Pregnancy Loss: How to respond with compassion

So, you have just learned of the pregnancy loss of a friend, a relative, a co-worker or an acquaintance. You want to offer an appropriate response, but you're not sure what that might be. In this blog we'll look at the considerations you'll want to keep in mind as you offer a comforting response.

A number of readers of my most recent blog have written to me, asking how to respond when learning of a pregnancy loss. You have acknowledged the awkwardness of not knowing what is the "right thing" to say, as well as the lack of familiarity with what the term pregnancy loss might encompass. And you are aware that, all too often, the world just turns its head when learning of a pregnancy loss. There may have been no bulging abdomen, no sonogram being passed around, maybe not even a public announcement of the pregnancy. Or there may have been all of these things plus more. What is missing in both circumstances is any ritual whereby comfort can be extended to the grieving couple. There are no Hallmark cards, no funerals, no gravestones, no memories to be shared among the mourners. Only a void. And it is into this void that you may decide to venture, with the hope that you are able to offer some support and comfort.

So let's consider a few things that will influence your thoughts about how to reach out to the couple. Keep in mind that a pregnancy loss may mean something different to each of them; also keep in mind that both are sad, so please do not fall into the trap of asking one partner how the no-longer-pregnant partner is doing. It is true that the woman has lost the pregnancy, but both of them have lost the dream of becoming birth parents to this baby, and both of them deserve a genuine expression of your sorrow.

Although pregnancy loss can mean a miscarriage or a stillbirth, it also can come about as a result of the agonizing decision of the parents to terminate the pregnancy, either because of learning the results of prenatal genetic testing or because a multi-fetal pregnancy reduction has been advised by the couple's physician who fears for the outcome of the pregnancy if the woman attempts to carry all fetuses to term. Some couples are comfortable sharing this decision with others, but many anticipate they will be harshly judged for their decision to terminate the pregnancy and they decide to present the pregnancy loss as a miscarriage. Regardless of how open the couple may be about the circumstances surrounding their loss, you will want to empathize with their sadness and to ask how you can help.

For some couples, the pregnancy loss is a dimension of their infertility. They may have had difficulty conceiving; they may have had earlier pregnancy losses; this may be a loss from an ectopic pregnancy (where the embryo begins to develop outside the uterus, often in a fallopian tube); or they may be told after an IVF procedure that, although they had a chemical pregnancy, the hormone levels did not rise sufficiently to sustain hope that the fetus would develop. For any couple grappling with infertility, a pregnancy loss is a terrifying reminder that they cannot take birth-parenthood for granted. Another, less discussed, form of loss occurs when a couple has made a plan to adopt, and the birth mother either loses the pregnancy or decides to keep the infant after its birth. The prospective adoptive couple has invested so many hopes in this adoption, that the loss will be a devastating end to what may have been years of infertility. So, with infertility as a backdrop, any form of pregnancy loss feels especially devastating.

Some people assume that the attachment to a pregnancy grows in proportion to the number of months the pregnancy was sustained. It is more accurate to let the couple tell you what this loss means to each of them, because that will enable you to understand more fully the emotions they had attached to this pregnancy, regardless of how far along it had progressed. And hearing from the couple will prevent you from saying hurtful remarks like "It's probably for the best," or "You can always try again." Instead it will feel more supportive to say "This is such a difficult time for you. Please tell me how I can be helpful/ let me know when you feel like a visit/ tell me if I can bring over some food (books, flowers) or run some errands for you." And then prepare to be a good listener.

Being a good listener is a gift, since it involves being emotionally present, accepting both anger and tears, and hearing various versions of events time and time again as the grieving person tries to make sense of this loss and what the future might hold. Although it may be tempting to offer what I call "false reassurances" ("I'm sure you'll be a parent some day," "You will begin to feel better soon,"), be aware that this response is more a reflection of your discomfort with the current sadness than it is an accurate prediction of hope for your friend. Try to be patient with the time your friend needs to absorb this sadness and to make sense of it.

Some couples decide that they want to have a quiet service to honor this baby who will never be born. Whether conducted by a spiritual leader or created by the couple and their loved ones, such a service can enable supportive friends to reassure the couple and their family of ongoing emotional support and compassion for their loss.

Some grieving couples appreciate the opportunity to talk about how they can memorialize this child whom they had hoped to parent. Keep in mind that many would-be parents have already discussed (and perhaps chosen) names, selected (or envisioned) nursery colors and decor, and begun to save items for the baby scrap book like congratulations cards and sonogram photos. For them this is not a pregnancy loss so much as the death of their dream child. In my book When You're Not Expecting, I mention couples who plant a memorial garden, donate to a children's library or a day care center, or identify a cause that they commit to in memory of their dream child.

Even months after a pregnancy loss, there can be a number of painful reminders that cause the pain to resurface. The previously-anticipated due date is one symbolic time. Celebrations of others' pregnancies and births can be emotionally difficult. Even the sight of a nursing mother or a father cuddling a newborn can evoke waves a sadness. These and other reminders of lost opportunities may be mentioned by someone who has lost a dream child, and your empathic response will be very much appreciated.

