While we cry ourselves to sleep, gratitude waits patiently to console and reassure us; there is a landscape larger than the one we can see.
Sarah Ban Breathnach

All of the same issues – dilemmas, guilt, and relationships – I have written about in the past three weeks apply equally to a perinatal loss.  However, after a miscarriage, stillbirth, health-related termination, or early infant death, parents must shoulder burdens not present in other losses: the hesitancy of others to recognize the personage of the baby, the difficulty in finding support, the decision of if and when to try to have another, and the anxiety of a possible loss during a subsequent pregnancy.

In my discussion of bereavement, I wrote that bereavement is the state of having incurred a loss.  Even though there are many losses we are subject to during our lives, we commonly think of bereavement as being the result of a death.  I also wrote that grief is the set of unique reactions we have to each loss and mourning is the working through of those reactions.  Many people have the notion that mourning over a death is only justifiable if the death is of something or someone with whom it was possible to have a relationship.  This line of reasoning also maintains that a relationship can exist only if there is a two-way interaction.  Therefore, since it is not possible to have a two-way interaction with an unborn baby (and some even contend with a newly born baby), the baby is not really a person and is not worthy of mourning.

However, the parents of a baby, born or unborn, know they had a relationship with their baby even when it is in the womb.  The start of that relationship is hard to pinpoint since it is different for each parent.  Perhaps it was when the mother became suspicious she was pregnant, received confirmation of her suspicions, heard a heartbeat for the first time, felt the baby move for the first time, or “began to show.”  The parents might have talked to him/her, prepared a room, considered names, built hopes and dreams for the future, etc.  In short, at some point they began to consider the baby to be a person, a member of their family.  This is important because when parents suffer a perinatal loss, one of the most challenging tasks they may have is to find others who will acknowledge their baby as a person, worthy of mourning.  Typically, the earlier in the pregnancy the loss occurs, the harder it is for others to make that acknowledgement.

The search for understanding, supportive people brings us to the second challenge unique to a perinatal loss – the disenfranchised grief the parents must endure.  In one of my support groups, a father said that he felt as if he were one of many silent, forgotten mourners when he was outside of the group.  While there are rituals and customs following the death of any other relation, there are very few for the loss of an unborn or newly born baby.  Many friends and family do not know what to say and so they say nothing, further failing to recognize the existence and personage of the baby.  Other times, good-meaning people may say something like, “You’re young, you can have another one,” or “God must have needed another flower in his garden,” or a hundred other comments that rarely provide any comfort; instead, they come across as negating the unique personage of the baby and his/her importance to the parents.  Would anyone say something like that if the child were five, ten, or fifteen years old?  Probably not, so why should it be okay to say it now?  The anguish of a perinatal loss does not depend on the length of time the baby is present, but rather on the nature of the attachment the parents have for him/her.

A couple of related challenges for parents are the decisions of if and when to try to have another child.  Sometimes, there is the urge to try again as soon as possible to take advantage of the mother being “ripe” for conceiving, to help redirect energy from grieving the lost baby to caring for a new one, or to hurry up before the mother’s biological clock runs out.  Unless there is a strong overriding medical reason to try again immediately, I suggest parents hold off until the deceased baby is appropriately mourned.

Another issue for parents considering trying to have another baby is their knowing that many perinatal losses occur because of something that was not supposed to happen did happen.  Statisticians can calculate that the chances of this or that occurring are 1 in 100,000, but the parents know they are that 1.  The fear and anxiety of trying again and possibly going through the same or similar loss experience can be overwhelming.  Deciding, if ever, that the reward of having a baby outweighs the fear of another loss can be one of the hardest decisions a bereaved couple has to make.

Finally, there is one area of the perinatal loss experience that I believe is commonly overlooked and downplayed – the effect of fear and anxiety of another perinatal loss during a subsequent pregnancy.  It is natural for us to protect ourselves emotionally in the face of possible pain.  One form of protection after a perinatal loss is to “maintain our distance” and not become as attached to the unborn baby as we did to the one who died.  We do this believing that if something bad happens, it will not hurt as much.  This defensive posture can last until a certain milestone has passed, such as the first trimester or the time when the previous loss occurred, or for the entire pregnancy.  If this distancing and lack of attachment becomes too extreme, it could have an affect on the emotional health of the baby.  In these cases, knowledgeable, professional help may be very beneficial.

In her book Empty Cradle, Broken Heart: Surviving the Death of Your Baby, Deborah Davis wrote that in 1991 there were 4.4 million confirmed pregnancies in the United States.  Of these, there were 500,000 miscarriages and 29,000 stillbirths.  In recognition of the impact of these losses on parents and families, in 1988 Congress passed a Senate Joint Resolution authorizing and requesting President Ronald Reagan to proclaim October as Pregnancy and Infant Loss Awareness Month.  I invite all of you to join with me next month in remembering those who died before they could experience life as we know it.

While it is not fair to compare one person’s depth of grief to another’s, those who have experienced the death of a child typically consider it to be the hardest to bear.  It makes no difference how old a child is – 18 weeks or 18 years, 5 years or 50 years – the pain never completely goes away.  A child is always remembered, especially at life’s significant events.  Even though the child is physically gone, he/she is still loved and lives in the hearts of his/her parents through their final day.