Pregnancy Loss and Postpartum Depression

Lately, following conversations with colleagues and patients, I have been doing a lot of thinking about pregnancy loss. In particular I've been wondering about its effect on subsequent term pregnancies, and relationships between parents and these children. In researching this subject, I came upon a study from 2011 in the British Journal of Psychiatry showing that depression and anxiety following a miscarriage may last for almost three years, even after the birth of a healthy baby. Researcher Emma Robertson Blackmore, PhD, an assistant professor of psychiatry at the University of Rochester Medical Center said of the study:

Health providers and women themselves think that once they have a healthy baby after a loss, all would be fine and that any anxiety, fears, or depression would go away, but that is simply not the case. I honestly thought that once a woman had a baby or had gone past the stage of her previous loss, the anxiety and depression would go away, but these feelings persist.

As a culture we often do not recognize the deep significance and impact of pregnancy loss. I still vividly recall my own family's well meaning reassurances of "don't worry you'll get pregnant again," that seemed so remote from the pain I felt following an early miscarriage.

In my work as a behavioral pediatrician, I frequently hear stories (identifying details, as always, have been changed to protect privacy) from mothers who have not had the opportunity to mourn the loss of a pregnancy. One mother told me about of having lost a baby at term and then suffering with severe postpartum depression (PPD) when her healthy child was born a year later. A five-year-old girl I saw struggled with severe separation anxiety. At first the focus of our work was on what to do to get her to sleep in her own room. But as we got to know each other, her mother, for the first time, spoke openly about her grief over a miscarriage when her daughter, an only child, was three. The little girl, it turned out, was worried about her mother. At the root of her separation anxiety was a wish to to protect her mother from feeling sad.

Mental health professionals who work with adults describe the phenomenon of the "replacement baby." These are adults who were born following the death of a previous child. When parents have not spoken of this child, or have not been able to fully grieve this loss, it may have significant long-term effects on the mental health of subsequent children. These effects may, in fact, persist for generations. One mother I worked with was such a "replacement baby." Her older brother had died at birth several years before she was born. When I saw this family, her son was 8 years old and the whole family was struggling. Separation anxiety was again the presenting problem. The marriage was strained because this mother had such an intensely close relationship with her son that her husband felt excluded. I learned that this son was named after her dead brother.

Interestingly, when I googled "pregnancy loss and postpartum depression" most of what I found asked if women could have postpartum depression following pregnancy loss. I think that both in terms of how we understand and how we treatment of these problems, it is important to think of them as two distinct and different phenomena.

Certainly a woman may slide from grief into depression following the loss of a baby. This may occur if the loss triggers memories of other losses, if she does not have an adequate support system, or there are other significant stressors in her life. But postpartum depression, as I describe in my previous post, is specifically a problem in a relationship. Untreated PPD often has significant long-term sequelae for the baby. Treatment of pregnancy loss focuses on the mother, while treatment of PPD needs to include the baby from the beginning.

What can we learn from these stories? As Massachusetts is currently working to address the issue of postpartum depession via the PPD commission, one very concrete we can do is to identify mothers who have had previous pregnancy loss, and especially those with multiple pregnancy losses and/or a stillbirth, as being at high risk for developing PPD. We can make sure that these mothers do not "fall through the cracks." One mother poignantly told me that because of a change in health insurance plans when her child was an infant, she was forced to give up the relationships with her health care providers that were very important to her, just at a time when she was most vulnerable.

Even before that, friends, family members, religious organizations and health care providers can be attuned to the nature of the trauma of pregnancy loss. Women themselves need to feel the right, and be given the space, to grieve a pregnancy loss. While the effects of such a loss can linger in any circumstances, it is unacknowledged and unprocessed grief that has to potential to have the tightest grip on people for years to come.