Written by Lizanne van Waart
Director & Founder of Wijnland Fertility Clinic / ART Counselling
MA. (Psychology) University of Stellenbosch

“Four beautiful thoughts of life:”

  1. Look back and get
  2. Look forward and see
  3. Look around and find
  4. Look within and find

Let’s talk about what Health Psychology is and why we at Wijnland try to support our patients through these difficult times.

Health Psychology, including psychology that aims to understand health, is a study done by Engel in 1977-1980. This study reflects the Biopsychosocial Model of Health and Illness. This model combines the psychological (Psycho) and the environmental (Social) into the traditional biomedical (Bio) model of health.

The bio factors refer to the illness itself – the viruses, bacteria, and lesions. The psycho factors refer to the behaviours, beliefs, coping mechanisms, stresses, and pain related to the illness. The social factors refer to class, employment, ethnicity, and people’s expectations of illness.

The definition of Health Psychology:aggregate of the specific educational, scientific and professional contribution of the psychology to the promotion and maintenance of health, the promotion and treatment of illness and related dysfunctions.” (Matarazzo 1980: 815)

Health psychologists are specially trained to help people deal with psychological and emotional aspects of health and illness, as well as supporting people who are chronically ill. They study psychology to better understand the behaviours relevant to health, illness and, healthcare in general (NHS, healthcareer.nhs.uk).

Health psychology aims to understand and explain illness.

  1. Evaluating the role of behaviour in an aetiology of illness.
  2. Predicting unhealthy behaviours.
  3. Evaluating the interaction between psychology and physiology.
  4. Understanding the role of psychology in the experience of illness.
  5. Evaluating the role of psychology in the treatment of illness.

Health psychology also aims to put theory into practice.

  1. Promoting healthy behaviour.
  2. Preventing illness.

Infertility can cause social anxiety – Silencing the inner critic

Whether infertility is linked to a physiological or psychological problem, many people -particularly, women – experience a range of emotional symptoms as a result of their battle to conceive.

Wijnland Fertility Clinic has noted that patients come to us with social anxiety that is directly related to their infertility. “Social anxiety manifests itself in everyday situations; from a meeting to a social occasion, and it can be triggered by a certain place or activity. Some patients who have been diagnosed with fertility problems report feeling overwhelmed with feelings of anxiety or fear in a range of social situations. It is deeply distressing for the patient and may in time manifest itself into avoidance tactics, causing the patient to withdraw from social situations or lose confidence at work. Couples who are experiencing infertility together can compound the experience by withdrawing from social life together.”

Lizanne van Waart explains that social anxiety is rooted in the perception that the person feels judged – by society, family, or peers. “For many people, the idea that they are not able to conceive naturally is met with feelings of failure. They begin to imagine that those around them are judging them as such. Of course, this is almost certainly not true, and it is in fact the person’s own inner critic that is voice they are hearing.”

Stress management is a key aspect in the treatment of infertility, and it is important to gently dismiss the inner critic. Van Waart counsels that there are a number of steps to take towards a return to social ease:

  1. Recognise the voice of the critical judge – what sort of conversation takes place in your mind just before and during a spike in social anxiety?
  2. Question the reasoning – the inner judge is very likely illogical, so question its line of thinking and poke holes in its theories.
  3. How do you feel about other people who make mistakes or who may have failed at something? It is likely that you feel compassion towards them – no doubt people feel the same towards you.
  4. Try and remove the dominating negative words that come into the vocabulary of the critical judge. Words like “never again” or “total idiot”.
  5. Make anxiety your friend – it can be a helpful tool in identifying and overcoming self-esteem issues.
  6. Be okay with imperfection – try making small deliberate ‘mistakes’, like not having your keys ready ahead of arriving at your car or not having dinner ready at the time you always have it ready.
  7. Try and stay in the present – be mindful of your breathing, that you are safe and alive in the now. Being mindful helps prevent your thoughts from running ahead and predicting negative and fearful outcomes.
  8. As a couple, accept that you are not perfect and that life is not always what we imagine it to be, begin seeing yourselves on a different journey to the one you intended.

“You don’t have to suffer the awful feelings that social anxiety brings,” says Van Waart. “Too many people wait too long to resolve it and when faced with infertility it can contribute to the barriers of conception. Seek help from a therapist who can help you overcome it and feel at ease with yourself again.”

Miscarriages are a reality

A woman never forgets the pain and loss of a miscarriage, and is always thinking about how old her child would have been now. Miscarriages are a reality. Every woman runs a one-in-ten risk of having a miscarriage.

