What could be worse than losing a child? The death of the firstborn was the last and worst of the plagues in ancient Egypt, and the Lord knew it would bring “a great cry throughout all the land of Egypt, such as there has never been, nor ever will be again” (Exod 11:6).

King David and Job expressed their grief at the loss of their children in other physical ways—David fasted, lay on the ground and wept (2 Sam 12:15-23), and Job tore his robe, shaved his head, fell on the ground and worshipped (1:13-20). Jeremiah prophesies King Herod’s ‘slaughter of the innocents’ (Matt 2:16-18) by describing Jacob’s wife, Rachel, grieving inconsolably over the lost children of Israel at the site of her tomb:

“A voice is heard in Ramah,

lamentation and bitter weeping.

Rachel is weeping for her children;

she refuses to be comforted for her children,

because they are no more.” (Jer 31:15)

It is only in the new heaven and the new earth that God will wipe every tear from our eyes (Rev 7:17, 21:4).

Any type of pregnancy loss is a devastating experience for the parents. Yet it is a strange grief, because you are mourning for someone you have never met. It often goes unnoticed by others, and can become a lonely journey for those who experience it: isolated, alone, confused, and gut-wrenchingly sad. Some aspects are experienced in common but every story is unique. It is thought that one in four known pregnancies ends in loss.

Different types of pregnancy loss

Pregnancy loss can be confusing because there seem to be so many names for the same thing. There is no internationally agreed list of terms to describe many of the events in pregnancy, and some terms have persisted that were developed before ultrasound was available for accurate diagnosis. Changes in terminology have been recommended to clarify these events, which would be helpful in improving data collection and research in this important area.[1] Unexplained stillbirth in late pregnancy is the single largest cause of death in perinatal life in the Western world. The lack of understanding about what causes pregnancy loss is a problem that must be addressed.

Below, I list different types of pregnancy loss and the various names that can be used to describe them. Categories marked with an asterisk (*) are not technically the kind of pregnancy loss that would be investigated as outlined below under ‘recurrent miscarriage/recurrent abortion’, but as parents may have a similar response regardless of the cause of the loss, they are included here. 

Miscarriage/spontaneous miscarriage/spontaneous abortion*

These terms refer to the ending of a pregnancy before 20 weeks gestation, a time when the baby is unable to survive independently. It involves the spontaneous expulsion of the baby from the womb. The loss may occur anywhere. There will usually be heavy bleeding, possibly blood clots and abdominal cramping like period pain. Sometimes there is a sudden release of fluid out of the vagina if the waters break. The cervix opens and the developing baby comes out with the blood. Sadly, there is little that can be done to prevent a miscarriage once it is underway.

It can be distressing for women who have the medical term for this—’spontaneous abortion’—written in their medical records, as non-medical people can confuse it with ‘elective abortion’. This is one reason it has been suggested that the term no longer be used.

Many women miscarry without even realizing, especially in early pregnancy. They may mistake a miscarriage for a late period. The miscarriage may be complete, which means the uterus is emptied, or incomplete, which means some tissue is left in the uterus and the mother will need a dilation and curettage (D&C) of the uterus under general anaesthetic to remove it. There is a risk of infection if this is not done.

Stillbirth

This term refers to a baby who dies before or during birth. The WHO definition of stillbirth is a birth weight of at least 1000g or a gestational age of at least 28 weeks (third-trimester stillbirth). However, there is still no international standard to define when a baby is considered stillborn. In Sweden, babies are considered stillborn at 28 weeks. In the United Kingdom it is 24 weeks. In the United States and Australia, a baby who has passed the 20-week mark is considered stillborn, while in Norway it is at 16 weeks.[2] Most stillborn babies are delivered naturally after the mother has gone through labour, even if it is known that the baby is dead before labour starts. In many places, stillborn children need to be legally registered as a birth and a death. Approximately half of stillbirths occur prior to 28 weeks of gestation and about 20% are at, or near, term.[3]

I just felt numb when I was told [that my baby had died]. And terrified that I had to give birth, remembers Rhea.

Blighted ovum/anembryonic pregnancy/early fetal demise/empty sac*

These terms describe a pregnancy where the egg is fertilized and implantation occurs in the uterus, but an embryo does not develop. There will be symptoms of pregnancy and there may even be an empty gestational sac in the womb on the ultrasound. 

Threatened miscarriage/threatened abortion

These terms refer to any vaginal bleeding before 20 weeks. There may or may not be cramping. The cervix is closed. Spotting (losing very small amounts of blood) in early pregnancy is common. Women experiencing spotting or bleeding during pregnancy should check with their doctor or midwife to see whether there is a problem. Up to half of these women will go on to have a miscarriage, but the rest of the pregnancies will continue normally. Tests may be done to check what is happening. Even when I went for the ultrasound, it was so surreal. I couldn’t believe this was happening to me. This was something that would only happen to someone else, said Jan.

