WITH up to 20% of pregnancies ending in miscarriage, for many medical professionals it’s seen as a common adverse pregnancy outcome.

However, for the parent who has just been told their long-awaited baby has died in early pregnancy, it’s a deeply personal, and often lonely, journey.

In a Reflection published in the MJA, Dr Melanie Keep wrote about her own miscarriage and the care she received that affected her experience.

“In the days, weeks and now years after our loss, I feel the silence of miscarriage reverberating through my life. This silence limits our ability as family, friends, colleagues, and health professionals to support women and their partners to reconfigure their lives after early pregnancy loss,” she wrote.

For Dr Keep, this silence started with the long-held belief that women should hide their news until after the third month of pregnancy.

“This rule exacerbates the silence around miscarriage, and permeates many Australian health and medical guidelines and legislation where miscarriage is not explicitly mentioned or acknowledged,” she wrote.

Perinatal loss practitioners suggest that health professionals encourage families not to wait to share their news and do away with this “12-week rule”.

Dr Renee Miller, a perinatal clinical psychologist and founder of the Perinatal Loss Centre, said that by not sharing the news of a baby early, it minimises the early pregnancy experience.

“What that’s done is create an environment where people minimise that baby in the first 12 weeks and just see it as a pregnancy. Those people around them aren’t privy to what it meant, and all the anticipation of that relationship with that baby,” she explained.

According to her colleague, bereavement midwife Eliza Strauss, it also reduces the support the couple receives if something goes wrong.

“It’s kind of a double whammy, because … we have to tell them we were pregnant, and then we lost the pregnancy. It’s harder for people to support you on the back of bad news versus being there for the journey,” she explained.

As a society, we find it difficult to talk about pregnancy loss. Even after a miscarriage, many people don’t share their loss with family and friends, reinforcing a sense of shame.

As medical professionals, Ms Strauss believes we need to be more open about talking about pregnancy and the things that can go wrong.

“We certainly need to talk more about when it goes so wrong that either mum or baby dies. We’re the health professionals and it needs to start with us. The more comfortable we are with it, and the better we are providing education around perinatal loss, that will filter through,” she said.

Many women with unexplained bleeding in pregnancy will head to their emergency department. However, according to University of Melbourne Primary Care researcher Professor Meredith Temple-Smith, the experience they have will vary enormously.

“Some emergency departments have protocols for how to manage women sensitively … and some of them can refer to an early pregnancy assessment. But others don’t have anything special that they can do. We really need to take this whole process and walk through the pathways to see where we can intervene to make things better,” she said.

Their miscarriage experience will also depend on the staff on duty that night and how busy the department is.

“At worst, they will get insensitive care, little acknowledgement for their loss, and the sadness that accompanies the shock of that news. And they’ll be sent home with ‘just come back if you have any problems’. That’s the worst-case scenario, but it does happen because I hear those stories,” Ms Strauss said.

When supporting families through a miscarriage, it’s important not to minimise their loss, regardless of the baby’s length of gestation.

“A lot of health practitioners don’t understand that the level of grief and loss is not actually associated with the number of weeks of pregnancy.

“There’ll be some people who lose a pregnancy very early on, and they will be incredibly grief-stricken for a very long time. There will be other people who have a miscarriage later on and who will be able to manage that grief in different ways.” Professor Temple-Smith explained.

It’s important to be guided by the family and come from a place of compassion

“This person in front of you has had something tragic happen. Once you’ve sorted out the medical side of their loss, whether you’re a GP, nurse, sonographer, you need to find a way to be in that space and sit with someone who’s just so sad about their loss. It’s hard, but that’s what they need. They remember years later what was said, not what was done to them,” Ms Strauss said.

The experience they have can also affect their mental health in the future.

“We know that about half of women who have a miscarriage had some kind of psychological morbidity afterwards. For a smaller proportion of them, some may end up with a major form of depressive disorder, and some will end up with heightened anxiety,” Professor Temple-Smith warned.

There is an increasing number of resources for both families and medical professionals. Organisations such as the Pink Elephant Support Network, SANDS and the Perinatal Loss Centre have resources such as fact sheets, extra support and training for medical professionals.

The Australasian Society for Ultrasound in Medicine is developing resources for supporting sonographers in communicating unexpected findings in an ultrasound.

However, there is still an absence of miscarriage in Australian health guidelines.

