Octavia Monroe, photographed at her home in Willingboro, NJ, October 19, 2013.
Dana Lixenberg for TIME
By Sarah Elizabeth Richards
November 20, 2014
IDEAS
Richards is a journalist who frequently writes about genetics and the author of Motherhood, Rescheduled: The New Frontier of Egg Freezing and the Women Who Tried It.

By the time Liz Abele, a real estate agent from Bethesda, Md., climbed onto an examination table for her 12-week ultrasound one June morning in 2011, she and her husband had already seen the grainy images of their growing fetus three times. They had admired its big head and tiny arms and legs. They had heard the swoosh of the heartbeat. But at this appointment, unlike the earlier ones, Abele, then nearly 40, felt unusually relaxed.

For any woman who has worried about her ability to carry a pregnancy to term, a 12-week ultrasound is a big victory. For Abele, it meant she had made it to the end of the first trimester, during which about 80% of miscarriages occur. It also meant that after spending the previous five years trying unsuccessfully to get pregnant before hitting the jackpot with in vitro fertilization (IVF), Abele could let herself believe she was finally going to be a mom. She was due a week before Christmas, and Abele imagined introducing her baby in red velvet outfits to relatives over the holidays.

Abele and her husband kept their eyes glued to the screen as the technician slid the wand across her belly. She held her breath as she waited for the familiar swoosh sound to fill the room. The technician stopped suddenly and set down the wand. “I’ll be right back,” she said. Abele reached for her husband’s hand and started to cry. The technician returned with the doctor, who said, “I’m so sorry. There’s no heartbeat.”

For the next few weeks, Abele couldn’t stop crying. “We had waited so long for this pregnancy,” she says. “It felt so much worse than I ever could have imagined.”

For generations past, when families were larger and medicine less advanced, miscarriages, defined as the death of a fetus before 20 weeks, were a difficult fact of life. Today, in an age of technology that boosts fertility and allows for ever earlier images of a fetus–as well as changing wisdom about how expecting parents can best handle a lost pregnancy–the 15% to 20% of pregnancies that end in miscarriage may exact a greater impact.

Doctors and researchers are increasingly recognizing the toll miscarriage can take on some women’s mental health and emotional well-being. The result is a major transformation in the script for how to deal with the loss of a wanted pregnancy, with no agreement on what’s healthier: a private and possibly quick form of grief or the growing movement to actively and publicly mourn with mementos and rituals, often over an extended period of time. And because these things are as personal as just about anything can be, a consensus isn’t likely, either.

The Modern Miscarriage

Women are having babies later in life than ever before. Of the almost 4 million births in the U.S. in 2013, nearly 15% involved women ages 35 to 44–up from 9% in 1990. And an increasing number of women in that age group, like Abele, are seeking fertility treatment, in which the financial and emotional stakes are high.

“The physical gestation might have been eight weeks at the time of miscarriage,” says Irving Leon, a psychologist who specializes in reproductive loss and an adjunct associate professor of obstetrics and gynecology at the University of Michigan. “But if a couple struggled to get pregnant, the psychological gestation could have been eight years.”

Also, it is increasingly likely that a woman who miscarries will have already seen ultra-detailed images of the fetus in utero via a vaginal or abdominal ultrasound during the first trimester. No matter where you stand on the question of when a fetus becomes an unborn child or a baby, these early technology-enabled encounters can result in an ever stronger emotional attachment for a parent hopeful about a successful pregnancy. “When you can hear the heartbeat and see the image of the body, it’s extremely powerful psychologically,” explains Leon. “You’re more likely to experience the fetus as a baby.” Which means the loss can be especially hard to take.

Studies show that the severity of what happens next, the emotional fallout from a desired pregnancy resulting in miscarriage–which can include sadness, shame, anger, guilt and depression–falls along a spectrum. A large study published in the British Journal of Psychiatry in 2011 found that about 15% of women who had had a miscarriage experienced depression or anxiety, and for some, those feelings lasted years.

Not surprisingly, according to numerous studies, women who have a weak support network or rocky marriage tend to fare the worst. Research indicates that the loss can be difficult for men too.

Some New Rituals

There’s a revolution under way in the understanding of how patients and physicians should best deal with the aftermath of a miscarriage. Hospitals, fertility clinics and patient organizations are creating support groups and holding memorial services, as well as Walks to Remember and candlelight vigils across the country on Oct. 15, which Congress has designated Pregnancy and Infant Loss Remembrance Day.

Medical students are also being trained in how to approach patients after miscarriages. Pregnancy-loss-related message boards and support groups are proliferating online too, like the March of Dimes’ Share Your Story.

Some of the new rituals take cues from ones that were once reserved for parents of stillborn babies, defined as fetuses who die after 20 weeks. These can include everything from naming the unborn child, planting a tree, donating to a special charity and holding a memorial to the more controversial practices of holding and being photographed with the fetus’ body. There’s even a burgeoning cottage industry selling miscarriage-remembrance jewelry and memory boxes.

In the weeks and months after Abele’s miscarriage, she was surprised that she couldn’t stop crying. Her husband Chris Kepferle, a television-commercial producer who was 50 at the time, tried to make her feel better by cracking jokes. While she wanted to talk about it, he wanted to move on. Her friends’ cheery comments–“Don’t worry. You’ll get pregnant again”–just made her cringe.