So, the take-away message to the question of how to respond with compassion is

• There are many ways in which pregnancy loss can occur. Communicate your wish to be a good listener so that you can understand the particular meaning this loss has for each member of the couple.
• Remember that the partner of the pregnant woman deserves to be recognized as someone who is entitled to grief, rather than being seen solely as the stoic comforter and protector.
• If infertility is a backdrop to this pregnancy loss, you will want to appreciate the couple's feelings of failure and desperation as they fear they may never become birth parents.
• Be patient, and let the couple know that you understand it takes time to grieve such a poignant loss and to make sense of how their lives have changed.
• Be aware of the mixed emotions couples may feel when being invited to celebrate news of pregnancies, births, or other events associated with successful reproduction.

Infertility gardens

As I'm looking out at the glorious spring weather, filled with sunshine and bursting blossoms, my thoughts of infertility take a slightly different turn today. I find myself thinking of the ways that the healing balm of nature has calmed sadness and grief of friends and clients experiencing infertility. For those of us tempted to seek solace on the internet, by reading articles and books, through comfort food, or just seeking some solitude, there's yet another option: creating a garden.

First, I will confess that I do not have a green thumb. Nor do I have any experience designing green spaces. But I do love to walk and hike in natural surroundings, especially in the spring. I have many acquaintances who have shared with me the comfort they have received by designing, planting and nurturing special gardens in their back yards and on their apartment building roofs. Perhaps you can identify with some of these scenarios (I will be changing all names and some identifying information to protect the privacy of my acquaintances).

Janice and her husband Bob experienced three miscarriages over the course of two years. After grieving these losses, they wanted to move forward emotionally, but they did not want to forget the hopes and dreams for these children who would never be born to them. So they decided one winter to spend time designing a back yard garden to plant in the spring. They planned their garden with three sections, each one unique in colors and plantings. Poring over seed catalogs during the winter, they planted some seeds in small pots indoors and purchased others in local greenhouses during the spring. Once the threat of frost was over, they devoted several weekends to tilling the soil, planting the bulbs, seeds and sprouting blooms, and applying fertilizer and mulch. Janice, still hoping for a healthy pregnancy, kept herself at a distance from the fertilizer, as she offered suggestions to Bob. Both of them found the garden to be a source of pleasure and calm during the warm months of spring and summer, and as they weeded and watered, they found their own relationship strengthening as they were able to talk openly about their diminishing grief and their continuing hopes for parenthood.

It had been four months since the funeral for Missy and Joe's stillborn son, Jason. The baby's body had been cremated, and they had been unable to decide where to place the ashes, which remained in an urn at the undertaker's. Both were anguished at their inability to find a resting place for Jason's ashes. In conversations with their minister, they eventually decided to plant a back yard garden and to scatter the ashes there. Having reached that decision, they enlisted the help of loving friends and family to offer suggestions about plantings, manual help with tilling and fertilizing, and especially cherishing a hammock that could be hung between trees nearby with a clear and shaded view of Jason's garden. When the time came to scatter Jason's ashes, their minister joined them and their loved ones for a small dedication of this garden planted in his memory.

When Carla had a miscarriage, she collected the remains and took them to her doctor. He indicated that he would send a small sample for genetic and other tests, and Carla decided to bury the rest of the remains in a rose garden in her back yard. She and her partner Kelly buried the material in a shoebox. To their horror, two days later they found that a mole had tried to burrow into the shoebox, disrupting both the garden and their peace of mind. They responded by placing the shoebox into an airtight metal box, which they reburied without further incident. Both now feel that this pregnancy loss has been softened by the presence of the surrounding beauty of the nearby roses.

Susan and Jared were reluctant to plant a back yard garden in their baby's memory, since they expected to move into a different neighborhood within a few years. It would be too difficult to have invested the emotional energy in planting flowers and bulbs, only to leave that garden behind when another family purchased their home. Instead, they decided to plant a tree, with a bench nearby, in a favorite park where they often spent time. Beneath the tree was a rock with their daughter's name and birth date engraved on it. They both derived comfort from this memorial tree, as well as from seeing other people pausing on the nearby bench to read, rest, or enjoy the natural beauty around them.

After two failed adoption attempts, Sandra and Jeff were in a quandary about whether or not to continue to pursue adoption as a path to parenthood. They lived on a dairy farm with gardens in which they grew fruits and vegetables. One day a friend of Sandra asked if she could bring children from her day care center on a field trip to the farm. As they discussed this plan, Sandra suggested that the children might enjoy a chance to create their lunch from the gardens: some gazpacho, a salad and some strawberry shortcake for dessert. The lunch was such a resounding success that the children begged to be allowed to come back again. Future visits included the chance to milk a cow, to feed baby goats, to cuddle newborn kittens and to romp in the fields. As time passed, Sandra and Jeff found themselves enjoying these short term fun experiences so much that they decided to remain childfree, but to nourish their contacts with several day care centers whose children relished the opportunity to visit their farm in all seasons of the year.

Karen and Chris had buried their stillborn daughter Nora in a cemetery plot near that of her grandparents. When spring came, they realized that the ground was untended near the grave, and they decided to plant bulbs that would bloom annually, as well as wildflowers that would bloom throughout the spring and summer months. They found that the flowers and plantings had a calming effect on them during what they had feared would be tearful visits to Nora's grave site.

Infertility and sadness are intertwined. Yet the beauty of nature can be a cushion against grief associated with the losses of infertility. As the scenarios above suggest, our own creativity in using the bounty of blooms and bulbs to create a garden can be a different approach to healing from sadness. A green-thumbed friend said to me recently, "Gardening tills the soul." In these days of spring, consider whether some plantings could offer comfort to you or a loved one struggling with infertility or pregnancy loss.