Becoming Parents and Overcoming Obstacles

Understanding the Experience of Miscarriage, Premature Births, Infertility, and Postnatal Depression

Emanuela Quagliata

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429911248
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

There are many books that deal with pregnancy and maternity, and a large number of magazines and articles on paediatric nursing that examine these subjects from different points of view. This volume is not a manual and is not intended to explain to future parents what to do and what to avoid. The objective is rather to look at the most significant and problematic aspects of this delicate phase of a woman's life and that of a couple. It seeks to offer a key to understand the deep significance and complexity of the path to follow to become parents and to face fears linked to the difficulty of procreation, using the tools of observation and psychoanalytic listening. Reviewing several experiences of clinical work, the authors offer reflections on the personal experiences of women and couples and the difficulties which can be met when the desire for a child is disappointed. A maternity and parenting project can be frustrated by miscarriages and encounter the fear of infertility. How are the problems of sterility or spontaneous abortion experienced?

CHAPTER ONE


A paradoxical pain: recurrent miscarriage

Emanuela Quagliata

Despite a growing interest in matters regarding pregnancy and infertility, the impact of a woman’s emotional response to the traumatic event of her previous miscarriages during a current pregnancy has received little research attention, although the broader category of stillbirth has been the subject of many studies. The existing literature has identified various emotional states associated with the interruption of pregnancy but seems to lack a deeper understanding of a meaningful connection between them.¹

What particularly struck me was the degree of distress and the depth of loneliness that this event, so invisible from the outside but so traumatic and present inside, could elicit in the couples I met. As happens when a couple faces the news of the death of a baby that is already born, the moment of the negative ultrasound result represented the end of all the parents’ unconscious fantasies about their unborn child and the collapse of all their plans, dreams, and hopes for the future of their child and their family: this reality was often faced in total isolation.

The depth and complexity of the pain and fear of another loss was often touchingly apparent in the couples, even if concealed behind very different individual behaviours and reactions. Talking to these women I became aware of how this experience, which I would call an “invisible loss”, was accompanied by all the manifestations of mourning.

Listening to my patients’ stories, the experience of their previous miscarriages was a subject which all of them felt the need to share from the first meeting. If, on the one hand, it seemed that they did manage to talk about it, even if only as part of the process of describing their current state, I think that a special urgency to do so originated from the pressing need to share a traumatic event which, in many cases, seemed not to have found a space to be understood at a deeper level; its unknown impact in their internal world may contribute to these women’s difficulty in developing their identity. For almost all of them the first miscarriage was felt as particularly traumatic although they were told that these were things “that could happen”, the sense of belonging to a large group did not helped to alleviate the impact of the event. A variable which turns out to be important in mitigating the traumatic effect of the loss of the baby was its predictability. By contrast, the second miscarriage was a relief for some mothers because they felt too ill, but for others the second miscarriage was not only unexpected, but also unexplained. What seemed to emerge from these experiences—which were different even in their similarity—was that it was not a question of how advanced the pregnancy might have been but that when the miscarriage followed a scan during which the baby’s heartbeat had been heard, and after the first movements of the foetus had been felt, the event was accompanied by strong feelings of loss, anger, and shock. The contrast between life and death seemed to be more marked and violent in these cases: reality destroyed signs of life which had already been clearly experienced.

An interesting contribution shows how PTSD (post-traumatic stress disorder) is prevalent in pregnancies following stillbirth. Women were found to be vulnerable to PTSD in the pregnancy subsequent to stillbirth, particularly where conception occurs soon after the loss (Hughes, 2001). A pregnancy or a birth following a miscarriage are not necessarily helpful in processing the grief, and the complexity of the reaction to a loss of this nature cannot be simplistically resolved by a new conception (Lin & Lasker, 1996). In the light of many studies, in fact, it could be speculated that the emotional feelings stirred by death were avoided by conception thus inhibiting the mourning process by pregnancy (Lewis, 1979; Lewis & Casement, 1986).

What is certain, however, is that if the subsequent pregnancy results in a new loss, the intensity of grief experienced is increased to a comparable degree. All these feelings influence the new pregnancy and often do not help these mothers to enter into intimate contact with the vital and creative aspects associated with their new conception. In particular, the emotions experienced by the mother also profoundly affect the couple relationship. The previous failures, as well as the uncertainty surrounding the pregnancy and the risk of further miscarriage, are often the cause of tensions in such couples who are forced to live for many months in a state of doubt and uncertainty.

Every woman and every couple reacts in a unique and personal way to solitude and pain. But sometimes, in particular in the case of recurrent miscarriages, the trauma of this loss is so profound as to be not only difficult to work on and overcome, but can also compromise the stability of the couple, contaminate a subsequent pregnancy, and undermine a woman’s own identity (see Raphael Leff, Chapter Five). Often the experience of the loss, and the need to cope with uncertainty, are factors associated with unconscious fantasies which render the experience deeply traumatic. The previous losses, and the threat of the loss of the baby during the new pregnancy, undermine the mother’s trust in her creative capacities and raise persecutory feelings in relation to internal objects which are felt to distrust her capacity to become pregnant, to keep the pregnancy, and to give birth.

