Living Through an Early Pregnancy Loss: an Autoethnographic Account
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Challenging the norm of silence around miscarriages in Indian society, this paper is my attempt at reflecting, documenting, and sharing the personal experience of living through an early pregnancy loss and subsequent grief. Here, I narrate the story of my “delayed miscarriage” and reflect on the implicit social scripts associated with pregnancy and motherhood in Indian metropolitan context. Additionally, I share the details of my encounters with various healthcare practitioners during the course of my short-lived pregnancy while simultaneously critiquing the healthcare practices adopted for patients of early pregnancy loss at hospitals in metropolitan cities in India. Methodologically, the inquiry adopts an autoethnographic approach wherein the researcher uses personal storytelling, self-reflection, and analysis to illuminate and theorize the cultural experiences and psychosocial meaning-making processes. “Pressures and contradictions of pregnancy scripts,” “silent suffering and discounting of loss,” “mystery of loss and meaning making,” “alienation,” “objectification of the pregnant body,” and “busy business of healthcare” emerged as significant themes for discussion in the autoethnographic account. Through a discussion of these themes, I highlight the ways in which the implicit cultural scripts attached to pregnancy and motherhood take away agency from women. I further argue for the necessity of challenging the prevailing the trend of silent mourning after miscarriages in India to promote mental health and well-being of women. With respect to the healthcare practices in India, I advocate for implementation of an ethically grounded biopsychosocial approach to caring for early pregnancy loss to restore women’s agency. Finally, reaffirming the autoethnographic stance, I discuss the possibility of healing through research and writing in the end.
KeywordsEarly pregnancy loss Delayed miscarriage Autoethnography Cultural scripts Bereavement Alienation Healthcare
Conceiving a child is an experience that transforms a woman at every level—physical, psychological, and emotional—and turns her into a “mother” in due course. Rather than landing in this demanding position by default, some women plan meticulously for this transition. For them, the journey towards motherhood starts with great deal of anticipation and significant preparations. However, if this journey does not reach its anticipated culmination and is curtailed by pregnancy loss, it could be a traumatic experience with a potential to disrupt the sense of self (Pontes and Bastos 2015).
Though pregnancy loss can happen at any point during the gestational period, it is most frequent in the early stages. Miscarriages are the most common form of early pregnancy complication, and it occurs in about 15–20% of all reported pregnancies. If one were to include estimates from community-based assessment considering that a large number of women do not reach out to hospitals, the figure could be as high as 30% (Farquharson and Jauniaux 2005). A recent population-based observational study of over 30,000 women in a low resource setting in South India confirmed these findings and revealed that the rates of spontaneous miscarriages in clinically reported pregnancy could be as high as 28% (Dhaded et al. 2018). The specific reason for miscarriages is difficult to discern in most cases, but complications may include chromosomal abnormalities, hormonal imbalances, and maternal trauma. Other risk factors for miscarriage are lifestyle problems such as malnutrition, maternal age, drinking, and smoking. Though the physical manifestations of miscarriage may be different in each case, the underlying experience of psychological and physical loss is the common denominator. It is pertinent to note that the experience of early pregnancy loss does not necessarily lead to grief. Women struggling with unwanted pregnancies, for instance, may feel relief rather than grief after voluntary or involuntary termination of their pregnancy.
There is a great deal of inconsistency in the medical terminology and classification surrounding the loss of pregnancy prior to viability which in turn makes it difficult to compare the research findings from different countries (Kolte et al. 2014). For example, as per the guidelines of World Health Organization (WHO) and International Committee for Monitoring Assisted Reproductive Technology (ICMART), “spontaneous abortion” or “miscarriage” is a technical term used when pregnancy comes to an end spontaneously within first 20 weeks of gestation (Zegers-Hochschild et al. 2009). A special interest group on behalf of the European Society of Human Reproduction and Embryology (ESHRE), on the other hand, defined “early pregnancy loss” or miscarriage as “spontaneous pregnancy demise before ten weeks of gestational age” (Kolte et al. 2014, p. 496). It is notable that Indian medical professionals and researchers use the defination of miscarriage as prescribed by WHO. “Recurrent miscarriage” are also qualified differently by different agencies. WHO and ICMART define “recurrent spontaneous abortion/miscarriage” as “spontaneous loss of two or more clinical pregnancies” (Zegers-Hochschild et al. 2009, p. 2687), while, ESHARE and the Royal College of Obstetricians and Gynecologists (RCOG) define recurrent early pregnancy loss as three consecutive losses of pregnancy (Kolte et al. 2014). The prevalence of rates of recurrent miscarriage varies significantly depending upon the criteria adopted by the researches. When defined as the loss of three or more recurrent pregnancies, the researchers (Bagchi and Friedman 1999; Branch et al. 2010) estimated the prevalence rate of recurrent miscarriage at 1%. But, if recurrent miscarriage is defined as loss of two or more clinical pregnancies, then the prevalence rate goes up to 5% (Branch et al. 2010; Garrido-Gimenez and Alijotas-Reig 2015).
