What happens when O and G professionals experience reproductive loss?
Reproductive loss is a significant life event for many individuals, couples and families. It creates a crisis of grief that can disrupt work and family functioning over months and sometimes years. Reproductive loss encompasses a range of losses including miscarriage, stillbirth, termination of pregnancy, neonatal death and involuntary childlessness.
The implications of reproductive loss in professionals involved in maternity care have not been addressed in the scientific literature.
In the general population, responses to reproductive loss vary, but some themes are consistent. Women experiencing miscarriage can experience intense grief and significant anxiety symptoms that can persist for up to six months after the miscarriage.1 The lifetime prevalence rate of post-traumatic stress disorder (PTSD) in women who have experienced stillbirth is 29 per cent and the rate of PTSD in the third trimester of pregnancy subsequent to stillbirth is 21 per cent.2 Fathers also experience significant levels of anxiety and PTSD following stillbirth, which can persist in a subsequent pregnancy.3
Grief is an inevitable human experience. It is a natural response to loss and the emotions experienced extend beyond sadness to include anger, anxiety and despair. Grief is not an orderly or predictable process and this is particularly true in the setting of reproductive loss.
Complicated grief refers to significant and prolonged functional impairment after loss. Consequences may include depression, drug and alcohol abuse, and family breakdown. The risk factors for complicated grief after reproductive loss include the absence of surviving children, poor social supports and pre-existing relationship difficulties.4 Many people who experience infertility and reproductive loss will for some time avoid events that may increase distress such as visiting family or friends with babies or returning to the hospital where care took place. Recovery is marked by a gradual return to, and increasing comfort with, these activities.
After the cyclone
In early 2011, I experienced the loss of my first pregnancy at 17 weeks gestation. I will never forget leaving the hospital that night with my husband, loading flowers into the car in the darkness of an empty car park. My baby was no longer with me, and my hopes and vision of the year ahead of me were shattered.
At the time, I was a senior O and G registrar. I informed my director that I would return to work in two weeks. I made the judgement that this would be the ‘right’ amount of time off. Despite my professional experience in caring for women during pregnancy loss, I had no understanding of the profound – and at times paralysing – grief that I would experience over the coming months. In those early days after the loss, I had not yet comprehended the almost impossible task that lay ahead of me: finding a way to work in a job where I was constantly confronted by pregnancy while grieving for the loss of my own.
Cyclone Yasi came to town two weeks later. I almost welcomed the distraction it brought in those early painful weeks. I returned to work after three weeks. The unit director was understanding and my role flexible, allowing me to not work on the birth suite until I felt ready. I faced unexpected and distressing scenarios frequently despite these changes. On more than one occasion I saw women with the same due date as my pregnancy in the antenatal clinic. One day I diagnosed a miscarriage at 17 weeks gestation in an antenatal clinic. For many months after this I would hold my breath while listening with the Doppler. I knew too much about what would follow if no heartbeat was heard. Negotiating these painful encounters and continuing to undertake routine work left me constantly, and at times overwhelmingly, exhausted.
Work became a little easier after the passing of the expected due date of our baby. However, a second pregnancy followed soon after. This pregnancy was dogged by complications and was a dark and difficult experience. I was constantly preoccupied with the possibility of loss while continuing to grieve. I worried that I would not have the strength to recover or return to my chosen profession if I lost another baby. However, 16 months after that terrible day, my husband and I were able to experience the joy of leaving hospital with our second daughter. In contrast to our previous experience, it was a sunny day and the car park bustling as we loaded up flowers, bags and our baby.
It took two years before I could practise obstetrics comfortably again. I remain grateful for the patience and support of senior colleagues during this time.
Anne
It is possible that O and G professionals who experience reproductive loss are at increased risk of complicated grief as they are unable to control avoidance of, and exposure to, emotionally distressing events during their work. Taking a long period of absence from work or modifying work arrangements may not be feasible for some practitioners. These issues require further investigation.
O and G professionals face other challenges in this setting. They may require medical treatment within the service in which they work, in particular, in rural and regional settings. This may create additional distress when returning to work in the setting of pregnancy loss as they may not be able to avoid painful places such as the room in which their baby was born. Their care will have been provided by peers and sometimes colleagues with whom they work. Doctors as patients often experience compromises to their privacy during care and this risk is even greater when treatment is provided within the profession. These professionals may also be subject to the misconception that their training provides them with expertise in the personal journey of grief after reproductive loss. This is a dangerous assumption, which may lead to inadequate empathy and support in the workplace, despite the challenges faced by the bereaved as outlined above.
