A miscarriage, medically referred to as a “spontaneous abortion” or “pregnancy loss”, is when an embryo or foetus dies before the 20th week of pregnancy, i.e. a miscarriage usually happens in the early stages of pregnancy. It is a rather commonly experienced kind of pregnancy loss, with Rajarata University Faculty of Medicine and Allied Sciences Department of Community Medicine Founder Prof. Suneth Agampodi sharing that at least 24% of pregnancies in Sri Lanka end in miscarriages.
Prof. Agampodi based his statement on a study conducted by himself, Prof. Ayesh Hettiarachchi, and Prof. Thilini Agampodi, affiliated with the same department, titled “Making miscarriages matter”. Prof. Agampodi shared that worldwide statistics may not be representative of the Global South and therefore, there are inaccuracies in the represented numbers.
He added that around 30% of pregnant mothers face this issue and therefore, they should not be depressed or discouraged about their miscarriage.
While medical professionals will tell you that feelings of grief and loss are normal after losing a pregnancy, it is an entirely different story whether women who have suffered miscarriages are offered the necessary psychosocial support to effectively deal with their experience.
Midwives’ Association President Devika Kodithuwakku shared her thoughts on the matter, expressing that in the case of midwives, they are the first touchpoint most pregnant women have with regard to their care and wellbeing. “When it comes to families in villages and rural areas, the midwife is an integral part of the community, and young couples who become pregnant are all always put in touch with a midwife in their area,” she said, adding: “The midwife would function as a second mother to the embryo or foetus, taking care of the pregnant mother and attending to all her needs and queries.” Therefore, a midwife would be the first person that a woman who suffers a miscarriage would lean on.
Kodithuwakku stated that despite this, however, with regard to midwife training, they no longer have to attend training on psychological support. “It used to be that those who undergo midwife training in nursing school would have to participate in a two-week course at the government mental health hospital to learn how to deal with the psychological aspects of pregnancy. This portion of the syllabus was later curtailed to a one-day training programme and since then, it has now been entirely abolished,” she said.
“This is very wrong and I think it should be reinstated because while we are able to show empathy and kindness, and we encourage our midwives to provide the best possible care to their patients, professional training could greatly elevate this service,” she shared, adding that there are many experiences she has had with women who suffered greatly after a miscarriage. She said that sometimes, mothers are aware of the struggle, but they need help to get out of that mindset, adding that many of them sometimes just wish for one to acknowledge that plight of “I have suffered a miscarriage, and I am grieving”, and regardless of the term in the pregnancy during which a mother lost her embryo or foetus, mothers will always grieve.
Speaking to psychiatrist Dr. Anoma Jayasinghe, she shared this is a very sensitive topic and one that is very rarely talked about, despite having potential to cause grave emotional suffering and damage. She said that there is very little to no research on the phenomenon of psychological morbidity resulting from miscarriages, and even less about the general psychological effects that women may experience.
She said: “Often, there is a belief that if the miscarriage happens early on in the pregnancy, i.e. perhaps in the first few weeks, then mothers may not grieve as much or they may not feel the sorrow as gravely as they would have had the pregnancy progressed a lot further. However, this is simply not true; the woman has experienced a grave loss and that grief is there, regardless of whether it happened early in their pregnancy term or not.”
Dr. Jayasinghe shared that there really is no targeted support for these women. However, the gynae ward will identify the cases of women who develop psychological morbidity and direct them to get support, and in case of women who may not appear to be experiencing clinical depression, most wards have a practice of arranging for a mental health professional to have a casual chat with the woman to gauge her status. “But this is not a thorough and full assessment,” explained Dr. Jayasinghe.
She also drew attention to an even lesser addressed misconception where a miscarrage takes place in the case of an unwanted pregnancy. “In cases where the pregnancy was the result of a rape, when they suffer a miscarrage, it can be viewed as a good thing. However, the woman may still experience grief; it is not cut and dry in that way,” she said.
Drawing attention to the consequent results of experiencing a miscarriage, Dr. Jayasinghe said that often, it takes a toll on the marriage because, “the thought of sex, which may have been associated with fun and feeling good, may now be for function, and this may affect the married life of the couple”. Dr. Jayasinghe added that there is the other side of things where the effects of a miscarriage are not only suffered by the woman; the husband too may experience a period of grief and that is an even lesser discussed area.
Gynaecologist Dr. Chandrika Yapa, speaking on the causes of miscarriages, shared that they are often due to either genetics or structural or other abnormalities and that a significant portion of it is due to a condition known as polycystic ovarian disease (PCOS), which is caused by a hormone imbalance. “Women with PCOS are more prone to early miscarriages, bleeding in early pregnancy, or growth restriction of the baby,” she said.
A study of the psychological impact on women undergoing a miscarriage in a Sri Lankan hospital setting, conducted by R.N.G. Rajapaksha – North Colombo Teaching Hospital Ragama; T.S. Palihawadana – Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Kelaniya; and L.R.A. Wijesooriya – North Colombo Teaching Hospital Ragama, stated: “Miscarriage is common and affects one-third of women some time during their lifetime. Its management has seen many advances in recent times including introduction of less interventional methods, thus seldom causing serious complications. However, the psychological morbidity associated with miscarriage is often overlooked and data on the subject among Sri Lankan population is scarce.”
Expressing similar sentiments, Sri Lanka College of Obstetricians and Gynecologists (SLCOG) President Dr. Pradeep de Silva expressed his frustration over the matter, stating that this is an area that needs absolute attention. He shared: “We are fairly behind in these matters; when it comes to the medical assistance offered for such patients, there are so many glaring elements that are lacking.” He added that when it comes to psychological support and counselling, Sri Lanka is simply lacking, noting: “Not only is the administration not facilitating these needs, but the general attitude of the public towards these very sensitive matters is disheartening and disappointing.”
It can be concluded that the medical community is generally dissatisfied with the way psychological support for those who experienced a miscarriage is handled, and while it can be expected that time will be a major factor in implementing effective change, perhaps the public could take point in acknowledging the importance of making women comfortable about talking about the difficulties they experienced as a result of suffering a miscarriage, and showing empathy and kindness to those who are grieving as a result of it.
