively (Obst, K. L., Due, C., Oxlad, M., & Middleton, P. 2020).

A systematic review by Obst, K. L,. et al (2020) highlighted several common emotional responses experienced by men following pregnancy loss: sadness, anger, guilt, isolation and confusion, followed by additionally the desire for distraction and outward emotion expression.

For example, men frequently experiencing guilt, which could be related to feelings of inadequacy in supporting their partners or questioning their own role in the loss. A sense of isolation is common, as many men felt that their grief was not recognised or understood by others, leading to feelings of loneliness. Many men sought distractions through activities such as work, sports, or creative outlets, which can be seen as a coping mechanism to manage their grief.

Many men reported feeling societal pressure to conform to traditional notions of masculinity, which often discourage emotional expression. This expectation to "be strong" and suppress emotions can lead to a lack of acknowledgment of their grief. As a result, men may feel compelled to hide their feelings, leading to a disconnect between their internal emotional experiences and external expressions.

Quiz

1 Male partners emotions during a pregnancy loss are just as important as a Females:

	True
	False

2 A pregnancy loss will always result in a grieving mother:

	True
	False

Conclusion

Pregnancy loss is unfortunately something that will affect at least one woman in your life. The loss of an unborn child can provoke many emotions, basic and complex. Our emotions have been understood over time and evolved through studies such as the locationist theory, the ideal of different brain regions activated for specific emotions and Ekman and his proposed criteria for emotions. Grief is an intense emotion experiences after death, and is no different when experienced in pregnancy loss. Kübler-Ross' stage theory of grief breaks down the 5 stages of grief experiences by woman, partners and family when there is a pregnancy loss. It was explored in the chapter if the nature of the miscarriage made a difference in the emotions, whether it would be amplified. The question 'Do emotions differ between medically intervened pregnancy loss and late pregnancy loss?' was answered through research proving miscarriages and emotions are all individual experiences and vary from person to person. Finally, the question "How do male partners experience grief and process emotions following pregnancy loss?" was answered that men have a lot of stigma around emotions and struggle to feel the emotions of a miscarriage. It was show that its common for men to take on a role to look after their partner in a time of grief and overlook their own emotions. However, the experiences is similar to woman in the sense it is individual.

What are the answers to the focus questions? Miscarriages and emotions are all individual experiences and vary from person to person. Men have a lot of stigma around emotions and struggle to feel the emotions of a miscarriage. It's common for men to take on a role to look after their partner in a time of grief and overlook their own emotions. However, the experiences are similar to those of women in the sense it is individual.

See also

• Abortion and Emotions (Book chapter, 2018)
• Stillbirth and emotions (Book chapter, 2017)
• Grief (Book Chapter, 2011)
• The hidden grief of a miscarriage (Google)
• Miscarriage and Loss (Google)

References

Andalibi, N., & Garcia, P. (2021). Sensemaking and coping after pregnancy loss: the seeking and disruption of emotional validation online. Proceedings of the ACM on Human-Computer Interaction, 5(CSCW1), 1-32.

Broquet, K. (1999). Psychological reactions to pregnancy loss. Primary care update for ob/gyns, 6(1), 12-16.

Dimitriadis, E., Menkhorst, E., Saito, S., Kutteh, W. H., & Brosens, J. J. (2020). Recurrent pregnancy loss. Nature reviews disease primers, 6(1), 98.

Ekman, P., & Keltner, D. (1970). Universal facial expressions of emotion. California mental health research digest, 8(4), 151-158.

Farren, J., Jalmbrant, M., Falconieri, N., Mitchell-Jones, N., Bobdiwala, S., Al-Memar, M., ... & Bourne, T. (2020). Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. American journal of obstetrics and gynecology, 222(4), 367-e1.

Hunfeld, J. A. M., Wladimiroff, J. W., & Passchier, J. (1997). The grief of late pregnancy loss. Patient Education and Counseling, 31(1), 57-64.

Karali, H. F., Farhad, E. S., Poh, D. S. C., Phong, Y. W., Soorianarayanan, P., Ting, J. S., & Zaigham, M. T. (2021). Comparing psychological impacts on male partners after experiencing various types of early pregnancy loss: A systematic literature review. International Journal of Clinical Obstetrics and Gynaecology.

Murphy, F. A., & Hunt, S. C. (1997). Early pregnancy loss: men have feelings too. British Journal of Midwifery, 5(2), 87-90.

Neugebauer, R., & Ritsher, J. (2005). Depression and Grief Following Early Pregnancy Loss. International Journal of Childbirth Education, 20(3).

Obst, K. L., Due, C., Oxlad, M., & Middleton, P. (2020). Men’s grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model. BMC pregnancy and childbirth, 20, 1-17.

Quenby, S., Gallos, I. D., Dhillon-Smith, R. K., Podesek, M., Stephenson, M. D., Fisher, J., ... & Coomarasamy, A. (2021). Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. The Lancet, 397(10285), 1658-1667.

Wheeler, S. R., & Austin, J. K. (2001). The impact of early pregnancy loss on adolescents. MCN: The American Journal of Maternal/Child Nursing, 26(3), 154-159.

External links

• Experiencing a pregnancy loss (Pregnancy, Birth and Baby AU)
• Coping with pregnancy loss (Centre of Perinatal Intelligence)
• Pregnancy and a new baby after loss (PANDA)
• Pregnancy loss (King Edward Memorial Hospital)