O and G professionals who experience reproductive loss require empathic support from colleagues over the months and years that follow. Where possible, colleagues should seek to provide flexibility in work arrangements, particularly in the first six months to one year of bereavement. Some professionals may choose to make permanent changes to their scope of practice after reproductive loss and this decision should be supported. The unique and very challenging aspects of the grief process for O and G professionals should be acknowledged. Colleagues should remain aware of events that may lead to increased distress or return of grief such as anniversaries, an expected due date, if relevant, or a subsequent pregnancy. If complicated grief is evident then professional psychological support may be required.
Things my Gigi has taught me
I’m writing this from a hospital room with one eye on the Ashes Test and the other on my two-day-old son, Quincy, who is snuffling peacefully next to me in his cot. My wife, Bec, and I are deep into that newborn fog as we marvel at what we’ve created while navigating the sleepless nights and the early challenges of remembering how exactly to bath such a tiny baby.
However, three years ago this very scenario seemed a million years away. Then, we were deep in the fog of grief having lost our daughter Georgie to stillbirth at over 36 weeks – ten days before her planned delivery. Back then the idea that we’d have the courage to endure the white-knuckle ride of another pregnancy seemed impossible.
Our pregnancy with Georgie – or Gigi as we’d come to know her – was the very textbook definition of uncomplicated. Despite the seemingly constant examples of heartbreak and tragedy obstetricians are exposed to, we’d merrily sailed through oblivious to even the potential for calamity. One Saturday morning, as I was leaving to start my weekend registrar’s shift on a busy regional hospital labour ward, I passed Bec, rubbed her belly and told her to take care of my precious cargo. Later that same day I discovered Gigi was gone. Bec and I had joined a club no one wants to be a member of.
This encounter with grief of such magnitude was my first. Having never dealt with loss previously, I was blissfully unaware of what an unwelcome visitor it would be. Did I say unwelcome? It was raw, and searing and unrelenting. It physically reached inside me and changed me in such a way that I was terrified it would leave me forever broken; not to mention no longer able to do the job that I had changed careers five times to find, and one with which I was experiencing a passionate love affair.
Now, nearly three years later and with greater clarity, I can see that while this has diminished me, Gigi has given me gifts I am blessed to have received. Talking about her gives her meaning and purpose. Existence. Sharing this experience – in some way – brings her to life and gives her back to me. She has taught me that when people join this godforsaken club, they want to hear their child’s name. They want you to ask for it and to use it.
By the same token, banish immediately from your clinical lexicon the expressions ‘it was meant to be’, ‘at least you have other children’, ‘at least you can have more children’ and, my personal favourite, ‘it’ll get better with time’. These platitudes not only don’t help, but – worse – they are really a way for the treating staff to make themselves feel better. This is not about you.
Gigi also taught me that it’s crucial anyone working in this field is aware of the services available to parents who are faced with the loss of their child. For example, when we lost Georgie nobody knew about Heartfelt, a national organisation of volunteer photographers who visit the hospital and take beautiful baby photographs. One of our greatest regrets is that we have only three grainy photos of our daughter.
Finally, if you ever care for such a parent in a subsequent pregnancy, you need to understand the sheer terror of the journey they are taking. You need to appreciate what an honour it is for you to shepherd them through, and offer them every reassurance and comfort you can.
Brad
References
- Brier NB. Anxiety after miscarriage. A review of the empirical literature and implications for clinical practice. Birth 2004;31:138-142.
- Hughes PM, Turton P, Evans CD. Stillbirth as a risk factor for depression and anxiety in the subsequent pregnancy: Cohort study. British Medical Journal 1999;318:1721-1724.
- Turton P. et al. Psychological impact of stillbirth on fathers in the subsequent pregnancy and puerperium. The British Journal of
Psychiatry 2008;188: 165-172. - Kersting A, Wagner B. Complicated grief after perinatal loss. Dialogues in Clinical Neuroscience 2012;14(2):187-194.
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