Missed miscarriage/delayed miscarriage/missed abortion/intrauterine death

This occurs when the embryo or fetus has died but a miscarriage has not yet occurred. Women who experience this may not know there is a problem until they have a routine check-up.

Wendy didn’t know she had miscarried the first time until she saw her doctor. He couldn’t find the heartbeat. An ultrasound was done to check on the baby, but the baby had died and was still inside her. This was extremely upsetting. How could I not know there was something wrong with my baby?

The mother may be allowed to choose whether to have a D&C (also called an ERPC—evacuation of retained products of conception) or to wait until labour starts so she can deliver the dead baby naturally.

Recurrent miscarriage/recurrent abortion

This refers to three or more consecutive miscarriages by the same woman. It is at this point that most women would start to have tests to discover the cause.

Ectopic pregnancy*

This term denotes a pregnancy where the embryo implants outside the uterus (usually in the fallopian tube), where the baby will not survive. It is a serious situation that is potentially fatal for the mother and requires urgent treatment. An ectopic pregnancy can be especially hard to cope with when the emergency situation may prevent a woman from fully comprehending that not only is she losing the baby but also her chances of having another baby in the future may be reduced.

How common is recurrent pregnancy loss?

A 1988 study found that the total rate of early pregnancy loss after implantation, including clinically recognized spontaneous abortions, was 31%. Most of the 40 women in this study with unrecognized early pregnancy losses had normal fertility, since 95% of them subsequently became clinically pregnant within two years.[4]

Across the globe, around 3 million babies are stillborn every year—more than 8200 babies a day.[5] Although 98% of these deaths take place in low-income and middle-income countries, stillbirths also continue to affect wealthier nations, with around one in every 300 babies stillborn in high-income countries.[6] This translates to around 6500 per year in the United Kingdom and around 2000 in Australia.[7] While no accurate data is collected in the United States, it is thought to be around 26,000 every year.

An Australian study found that, on average, for every 10 women aged between 28 and 33 years who had ever been pregnant, 5 would have had a birth only, 2 would have had a loss only, and 3 would have had a birth and a loss.[8]

Causes

After a pregnancy loss, there can be an overwhelming need to find out why it happened. Many people will spend time searching the internet for answers, but there is a lot of inaccurate information out there. Check with your doctor if you have questions about information you have found.

Although there are still many unknowns, some causes for pregnancy loss have been recognized. Miscarriage and stillbirth occur along a time continuum of nine months, so the conditions that can cause them do overlap.

Miscarriage

It is still not known what causes many miscarriages, but it usually seems to be because a pregnancy is not developing normally. Most miscarriages occur in the first trimester (first 3 months of pregnancy). The most common known cause (over 50%) is genetic abnormality (abnormal chromosomes).[9] Many non-chromosomal problems have also been associated with miscarriage—these include hormonal abnormalities, physical abnormalities (e.g. an abnormally shaped womb or a weak cervix), platelet problems, environmental exposure to toxins, infections and immunological factors.[10]

Stillbirth

There is still a lot of research that needs to be done to discover the causes of stillbirth. Researchers talk more about ‘associations’ than ‘causes’. In 2011, the top 5 known causes of stillbirths assessed worldwide were:

1. childbirth complications (such as pressure on the umbilical cord, which cuts off the baby’s blood supply, or a problem with the placenta such as it tearing away from the uterus wall)
2. maternal infections in pregnancy
3. maternal disorders, especially hypertension (high blood pressure) and diabetes
4. fetal growth restriction (small babies)
5. congenital abnormalities (such as lethal chromosome disorders and malformations in the baby).[11]

In high-income countries, placental problems and infection associated with preterm birth are linked to a substantial proportion of stillbirths.[12] Good antenatal care reduces the risks.

Is there anything that can be done to reduce the risk of miscarriage or stillbirth?

Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has stalled in recent years. The present variation in stillbirth rates across, and within, high-income countries indicates that further reduction in stillbirth is possible.[13] Since we don’t know what causes many miscarriages and stillbirths, much interest centres on what puts a couple at increased risk of pregnancy loss.

Research into risk factors hopes to find ways to reduce the frequency of pregnancy loss. The identification of risk factors is intended to help parents, and not to make anyone feel guilty. Remember that risk factors can influence the outcome, but they have not been proven as a definite cause. They are certainly not grounds for blame. Obviously, the risk factors we most want to know about are those we can do something about. Potentially, as many as 40% of stillbirths could be due to the three combined risk factors of maternal age over 35, history of smoking, and being overweight or obese (Body Mass Index [BMI] over 25). These factors also carry an increased risk of miscarriage.[14] It is not unethical to try and reduce risk factors, so long as we are mindful of the need to be wise stewards of our time and our money, and we do not allow it to interfere with relationships.

