How to manage perinatal mourning as individuals, church and society? “We have to listen”, says Ana Amelia Sánchez, a psychologist with years of experience in that issue.
In 2021, the perinatal mortality rate in Spain reached 4.03 children per 1,000 births, according to the National Statistics Institute (INE).
That is, for every thousand pregnancies that reached birth, in four cases the baby died in the mother's womb before the 22nd week of pregnancy, which is when the World Health Organisation speaks of perinatal death.
The figures would be much higher if babies lost in the first days and weeks (stillbirths) are taken into account. This is known as a miscarriage.
“There are many women who want to make a distinction between abortion and voluntary termination of pregnancy”, says Ana Amelia Sánchez, a health psychologist specialising in perinatal mourning with years of experience.
Sánchez stresses that “we have to listen, as professionals, as brothers and sisters in faith and as family. Sometimes we listen just to respond, and not to understand".
Thinking of the church, she adds, “there is a need for couples and people who talk about their vulnerabilities and who can be a support for others”.
But she also emphasises the complexity of the issue and urges for caution. “I like people to talk about these situations, but I don't think they can do it with everyone, because you also have to take care of yourself and protect yourself”, she adds.
Question: Sometimes it seems that there are more cases of gestational death now than before. Is that true?
Answer: It doesn't seem that there are more perinatal deaths, it's just that now we find out about pregnancies earlier.
Before, there were more pregnancies and therefore more perinatal deaths, but quite often women didn't even know they were pregnant. They might know by the third or fourth month, but those who were lost in the first or second month would go completely unnoticed.
A statistic that has remained fairly stable over the years estimates that one in four pregnancies does not go to term. If biochemical miscarriages are also counted and the pregnancy ends in the first few weeks, then it would be one in three.
Another factor is that the age of motherhood is delayed, especially in Western countries. This leads to a higher risk of perinatal death. From the age of 36 onwards, there is an increased risk, including the risk of gestational death.
Moreover, until recently this was taboo. Today, up to 12 weeks of pregnancy, many professionals and families and mothers ask that it should not be counted as a loss.
This reflects the taboo of death, because after 12 weeks a woman has to talk about loss or miscarriage. Since this is something that is changing, as with mental health, and it is possible to start talking much more openly, we are also hearing more about it, although looking at the data it doesn't seem to be more.
Q: Why people didn't talk about it before?
A: It has been a taboo because death, in general, is a taboo subject. Most people prefer to live thinking that they will never die. But this is also a women's issue. Until recently it was not allowed to talk about it because it was seen as part of women's sexual life and reproductive stage.
It also has to do with a process that is silenced because of the low value placed on human life in those early stages, so that the man or woman is not seen as the father or mother of those lost babies.
This is not a widespread issue, but it does happen. Some people are reluctant to talk about it because they have told others about it and they have responded with the typical phrases: "Well, there must be a reason. God had a plan"; "better now than later", " you are young and you will have more".
All of this leads to a refusal to talk about it, because it invalidates the mourning. And these comments are not only made at home or in churches, but also by professionals.
Q: In your professional experience, how do you deal with this kind of situation?
A: Usually the mothers come, but increasingly also the fathers. I applaud, thank and invite them to do so. In fact, the experience of the father and the mother are different.
The approach is very similar to that of any mourning. However, for women, some neurological changes begin to take place from the moment they begin to desire motherhood and to think about becoming pregnant, which can already be observed from the week after becoming pregnant.
Therefore, you have to take care of the process with a lot of listening. First, to see how the person is experiencing it, because not all women consider that they have lost a baby.
Sometimes the grief is more about the idea of motherhood. Each case is unique: sometimes it is not the first miscarriage, and sometimes it comes from several years of searching. It is not usually for a single reason, but due to many factors.
It is very important to give much value to the life of the baby. This usually brings great consolation. To understand that, although it was not born alive, it did have life, to dignify the lifetime of a baby who dies in the womb brings much comfort.
It is also necessary to give place, space and time to mourning. That is, to talk about it, even to name it, to say goodbye and to give it a place in the family. Because, perhaps, other pregnancies will follow and if the first one has not been properly closed, certain emotions may be aroused.
Q: The mourning process must be very different in each case
A: Many women come to the doctor with feelings of guilt because they think they should have done something to prevent what has happened.
Guilt is something that, although it is present in many situations, it is not in every mourning. However, it is very common in perinatal grief processes.