Unresolved earlier conflicts with the maternal figure are certainly intensified by the narcissistic wound received as a result of the devastating effect of the loss of these women’s babies. Internal persecutory figures do not allow them to become mothers and fuel a conflict between the thoughts that encourage life and those that deal with death.

As well as the fear of another loss of a longed-for child, and the related unconscious fantasies, a further difficulty in confronting pregnancy and the possibility of another death of the foetus is the painful reawakening of feelings connected to the experience of unprocessed grief over previous deaths. This means that, if before or in conjunction with pregnancies, future parents have had to face important bereavement—such as, for example, the death of a parent—the thought of those deaths seems to return to life in the moment of a new conception and to influence the perception and fears about the new pregnancy. In this way, the ‘unmetabolized’ feelings are then reactivated at the time of the loss of the child and, also, the story of the new life seems to become inextricably entangled with the memories of the previous experiences of pain and death. It is important for these women to work through the loss of their previous pregnancies and to understand the significance that has been attributed to them.

Interesting hypotheses suggest that a relationship is created through chemical and biological messages between the mother and the foetus (Mancia, 1981), and also the observation of the foetus by ultrasound scanning (Piontelli, 1992), explore the subject of the balance between hereditary and environmental influences. Clinical experience has taken us increasingly further back, to trace how fundamental the very early stages of a child’s life are for all of its future development: here we have arrived at the age of “minus three-quarters” (nine months before birth), in that area of pregnancy which is fundamental for preventive purposes.

Often the event of a spontaneous abortion tends to pass unnoticed, not only by the people who are emotionally closest to the woman undergoing the experience, but also by medical staff. Menzies Lyth, 1959) carried out an in-depth analysis of the defence mechanisms set in place by nursing and medical staff to protect themselves from the emotional pain and feelings about life and death which are intrinsically part of their work. It is not easy for medical staff to give special attention to women who present these ailments which interfere with their ability to procreate. The common experience was for women to encounter a tendency by staff to diminish the problem, as though it is no less difficult for them to face this “small”, “invisible loss”.

The memory of trauma and fear of a new start, the anxiety of being simultaneously in contact with life and death, the memory of a dead child and the identification with a precariously live one, are particularly unbearable. A painful event requires a great deal of working through in the mind: the ability to transform painful and undigested experiences into thoughts is what Bion referred to as “alpha function” (Bion, 1962). Ingham writes: “Trauma occurs when this work, alpha functioning, is overwhelmed and unable to contain and digest the quality and quantity of stimuli involved and therefore breaks down … It is in the recognition and the acknowledgement of separateness and the working through of the experience of absence of the providing mother, that thought and mental work are constituted … this process is essentially a mourning process” (Ingham, 1998, pp. 98–99).

Pregnancy is a time of psychological as well as physiological preparation and “a certain amount of anxiety in pregnancy, as in any other major life event, is an indication that this psychological work is taking place, that a woman is preparing herself by being receptive to the natural fears in the face of a situation which carries many unknown” (Breen, 1989, p. 7).

Women who have suffered previous miscarriages need to find a deep understanding of the unique nature of their experience. Psychoanalytically oriented interviews can help them to cope with the intense anxieties of a new pregnancy and can therefore play an important preventive role, as it is a way of protecting the development of the bond mothers will make with their new baby.

Anna: search of an identity and the sense of emptiness

“Pregnancy, particularly the first pregnancy, is a crisis point in the search for a female identity, for it is a point of no return, whether a baby is born at the end of term or whether the pregnancy ends in abortion or miscarriage” (Caplan, 1959; Pines, 1972). In particular, in the case of spontaneous abortion, this “crisis point” I think manifests itself in patients’ experience as a trauma and as such represents “a breakdown of an established way of going about one’s life, of established beliefs about the predictability of the world, of established mental structures, of an established defence organization” (Garland, 1998, p. 11).

Miscarriage can be experienced as an emotional earthquake which deeply undermines the confidence at the heart of women’s identities and, therefore, their creative capacity. Naturally, the impact which a miscarriage has on a life can only be understood within the individual story which has given form to the individual’s internal world. I found myself confronting differing levels of anxiety: there were women who, although they were going through similar experiences, had greater resources than others and different degrees of vulnerability. However, my impression was that, often, many of the women I met could not succeed in finding, in their internalreality, a maternal figure to help them gradually elaborate their pain and anxieties.

I was surprised to note that very often patients didn’t want to get closer to their mothers at this difficult time except for the most practical support and I wondered what the role of the expectant mother’s identification with her own mother might be during the course of the pregnancy. According to the psychoanalytical model, primary relationships influence the way in which events performed externally are constructed in the internal world. These early relationships inevitably influence the nature of the damage felt as loss, also determining the degree in which personal resources can cope with this damage.