The prevailing practice of using the term “abortion” and “miscarriage” synonymously in India is misleading, outdated, and insensitive. The term abortion has overtones of voluntary termination which is very different from the disappointing experience of spontaneous and unwanted loss. Therefore, for two decades now, the researchers have advocated that the term miscarriage be used with appropriate adjectives like incomplete, complete, and delayed instead of the term abortion. (Hutchon 1998; Farquharson and Jauniaux 2005). Unfortunately, despite potent academic and practical arguments, the medical professionals in India and governmental agencies and platforms like National Health Portal by Ministry of Health and Family Welfare, Government of India, still do not make a distinction between abortion and miscarriage and describe “delayed miscarrigae” (a condition where a non-viable fetus is not immediately expelled from the uterus) as “missed abortion” (which is clearly an incorrect usage).
I was completely unaware of all these medical terms and prevalence rates until a few years back. It was in the month of March 2016 that I discovered my pregnancy, and subsequently, in the month of May, it ended abruptly. Subsequently, I had to go for a treatment known as “dilation and curettage” (D&C) (i.e., a surgical procedure for removing the fetus from the uterus) for the management of my delayed miscarriage. Multiple consultations with the specialists, numerous diagnostic and clinical procedures, hospitalization, surgical procedure, and countless hours of Internet search over 6 weeks were sufficient for turning a naïve yet curious person like me into almost an expert on the subject of early pregnancy loss.
I was surprised to discover that despite early pregnancy loss being such a common event, it has received little attention among the researchers, healthcare professionals, and policy makers. According to Frost et al. (2007), p. 1005), “it was only in 1980s that miscarriage was clearly acknowledged as a source of bereavement”. It is also important to appreciate that the bereavement experienced in the case of miscarriage is quite complex as “there is no visible child to mourn, no memories or shared life experiences, the death is sudden, and there is often a lack of recognition of the significance of such loss by society” (Lee and Slade 1996, p. 239). This makes the process of grieving multifarious. Yet, miscarriage is not acknowledged as significant as other forms of pregnancy loss such as stillbirth (i.e., loss of fetus after 28 weeks of gestation) or neo-natal death (death occurring in first 28 days after birth). People may erroneously assume that since the baby was lost in the initial stage of pregnancy, the loss is not as real. The research by Plagge and Antick (2009) demonstrated that the participants’ willingness and proactivity to offer social support to women who suffered pregnancy loss was dependent on the gestational age at the time of the loss. The respondents in the study expected significantly greater grief and personal discomfort among the women who experienced stillbirth and, thus, offered to extend greater support to them as compared to women who miscarried. This study indicates that the psychological impact of miscarriage on couples, even by their family and friends, may be inappropriately undermined.
My further exploration led me to the articulations of various researchers (e.g., Neugebauer et al. 1992; Cecil and Leslie 1993; Beutel et al. 1995; Lee and Slade 1996; Walker and Davidson 2001) who have convincingly argued that after miscarriage, women tend to suffer from many detrimental psychological consequences such as clinically significant posttraumatic stress, anxiety, and depression. These symptoms may last for as long as 12 months in many cases. Researchers have also concluded that women are more likely to experience self-blame, guilt, isolation, and loneliness subsequent to an early pregnancy loss (Goopy et al. 2006; Adolfsson et al. 2004; Wong et al. 2003, etc.). Feeling of guilt is further compounded by the thought of failing the expectations of the family members. Eventually, this self-blame and guilt may result in compromised sense of self and personal identity (Frost and Condon 1996). Researchers have also investigated the derimental psychological impact of recurrent miscarriages. Rai and Regan (2006) reported increased rates of clinical depression and anxiety among women who have suffered from recurrent miscarriages. Serrano and Lima (2006) studied the impact of recurrent miscarriage on couples and found that though the relationship itself was not adversely affected, their sexual engagement declined. The study also reported that grief was related to the quality of sex life in men and to quality of communication in women. Pontes and Bastos (2015) analyzed the case of a woman who endured multiple gestational losses and proposed that the pregnancy loss may be understood as an unexpected and abrupt interruption of an identity-construction process. They further argued that while going through these successive ruptures along the reproductive journey, self builds continuity in the cultural context.
These researchers also emphasize the fact that the experience of loss is equally significant for expecting fathers, and thus, their bereavement needs to be understood in its own right. They should also receive adequate emotional support while they make sense of their loss.
“The perception that men have only a supportive role in pregnancy loss is unjustified, as it ignores the actual life-world experiences of the men, and the meanings they attach to their loss, in what may be a very personal emotional tragedy for them where they have limited support available.”