Dr Keep hopes that if she is ever unfortunate enough to have a miscarriage again, her experience might be different.

“I am hopeful, however, that between my losses, medicine and health would have listened beyond the silence,” she said.

With October being Pregnancy and Infant Loss Awareness Month, there’s never been a more important time to talk and listen. It’s time to change the narrative of miscarriage.

12 thoughts on “Silence of miscarriage: time to ditch the 12-week rule

  1. Dr Selina C says:

    As a medical registrar who has had recurrent miscarriages this year, including one past the “12 week safety mark”, I have to say that I disagree with some of the comments here. Women know very well that miscarriage is common. Many have apps, are part of pregnancy discussion boards and discuss fertility and pregnancy planning with their friends (it is 2021 after all!) Despite this knowledge and preparation, let me tell you that NOTHING can prepare you for that earth shattering moment when you are told that there is no longer a heart beat.

    Suggesting that the patient’s emotional response and expectations are the problem is comparable to telling off a patient for grieving the death of a loved one. Insensitive is the least offensive word that comes to my mind. When did we become so emotionally blunted as a cohort?

    Apologising, acknowledging how terrible the situation is and spending quality time with the patient is the bare minimum of what doctors can do for patients in what is arguably one of the worst times of their life. Offering support services such as Pink Elephant and SANDS and suggesting a follow up appointment to check in on their wellbeing and/or address any lingering questions/concerns should be mandatory.

  2. Anonymous says:

    I agree prospective parents need to be prepared for the possibility of early pregnancy loss so I introduce the subject early, before there is a pregnancy if possible. With regards to the 12 week rule – I say something like tell those who can and will support you through the journey whatever happens,. Nature is incredible and she’s also cruel sometimes. I must heartily disagree with the idea that there is “ a correct emotional response” to miscarriage. Why would we imagine we have any right to dictate a correct emotional response? . Our role is to inform, to support and meet our patients where we find them including emotionally. Tell a woman who has just passed the foetus on her bathroom floor along with more blood than she has ever seen, after two previous pregnancy losses that her correct response is “ disappointment” and I promise you she will not experience that response as remotely helpful , far less compassionate. If we are to truly support patients to process what is often a terrible loss despite what they knew leading up to it, then our job is listen and validate their experience rather than diminish it , and in so doing help them come to terms with it.

  3. Anonymous says:

    I think there are a spectrum of responses to early pregnancy loss. Education around the incidence of miscarriage is important. The parents can then choose how they want to acknowledge early pregnancy to others. Individualised responses are most appropriate if miscarriage occurs. I was given the speech about how it’s “natures way of taking care of her mistakes” which I found hurtful. It’s a tough time. Hopes and dreams for that potential child are dashed.

  4. Max says:

    One cannot help but be struck by the screen that is drawn between two conversations.
    On the one hand here are the stories of rightly anguished mothers who have miscarried and are forlorn at the loss of their highly cherished baby.
    On another day and another site will be a discussion about termination, where at less than 12 weeks the term ‘baby’ will never be uttered.
    We remain unable to reconcile these two conversations and to understand how the ethical and philosophical status of that entity we here call a baby can be so utterly dependent on whether it is desired or not by another person who happens to be bearing it.

  5. Anonymous says:

    I 100% believe in the 12 week rule. As a medical professional, I know how common miscarriage is, but as a patient who struggled to conceive and then miscarried, I needed to deal with this in my own way and time. The prospect and thought of having family and friends know I miscarried leads right into the path of them finding out regarding our private fertility issues. I also know and hear the well-meaning but ultimately insensitive comments that others have been on the receiving end of. I confided in a few close friends, and they provided deeper support having understood how much this pregnancy meant given our history. My family didn’t need to know this, and would not have understood or provided appropriate supports. I am certain that familys comments would have resulted in worsened grief and a stronger sense of being alone in unfamiliar territory.

    The 12 week rule is good, but should a miscarriage occur then encouragement to talk to a few well supportive family members or friends should be encouraged… but not a mass announcement that may need retracting later!

  6. Anonymous says:

    i had the privilege of being a specialist Ob/Gynae. i visited a rural community approx 100 kms from the nearest capital. this on a monthly basis to see through an operating session in the morning ,and a clinic in the afternoon.
    i became aware that those miscarrying in the rural catrchment were more “relaxed” about first trimester miscarriage, as opposed to their city/ suburban cohort.
    i came to realise that country folk were aware that not every animal pregnancy went well, therefore seemed more balanced about miscarriage as human animals . Unlike the city cohort who were far more dramatic about their animal failing as they had no exposure to natures falability.

