On This Day of Mothers and Sons

I was moved by this essay, which clearly was written by someone who is not only a gifted caregiver, but also a gifted writer. In sharing this experience, Dr. Shields provides a valuable model of courageous, compassionate care-giving during the heartbreaking process of diagnosing and communicating fetal demise. I particularly appreciated her decision to be honest with the patient about the likelihood of loss before waiting for sonographic confirmation, and her choice to confirm the bad news promptly and directly while in the sonogram room. I was also impressed by her willingness to make herself available to this woman during “most of the rest of the morning,” answering questions, going over options, consoling her with words and touch.

In addition to such exemplary care at the time of bad-news breaking, there is much that should be done both before and after this pivotal moment to reduce suffering. There is no getting around the fact that the loss of a wished-for pregnancy is devastating, but twenty years of ethnographic research have convinced me that middle-class American women are sorely and inexcusably under-prepared for the possibility of loss. In the wake of second-wave feminism’s embrace of the credo, “knowledge is power,” and a move in American medicine to be more forthright with patients about their “chances,” it is stunning how little pregnant women are told about the possibility of pregnancy loss. It is not normally discussed at the first prenatal visit, even though the greatest chance of loss is during the first weeks. In fact, doctors often wait to schedule the first visit until after the greatest risk of loss is past, but in not sharing their knowledge about the frequency, symptoms, options, and consequences associated with pregnancy loss, they do their patients a great disservice. Dr. Shields wonders why her patient did not come in sooner, given the prolonged lack of fetal movement. My guess is that she had not been told that a decrease in fetal movement might be a sign of fetal distress and that if it occurs she should seek medical care because of physicians’ desire not to inflict undue worry on their patients (and to protect themselves from an onslaught of hysterical women demanding to be seen). Similarly, physicians balk at the idea of presenting pregnant women with information on early pregnancy loss in a timely manner for fear of diminishing the pleasure for both physician and patient of a welcome pregnancy. But withholding information like this is patronizing and no longer acceptable in other branches of medicine. Furthermore, we know that the ability to hear, take in, and rationally process new information is diminished in a crisis, yet it is precisely at such moments that women are presented with information on pregnancy loss. I discuss a number of ways to better prepare women in my forthcoming article in Feminist Studies, “‘A Women’s Health Model for Pregnancy Loss’: A Call for a New Standard of Care” including more thorough and appropriately timed coverage at prenatal visits, in pregnancy preparation classes, in lay pregnancy guides, as well as more frequent, detailed representations of loss in popular culture.

This brings me to another moment in Dr. Shield’s account. She describes suggesting “a moment to collect ourselves” before walking back to the examination room from the sonogram room since the route required traversing two waiting rooms. This raises a number of important issues. Given the frequency of pregnancy loss and the standard use of sonograms to confirm fetal demise, such journeys must happen on a regular basis. Why hasn’t any prior thought been given to the consequences of this office layout? Why haven’t alternate routes been designed? I know from my own experience how excruciating it was for me to walk out through a waiting room of bulging bellies after having my womb emptied with a D&C in my doctor’s office. Dr. Shield’s comments also reveal her awareness of the impact of this design on other patients. She is cognizant of the spectacle they will make, “not the expected joy of pregnancy but rather a red-eyed pregnant woman with somber companions.” While I believe that it would be better for the grieving mother to be spared this experience, the alternative would be another way of masking the painful reality. Given the dearth of exposure women have to the possibility of loss, this spectacle may actually serve some remedial function in alerting others to this potentiality, but, as I have mentioned above, there are plenty of other ways of informing and exposing them that do not require additional suffering on the part of a grieving mother.

In addition to better preparing women before a loss, and thoughtful, patient-centered care when a demise is discovered, there is room for improvement in the care provided women during their loss. Given the advanced stage of Dr. Shield’s patient’s pregnancy, it is likely that she was given the option of either inducing labor or waiting for labor to begin, and would have been given appropriate, sensitive care in a hospital during her birth. But for women who suffer the much more common miscarriages, current standards of care are inadequate. Women are generally given the option of unnecessary surgery or (whether medically or expectantly managed) sent home to miscarry on their own. Just because there will not be a live birth does not mean that women do not deserve the same level of trained, hands-on support offered to women who have the prize of a baby to show for their efforts and suffering. Homebirth provides a valuable, easily adaptable model for home pregnancy loss.

A final issue this essay raises is support to bereaved mothers after a loss. In the last twenty-five years there has been much progress in this area, both in the form of hospital bereavement teams and peer-based support with more and more of the latter taking place on the web (although face-to-face groups still play an important role). It is unclear how good the resources would be for someone like Dr. Shield’s patient, a Salvadorian with little English. There are some print materials in Spanish, but most likely she would have limited access to support groups or internet support, so equitable access is an issue which still needs attention.

As a bereaved mother (7 miscarriages) and pregnancy loss advocate, I appreciate Dr. Shield’s generosity in offering her patients such high quality care and in sharing her experience in this forum.

Competing interests:   None declared