Abele and Kepferle ended up taking the advice of their case nurse at Shady Grove Fertility Center in Rockville, Md., to see a counselor. Sharon Covington, the clinic’s director of psychological support services, urged them to create a ritual to acknowledge their grief and honor their unborn child. An autopsy indicated the presence of female tissue, and doctors said the child was likely to have been a girl. They decided on the name Christina.

One evening that fall, the couple stood on the white sands of their favorite beach in Indian Shores, Fla., with her parents while Abele read a letter: “This child’s life was short, yet her death left a huge void in our hearts and lives. Let us remember the tiny baby who will never reach childhood or adulthood but will remain our tiny baby forever.”

After reciting some prayers and psalms, they threw a dozen white roses into the Gulf of Mexico and watched the sun set as waves slowly pushed some to shore and took the rest out to sea.

“I felt like we had done something to move through the grief,” says Abele, now 43. Still, the next year was agony. Seeing kids trick-or-treat on Halloween. Receiving holiday cards with photos of smiling families. Passing moms pushing jogging strollers in their neighborhood. Sometimes, she felt so overwhelmed with sorrow that she declined invitations to baby showers, and she decided to take a break from Facebook. At about the time she would have given birth, Abele put on a brave face to welcome the arrival of her older brother’s first child. “I had imagined the cousins growing up together, since they would have been so close in age, and how fun it would be to see them playing on the beach,” she says.

The clincher was Mother’s Day at church. When the pastor asked all the mothers in the congregation to stand up, Abele stayed in her pew and quietly wept. “All I could think was, Am I ever going to be a mother?” she says.

“It’s Been a Month”

If Abele is typical of the new way of mourning a miscarriage, Rose Carlson of St. Charles, Mo., exemplifies the old way.

Carlson was 22 when she had her first miscarriage, at 11 weeks, in 1986. Over the next seven years, she had three more–one at five weeks, one at 12 weeks and then one at 10 weeks. After each, doctors discharged her with instructions: Call if she had a fever or excessive bleeding. “No one asked, ‘How are you doing emotionally?'” she says.

Carlson gave birth to a son after the second miscarriage. Shortly after giving birth, she experienced two more miscarriages within three months of each other, causing her to fall into a deep depression. Her husband tried to joke with her: “Well, we’ll just have fun trying to make more.” A friend commented, “You need to get over this. It’s been a month.”

“People were surprised I should be sad,” says Carlson, now 51. “I kept thinking, ‘Why am I making such a big deal of this? No one else is.’ I felt like a freak.” Six months after her last miscarriage, when she was 29, she became pregnant again. She eventually gave birth to three more children.

Ten years ago, Carlson, who was formerly a stay-at-home mom, started volunteering at the national headquarters of Share Pregnancy & Infant Loss Support in St. Charles, and she now works as its program director. Founded in the late 1970s, Share holds seminars for emergency-room staff and hospital social workers and chaplains to teach them to be more sensitive to miscarriage patients, since not all hospitals have separate labor and delivery units. The nonprofit organization runs more than 80 support groups across North America and donates memory boxes and books, crocheted blankets and hats, among other things.

A Smaller Corner

So how does one best move on from a lost pregnancy? Despite the evolution in care, there’s still no agreement about what is the most effective way to heal, says Leon.

When Octavia Monroe, a 21-year-old college student from Willingboro, N.J., doubled over in excruciating pain while watching television with her fiancé last summer, she never imagined she would end up at the emergency room in labor at just 21 weeks. It was a stillbirth. “I had held him in my body for five months and felt him move. Then one day he was gone,” she says.

Monroe tried a hodgepodge of so-called best practices to deal with stillbirths and miscarriages. She named him Aidan Rodney Bell and was photographed holding his body. She attended a weekly pregnancy-loss support group in which she was inspired by one woman’s story of planting a tree in memory of her miscarried baby. Monroe and her mom had Aidan’s body cremated, and they placed the urn on a stand in their living room.

But when asked what helped her survive the hardest months, Monroe credits the little things that staff members at Virtua Memorial Hospital in Mount Holly, N.J., did–making the case that when it comes to losing a pregnancy at any stage, simple kindness might matter most. They gave her a teddy bear in memory of her son. They gave her a baby blanket and a cap and a white gown knitted by local volunteers. They sent flowers to her home with a personal note from her nurse and information about grief rituals. “It just made me feel cared for,” says Monroe, who has since given birth to a baby girl. “Your family has to be supportive, but there was something about these strangers giving me hope.”

Leon says the overwhelming symptoms of grief usually lessen within nine months to a year. “Initially, it may feel like a tsunami, and waves of grief come one right after the other,” he says. “But after a while, they are less intense and less frequent. Women will start to feel like they’re getting back to normal.”

Whenever Abele talks about Christina, the daughter she lost after the 12th week of pregnancy three years ago, she still gets choked up. But the sorrow occupies a smaller corner of her heart now. It helped that she finally became a mother. After another miscarriage and three more IVF tries, the couple welcomed Andrew Ryan Kepferle into their lives in June last year.

Contact us at editors@time.com.

This appears in the December 01, 2014 issue of TIME.

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