  7. Dr Chris Briggs says:

    Absolutely agree.
    Even aside from the barrier this ‘rule’ creates in accessing support in the event of a miscarraige, it only serves to make life for difficult for ALL pregnant women during this first 12 weeks. Women shouldn’t feel they have to actively hide and lie about their pregnancy to those close to them, often whilst feeling horrendous with nausea/vomiting/exhaustion, often whilst also trying to manage work as though nothing is going on, and perhaps whilst managing other children! I’ve no idea how they do it!
    The more support, and the earlier, the better, for ALL pregnancies, I would think.
    And if miscarraige were a less hidden issue, maybe we could even work towards some form of dedicated employer supported leave, rather than calling it ‘sick leave’.

  8. Anonymous says:

    Education needs to be provided to ultrasonographers /radiology practices as well – the absolute worst moment for me when I had a miscarriage in my second pregnancy at 7 weeks was when the ultrasonographer left the exam room saying she needed to check the images with the radiologist. As a medical practitioner I knew exactly what had happened ( I had been bleeding for 2 days) and I said to her “there’s no heartbeat is there” and she just walked away.
    I know that radiographers are not permitted to interpret scan findings or report them to patients – but I don’t know what the answer in this situation is meant to be. I suspect that most women even without medical knowledge would have been able to work out what was going on. My distress was made so much worse by being abandoned right then.
    This was 25 years ago but I can recall it precisely.

    I was fortunate to have another baby after this miscarriage. I do however remember clearly not feeling normal until I was pregnant again- like something was missing. Having told no one about my first pregnancy till 16 weeks (very paranoid – not sure why ) I told all my friends and family about the second pregnancy basically the week before the miscarriage and telling them all I’d miscarried was very traumatic – like double whammy.

  9. Anonymous says:

    A problem is lack of such high quality communication yes. another problem is the direction of society’s travel to add lots o mental/emotional attachments to elements of natural normal life. We could and should tell people just how common miscarriage is. But if 5 minutes later they are reading facebook with heaps of the diametrically opposite message pushed by people or indeed researchers/institutions/companies/publications who have things to gain from telling people how sad/traumatised they should be then the outcome for us will be poor. I noted that the singer lily Allen got a heap more pubilcity for her miscariage than a lot of her professional work. Why? What it is about people’s traumas that sells so very well.

  10. Jules Black says:

    As a retired Ob/Gyn, I always found the truth is always the best path to go down once you’re absolutely certain, no matter what the gestation. Women have a heightened “radar” looking for all clues in pregnancy. She sees the frowns appearing on the sonographer’s face or other medical attendants. After all, perhaps as example the morning sickness has suddenly got better, their breasts are no longer as full, their polyuria has decreased suddenly. I have learned to say to the women, “I think you know what I’m going to tell you”. “I’ve lost it” or similar is the invariable response. THEN the full discussion follows.

  11. Neville Steer says:

    This is an important issue. I was encouraging women to avoid this 12 week rule at least 25 years ago. Unfortunately a lot of the belief in the need for secrecy relates to social “norms.” This is a role for social media influencers to pick up on and promote change.

  12. Dr Julian Fidge, rural GP says:

    The problem is with the medical profession. We know so much and communicate so little.

    Parents should be informed before they become pregnant that miscarriage is common. The reasons for this are that education is protective against trauma developing into a disorder and that we have a duty to tell patients what we know are significant risks. I don’t think most doctors or nurses give the risk of miscarriage the attention it merits.

    Parents should be informed the creation of life is extremely complex, and does not always occur successfully. Miscarriage is usually for a reason that makes the pregnancy unviable, and so it is best for the pregnancy to end as soon as possible so the parents can try again if they wish.

    Parents should be informed that the correct emotional response to early miscarriage is disappointment, not grief. The miscarriage most probably prevented an unviable pregnancy from progressing and creating further distress for everyone.

    How the parents are managed determines the outcome. I have friends who take the same date off work every year, and have done, for thirty years, because of a miscarriage. If they had been better prepared for the possibility of miscarriage, I think they would have been much less traumatised.

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