Family Ministry Today

The Center for Christian Family Ministry at The Southern Baptist Theological Seminary

Family Physicians’ Forum: Pregnancy Loss, A Grief Unspoken

by William Cutrer – Oct 22

“Like arrows in the hands of a warrior,” the psalmist sang, “so are the children of one’s youth. How blessed is the man whose quiver is full of them (127:4–5). When the wonderful news of pregnancy is announced, we rightly rejoice! But what about those who go on to miscarry, to experience fetal demise or tubal pregnancy, or who are infertile? How can we minister to those suffering such profound pain? As a specialist in obstetrics and gynecology, I have spent much of my life and ministry involved with young couples and families. This article will address several all-too-common situations to aid the caregivers and ministers who serve these couples. First, I will provide the medical infor- mation from the patients’ perspective, then I will offer a few practical ministry suggestions.

Miscarriage, known in medicine as “spontaneous abortion,” refers to pregnancy loss before approximately twenty weeks’ gestation. Statistics suggest that annually almost one- third of the approximately six million pregnancies in the U.S. result in loss. Perhaps 600,000 of these represent miscarriage, and another 64,000, ectopic pregnancy. Most miscarriages occur in the first trimester (twelve weeks of pregnancy), counted from the last menstrual period. Enhanced testing suggests that as many as half of all pregnancies fail to result in a live birth. God has blessed humanity with the privilege of being fruitful and multiplying, yet the process often becomes the source of intense pain.

The excitement of the positive home test can quickly turn to fear at the first evidence of spotting or cramping. The fact that almost half of all pregnant women experience such complications makes the first trimester an anxious time for new mothers. Advances in ultrasound technology grant visual access into the womb whereby diagnoses of developing pregnancy can be made, yet waiting on an appointment can seem like an eternity for a couple when the baby’s future seems in doubt. Sonography can detect the baby’s “gestational sac” as early as three-and-a-half weeks from conception but until the fetal pole with its recognizable yolk sac and heart beat can be detected, only baseline information can be stated with certainty. Yes, a pregnancy has begun, and it is located within the uterus, but until the heartbeat is visualized (about four weeks from conception) or heard with the Doppler (a sound wave device allowing audible heartbeat to be appreciated at about 10 weeks from last period) miscarriage rates are still quite high. After the heart beat is audible and the pregnancy reaches ten weeks, miscarriage risk falls dramatically, but not completely.

Treatment of miscarriage depends on several factors. If fetal death occurs at less than six weeks, the mother’s body can generally facilitate the miscarriage without medical intervention, aided sometimes with medications. If the pregnancy has progressed beyond ten weeks’ gestation, a surgical procedure known as “D. and C.” for “dilation and curettage,” is usually recommended. This procedure predictably completes the miscarriage while minimizing the risk of hemorrhage or infection. D. and C. is a surgical procedure, even though no inci- sions or stitches are required, an it can be physically and emotionally stressful. Pregnancies that progress to six-to-ten weeks before failing require a physician’s judgment in close consultation with the parents. If they live near healthcare facilities, allowing the miscarriage to occur without further procedures may make sense. If they live far from medical care, the miscarriage might involve considerable bleeding and danger to the mother, so safety might dictate scheduling D. and C.

Though far less common than miscarriage, the death of a child in the womb after the first trimester can cause dev- astating grief as well as marital distress. Typically, the baby has already been seen on ultrasound, the heartbeat heard, and even the gender of the child announced. Whereas most first trimester losses relate to chromosomal abnormalities preventing normal early development, tragedies after the first semester often come without clear diagnoses. Cord accidents, placental problems, and intrauterine infections can be at fault. Certain chromosomal problems may not cause death until the second trimester as well, but often no clear diagnostic picture emerges. Yet even if the diagnosis is known, little relief is felt from such knowledge, because the parents really yearn for the child they have lost, not an explanation.

Delivery of the deceased child can generally be accomplished by induction of labor and birth, though physicians often wait several weeks for natural labor to ensue. The mother’s body often takes a little time to recognize that the child has stopped growing. Typically, the physician will induce labor before four weeks have passed since the child’s death to avoid complications related to blood clotting.

