Important Research on Grief After Miscarriage

The loss of a child is well known to be a type of grief that can lead to a couple struggling emotionally, even to the point of struggling to stay together—but what if the child is lost in pregnancy? What if the loss is so early that those outside of the couple’s circle may not have been aware? 

This type of loss is often managed quietly, within a small circle of support and is often treated as something that is easily healed because of the less tangible nature of the child. The reality though, for those that have experienced a miscarriage, is that the grief is real.

With the goal of better understanding how losing a pregnancy impacts both women and their partners the study titled “Differences in post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy between women and their partners: multicenter prospective cohort study” was developed and published in 2020. The authors (Farren et al.) were hoping to help begin building literature that would shed light on the psychological experience of both partners, not just those who were pregnant.

Women were approached in three London hospitals in order to identify couples who had experienced pregnancy loss either through miscarriage or ectopic pregnancy. It was a small study, in which 386 were approached and ultimately 192 couples chose to join. Couples were asked to complete surveys at 1, 3, and 9 months following their pregnancy loss in order to assess their anxiety, depression, and post-traumatic stress levels at those intervals. The study authors were specifically looking to gather information on the mental health impact of a miscarriage on a partner as there is little to no previous research in this area. Additionally, they were looking to compare and contrast the mental health impact between partners.

The study recruited participants by having an investigator speak with them when they received their diagnoses of pregnancy loss or at a subsequent appointment up to 1 month post-loss. They did not exclude same-sex couples or transgender individuals, but all those who joined were women with male partners. They did exclude anyone under 18, and those with a “lack of proficiency in the English language, inability to give informed consent and voluntary termination of pregnancy.”

The study utilized two screening questionnaires that focused on depression and anxiety and considered their screening to be assessing for “probably PTSD” thus using the language of Post-Traumatic Stress vs. Post-Traumatic Stress Disorder. The authors described their work as using “…criteria involving endorsement of each symptom cluster (re-experiencing, avoidance and hyper-arousal clusters) as well as a total severity score cut-off of ≥ 18, as this has been found to maximize accuracy in the diagnosis of PTSD in victims of motor vehicle accidents and physical and sexual assault.”

The trends in the findings were that the women who had experienced the loss were more likely to respond to the questionnaires than their partners and additionally were more likely to affirm elevated anxiety/depression and PTS. Interestingly, while only 7% of partners met criteria for PTS at one month, 79% affirmed having “re-experiencing” of the loss and “Approximately one third of partners met the criteria for the avoidance and hyper-arousal clusters at 1 month.” Meanwhile, in the women who experienced the loss, the numbers were 95% affirming re-experiencing and close to 2/3 meeting these criteria. So, while they may not have met a threshold for diagnosis, there was a consistent report of trauma symptoms related to the brain working its way through the event. In particular, avoidance refers to avoiding reminders and thoughts of the traumatic event and hyper-arousal refers to an umbrella of symptoms that may involve physiological arousal, sleep disturbances, aggressive or self-destructive behavior. The consistency of these two clusters is intriguing and I would hope the study authors would continue to explore. The data also shows a high affirming of feeling helpless in both women and their partners, which stayed at around 82-86 percent for both groups. Educating both partners on the likely shared feelings of being helpless and the possibility for increased post-traumatic type symptoms couple could be a way to help build empathy when working through this type of loss, even if the partners have disparate emotional impact.

The study also considered anxiety and depression in both the women and their partners. Again, the trend was followed that the rates for anxiety and depression were higher for the women than their partners. Both groups had anxiety and de-pression in numbers that tapered over the 9 months, with the women having rates of anxiety starting at 30% and going down to 22%, while their partners started at 6%, went to 9%, and back to 6% at 9 months. Depression numbers for women started at 10% and went down to 7%, while men started at 2%, then 5%, and down to 2%. The study noted that the rates of anxiety and depression in partners were aligned with the general rates of the male population in England, so it is less informative whether the pregnancy loss was the cause. Additionally, the numbers of respondents decreased on each survey, so the percentages are representative of the reduced number.

The authors concluded that the significant differences between mental health impacts is concerning due to stress on a relationship after this type of loss. However, they also note that while only a small number of partners met diagnostic criteria for severe depression or anxiety, the consistent rating of post-traumatic stress type symptoms was still a concern. The authors wrote that “in view of the high frequency of losses and the seriousness of this condition, this is an important finding. Men are generally less likely to seek support for mental health issues and may have poorer peer support. It is also important to recognize that, although symptoms usually fall short of the threshold to suggest PTS, there is still an appreciable impact, as indicated by endorsement of individual symptom clusters and the impact of the symptoms on their lives.” Essentially, the numbers may be lower for mental health impacts, but the type of impact would indicate intervention would be beneficial.

The limitations of the study are most obviously the tapering response over time, which makes it difficult to assess if these are big picture trends or just the trends of those who responded. Additionally, the authors wondered if there was some selection bias due to only being able to recruit partners present at appointments.

Regardless of its limitations, the study highlights the traumatic impacts that both women and their partners can experience following a pregnancy loss. This blog often seeks to shine a light on the experience of pregnancy loss as a reminder that the grief when a child is lost at any stage of gestation is visceral and real. This study only considered losses prior to 20 weeks, so prior to “viability” and still we see significant mental health impacts for all involved. The authors of the study wondered if couples could achieve better outcomes with access to mental health resources to assist the woman in her grief and trauma, as well as helping the couple navigate the loss. Perhaps this would help partners bridge any mismatch in emotional impact as they process and heal. Let’s hope that researchers continue to gather information in these areas in order to improve pregnancy loss care.

[Today’s guest author is anonymous. Photo credit: The Good Funeral Guide on Unsplash.]