At Wijnalnd Fertility, we run a miscarriage clinic: an academic point of view

Having a miscarriage (especially in your first pregnancy), can be a traumatic experience if the underlying anatomy and physiology is not fully understood. Every pregnancy carries an approximate risk of 1/10 of ending in a miscarriage. The main reason is that some abnormality has occurred. This might include chromosomal abnormalities (e.g. Down syndrome, Turner syndrome etc.), anatomical abnormalities in the foetus (e.g. Heart abnormalities etc.), anatomical abnormalities of the uterus (e.g. Septum etc.) and many others. Having a first miscarriage is thus considered to be nature’s way of “protecting” us against abnormal babies. However, having 2 or more miscarriages cannot automatically be accepted as being “normal”. On the medical side a thorough Gynaecological and Obstetrical history and examination (including a specialized ultrasound) are indicated and some specialized blood tests might be needed. After 3 miscarriages, a full miscarriage screening is indicated. The psychological impact of losing a pregnancy can also not be ignored and at Wijnland, dealing with this trauma, is part of our ethos.

We have therefore created a special space and service for patients who have experienced 2 or more miscarriages. If you make an appointment to make use of this service, remember to state these facts so we can allocate you to the correct avenue in our clinic.

The latest provisionally audited pregnancy results (January 2019 – September 2019) at Wijnland Fertility Unit:

Pregnancy rate per embryo transfer (all patients) = 63.9%.

Our fully audited results are done at the end of each year. See our website at www.wijnlandfertility.co.za for additional information.

1 Psychological and emotion impact

1.1 Psychological effects of miscarriage and stillbirth

Patients who miscarried or suffered stillbirth may experience adverse psychological effects. As the incidence of miscarriage in clinically recognised pregnancies is estimated to be approximately 15%-20%, this subject has been well studied in terms of psychological impact.

While the physical effects of miscarriage and stillbirth are associated with a varying amount of bleeding, cramping, backache and abdominal pain, the psychological and social effects may be considerably more severe and longer lasting.

The psychological impact of a miscarriage can be devastating and can last for a long time, esp. in patients with increased risk factors such as pre-existing anxiety or insufficient social support. There are a number of risk factors that predispose women to feeling psychological distress after a miscarriage, e.g. a history of psychiatric illness, childlessness, lack of partner support or other social support, and previous miscarriage.  These factors increase the chances of severe psychological distress after miscarrying. At-risk patients may experience longer lasting psychological complications. An older patient who has her first pregnancy at age 40 and miscarries may experience significantly more psychological distress than a younger woman who suffered a miscarriage.

Patients who miscarry (or suffer stillbirth) also experience distressing physical symptoms if medical intervention was used to remove the foetus or baby, and continued heavy bleeding occurs.

There is no evidence that different methods used to remove the foetus following the loss of the pregnancy result in different psychological reactions i.e. – whether the patient has a missed or retained miscarriage, incomplete miscarriage and a complete miscarriage does not impact on the grieving process and in all cases would be similar. These are all experienced as a “loss”.  A miscarriage (or a stillbirth) represents the loss of an opportunity to give birth to a live baby, to be a parent and to raise a child.

The psychological impact of stillbirth (loss after 22 weeks of pregnancy) and perinatal death is more severe in terms of grief intensity and of longer duration. Patients do normally experience this as a bereavement and post-traumatic stress.  Here the option of a burial is often relevant, and a death certificate is normally issued.

Studies have shown that reactions of women immediately after miscarriage may vary. Some may experience no psychological symptoms, others may experience grief, or depression, or both grief and depression. Other studies have shown that some women may suffer from anxiety and that the majority of women who miscarried may experience elevated levels of depression after the loss.

The psychological effects may include increased anxiety, grief and depression lasting up to 4 months after the event.  Symptoms of grief, sadness and depression include loss of appetite, weight loss, guilt, insomnia and morbid thoughts.  This may strain a couple’s relationship.  A number of disorders have also been described in the context of the loss of a pregnancy, including post-traumatic stress disorder, obsessive-compulsive disorders and panic disorders that require treatment.

Patients with pre-existing anxiety and increased risk for depression, may endure psychological symptomology for 7 to 12 months after the loss of the pregnancy.

The grieving and coping processes following a loss starts immediately after a loss.  Men and women grieve differently, and culture also plays a major role. In some cultures, the loss of a pregnancy still carry stigmatisation, and a woman may suppress her emotional needs for fear of social consequences.

A first miscarriage should be distinguished from a recurrent miscarriage as the recurrent miscarriage has more severe psychological consequences. Women who miscarried before are also at an increased risk of developing psychiatric illness during a subsequent pregnancy. Stress and anxiety experienced during a later pregnancy can have an adverse effect on the foetus.