Unlike losses in the first trimester, delivery with the opportunity to view and hold the child’s body may be possible. Decisions made at this juncture are important for the grieving process, so patience and allowing the couple to come to grips with the devastating reality allow for better recovery. Plans for memorial services and burial should be considered.

Ectopic means “out of place.” An “ectopic pregnancy” is sometimes called “tubal pregnancy” because the fallopian tube, rather than the uterus, is usually the site of implantation for such pregnancies. This condition represents an impending medical emergency. Ectopic pregnancies can actually implant anywhere outside the uterine cavity, including within the cervix, the portion of the fallopian tube that traverses the uterine wall, within the tubes, or even outside the tubes on the ovary, the bladder, or on the intestine. Such pregnancies will outgrow the tube’s capacity, so eventually either the growing child will die or cause the tube to rupture, leading to potentially life-threatening hemorrhage.

The symptoms of tubal pregnancy may not be spe- cific, but they may include bleeding, localized pain, and cramping after about six or eight weeks of pregnancy. Until that time the pregnancy—the baby plus supporting structures—may be small enough to grow normally. Eventually, however, the pressure on the tube causes a pain unlike cramps, usually localized to the side of the ectopic pregnancy.

All doctors trained in obstetrics will listen for these symptoms, and must rule out tubal pregnancies by exam and ultrasound. Blood levels of the hormone Human Chorionic Gonadotropin (HCG), the very hormone that turns the pregnancy test positive and gives those symptoms of early pregnancy, rises in a manner in normal pregnancies such that, if the level is not normal, either a miscarriage or a tubal pregnancy can be identified.

Sadly, there is no technology available to move the pregnancy once it has implanted, so nothing can be done to save the baby. Much can and must be done to save the mother. Even in the United States, young women die every year due to undiagnosed ectopic pregnancies. Treatment can involve surgery to remove the pregnancy, or, if detected early enough, a type of chemotherapy can be used. Neither choice is desirable, and both leave husband and wife with significant grief, yet procrastination can lead to tragedy.

Every year I field calls pertaining to a pregnancy complication such as anencephaly (the absence of forebrain and skullcap) or to certain chromosomal and anatomic disorders that are incompatible with life outside the womb. Upon a firm diagnosis of a living child with a deadly disorder, parents face the difficult decision of carrying the pregnancy to term and awaiting imminent death or terminating the pregnancy. Even many Christian physicians point their patients in the direction of terminating the pregnancy. Unfortunately, terminating a pregnancy at around twenty weeks gestation presents medical challenges, not to mention ethical challenges. Years of experience leads me away from recommending a dilation and evacuation procedure that destroys the baby. As difficult as carrying such a pregnancy may be, surgical intervention can lead to long term emotional consequences.

With an early loss of a child, wives often experience emotional upheaval as hormones plummet as a result of the baby’s death. Along with cramping, bleeding, and the prospect of a surgical procedure, their moods may fluctuate dramatically. Since fathers do not experience the same hormonal changes they may not understand the emotional instability. By suppressing their own feelings, husbands often withdraw into a posture of distance and stoicism. Sadly, this is counterproductive. Most women are overwhelmed by this pregnancy loss and need to grieve alongside their husbands. Wise husbands listen patiently as the wife repeats every word the doctor said, and every symptom she has felt or not felt. Weep with her, weep for the child, and cling tightly to one another. Presence and tender touch will communicate far more than words can. Physical recovery progresses more quickly than the restoration of emotional and spiritual wellbeing.

From the ministerial standpoint it is important to avoid compounding grief by saying insensitive things. To suggest that “there was probably something wrong with the baby anyway” offers no comfort. Declaring that the parents can always try again, or saying, “at least you conceived this time,” sounds patronizing, not edifying, and suggests that the child conceived is replaceable. To say, “It’s for the best” or “God knew there was something about this pregnancy that wasn’t right,” only adds to the burden of loss. Indeed, God does know all things, and he could have prevented the miscarriage or prevented the abnormality to begin with. Yet the reality is that he did not. Why He did not remains a mystery.

What, then, helps? Showing up. Caring. Expressing sorrow for the loss simply and honestly. (This is a genuine loss of a human life.) Human beings have eternal significance, whether they live a few days in the womb or a century on the earth. God is sovereign, and the pain is real. These are not mutually exclusive truths. One can fully trust God and still hurt, weeping over the pain and loss. God knows our suffering, and he will not leave or forsake this family in the midst of their trial.