The scholarship on early pregnancy loss consistently highlights the inadequacy of healthcare systems. Researchers (e.g., Wong et al. 2003; Moohan et al. 1994; Cecil 1994; Friedman 1989) have documented the participants’ expressed dissatisfaction with the attitude and behavior of healthcare professionals, the (mal)practices and impersonal policies adopted by the hospitals, and lack of follow-up care for mental health issues. The medical professsionals treat miscarriage as a frequently encountered gynecological complication and do not acknowledge it as an event of personal tragedy (Wong et al. 2003). Hence, there is a mismatch of expectations and misunderstanding of needs (Friedman 1989) between the couples and healthcare givers. Therefore, Murphy (1998) underscored the need of inter-personal skill training among care givers at the hospitals so that they are able to handle the event of early pregnancy loss with greater sensitivity.
It is noteworthy that the research related to the various forms of pregnancy loss has taken a narrative turn in recent years. Many researchers have documented the experiences of loss of their participants (e.g., Gerber-Epstein et al. 2008; Frost et al. 2007; Adolfsson et al. 2004; Wong et al. 2003; Murphy 1998). Others have reflected and documented their own pregnancy loss by employing the emerging method of autoethnography. Some noteworthy examples are Leith’s autoethnographic account of meaning making through multiple pregnancy losses over a period of 9 years (Leith 2009), Forhan’s personal and familial account of recovering from a perinatal loss (Forhan 2010), and Weaver-Hightower’s account of grief following his daughter’s stillbirth (Weaver-Hightower 2012). Significant autoethnographies on early pregnancy loss include Sell-Smith & Lax’s account of multiple miscarriages (Sell-Smith and Lax 2013), Lahman’s account of living through a high-risk ectopic pregnancy (Lahman 2009), and Peel and Cain’s critical feminist account of “silent” miscarriage as recounted by a lesbian and a hetrosexual couple in Britain (Peel and Cain 2012).
The discussion thus far clearly establishes that the academic discourse on the lived experience of early pregnancy loss as it unfolds in the socio-cultural context is deficient. This is especially true in India where the researches on early pregnancy loss are majorly situated in the medical paradigm and are limited to assessing the prevelence rates and potential causal factors. There is also a dearth of systematic qualitative exploration on the subject in India and the voices of women who have experienced the loss are seldom accounted for. Autoethnographic research itself has not gained visibility in India thus far, and the autoethnographic account of early pregnancy loss by Indian scholars has not yet been attempted. In this backdrop, the current inquiry aims at addressing this lacuna in the research literature by presenting an autoethnographic account of early pregnancy loss which took the form of a delayed miscarriage.
construct and share a reflexive account of my early pregnancy loss to challenge the norm of silence surrounding the early pregnancy loss
uncover the process of meaning-making and reconciliation with loss
contribute to the understanding of the implicit socio-cultural scripts associated with pregnancy and mothering in urban north Indian metropolitan context
critique the care-giving practices adopted in case of early pregnancy loss by the healthcare practioners
Apart from challenging the norm of silence surrounding the early pregnancy loss, the other three objectives of inquiry are identified for specific reasons. Firstly, in the absence of a clear-cut identifiable cause of loss in most cases of miscarriage, the act of making meaning is at the heart of reconciliation and coping. Therefore, in my opinion, it deserves attention in its own right. Secondly, since the process of meaning-making unfolds in a social and cultural backdrop, it is pertinent to uncover the implicit socio-cultural scripts associated with pregnancy and mothering as these are likely to influence reconcilliation and coping in case of early pregnancy loss. Once these implicit socio-cultural scripts are uncovered, the possible contradictions in the scripts could be reconciled, gender-biases could be identified, and maladaptive scripts could be challenged and replaced. Lastly, medical professionals occupy a significant position in lives of pregnant women. Their suggestions are valued and their support is solicited. But, their care-giving practices are not value-free and culture-proof, rather, they may be unduly influenced by the gender biases and market forces. Thus, these practices should be examined and critiqued so that the malpractices could be curtailed and more ethical and sensitive practices could be introduced for better health-related outcomes.
“Autoethnography is an approach to research and writing that seeks to describe and systematically analyze (graphy) personal experience (auto) in order to understand cultural experience (ethno)” (Ellis et al. 2011). As the name suggests, this method brings together the elements from autobiographical and ethnographic approaches. “Autoethnographers use personal stories as windows to the world, through which they interpret how their selves are connected to their sociocultural contexts and how the contexts give meanings to their experiences and perspectives” (Chang et al. 2013, pp. 18–19). Hence, the personal act of “making sense” (Ellis et al. 2011, p. 27) of the complex social realities is at the core of the autoethnographic method.
Autoethnography has its roots in the postmodern philosophy that questions the hegemony of the dominant positivist scientific paradigm. “The essence of postmodernism is that many ways of knowing and inquiring are legitimate and that no one way should be privileged” (Wall 2006, p. 147). This method also challenges the canonical ways of representing the self and the other in the traditional research paradigms like positivist. Unlike the positivist paradigm, where the subjectivity of the researcher is a source of bias that contaminates the data, the autoethnographer appreciates and accommodates the myriad ways in which the personal experiences influence and inform the research process. In other words, the distance between the self and the topic of inquiry is minimized by researcher playing dual role of both the researcher as well as the participant. “Autoethnographers place value on being able to analyze self, their innermost thoughts, and personal information, topics that usually lie beyond the reach of other research methods” (Chang et al. 2013, p. 18).