Advanced age

The majority of early miscarriages are thought to result from chromosomal defects, and the only known risk factor for that is advanced maternal age (greater than 35 years).[15] One study found that while younger women (20-25 years) had chromosomal abnormalities in 17% of their eggs, by 40-45 years this figure had risen to 79%.[16] There is some evidence that increased paternal age (greater than 40 years) may also contribute.[17]

 

Smoking

If a mother continues to smoke cigarettes, the risk of the baby dying during pregnancy increases by about 30%.[18] It is important to give up smoking before getting pregnant, even though this may be very difficult. Try to avoid second-hand smoke as well, because even if the smoke comes from someone else’s cigarette, it can still cause problems if you breathe it in.

 

Obesity

Apart from increasing health risks to the mother, obesity also increases the risks of miscarrying a normal baby and recurrent miscarriage. Some studies also show an increase in stillbirths.[19] (There may also be a risk if the mother is underweight before she gets pregnant,[20] so aim for a normal BMI of 20-25.) I know it’s not politically correct to say someone should lose weight, but you only need to see the tragedy associated with this reversible problem before you say it anyway.

Illegal drugs

Cocaine use increases the risk of miscarriage in the first trimester, and heroin use increases the risk of the baby dying in pregnancy or soon after.[21]

 

Previous miscarriage or termination of pregnancy

There does seem to be some association between pregnancy loss and past history of pregnancy loss, but research results are mixed.[22]

 

Caffeine

Some research has indicated a link between miscarriage and the consumption of drinks containing caffeine. A much-publicized study in 2008 suggested that pregnant women who have 2 or more cups of caffeinated drinks a day have twice the risk of having a miscarriage than those who avoid caffeine.[23] By 2 drinks they mean 200mg of caffeine, which is equivalent to 2 mugs of instant coffee, or 4 cups of medium-strength tea or hot chocolate, or 6 cups (5 cans) of cola per day. If you get your coffee from a café you may be getting more than 200mg of caffeine in one cup, depending on the beans and how it is made. For example, Robusta beans generally contain more caffeine than Arabica beans. (200mg is less than a ‘tall’ Starbucks coffee.)

The study’s authors suggested that women who want to become pregnant should stop drinking coffee for 3 months prior to conception and throughout the pregnancy.

 

Maternal health

If the mother has health issues such as hormone problems, diabetes or immune disorders, there can be an increase in the incidence of pregnancy loss. However, good control of these conditions before and during pregnancy will reduce the risk.

Regular or high alcohol consumption

This link is not definitely proven, but there is increased risk of stillbirth with heavy drinking, binge drinking (5 or more drinks in a row) and having more than 3 drinks a week in the first trimester.[24] It’s safest to avoid alcohol altogether.

Exposure to toxins

High mercury levels can lead to miscarriage. To be safe, pregnant women should avoid sushi, limit their consumption of fish high in mercury levels (such as tinned tuna), and eat fresh cooked fish no more than 2-3 times per week. It’s also good to try to reduce exposure to household pesticides and any toxic chemicals in the workplace.

Experiencing stress

Feeling stressed or anxious—whether from recent emotional trauma, major life events during pregnancy or stressful employment—has been linked to an increased risk of miscarriage, but study results are mixed. Feeling happy and relaxed, or well enough to have sex, may reduce risk[25] (vaginal intercourse can’t harm the baby during pregnancy and doesn’t cause miscarriages[26]). This is a difficult issue for those couples who have already experienced a pregnancy loss, because it is hard to relax completely when you worry about whether it will happen again.

Antenatal infection

If the mother contracts an infection such as rubella, listeria, chlamydia or toxoplasmosis in early pregnancy, the risk of miscarriage or stillbirth later in pregnancy is increased. Other infections such as cytomegalovirus, parvovirus and Group B streptococcus can also cause problems. Women should check with their doctor or midwife if they are concerned.[27]

Rubella infection (German measles) is best avoided by vaccination against the disease; women of child-bearing age should consult their doctors.[28] Other ways to reduce the risk of rubella infection include staying away from those who are known to be suffering from rubella and those who have been exposed to the disease.

Listeria infections are reduced by not eating contaminated foods. In order to do this, it is best to avoid unwashed vegetables, uncooked meats and fish, unpasteurized milk products (watch out for soft cheeses like brie), cooked delicatessen meats, refrigerated smoked seafood, chilled pâtés and spreads, and ready-prepared meals. Listeria bacteria are destroyed by cooking and pasteurization, but not by refrigeration. Although some foods—such as cold cuts of meat and ready-prepared meals—are already cooked, they can become contaminated with listeria when they are chilled.

