That was the first night after I miscarried at 12 weeks pregnant. Those early morning flashbacks lasted for weeks. After my miscarriage was handled medically, the effect on my mental health also needed attention. But no follow-up appointment was offered, and there was no acknowledgment of the intense emotions that rock many women who have miscarried.
As many as a quarter of all pregnancies end in miscarriage, and the impact on women’s mental health is well established. Yet, none of the medical staff I met with mentioned any potential emotional aftershocks.
Up to 55 percent of women who miscarry experience depressive symptoms shortly after. Up to 40 percent experience anxiety immediately following the miscarriage. Up to 15 percent reach the clinical threshold for a major depressive disorder in the months after the loss.
According to a study by Imperial College London, 45 percent of women reported symptoms of post-traumatic stress disorder three months after their miscarriage. About 30 percent of these women reported that the symptoms affected their professional life; about 40 percent, their relationships with family and friends.
Tessa Sugarbaker, a gynecologist who now works as a therapist in the San Francisco Bay area treating clients who have experienced pregnancy loss, says “the two most common things I see women for after a miscarriage is trauma, grief or both. I think the trauma can come from feeling helpless that nothing could be done, from doctors not being sensitive to the experience of the woman, and from society not recognizing it as a loss.”
These mental health issues are not confined to the days and weeks following a miscarriage. For women who become symptomatic for depression and anxiety, these symptoms can persist for one to three years, research has found. The progression is not always linear. In one study, 11 percent of women who miscarried did not show depressive symptoms until three to six months later.
Women who miscarry are at higher risk of depression and anxiety during subsequent pregnancies. Maternal distress during such pregnancies can have negative effects, such as preterm labor and low birth weight.
“Traumatic experiences get imprinted on us,” Sugarbaker says. “There is an evolutionary benefit to us remembering. So when a woman gets pregnant again after having a miscarriage, her body and mind remember and she can have significant anxiety and can re-experience aspects of the trauma.”
Johnna Nynas, an OB-GYN at Sanford Health in Minnesota whose work and research focuses on pregnancy loss, agreed.
In her experience only “a vast minority of patients” who have gone through a miscarriage and then had a successful pregnancy “did not suffer some kind of anxiety symptoms that were disruptive to them” during that next pregnancy.
The birth of a healthy baby does not necessarily resolve these symptoms.
One study found that almost 15 percent of women who miscarried suffered from depression or anxiety for up to three years after a subsequent healthy pregnancy, and that women who miscarry are at a higher risk of postpartum depression.
Studies indicate that the health-care services that a woman receives — or doesn’t — post-miscarriage can harm her mental health.
“In my experience, women will continue to experience the symptoms that happen shortly after a miscarriage until they are addressed,” Sugarbaker says.
Although about 50 percent of miscarriages are caused by chromosomal abnormalities (60 percent for recurrent miscarriages), many women feel at fault. There is a demonstrated link between feelings of self-blame and anxiety and depression.
When Mandi Abbott, 33 and eight weeks pregnant, went to the emergency room with intense cramping, doctors determined she had miscarried or was in the process of miscarrying and sent her home.
“I felt a lot of guilt for a while because I thought I must have done something. I wasn’t being careful with my diet. I wasn’t being careful managing my stress,” Abbott says.
In a large national survey in 2013 conducted by several academic medical centers, 47 percent of the women who miscarried (and their partners) felt guilty, 41 percent thought that they had done something wrong and more than 75 percent erroneously believed that a stressful event can cause miscarriage.
Yet, no standard of care exists in the United States for the treatment of the emotional toll that women experience after miscarriage. If a doctor does not find any risk to the mother’s health, there is often no follow-up.
“As long as there are no complications . . . from a medical standpoint, there is generally no need to do any specific follow-up as long as women get their periods back,” Nynas says. “But, what we are not addressing . . . is that women are grieving, and that women have a lot of fears and frustrations, and are dealing with a lot of emotions often times after these losses and we are not following up on that. In my opinion, that’s a huge gap in where we could do better to serve women.”
The American College of Obstetricians and Gynecologists recommends that medical providers screen patients during the perinatal period and postpartum for “mood and emotional wellbeing,” according to its website. ACOG also suggests that OB-GYNs “provide emotional support and bereavement counseling; referral, if appropriate, to counselors and support groups.”
But not all doctors make these efforts, and women who miscarry often find they are responsible for seeking out the care they need for any mental health issues.
“At a minimum, I think it would be helpful for doctors to provide women with information on grief, the available local pregnancy loss or general grief support groups, and how to look out for signs of depression. If any signs or symptoms are present it would be good to screen them for depression — or PTSD and anxiety for that matter — or refer them to a mental health specialist,” Sugarbaker says.
After my ultrasound, the doctor told me I had miscarried. She said she was sorry for our loss and then left.
Minutes later, she returned to explain our options — let the baby pass naturally or undergo a dilation-and-curettage — or D&C — procedure. She left again. And a few minutes later, she interrupted us again, as we were holding each other and crying, to request that we leave the room. I underwent a D&C that afternoon.
I am not alone in my experience. Only 45 percent of participants in that national survey said they felt they received adequate emotional support from the medical community after a miscarriage.
It has been six months since our loss. Since my miscarriage, my periods last longer and I experience more intense symptoms of premenstrual syndrome. I recently underwent an ultrasound to check my physical recovery.
After greeting me, the ultrasound technician asked when I had my last ultrasound.
“In April, when I miscarried,” I replied.
“I’d like to take a look at those images,” he said as he double clicked on a file on a computer screen visible to both of us.
“I don’t want to see that,” I shouted, hoping my words would arrive at his ears before the image hit my eyes. I closed my eyes. When I opened them, the technician had blocked my view with his body.
Nothing can take away the pain of a miscarriage. But recognition of the known mental health consequences by all medical providers is an important start.