Since the personal experiences are always in the foreground of autoethnographic researches, researchers tend to write about an array of topics such as their field experiences, identity issues, and epiphanies. Epiphanies are “those remarkable and out of the ordinary life-changing experiences that transform us or call us to question our lives” (Ellis et al. 2011, p. 26). The present work is also situated in such an epiphany that was traumatic and unsettling yet eventually proved to be thought-provoking and transformational.
Like other emergent qualitative methods, autoethnography has also met with severe criticism. Since autoethnographers rely on subjective self as the source of data, they are accused of being “self-indulgent, narcissistic, introspective, and individualized” (Wall 2006, p. 155). According to Sparkes (2002), this universal charge of self-indulgence levied against autoethnography is grounded in the deep mistrust of the value of self and act of reflexivity. Autoethnography is also dismissed for being too literary, non-rigorous, theoretical, emotional, and thus, non-scientific. However, autoethnographers argue that the usual scientific measures of rigor are not applicable to the method due to the difference in ontological and epistemological assumptions. Autoethnography makes use of the researcher’s credibility, reflexivity, and trustworthiness to ensure rigor. “These criticisms erroneously position art and science at odds with each other, a condition that autoethnography seeks to correct. Autoethnography, as method, attempts to disrupt the binary of science and art” (Ellis et al. 2011).
Since mothering, loss, bereavement, and grief are heavily personal as well as culturally situated experiences, apart from understanding the phenomenological narrative of miscarriage, there is also a need to uncover the culturally laden undertones of the experience. Additionally, an inquiry into these sensitive topics should be well informed by the ethics of research practice and representation. Given this context, the method of autoethnography is an apt choice for the present inquiry as it considers all these concerns. This method is also liberating as it is likely to give me a unique opportunity to share my story of loss as a woman while legitimately contributing to the body of knowledge on early pregnancy loss as an academician.
Analysis and Discussion
As mentioned earlier, my short-lived pregnancy lasted for around 6 weeks. During this period, I kept a journal to record my experiences and reflections. Though I did not make entries in the journal on regular basis, I made it a point to record compelling observations, insights, and events as they occurred. Presented below are some excerpts from the journal that are likely to offer insight into the major events associated with my pregnancy and its subsequent loss.
I held the pregnancy tool kit with my shaking hands and stared at the two parallel lines that appeared within seconds. In that moment of anticipation and anxiety, I could feel everything changing. It all appeared so unreal.
It has not sunk in yet. Everyone around is overjoyed with the news. They have been waiting for it since a long time. Perhaps, it is though their happiness that I am beginning to cut through my disbelief.
I am beginning to get uncomfortable with the excessive attention from everyone. Pregnancy seems to have given everyone a right to tell me what to do and what not to do. It is as if my autonomy and privacy stand no ground in front of the self-assumed responsibility of ‘care-giving’ of the family members. Sometimes, I feel less like a person and more like a womb carrying the child.
What I initially thought would be a routine procedure at the ultrasound clinic turned out to be a decisive moment in my pregnancy. After going through a disturbing and violating experience with the trans-vaginal ultrasound at the clinic, I was informed that the heartbeat of the fetus is non-cognizable. I was advised to wait for a week and repeat the procedure and get in touch with my doctor in the meantime. Anticipating the worst while driving back home, I cried. I became restless as the possibility of everything ending seemed far too real. The worst part of it all is the uncertainty of the situation and my helplessness for not being able to do anything about it.
After waiting for what appeared to be the longest week ever and after enduring another trans-vaginal ultrasound, I was given the dreaded news at the clinic today. Subsequently, my doctor announced coldly that the baby has somehow stopped growing. “I am sorry, but, we would have to manage it differently now”, she announced. The word “manage” somehow stuck out in the conversation.
I did not want to give up yet. I had so many questions. Most importantly, I wanted to know if I could have done something different to avoid this. But, all she did was repeat how common early pregnancy loss is. She seemed to be in a hurry to let me go and move on to the next women waiting for her. Well, it could be routine for her, but, surely for me, it was not routine. I was overcome with a strange concoction of grief and anger as I left the consultation room.
My diagnosis and doctor’s advice remain unchanged even after consultation with other two gynecologists. As they say it, it is a case of ‘missed abortion’. In other words, it is a dead baby that my body refuses to let go off. Doctors say that I have to undergo a surgical procedure as soon as possible in order to ‘manage’ it. All the doctors for some reason are keen on getting over with the surgery.
I do not know what I feel anymore, there is a strange sense of numbness that has taken over. Maybe it is protecting me from the trauma that I think I am not quite ready to face as yet.