Chlamydia infection is a sexually transmitted disease. There is a risk of infection from unprotected anal, vaginal or oral sex with someone who is infected. To avoid infection, a condom should always be used during sex; this is especially important if either partner has had multiple partners.

Toxoplasmosis is an increased risk when cleaning the litter box of an outdoor cat, which might have eaten an infected bird or mouse; so too is eating undercooked meat.

Antenatal screening tests

Two tests that are used in normal pregnancy to screen the baby for disease can cause miscarriage. These are amniocentesis (1% risk) and chorionic villus sampling (CVS; 1%-2% risk). Note that these tests do not need to be performed.[29] Therefore, this risk can be completely eliminated.

 

Fetal reduction

This procedure involves the abortion of all but one or two fetuses in a multiple pregnancy so that the remaining ones have a better chance of developing normally. The risk of miscarriage is 5%-10%.[30] Note that this procedure is unethical for those who wish to protect life from its beginning.[31]

 

Post-term (over 40 weeks) gestation

While most miscarriages occur in the first trimester, there is also an increased risk of pregnancy loss after 40 weeks gestation (this is thought to contribute to about 1% of stillbirths).[32] This has raised the question of whether labour should sometimes be induced rather than waiting for it to happen naturally. It is important to get regular antenatal care so the progress of your pregnancy can be monitored.

 

Growth restriction

A significant number of stillbirths are associated with restricted growth in the baby.[33] This is known to be associated with a reduction in fetal movements. The mother’s perception of whether she has experienced a decrease in movements for 24 hours is thought to be a reliable guide. The way to find out if fetal kicking is reduced is to count, once a day: in the third trimester, some practitioners will recommend that the mother spends some time each day counting the baby’s kicks. There are lots of different ways to do these ‘kick counts’, so she should ask for specific instructions.

Here’s one common approach: choose a time of day when the baby tends to be active (it’s preferable to do this around the same time each day). The mother should sit quietly or lie on her side to avoid distractions and then she should time how long it takes to feel ten distinct movements—kicks, punches and whole body movements all count. If she doesn’t feel ten movements in two hours, she should stop counting and call the midwife or doctor.[34] It is advisable to avoid comparing notes with other mothers, as every baby has their own routine.

While there is some debate as to the value of fetal movement monitoring (because of the variation in what is ‘normal’ and the risk of increasing anxiety unnecessarily), a trial which is currently underway in Australia has not only demonstrated that there is an association between a decrease in the mother’s perception of fetal movements and stillbirth, but also that 59% of women were not given any specific information regarding fetal movements during their pregnancy.[35]

 

Diet

A British study found an association between a reduced risk of miscarriage and eating fresh fruits and vegetables daily and using vitamin supplementation before and during pregnancy (in particular, folic acid, iron, iodine and multivitamins).[36] Plus—some good news, at last—eating chocolate daily was also associated with a reduced risk of miscarriage in the first trimester.

 

Of all these risk factors, the most important to address in high-income countries are obesity, smoking and advanced maternal age.[37]

Investigations

In most places, one miscarriage in the first trimester does not warrant having any tests because it is so common. If a woman has a miscarriage in the second trimester, or two or three first-trimester miscarriages, her doctor may suggest some tests to try to work out what is causing the miscarriage, in case there is something that can be done to prevent it. All stillbirths should be investigated.

These tests may include:

• blood tests to check for chromosome abnormalities (both parents), hormone or immune problems (mother only)
• tests on the baby’s body looking for chromosome abnormalities
• ultrasound or x-ray of the uterus
• endometrial biopsy (suctioning a small piece of the tissue from the uterus lining to check that the hormonal changes are normal).

 

Genetic screening

Sometimes when a woman has recurrent pregnancy loss, she will be advised to become pregnant using assisted reproductive technology (ART)—in particular, in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) screening of the embryos. The idea is that if the miscarriage is due to chromosomal defects, you can check the genetic profile of the embryos created before they are implanted, so that only the normal ones are transferred (one at a time). The rest are discarded. This is not an ethical option for those who value human life from the time of conception.[38]

Living through a loss

There are several things that make the loss of a pregnancy at any stage difficult to cope with. One can be the lack of public acknowledgement, particularly if the loss is early in the pregnancy. Another is that the loss is rarely expected; one moment the parents are full of dreams about the coming baby, decorating the nursery and welcoming this little one into their lives, and the next moment it’s gone. Sandra said, I thought it was getting pregnant that was difficult. No-one told me that staying pregnant is just as hard. Ruth said, I can’t get excited about anyone’s pregnancy now. I always wonder if something will go wrong. These losses are so frequent, yet as a society we really aren’t very good at dealing with them.

