Losing a Baby: The Impact on Subsequent Pregnancy and Birth

The loss of a baby is profoundly shocking - the disintegration of hopes and dreams that goes against the perception of the natural order. It might be termination for foetal abnormality, miscarriage before 24 weeks , still birth post 24 weeks , neonatal loss during birth or in the first 4 weeks of life or Sudden Infant Death Syndrome. The world feels dangerous, unjust and uncontrollable and life unbearably fragile.

It is more common than many realise because it is often not talked about, leaving bereaved parents bereft, stigmatised and isolated. There have been considerable advances in intervention by medical staff and therapists following a death - perinatal counselling in some hospitals following baby loss; enabling parents to engage with their still-born, to create memories and observe religious rituals; and private therapists offering specialist support. Support groups can also be invaluable. However, the experience remains traumatic and can have deep implications for pregnancy and birth of a subsequent baby.

Mothers may feel external or internal pressures to conceive very soon or to wait while they process the loss. Well-meaning family and friends weigh-in with advice, perhaps to deal with feelings that they cannot cope with. Medical advice suggests waiting up to a year for full recovery. Yet women may be anxious to conceive again quickly in order to move on, bury the loss, prove that their body can do what it is meant to do or counter the ticking of the fertility clock. At the same time, they may feel intense guilt and sadness and not want sex or fear another pregnancy. This ambivalence creates tensions within couples who may be grieving differently and have different aspirations for a future family.

Pregnancy after the loss of a baby

When a couple does conceive again, joy may be darkened by incomprehensible emotions. They cannot allow themselves the excitement of pregnancy milestones such as getting past the first trimester, the 20-week scan, the first foetal movement etc. They are hyper-vigilant, terrified and can feel unworthy, insecure and unprotected. There may be intense fear that something will go wrong again, giving rise to almost intolerable daily anxiety.

Some women avoid medical intervention due to traumatic previous experiences. I have counselled women terrified by blood pressure tests or who dread every visit to the toilet in case of tell-tale blood spotting. Others become obsessed by the need to check their pregnancy daily, especially before visible signs or foetal movement can be detected. They request extra NHS or private scans just to hear the heartbeat and see the developing baby - although the reassurance is short-lived and only creates a burning need for further proof that there is still a healthy baby. Women living with this new state of their body and its mental and physical changes may resent partners who seem able to get on with life and switch off anxiety. I try to help couples see that it is not that either of them FEELS any less, only that they experience and manage these feelings differently and how important it is that they communicate.

The symptoms of trauma

Women and men who have experienced a traumatic baby loss, perhaps with serious risks to the mother's life, may experience symptoms of post-traumatic stress disorder  PTSD . This condition -  often associated with war or disasters - is common after difficult births or baby loss. Characteristics include flashbacks, panic attacks, nightmares, difficulty sleeping or concentrating, depression, numbness and avoidance of places, people or situations that generate memories. If untreated, symptoms can recur with a vengeance during a subsequent pregnancy, leaving women terrified and debilitated by this new baby they are carrying, because of the memories of what happened before.

For others there may be a range of other difficult emotions associated with pregnancy after baby loss. Unresolved grief; incomprehension and a longing for explanations; anger justified or not at health professionals; envy of those with healthy babies; guilt and shame at not protecting their lost baby; a fear that their body is toxic and could harm another baby; and the impossibility of believing in a viable new life. It can shift parents' understanding of life and death. They feel obliged to hide sadness in case they are shunned or seen as a negative influence. There is social isolation in the "abnormality" of losing a baby and being excluded from the normal excitement of pregnancy. One woman said of her antenatal classes "I felt I shouldn't be there. My sadness and loss might contaminate the others. They talked about the colours of buggies and breastfeeding and sleeping tips and I wanted to scream 'All I want is for my baby to LIVE...'.

The potential impact on future children

There is also a potential significant impact of previous loss on the new baby. The process of "attachment" - the vital emotional connection of a child to primary caregivers that significantly influences the ability to form and maintain relationships throughout life - is believed by many to begin while the baby is in the womb. The violent rupture of this prenatal attachment when a baby is lost can inhibit the process of developing attachment with a subsequent foetus. It may also impact on bonding and parental relationships once the new baby arrives and can adversely affect the child's healthy attachment to the parents, with the risk later in its life of other psychological problems.

Research studies have examined the "vulnerable child" syndrome or the "replacement child". Mothers may feel emotionally guarded or excessively protective of a new baby and over-react to the normal illnesses and risks inherent in childhood. One mother I know still describes her 18-year-old robust and healthy son, born after four late miscarriages, as "my miracle baby" and is aware that she has favoured and over-mothered him in subtle ways all his life. Another went to A&E 10 times in the first three months, terrified that her baby was dying. A child is often aware that s/he has been born into a grieving family and may feel pressure to live up to the characteristics and expectations of the lost child, feeling that they have to fill the gap. The new baby may resemble the dead baby physically in ways that parents find agonising. The child may experience "survivor guilt" - guilt and confusion that s/he survived while the longed-for sibling did not and experiencing an overwhelming responsibility to compensate.

How can these risks be minimised?

• Baby loss must be known, acknowledged and respected. Parents need time to grieve in the most appropriate way for them, however long it takes. Suppression of grief is mentally harmful. There is no formula to manage grief, although some writers suggest time frames,  methods and techniques in ways that help some people. Yet grief is different for everyone. Parents may still be grieving while awaiting a new baby and, if handled sensitively, this is not necessarily incompatible or detrimental. Incongruent grief of women and men must be acknowledged.
• Ambivalent feelings must be explored for what they are - not as an indicator of mental instability. It may be helpful to keep a family place for the lost baby but not to the detriment of those who are living - a balance must be kept.
• Therapy and counselling can be very helpful at many stages of this process from death to new life and beyond. In the depths of a couple's despair the therapist can hold the hope of the new baby until they can accept it for themselves. They owe it to their new baby as much as to the lost baby and other siblings to prepare their mental space as healthily as possible for a new beginning. Therapy continues to be very important after the birth of the new baby to understand how the previous loss may still impact on the family.
• PTSD needs specialist treatment and should not be ignored.
• For an extremely anxious mother and if financially feasible it can be helpful to have a private midwife who is available throughout the whole pregnancy and present at the birth, working alongside wonderful NHS midwives who cannot dedicate themselves throughout a pregnancy to the same woman. For other women, support organisations may be helpful.
• The idea that a lost baby can be replaced by a subsequent pregnancy is wrong and especially hurtful - family, friends and medical staff should avoid such unhelpful misconceptions. If in doubt, be guided by what the parents are saying.
• Remember that bringing new life after death can help parents develop resilience and empathy with others who are struggling towards parenthood. It can lead to a positive change in family priorities and a greater sense of the preciousness of life that fully acknowledges the place of lost baby and the new life that follows.