For Providers - Talking with Your OB Patient About Pregnancy After a Loss
Pregnancy is supposed to be an exciting and joyful experience. Even the words “I’m expecting” denote the anticipation of a healthy, full-term delivery. Unfortunately, for some, even if able to conceive spontaneously and straightforwardly, the happily-ever-after is abruptly and dramatically interrupted when the miracle of pregnancy transforms into the nightmare of loss.
Sadly, babies can and sometimes do die during all three trimesters of pregnancy, labor and delivery, the postpartum period, and early infancy. Despite ongoing advances in perinatal care, these losses can occur with or without warning, and with a staggering frequency. The causes range from complications of placenta, cord, or membranes; infection and injury; chromosomal and congenital anomalies, or other maternal health issues.
Independent of how or when they occur, they all represent an extraordinary disruption in the path a pregnant woman was expecting to pursue. She was going to be a mother. Yet, as heavy and overwhelming as her sadness may feel, for most women, grief will not extinguish the continuing desire for a baby. In fact, it may deepen it.
Most women who experience a perinatal loss begin thinking about a subsequent pregnancy immediately. They have learned, first hand, that pregnancy alone is not the promise of a baby and that bad things can and do happen. Further, they are now acutely aware of the rapid passing of time and advancing edge of a reproductive window. For most, it is not a question of if they will try again; rather, it is a question of when.
And yet, most women are hesitant to ask their providers when they may try for another pregnancy, fearful others will think they are inappropriate and premature in this pursuit, or trying to replace their deceased baby. Neither concern could be farther from the truth, because in the case of reproductive loss, time doesn’t heal all wounds. Instead, time can become the enemy given a limited window of reproductive opportunity. And, as most bereaved women know, there is no such thing as a “replacement” baby. Every baby is individual and unique.
Some providers may be hesitant to initiate a discussion about subsequent pregnancy out of respect for their patient’s grief, believing that waiting will allow the patient more time to heal emotionally. That would work well if the grief process was linear, with every week being better than the last – but it’s not. Most patients don’t “get over” losing their pregnancy or deceased baby, but they can, over time, find ways to live with their loss. But if these women waited until they felt “better” before trying again, they just might lose their window of opportunity.
There are many emotional pros and cons to both trying soon and waiting. If the choice was exclusively up to them, most bereaved women would proceed with another pregnancy sooner than later due to anxiety over:
No guarantee of repeat conception.
The fear of repeat/recurrent loss (no matter how low the risk).
Advancing maternal age and its associated risks.
The closing window of reproductive opportunity.
The desire for more than one living child.
Historically, after a loss, most physicians counseled their patients to wait three months before trying again. That was before ultrasound was used to establish an accurate due date. Today, most physicians agree that after an early first-trimester loss, most women should wait one normal menstrual cycle before trying again. For later losses, physicians may recommend waiting anywhere from three to eighteen months, particularly if the loss occurred at term. There are legitimate and important medical reasons a provider may counsel a woman to wait (for example, in the case of pre-term labor), but these factors must also be weighed against very real emotional considerations, which may potentially increase and intensify mental health challenges as more time passes.
Losing a baby can be traumatic at any gestational age as the depth of grief is not based on the length of gestation; it’s based on the depth of attachment. Along with facing the physical loss of the pregnancy/baby, your patients will struggle with additional losses of control, confidence, clarity, identity, and time. It can be beneficial to initiate a conversation with your patients soon after a loss to acknowledge that while grieving, they may also be thinking about the future. You are in a unique position to support your patients on multiple levels, including removing stigma and empowering them to engage in this conversation when they feel ready enough to participate. The more time there is to discuss, the greater the potential to reach a thoughtful and medically responsible decision about an appropriate interpregnancy interval that is based on a woman’s medical and mental health history and current status.