In the delivery room—stillbirth

It may or may not be known beforehand whether the baby has already died or will die soon after delivery. If there is advance warning, plans can be made for the delivery ahead of time so that the parents can make the most of the short time they will have with the baby. Even if the stillbirth is unexpected, many of the suggestions in the box below can be followed.

One thing that parents of a stillborn baby often mention is how quiet the room is when a stillborn baby is delivered. No cry of a newborn baby, no calls of congratulation. Nothing.

They talk about a baby who was born sleeping, and then going home with empty arms. I do not think I can do justice to those parents who have suffered such a loss with my words alone. I recommend reading the texts listed at the end of this book,[39] to hear from those who have experienced the loss of a child in their own words.[40]

Other children in the family

If there are already other children in the family, thought should be given to how they will be told of what has happened or will happen. An open and honest approach is recommended; children can often cope better with loss than their parents. Don’t try to pretend it hasn’t happened, as it will affect them whether you tell them or not. Thought should also be given to whether they will be given the opportunity to see the baby. Ask them what their questions are, as you might not be aware of what they are thinking.

At the funeral for a stillborn sister, a little girl was listening to the sermon. Afterwards she asked her parents why the minister had said there would be no mourning in heaven. Before they could respond, she continued, If there is no morning in heaven, when will (my sister) wake up?[41]

Afterwards

Saying goodbye is hard. For Maisie, the most difficult time was leaving the hospital: I wasn’t prepared for it. It just hit me as we were driving out of the parking lot and I cried and cried. Grief may well up when it is least expected, and that’s okay.

Despite the difficulties of coping with a child’s death, parents still have to deal with the formalities, such as a funeral. This may be a time when the husband can contribute in a meaningful way while the mother recovers physically. The parents may find it helpful to mark the passing of their baby with some sort of ceremony, even if there is no body. It is a pity that our Western society has lost its traditions around death and that there is no recognized way to mark the passing of a baby through miscarriage or stillbirth. The Japanese have Mizuko kuyō, or ‘fetus memorial service’, which is a ceremony for those who have had a miscarriage, stillbirth or abortion. Temples usually sell statues for display near the temple, which, in some places, the parents dress up with little clothes. Parents say they have found the ritual comforting.

I think the closest thing we have in the West is a church funeral. What I felt was so important was the funeral. It enabled us both to plan and be active during that incredibly difficult week after her birth. It also enabled me to recognize her as a real person, who deserved a real goodbye. So it marked a very clear full stop to that terribly sad chapter of my life, and therefore enabled us to move on. Some hospitals provide memorial services to remember the babies who have died at that hospital. I have attended funerals for stillborn children that, although incredibly sad, were a wonderful testament to the value of every human life.

Parents may choose to make the funeral private or public, and they should be aware that there is no need to rush. Services can help extended family and friends acknowledge their loss too. Once again, it may be difficult. Roxanne and her husband decided to bury their child. She said, I was okay until they put him into the ground. Then I lost it.

If parents have had to register the birth, they will have given thought to naming their child. Even if the baby was too young for this requirement, it is still helpful to name the child in order to validate the birth and make verbalizing memories easier.

Some parents bury the child’s remains in their back yard and mark it with a cross or a tree. Some parents scatter the ashes in a special place. Some families have a formal burial. Close family and friends may have made clothes for the baby, which can be worn by the child at this special time. Jenny and Chris invited their children to put toys in the tiny coffin.

It may take a long time before the parents recover from their grief, and life for them will never be quite the same again.

Many families find ways to remember their baby as life goes on, perhaps with a piece of jewellery, or a memento displayed at home, or maybe each time they see a particular flower. Some families will celebrate the child’s birthday each year, or just keep remembering how old their child would have been had they lived. Each family finds its own way to remember the child who isn’t there.

Post-mortem examination/autopsy

While it can be distressing to think about having a baby’s body examined, it can sometimes provide an explanation as to why the death occurred, and it can contribute to medical understanding of stillbirth in general. It is hard for parents to think this issue through at such a difficult time (immediately after the birth), but only they can make the decision they feel happy with. It is possible to do some tests (such as swabs for infection, x-rays or genetic examination) without a complete autopsy. Results can take up to weeks and months to be completed; parents should discuss the findings with their doctor, as they are usually explained in technical terms, and they will want to know what should be considered for future pregnancies.