As I regain awareness after the surgery, I felt exhausted and cold. The touch of my partner seemed to be the only source of comfort in that moment. As I recovered from the chills and waited for my discharge from the hospital, an overwhelming sense of loss enveloped me.
After the surgery, it was difficult for me to get back to the journal as it reminded me of my loss. So, the reflections on the events after the surgery are drawn from my memories. The themes discussed below have been extracted both from the recorded entries in my journal and from my memories and experiences prior to pregnancy and after the surgery.
“To Be or Not to Be?”—a Blasphemous Question
Pregnancy and childbirth are particularly celebrated events in the Indian culture. Motherhood is considered the essence of feminine existence, and many believe that being a mother is the most meaningful role a woman could assume. People assume that a woman’s life is incomplete in absence of a child. In this backdrop, it is not surprising that women feel tremendous social pressures for childbearing. Many educated women like me, particularly those working and residing in metropolitan cities, are experiencing conflict with respect to these social pressures. Women are beginning to question the centrality of the motherhood to their identity rather than taking the idea of maternal instinct for granted. They are challenging the naturalness of the desire and obviousness of the necessity to be a mother. In this backdrop, when I insisted on my choice of wanting or not wanting motherhood instead of negotiating the timeline, it was blasphemous for my parents, in-law, and relatives.
To give a backdrop to my narrative, when I got married almost 8 years back at a rather young age of 23, I expected the pressure of childbearing to build up soon after. Being my stubborn self, I was already determined to resist it and I did so with great might for years all together. It was more difficult than I imagined as the pressure kept on intensifying with each social gathering, family dinner, anniversary, and birthday to a point where I started dreading those occasions. These were the occasions where the desolate tales of loss on account of delayed mothering were told and I was constantly reminded of my ticking biological clock.
Apart from my family members and relatives, even my colleagues took it upon themselves to make me understand that having a child or its timing was not our decision to make as a couple, rather, the expectations of the in-laws, parents, and society at large should be the deciding factor. Given that in many Indian families, the grandparents and the extended family members often push the parents in the background and gladly assume the primary responsibility of caring for the child; the social pressure for childbearing is legitimized in the name of parental respect and reciprocity. When I did not cave in under the pressure and insisted on my right to choose mothering, I was branded as the “black sheep” and was accorded the title of being “heartless” and “unwomanly.” At that time, I felt isolated in my struggle. However, now as I write this, I find myself in good company of women who have been through the similar struggles and endured. Many women in Indian metropolitan cities are exercising their choice of mothering and some women are even happily going “childfree.” Bringing forth the voices of such urban women from India, Nandy (2013, p. 54) probed the “notions of agency, autonomy and subject-hood within the narratives of childfree women or those who choose not to have children, and the fence-sitters or those who are ambivalent about having children and procrastinate inconclusively.” If one were to go by the categorization proposed by Nandy, I could very well fall into the category of an ambivalent fence-sitter.
The Perplexing Contradictions of the “Pregnancy Script”
Despite sexuality being such a taboo in Indian society, even among married couples, the timing of my periods and the birth control measures that we used became a matter of concern for my mother-in-law. On multiple occasions, I felt that my privacy as a person and our privacy as a couple was violated and that too with great nonchalance. It irked me no bound. Gradually, I discovered in my interaction with other married couples that this intrusion in privacy was a norm rather than an exception, especially for the couples co-habiting with the parents/in-laws after marriage. It is also significant to mention that such living arrangement is adopted by a majority of India families where a lot of value is placed on being together as a family due to the male offspring’s responsibility of taking care of the aging parents. This very arrangement absolves women from the responsibility of caring for their aging parents. Women who continue caring for their parents after marriage are often frowned upon for their “over-involvement” in their maternal family.
The series of events discussed in this paper unfolded when I conceived for the first time in the sixth year of my marriage. Though it was not a planned pregnancy, we decided to go ahead with it. While I was ambivalent about the pregnancy, my partner was excited. His enthusiasm was reassuring and helped me overcome my initial anxiety. As we shared the news of conception, another contradiction of the “pregnancy script” became evident. The male members of my family, particularly my father and uncles, were both happy and embarrassed at the same time. The frankness with which we shared the news was apparently culturally inappropriate and was awkward for their traditional sensibilities. As I reflected, I understood that probably my image of a daughter is incompatible with my image of a sexually active woman carrying a child. Since procreation is an undeniable marker of sexuality, it is culturally inappropriate on part of males to knowingly or unknowingly make any reference to the pregnant condition of a woman. A curious incident happened when I went to take a blood test at the diagnostic center in the second week of my pregnancy, as an elderly man asked me the reason for my blood test. As I answered the question without hesitation, he was visibly embarrassed. It was as if he had transgressed a boundary and he immediately apologized for being inappropriate. Subsequently, I had to assure him of the unnecessity of the apology.