When the pregnancy has progressed to the second or third trimester before the baby dies, the minister should expect deep grief. Such a death, while relatively rare, usually occurs without any warning symptoms. Women have enjoyed smooth pregnancies only to find at a routine office visit or scheduled sonogram evaluation that the baby has died. Sometimes the mother has noticed decreased then absent fetal movement, but more often the news comes as a total surprise.

The minister involved in such cases will do well to remember the power of prayer and presence. No words can undo the tragedy. In fact even when the answer to “Why?” is known (knot in the cord, placental problems, abnormal fetal development), these facts offer little relief. The pain is unspeakably deep. The mother needs to see the child and even hold the baby after the birth, if at all possible. Even babies who have been dead for an extended period of time or have major birth defects have areas of beauty that the medical staff can highlight. My experience tells me that the mother does need to see the infant if possible to experience closure and to feel certain that the baby did die. For those rare exceptions when the mother refuses to see the child or for medical reasons cannot, I recommend the staff take a few pictures or provide a lock of hair because, weeks later, mothers and fathers may find considerable comfort in these keepsakes.

Babies who reach the second trimester may weigh one-half pound to two pounds and will be fully formed when delivered. A memorial service and burial may be appropriate. State laws vary as to what is considered a “stillbirth” requiring funeral arrangements and what is considered miscarriage, handled by the hospital. Sensi- tivity is essential here. It is best simply to grieve the loss along with the grieving parents.

When dealing with a couple that has been diagnosed with an anencephalic child or other disorder incompatible with life, one must appreciate the delicate balance between mother’s mental wellbeing and the life of the infant. Though imperfect, as we all are to some degree, this baby too is precious and made in God’s image. I suggest allowing the couple time to grieve, to pray, and allow a few days before making the decision about timing of delivery. Often alternative options may seem far more suitable. As one patient relayed to me, “This is the only time I’ll ever have to spend with this child. I will treasure it, and her.” This particular patient carried the baby to term, whereupon the baby died shortly after delivery, but there was time to grieve, to say goodbye, and to plan a memorial service including naming the child. This decision demonstrated appropriate respect for the dignity of this human life, even with imperfections. These are unspeakably difficult ministry situations, but they can be handled well.

Obstetric deaths raise theological issues. Wisdom would demand deep reflection as a minister before encountering such a crisis. This includes having clarity about babies’ eternal destinies before being approached to preside over a baby’s funeral or minister to a couple facing or following miscarriage. Such memorial services are incredibly difficult but can minister grace and hope at such a time.

When sin brought judgment on Adam’s offspring, the curse on the woman connected pain and suffering with childbearing. Pregnancy loss drives us to God in humility, recognizing the implications of humanity’s Fall. This is not to suggest that a woman who has experienced a pregnancy loss is in some way at fault for the loss. It means only that all humans experience the ramifications of the Fall and yearn for a day when all creation will be restored.

The person seeking to offer comfort must walk with the couple not only through the process of the funeral, but also in the months to come. Remembering the anniversary of the baby’s “due date” and the death date can make an enormous impact. It is wise to consider one’s own emotional health during these crises as well, because bearing such burdens will exact a significant toll on the minister. “I lift up my eyes unto the hills? Where will my help come from? My help comes from the Lord, creator of heaven and earth” (Psalm 121:1).

Cutrer, William. The Church Leader’s Handbook. Grand Rapids: Kregel Publications, 2009. Glahn, Sandra, and William Cutrer. When Empty Arms Become a Heavy Burden. Grand Rapids: Kregel Publications, 2010.

MacArthur, John. Safe in the Arms of God: Truth from Heaven about the Death of a Child. Nashville: Thomas Nelson, 2003.

About the Author: William Cutrer (M.D., University of Kentucky) is the C. Edwin Gheens Professor of Christian Ministry and Director of the Gheens Center for Christian Family Ministry at The Southern Baptist Theological Seminary. Dr. Cutrer has authored or co-authored several publications including The Church Leader’s Handbook: A Guide to Counseling Families and Individuals in Crisis.

[Editor's Note: This article originally appeared in The Journal of Discipleship and Family Ministry 2.2.]