Psychological trauma and grief

In many places, there is no routine follow-up for patients who have suffered miscarriage, and so they do not receive the care they need at an emotional level. Miscarriage is known to lead to depression and anxiety, as well as grief. A 2009 survey by the Stillbirth and Neonatal Death Charity (SANDS) in the United Kingdom found that 81% of parents said they suffered depression after the death of their baby; 39% said it affected their physical health; and, 25% said they lost earnings because they had to change jobs or career.[45] The bereavement experienced by these parents may seem protracted and intense compared to other types of grief.

Some researchers have likened it to post-traumatic stress disorder, similar to that suffered by trauma victims.[46] High levels of guilt are common, as well as a sense of having lost part of oneself. There is no standard pattern of grief but talking about it is usually helpful, and although parents won’t forget, the grief does ease with time.[47]

One problem is that many people don’t realize it is grief they are experiencing. It may be the first time the parents have lost a loved one. They may need to be told that grief is a normal reaction to bereavement. The lack of acknowledgement of the miscarriage or stillbirth may mean that not even the parents consciously register that the death of a real person has occurred. Legitimizing the grief process can help parents move through it.

It is not uncommon for grief to be associated with a sense of physical fatigue. It can be difficult to sleep, concentrate or even communicate with others. Those who are grieving may seem withdrawn and depressed and it may be hard for them to get out of bed some days. It is important that they do not feel they are to blame for what has happened. They should not rush back to work. They should let themselves feel what they feel, because they have had a significant loss.

It is not unusual for mothers and fathers to grieve in different ways.[48] Mothers may have a more intense reaction and be more likely than fathers to cry with others. They are more likely to seek support, desire to talk endlessly about their baby, and be preoccupied by their loss. But this does not mean that fathers care less. It is difficult for grieving men in our society, where displays of male emotion are frowned upon. However, these fathers often have a preference for solitude, and may be unwilling to discuss the baby in social and work situations. They may feel a responsibility to be ‘strong’ for their wives and not share their tears, even with them; this can lead to couples feeling even more distant from each other.

Generally, the condolences—if there are any—are directed to the wife. That can leave husbands with very little support. Some may have had to go home from the hospital to an empty house with an empty cot in the nursery, although some will be allowed to stay at the hospital. One of the saddest stories I heard was of a new father cuddling his stillborn daughter with tears in his eyes, saying he just wanted to try and warm her up.[49] Fathers feel protective of their children as well as their wives, and it is a terrible hardship when there is nothing they can do.

A woman is more likely to feel a stronger sense of responsibility for the miscarriage, and guilt that her body has ‘let down’ both the child and her husband. She may feel she has failed as a woman. Self-blame is increased in those who have missed miscarriages, and in those where no cause for the miscarriage is identified.[50]

Even when they think they have recovered, a wave of sadness may hit these parents when they least expect it. There are ‘grief and loss’ websites for parents that can be helpful. Sometimes, when everyone around the parents is telling them to count their blessings, it helps for them to connect with other parents who are feeling the same way and not wanting their loved ones to be forgotten. You can count your blessings and still grieve your losses. Parenting after a loss can be complicated by the memory of the one(s) who didn’t come home. Counselling may be needed to sort through the confusing thoughts and emotions experienced.

Taboos

Susie turned to me at work and said, Why don’t we ever talk about it? I’ve been listening to stories about every baby that’s born, and I’ve never heard of one miscarriage. Miscarriage is still a taboo subject, which makes the grieving harder. Paul said, I wonder why? Is it because they are worried it might happen to them, or because they’ve been hurt by it themselves?[52]

It often helps to talk. It helps make the baby more real and helps people feel better. Words from bereaved parents may help others when it happens to them. So many people don’t know how common pregnancy loss still is. Even that term can be unhelpful; it wasn’t just a pregnancy that was lost—it was a baby.

Apparently some things have improved over the last few decades; there was a time when the parents would not get to see their baby. I once met an older woman who hadn’t been told whether her stillborn child was a boy or a girl. Her husband wasn’t even allowed into the delivery room.

It is hard to talk about a child who has died prematurely; we often do not know what to say. But it helps those who are grieving when others resist the desire to avoid the topic altogether. Sarah Williams, who found out that her child would die at birth, was grateful when a pregnant friend reached out to her across the gulf separating them. She remembered a verse of Scripture that instructs us to “rejoice with those who rejoice, weep with those who weep” (Rom 12:15). She writes: Both grieving and rejoicing are choices we must make actively out of love for one another within the resilience of community. Her friend chose to mourn with her as she learnt her baby would die. Later, Sarah would choose to rejoice with her friend when her baby was born. Both choices were costly.[53]

When should another pregnancy be attempted?