Ironically, despite such socio-cultural preoccupation with procreation, there is a great deal of secrecy around disclosure of the “good news.” High degree of discretion is exercised, particularly in the first trimester due to the uncertainty of pregnancy. There is also a culturally engrained fear of “nazar” or “an evil eye” that may arise from the malevolent intentions of people around the pregnant woman making her more vulnerable to mishaps and losses. Thus, the extended family, neighbors, and colleagues are expected to discover the pregnancy only when there are visible markers. We, as a couple, were not so discreet. We proactively shared the news with the loved ones. However, the perceived inappropriateness of this gesture was later highlighted by the friends and family when the miscarriage happened. I disagreed with their point of view. It dawned upon me that this very secrecy about the news of pregnancy is reinforcing the culture of silence around the early pregnancy loss. In words of Sell-Smith & Lax (2013, p. 12), why turn miscarriage into “hidden loss, potentially adding layers of shame and secrecy to mounting emotions”? I further questioned that does not the act of isolating oneself in the moments of happiness or grief point to the cynicism prevailing in the society? Besides, what is the point of having family and friends if they cannot be trusted with one’s delicate emotions and vulnerabilities?
Disenfranchised Grief: Silent Suffering and Discounting of Loss
Despite the presence of supportive family members and other well-wishers, I felt that my loss was not acknowledged. The statements like “it was god’s will,” “whatever happens, happens for the best,” “you are not the only one going through it, it is very common,” and “don’t you worry, you will soon have another one” were made frequently in reference to my miscarriage. I felt that with these reassurances, people discounted my pain and dismissed my mourning. They could not relate to my loss as for me, the loss was not just of a fetus, it was a loss of a possibility. Sell-Smith & Lax (2013, p. 8) further pointed out that miscarriages are “potential trigger for complicated forms of grief, particularly when there may be no physical object to mourn and no public acknowledgement of the loss.” It should also be noted here that despite the elaborate rituals associated with death and mourning prevalent in Indian culture, there are no rituals that mark the loss of family after the miscarriage. To account for this trend, Doka (1989) aptly used the term “disenfranchised grief” to refer to the grief which is usually discounted by those who have personally not experienced it.
Mystery of Loss and Meaning-Making
In most cases, since there is no identifiable cause for the early pregnancy loss, it cannot be reasonably explained through the traditional medical framework. It is for this reason, miscarriages may be considered an example of “imperfectly scientised form of death” (Frost et al. 2007, p. 1006). The absence of a clear-cut identifiable cause for miscarriage usually perplexes the grieving women and retards their coming to terms with the loss (Frost et al. 2007). Often, in their desperation to seek an explanation, grieving women internalize the loss, blame themselves, and feel inadequate. Apart from the usual physiological and behavioral explanations, women seek refuge in religious and supernatural speculations. In Indian context, even the educated urban women make frequent references to kismet (destiny) and doctrine of karma to explain the loss. I did so too. I too experienced a strong need for an explanation to make sense of my experience. It was as if I wanted to fill in the gaps in the story and attain closure. Jaffe and Diamond (2011) also established the significance of uncovering the “reproductive story” to bring about healing in the clients who have suffered the pregnancy loss or infertility. Though arriving at my reproductive story may not have been a very conscious motive at that point, now I realize that my decision to write this autoethnographic account was itself an act of meaning-making. I reckon that the coping strategy I resorted to was intellectualization. Writing this account not only helped me maintain an intellectual distance from my pain but also made me feel “productive” when I needed it the most.
While expecting a child is an experience of deep connection, pregnancy loss is arguably an experience of alienation. The mourning is not only for the loss of the unborn child but also for the loss of parenthood. Echoing the similar sentiments, Pontes & Bastos (2015, p. 58) posited that pregnancy loss is “not only the loss of the “" baby,” but also of a certain ideal of family, the social role of mother, a certain control over the woman’s body, and even her own life.” After the miscarriage, I felt disconnected to my body which was, quite literally, the sight of the loss. Accepting and getting used to my pregnant body was a challenge to begin with and then going through medical termination and being unpregnant in a matter of weeks was disturbing. I was physically exhausted and emotionally numb. It was only after a couple of weeks that I regained a sense of ownership of my body.
I also felt estranged from my partner as both of us experienced loss differently and could not be there for each other in ways the other wanted. Thus, our failure at sharing grief made mourning an isolating experience for both of us. Socially, males are relegated to the periphery of the mourning sphere, more so, in case of early pregnancy loss. The idea that the father-to-be could have bonded with the potential child so soon, even in the absence of a physical connection, appears absurd to most people. Consequently, males often do not acknowledge and share their sense of loss. They may suppress the expression of grief in their struggle to be supportive to their partners who are presumably at the epicenter of the grieving sphere (Murphy 1998). In retrospect, I realized that I might have also contributed to the perpetuation of the same script by attaching greater significance to my grief than my partner’s loss. I was preoccupied with my physical and psychological conditions and expected my partner to act as a pillar of strength. I was too full of myself to cognize his need for support and depth of his loss. I could not appreciate that his grief could be as profound as mine and his ways of coping could be very different from mine.