1.2 Treatment and duration thereof

Internationally, studies have shown that psychological interventions after miscarriage improved patients’ well-being.

As anxiety, depressive symptoms, post-traumatic stress disorder and other psychological symptoms can last for several months, psychological support and care should start immediately after the loss of the pregnancy. The psychological treatment should continue weekly in 50-minute sessions for at least a 4-month period.  In the case of recurrent miscarriage, individual assessment is critical as counselling and support may be needed weekly for up to 7 months.  At-risk and older patients may also require psychological support for up to 7 months. 

Patients who suffer from severe post-traumatic stress disorder following miscarriage or stillbirth should receive weekly cognitive behavioural therapy for a period of 4-6 months. An alternative approach would be to allow for daily 50-minute sessions over a period of two weeks – i.e. 10 sessions in total.

Psychologists specialising in women’s health may be able to assist women who suffered miscarriage.

Patients who lost a pregnancy and who are at higher risk for developing more severe psychological problems, e.g. due to their pre-existing anxiety disorder or other psychological illness, or multiple miscarriages, should have psychiatric evaluation.  Such patients may benefit from psychiatric treatment in the early stages following the loss and prescribed medical treatment/medication should be initiated as indicated. 

Men/partners experience the grieving process differently and weekly support counselling for up to 6 weeks is sufficient. 

Counselling programmes for couples who experienced stillbirth or neonatal death may also be effective.

In all cases a once-off psychological assessment follow-up after one year is indicated. Here the need for individual longer-term treatment/support will be evaluated.

2 Longer-term medical treatments

2.1 Direct medical treatment

Women who miscarried or suffered stillbirth as a result of contracting LM will normally not require further medical treatment if the process described in par 8 above goes uncomplicated.  If managed correctly, no further direct treatment should be needed.

2.2 Indirect treatment

If a pregnancy was enabled with fertility treatment and the patient lost the pregnancy, she may require further fertility treatment in future in order to conceive again. This will be individualised by taking into consideration the pregnancy/fertility facts.

The patient’s age is important as it is well known that older women (>35 years) would generally have greater difficulty conceiving and also have a higher chance of miscarriage. The “preciousness” of the pregnancy lost should also impact.  If the pregnancy was with the help of fertility treatment (IUI (Intra Uterine Insemination) or IVF (In Vitro Fertilisation)) then the future treatment will include these options.

In terms of the fertility issues, these should be addressed along with the psychological issues and attended to as soon as possible to reflect the age-related fertility wishes of the patient.

A healthy and normal pregnancy as the miracle it really is.

Many women blame themselves and think that the miscarriage was caused by something they did.

“It’s very difficult for any woman to cause a miscarriage herself.”

However, if a woman miscarries repeatedly, danger signals are flashing and she should go for tests to eliminate any fertility abnormalities. A woman should never simply accept that it is simply her bad luck.

Age does play a role in miscarriages because in older women there is a bigger risk of chromosome abnormalities. It is advisable to complete your family before you turn 37.

A miscarriage is very traumatic and should be handled as a bereavement.

“Couples should be given time to mourn. One should allow the mourning process to run its course before trying to become pregnant again. It’s unwise to replace one pregnancy with another,” Lizanne.

We offer the following hints to help couples think differently about miscarriages.

– A miscarriage spares one the terrible trauma of an abnormality.

– A miscarriage strengthens relationships.

– A miscarriage can help one to see

3 Bibliography

  1. Zach T & Steele RW. 2018. Listeria infection. 9 Jan. At www.emedicine.medscape.com (Accessed 3 May 2019).
  2. Frean J, Blumberg L, McCarthy K & Thomas, J. 2018. Plague and listeriosis: current outbreaks, and an historical South African connection. South African Journal of Infectious Diseases 2018; 33(1):3-4.
  3. Weinstein KB & Bronze MS. Listeria Monocytogenes Infection (Listeriosis). 18 Dec. At www.emedicine.medscape.com (Accessed 3 May 2019).
  4. Van den Akker OBA. 2011. The psychological and social consequences of miscarriage. Expert Rev. Obstet. Gynecol. 6(3). www.expert-reviews.com
  5. Murphy FA, Lipp A & Powles DL. 2012. Follow-up for improving psychological well-being for women after a miscarriage. Europe PMC Funders Author Manuscripts. March 14. doi: 10.1002/14651858.CD008679.pub2

 


Written by Lizanne van Waart

Director & Founder of Wijnland Fertility Clinic / ART Counselling
MA. (Psychology) University of Stellenbosch