Everyone is different, but it is recommended that parents wait until the woman is physically and emotionally ready, and has had any tests recommended by the doctor, before attempting another pregnancy. Medically, it is safe after one normal menstrual cycle. Most women will have a period 4-6 weeks after a miscarriage. However, it may take much longer for parents to feel ready to try again due to the challenge of coming to terms with the loss.

Talking about the baby

Tammy says, At our church, on Mother’s Day they handed around chocolates to all the mothers. I didn’t get one, but I felt like saying, “I had a baby but she died”. Bereaved parents won’t want to explain things to everyone, but it may be that sometimes they will want to acknowledge the child that is not sitting beside them. If they think beforehand about how to say what they want to say, it might make it easier. And at church on Mother’s Day, give all the women a chocolate. No-one needs a reminder of those they have lost; even if they don’t have children, they do all have a mother. Williams notes: The thing about losing a child is that you do not just lose them once, but you go on experiencing the loss of what they would have been.[54]

Some parents call their little ones ‘angels’. Christians are aware that an angel is another type of being entirely. I think this usage just reflects the difficulties for secular parents attempting to find the vocabulary to talk about these things.

Theology

Where is God in all of this? These are challenging things to comprehend, so thinking about them before tragedy strikes can make things easier.

However, it does not always work out that way. If your sense of loss is still fresh, it may be better for you to look at the psalms, especially Psalm 23 and Psalm 90. Otherwise, read on.

One of the things I love about the Bible is the way it helps us understand why the world is the way it is. Reading the book of Genesis helps us understand how we should respond to bereavement; sickness, death and grief are now unavoidable realities in our world because of human sin and God’s judgement.

We all know the story. God said to Adam, “You may surely eat of every tree of the garden, but of the tree of the knowledge of good and evil you shall not eat, for in the day that you eat of it you shall surely die” (Gen 2:16-17). But Adam and Eve, persuaded by the serpent, ate of the prohibited fruit. As a result, God told Adam that he would return to the ground from which he was taken: “for you are dust, and to dust you shall return” (Gen 3:19b). And they were banished from the garden so they could not eat from the tree of life and live forever (Gen 3:22-24).

Death came into the world with the Fall, rendering this life “vanity and a striving after wind” (Eccl 1:14). Death is the last enemy to be destroyed (1 Cor 15:26). It is not what God originally planned for us, and we are right to find it an outrage.

Ecclesiastes is one book of the Bible that clearly talks about the transience of life on earth:

If a man fathers a hundred children and lives many years, so that the days of his years are many, but his soul is not satisfied with life’s good things, and he also has no burial, I say that a stillborn child is better off than he. For it comes in vanity and goes in darkness, and in darkness its name is covered. Moreover, it has not seen the sun or known anything, yet it finds rest rather than he. Even though he should live a thousand years twice over, yet enjoy no good—do not all go to the one place? (Eccl 6:3-6)

The life of the stillborn child is compared to that of a rich man. The child has no identity and no opportunity to develop character or personality. It has no experience of life. And yet the Preacher thinks the child is better off for being spared the prolonged misery of the dissatisfied rich man who, like each one of us, will also die.

As Job protests against his suffering and curses the day of his birth, he cries to God:

“Let the day perish on which I was born,

and the night that said,

‘A man is conceived’…

because it did not shut the doors of my mother’s womb,

nor hide trouble from my eyes.

Why did I not die at birth,

come out from the womb and expire?

Why did the knees receive me?

Or why the breasts, that I should nurse?

For then I would have lain down and been quiet;

I would have slept; then I would have been at rest…

Or why was I not as a hidden stillborn child

as infants who never see the light?” (Job 3:3-16)

In this passage, Job—out of desperate grief and sorrow—proclaims the life of a stillborn child to be a blessing compared to the intolerable suffering he has just experienced.

Experiencing the harsh realities of our existence, becoming acquainted with grief as the unthinkable happens, and realizing, as we protest helplessly, that sometimes parents must bury their children, we “groan inwardly as we wait eagerly for adoption as sons, the redemption of our bodies” (Rom 8:23). God knows how much we suffer. “Likewise the Spirit helps us in our weakness. For we do not know what to pray for as we ought, but the Spirit himself intercedes for us with groanings too deep for words” (Rom 8:26). And we are not left alone: “for you have been my help, and in the shadow of your wings I will sing for joy. My soul clings to you; your right hand upholds me” (Ps 63:7-8).

There may be times when we doubt the goodness and sovereignty of a God who allows children to die before they are even born. But God knows how many days he has ordained for each baby before one of them comes to be (Ps 139:16). He reserves the right to take human life. Job recognized this when he said “Naked I came from my mother’s womb, and naked shall I return. The Lord gave, and the Lord has taken away; blessed be the name of the Lord” (Job 1:21).