Objectification of the Pregnant Body and Medical Gaze
This reproductive function of the female body makes it naturally more prone to objectification. The body of a pregnant woman is not just her body anymore; it is more so an instrument of giving birth to the child. Complete strangers, especially women, feel free to touch a pregnant woman’s belly (Cummins 2014). Quite early on in pregnancy, a pregnant woman is “disciplined” by significant others and medical professionals to act “selflessly” so that she becomes a better “container” for the “precious cargo” (Lupton 2012). Thus, in no time, the fetus becomes more important than the woman herself and she loses control of her body to both society and to medical professionals.
The excessive and often unsolicited care and attention that I received early on in the pregnancy from my family members gave me an impression that I was more importantly womb carrying a child rather than a person. Though my pregnancy ended way too early, it lasted long enough me to get a taste of objectification at the hands of the medical professionals as well. I had to go through transvaginal ultrasound twice after which I was informed that the pregnancy was no longer viable. Keeping aside the bad news, going through this procedure itself was a very distressing experience on both occasions. On the first occasion, the doctor neither briefed me about the nature of the procedure nor did he bother to take my consent. Rather, the procedure was performed harshly and insensitively. I was appalled that I was not even given an opportunity to psychologically prepare for a procedure that involved probing my vagina by insertion of a tubular structure at the hands of an unknown doctor. On the second occasion as well, though the procedure was performed by a skilled technician in a well-known hospital, it was performed with the same insensitivity. I felt reduced to a vagina that was technologically probed by a skilled diagnostician in yet another run of the mill diagnostic procedure. To say the least, I felt violated by a stranger in the name of medicine and it was indeed disturbing.
My subsequent readings made me realize that what I experienced was the enormity of the “medical gaze.” Medical gaze is a termed coined by Foucault (1973) to refer to the institutional privilege which endows medical professionals with the power to engage in surveillance and “decide and intervene in/on the patient’s body on behalf of the patient” (Cummins 2014, p. 42). In reference to pregnancy, feminists argue that medical gaze not only undermines women’s control over their bodies but also becomes the voice of authority that “alienate pregnant women from their bodily experiences” (Rudolfsdottir 2000, p. 339). Particularly relevant in this regard is the work of Cummins (2014) who employed Foucault’s notion of panoptic gaze to delineate the different ways in which the modern discourse disciplines the pregnant body to keep women docile within the framework of body politic. One of the strategies employed to discipline the pregnant body is the expectation that the woman should respond willingly and proactively to the medical gaze. I, for sure, was not ready to surrender to the medical gaze.
Busy Business of Healthcare
Despite availing services of one of the best healthcare facilities in the capital city of India, I was highly disappointed. The setup appeared more like a business facility rather than a healthcare facility. The doctors and the support staff in the gynecology department were well trained to handle the tremendous volume of patients that poured in each day at the OPD, but they were completely ill-equipped to handle the complex emotions and difficult situation that are bound to emerge every now and then.
I also observed that the healthcare professionals did not consider miscarriage significant and treated it like a standard surgical procedure. The medical professionals that I interacted with did not appreciate that miscarrying women experience the loss as a holistic event with social, emotional, and practical consequences. In reference to breaking the bad news, they readily used phrases such as the “management of the miscarriage,” “removal of the contents the uterus,” and “failed pregnancy” in front of the patient. It appeared to me a clear case of the “medicalization of miscarriage,” where miscarriage is viewed by the medical fraternity as a “singular event” with its “outcomes” and possible “complications.” Naturally, this “medicalized approach detracts from the complexity of this experience and contributes to a sense that miscarriage is being trivialized and its seriousness for the woman denied” (Frost et al. 2007, p. 1005).
Making the matters worse, the information I sought regarding the different medical options available for the termination of the pregnancy was not given either by the gynecologist or by the support staff. To be able to make an informed choice on the issue and to understand the future course of action, I had to resort to the articles on the Internet. Despite paying a hefty consultation fee, when I inquired about the possible reasons for the delayed miscarriage and the risk of similar complications in the future pregnancies, I was made to feel that I was taking too much time and was being too imposing with my questions. Even more alarming were the unethical practices rampant at the hospital. Despite the fact that I clearly opted for the D&C procedure for which I was going to be charged heavily, the doctor prescribed me medicines for medical management of the miscarriage a day before the procedure. I figured it due to my personal reading on the subject and immediately changed both the doctor and the hospital.