Anna, aged thirty-two, was suffering from an autoimmune disease.² She came to the unit with a history of two miscarriages: the first, which occurred in the fifth month, terminated a pregnancy which had been full of problems from the start, sustained by means of therapies and bed rest and had happened about three months before our first meeting. The second miscarriage was in the fifth week of pregnancy and coincided exactly with the start of our sessions. The traumatic nature of the first miscarriage was the reason she had come to see the gynaecologist, Dr. V., and had then accepted the suggestion that she should come to see me.

Anna arrived for our first appointment with her husband. They both came from a town in the vicinity of Rome where both of their parents’ families still lived, and had been married for four years. Although she could have been attractive, she tended to wear somewhat severe and outdated clothes which made her look older than her years. She was also very pale with dark shadows under her eyes which gave her an “ill” look and, without a trace of make-up, her eyes had a sad expression. I invited both of them to speak. He began to talk about the miscarriage which had occurred three months earlier, about the threats of miscarriage which his wife had from the start, the times she had been taken into accident and emergency, and the fact that, in spite of everything, the pregnancy had lasted up to the fifth month. She told me the exact date of the miscarriage and about the heart defect which had been diagnosed in the foetus. At the time she had been told: “In such cases nature takes care of itself”, implying that in any event the child would have died shortly after its birth, but Anna kept on wondering why nature should have “taken care of itself” only at the fifth month, leaving things late enough for her to have seen her baby daughter sucking her thumb just the day before when she had had a scan. The pain attached to the loss of a baby at such an advanced stage of pregnancy is very intense, and I expressed my understanding to them. Following a pause which was heavy with sorrow, the husband forced a smile in an attempt to defuse the situation and added that his wife believed that she would also lose this child in spite of the fact that she was now being looked after by Dr. V, in whom she placed great trust. He emphasised Anna’s “pessimistic nature” in contrast to him being an “optimist”. In any case, the loss of the baby had also affected him greatly and had brought about a strong feeling of isolation in both of them. This was also due to the fact that the people with whom they had the closest friendships recently were four couples all of whom were expecting babies: the miscarriage had inevitably distanced them from the others who had had their children.

Anna told me of the great distress caused by her GP who, in the past, had merely given her some tranquillizers, whereas the gynaecologist advices her to see a psychotherapist. She also told me that she suffered from insomnia and that, for about three years, she had also been having panic attacks, which had been aggravated by the pregnancy. The onset of these attacks had coincided with the time of their move to Rome from a smaller town because of the husband’s work: in the new city Anna had immediately felt even more isolated, unable of doing anything at all—even of driving the car or taking a bus—without being accompanied by someone. However, as far as the miscarriage was concerned, the night it came she was alone, but she was able to deal with it quite well despite the fact that her husband, who worked in public transport, was on night shift and she had thought she would never have been able to manage. Following the miscarriage they immediately tried to have another baby but it seemed reluctant to come, transforming every menstruation into a huge disappointment and increasing their anxiety. Finally conception occurred in October, much to Anna’s surprise, given that, due to a psychological problem which she described as a “sense of emptiness”, the couple had significantly reduced the frequency of their sexual relations.

As often happens, too little time was allowed to grieve for the first child and I observed how the past—the loss—seemed to invade the present. Anna remembered, with emotion, how she had heard her baby’s heart-beat at the time of the last scan and now she feared that she would have to wait, once again, as long as the fifth month before knowing how it would all turn out. After all, she added, not even the doctors know, “only God knows!” A sad, tense moment followed this statement, which expressed all the gravity of the trauma experienced by the couple. Then the husband broke the silence pointing out, with surprise, how his wife was talking much more than she normally did. She confirmed that in general she felt uncomfortable with people and had done so ever since she had been a little girl. She told me that her father had been a teacher and that her class teacher had always been in competition with him: every time she made a mistake he would humiliate her publically in order to demonstrate that her father did not know how to teach. Unfortunately she had this same teacher for the whole five years of primary school. After this she always had problems with school but, notwithstanding these difficulties, she managed to do well in her final school exams. I observed that clearly she was capable of reacting and asserting herself in spite of her difficulties. But Anna responded saying that when things went well she considered it to be purely by chance whereas her husband was always cheerful and happy with things, even too much so.

Once again this difference emerged between them, further confirmed by a statement made by the husband regarding the fact that she was never affectionate and never gave him satisfaction. We explored her past experiences of finding herself interacting with people who made her feel discouraged and who devalued her, just as they used to when she was a child, and who, perhaps, continued to do so during her pregnancy; and she was reminded of her previous pregnancy, during which period she had been taken into hospital five times: every month she had suffered a haemorrhage. Then she recalled how, on the day of the miscarriage, there had been no room at the hospital, how her gynaecologist had not been there, and how she had not wanted to disturb him by calling him on the telephone. They had told her to push, but “it was hard to push knowing that afterwards it woul...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Editor and Contributors
• Introduction
• Chapter One A paradoxical pain: recurrent miscarriage
• Chapter Two The experience of parents of a premature baby
• Chapter Three Emotional turmoil around birth
• Chapter Four Parenting the next child in the shadow of death
• Chapter Five “Opening shut doors”—the emotional impact of infertility and therapeutic issues
• Chapter Six Overcoming obstacles
• Index