It might be difficult to say that God is both good and sovereign, if the death of an unborn child was the only thing we could look at. But it isn’t the only thing; we can also look at a dearly loved only Son, who suffered and died for us on a cross while we were still sinners. God is also a parent, whose only begotten Son died before his time. And that tells us how much he loves all his children. “Behold, God does all these things, twice, three times, with a man, to bring back his soul from the pit, that he may be lighted with the light of life” (Job 33:29-30). In the words of Don Carson, sometimes God speaks to us in the language of pain.[55]

In Romans 5, we are told that even as death entered the world through one man, Adam, because of sin (v. 12), all men can now have eternal life because the Lord Jesus Christ died for us (vv. 8, 21) if only we will trust in him: “For the wages of sin is death, but the free gift of God is eternal life in Christ Jesus our Lord” (Rom 6:23). We will still mourn, but we know death is not the end.

If life is eternal, where are they now—these children who have died in infancy or in the womb? The Bible does not speak clearly to us on this matter. When King David was told that his son by Bathsheba would die, he fasted for 7 days while pleading with God for mercy. When his servants told him the child had died, they were amazed at his subsequent composure—getting up and washing, going to the tabernacle to worship, and asking the cook for some food. What was David trying to achieve by his praying and fasting? David tells us himself:

“While the child was still alive, I fasted and wept, for I said, ‘Who knows whether the Lord will be gracious to me, that the child may live?’ But now he is dead. Why should I fast? Can I bring him back again? I shall go to him, but he will not return to me.” (2 Sam 12:22-23)

He knew his God. He knew that his was a God of grace.

We know that David believed in a life after death (see Pss 16:10-11, 17:15). Some commentators have understood his reply, “I shall go to him, but he will not return to me” (2 Sam 12:23) as indicating that children who die young go to heaven. This may be reading too much into the text. It is more likely to reflect the fact that although David did not have the full light of the revelation we have received through Christ, he was aware that there is a life after death, that the child still lived, and that he would join him when he also died.[56] Yet it shows David had the confidence to trust God and leave the child’s destiny in his hands.

In the Bible, death does not equal annihilation.[57] Jesus referred to relationships after death while engaging in a debate about the resurrection, in Matthew 22:23-32. He quotes Exodus 3:6 where Yahweh spoke to Moses from the burning bush: “I am the God of Abraham, and the God of Isaac, and the God of Jacob”. Jesus reminded the crowd that the use of the present tense in this Exodus passage reflects the unbreakable relationship that God’s people have with him beyond the grave, in a living union that continues to honour the covenant he had made with Abraham (Genesis 15). “He is not God of the dead, but of the living” (Matt 22:32).

Furthermore, God’s covenant is upheld even when we can’t see how it can possibly prevail. After the miraculous birth of Isaac, Sarah’s only child, we struggle to understand why God would ask Abraham to sacrifice his son (Gen 22:1-3). Why does God threaten the child of the promise? We see from the rest of the chapter that God was testing Abraham, and that he reaffirmed his promise after Isaac’s last-minute reprieve. Dale Ralph Davis observes that God is very kind in allowing us to see these events in the Bible, showing us that it can be a part of the normal Christian experience to think God is contradicting his own character: after blessing Abraham with a son, God appeared to be sabotaging his own plan. Abraham was praised for obeying God (Gen 22:18) even though he was walking in the darkness, unable to see the light. In Daniel 2:22 we read: “[God] knows what is in the darkness, and the light dwells with him”. I do not know what happens to those little ones who die before they are born, but I do know something of the character of our God. In Genesis 18, Abraham asked God for grace and mercy, on behalf of the people of Sodom and Gomorrah. He approached the Lord and said:

“Will you indeed sweep away the righteous with the wicked? Suppose there are fifty righteous within the city. Will you then sweep away the place and not spare it for the fifty righteous who are in it? Far be it from you to do such a thing, to put the righteous to death with the wicked, so that the righteous fare as the wicked! Far be that from you! Shall not the Judge of all the earth do what is just?” (Gen 18:23-25)

We do not know with certainty what happens to those infants whose passing we mourn. What we do know is this: the Lord and Judge of the universe can be trusted to do what is right. Even though we may be walking through the darkness, God knows what is there and the light dwells with him. He will keep his covenant with us.

Often we live in the here and now, at times forgetting that “the sufferings of this present time are not worth comparing with the glory that is to be revealed to us” (Rom 8:18). We will still weep—knowing that a little one is not going to suffer a lifetime in this fallen world will not make us miss them any less. But in the dark times we must try to look ahead to the resurrection (1 Cor 15:20-26), because “Death is swallowed up in victory… thanks be to God, who gives us the victory through our Lord Jesus Christ” (1 Cor 15:54, 57).