Only after my experience of miscarriage, I realized that early pregnancy loss is not yet widely acknowledgement as a form of bereavement. Healthcare professionals mostly normalize the event, and couples are mostly left all alone to grapple with their loss. The provisions of follow-up care, counselling, or support groups for couples experiencing early pregnancy loss are practically non-existent in India. I strongly feel that there is a need for creating awareness among healthcare professionals about the psychological consequences of miscarriage so that they are better attuned to the magnitude of the loss. Education and training should also be imparted to the healthcare professionals to enhance the inter-personal skills so that they are able to adequately respond to the needs of the patients. Such services are likely to minimize the danger of isolation and silent mourning. In this regard, it is pertinent to note that many researchers have assessed the efficacy of psychological interventions in improving the mental health outcomes for women after miscarriage. But, these reports have yielded mixed findings. A randomized trial research by Nikčević et al. (2007) demonstarted that the psychological interventions like counselling in addition to medical consultation is useful in reducing women’s distress after miscarriage. On the other hand, a large-scale randomized trial research by Kong et al. (2014) in China revealed that psychological counselling did not significantly lower the psychological distress of women after miscarriage. On the similar lines, another small-scale study by Rowsell et al. (2010) noted significant improvement in psychological adaptation after counselling among women who have experienced recurrent miscarriage, but the results could not be solely attributed to the counselling intervention. Given that the studies thus far have yielded inconclusive findings, perhaps there is a need to refocus on testimonials of women to assess the efficacy of interventions rather than relying solely on quantitative measures.
Based on the discussion above, in reference to motherhood, it may be convincingly argued that often the socially fueled explicit demands and culturally rooted implicit expectations take away women’s agency. Culture discourages the acts of questioning, and society renders the idea of choice meaningless in the name of the naturalness of the maternal desire, legitimacy of the institution of marriage, respect for the family, silence for preserving the dignity, and submission to the medical authority. In this paper, I submit that the act of questioning the expectations surrounding motherhood is crucial for women in reclaiming their agency in face of the hegemonic and patriarchal socio-cultural scripts. These scripts are patriarchal as while negating the subjectivity of a woman, they reduce a woman to a body that is merely an instrument of childbirth. These scripts are hegemonic as they force-fit the women from different leanings and background to surrender to the socially constructed idea of “motherhood” while relegating the non-conformists to the margins.
The cultural script of silent mourning in case of miscarriage may be considered as an extension of the prevailing patriarchal undercurrent where a failed outcome of pregnancy does not merit attention. The woman’s body in this case becomes a site of failure which needs resetting and prepping before the project of pregnancy could restart. In India, the healthcare professionals are interested in “fixing” the womb rather than helping a bereaved and perplexed woman make an informed choice with respect to her lost pregnancy. The medical professionals operate from a purely biological standpoint deriving the power from their medical expertise and clinical proficiency. Therefore, they find it convenient to take the decisions on behalf of the patient rather than sharing the necessary information to facilitate her agency and choice. In my opinion, this infantilization of women and the objectification of bodies at the hands of medical professionals are highly objectionable and unethical. The healthcare policies in India should mandate the medical professionals to empower women so they are in a position to assert their agency and make informed choices with respect to their body. It is important to cognize that the silent suffering in case of early pregnancy loss is detrimental for women’s mental health, and therefore, the stories of loss should be shared and deliberated upon in academia and beyond.
The series of events recounted and theorized in this paper took place almost 3 years back. The readers of this autoethnographic account might wonder why I took such a long time to document my experience. Why did not I share my story while it was still fresh in my memory and more alive in my experience? To this I would respond that though I started penning down my experience long back, I could not sustain continuous writing. It is significant to mention here that reflecting on, documenting, and conveying the sense of loss that I experienced so intimately was disturbing as it did tantamount to reliving the past in all its intensity. Consequently, I kept on abandoning this writing every now and then with no intention of resuming. Yet, I did return to it each time. I now reckon that the phases of abandoning and returning were helpful. Through my meanderings, I not only let myself grieve at an idiosyncratic pace but also managed working through my complex emotions. This spacing out also gave me much needed distance to hone my reflexivity which was instrumental in bringing out an honest recollection.
Until given its due space and redressal, grief has a way of sticking around, seeping in, and making us fragile. I intended to subvert that possibility and, thus, embarked on the journey of writing this account. It was a healing experience indeed. Working on this expression has helped me accept, address, and come to terms with my loss. Despite many abandonments, sustaining and finally culminating this writing has been my act of strength. I could gather that strength due to my resolve of deriving meaning from my loss. This tragedy was a loss of a possibility–possibility of being a mother, having different life, being a different person, and above all, having a child.
Having experienced the cultural silencing and resultant isolation, I now know that there are countless other women whose stories of loss are seldom told. I feel this cultural norm of silence around miscarriage is dysfunctional. It should be deconstructed, challenged, and abandoned in favor of a culture of sharing and compassion. As an academician, I have taken a step in this direction. I urge that my autoethnographic account be treated as an act of rebellion to challenge the norm of silence around pregnancy loss in the Indian society. Through this act of writing, I refuse to be relegated to the realms of silent mourning and reclaim my space for sharing and grieving.
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