It is true that it is totally different for some situations than for others. But, for example, in cases of unwanted pregnancy, the woman accepts to have the baby and if she later loses it, contrary to what usually happens, she does not usually experience relief, but rather there is a deep sadness and a feeling of guilt that links the death to the lack of desire.
This needs to be addressed because perinatal death is very common. On many occasions, the guilt comes from ignorance. Very often a woman suffers an abortion and tells a friend about it and discovers that she had also suffered one.
A situation in which perinatal death is often experienced with much regret is when there is a late search and the woman becomes pregnant at an older age. Then, time matters and there is a sense of urgency every month.
The role of the father also affects much, whether he values the loss or the level of involvement he had in the pregnancy. There are women who can feel very misunderstood in this regard.
Q: How does perinatal death affect men, do they mourn?
A: Absolutely, and it's as diverse as it is for women.
There is a biological issue that is important. Although it seems obvious, pregnancy takes place in a woman's body. From very early on, they begin to undergo changes in their physiology. Moreover, we know that there are microchimerisms, which is a phenomenon whereby the baby's cells become attached to different organs of the mother from very early weeks of pregnancy.
In other words, there is a whole hormonal, physiological, neurobiological and neuropsychological process that occurs in women that men do not experience.
He will not experience it in the same way because nothing has apparently changed in his body or in his routine, but this does not mean that he is not allowed to suffer either.
This is changing, but it has always been said that men do not cry. If they usually have no space to talk about their emotions, in this context, in which the protagonist is the woman, it is totally impossible.
For me this is important, because I believe that there are no protagonists in this issue. It is true that the experience is not the same, and the woman needs space and time to heal inside and out, in body and mind, and perhaps during this period the man should step aside a little to allow this process to take place.
But afterwards, it is very important that he has his place, that he can talk and be welcomed and supported, both in the marriage and outside it.
This has nothing to do with whether she has more suffering, because you can't measure that. It has to do with how involved they are in the pregnancy.
But the woman's process has so much to do with her reproductive cycle. The woman bleeds, she has physical pain, and she may even have started to produce milk. She experiences a lot physically.
And maybe he needs support for a while not from his wife, who needs to be supported, but elsewhere. And the church is the ideal place to do that.
The problem is this idea that men don't cry. Often they are not even asked how they are doing. They only get questions related to their wives and the typical comments. But they are not even asked how they are coping. If they are not asked, they have nowhere to talk.
Q: What impact does the current debate on the voluntary termination of pregnancy have on the approach to perinatal mourning?
A: There is no professional consensus on this issue. In my opinion, words can do so much harm. For many women, when abortion is equated with voluntary termination of pregnancy, and in Spanish we use the same concept for both, it hurts them deeply because it is not the same thing.
Abortion is spontaneous, while voluntary termination of pregnancy is induced. To reduce the importance of voluntary termination of pregnancy and to believe that all women who abort, in this sense, do so thinking that the foetus is a sack of cells, is a lie.
The complexity of voluntary termination of pregnancy is enormous and has a lot to do with the dignity of the baby's life, but also with the lifestyle system we have, where we believe that we must all be functional and perfect.
Being more realistic, we realise that what is demanded of us and what we demand is productivity. In this scheme of things, every person with any kind of disability does not count. In fact, the UK has just ratified abortion up to the moment of birth for babies with Down's syndrome.
The debate on voluntary termination of pregnancy is very important, but in all its complexity, because there are women, and I have had them in my practice, who have decided to terminate a pregnancy first and later have not been able to get pregnant or have had a [spontaneous] abortion, awakening in them a whole series of reflections about what causes their pain.
For some it is the baby, for others the idea of motherhood cut short. In psychological terms, this experience can make the person more sensitive and aware that the first interruption was also the interruption of a baby, or it can encourage them to experience the later loss not as a death, but as something that has not succeeded. This is my professional opinion, based on my experience.
Voluntary termination of pregnancy is defended as free, safe and without charge, as the Minister of Equality Irene Montero says.
However, I work with women every day and I have not seen any of them ever terminate their pregnancies happily, we could even question if freely. There are also perinatal mourning processes in cases of voluntary termination of pregnancy in practically all women.
Another thing is that it is pathological or causes suffering, but the part of the loss is there, even if it does not cause discomfort nor lead to a mental health consultation.
Q: Is there a way to direct the course of the perinatal mourning process?
A: We cannot condition anyone. But in the process of mourning we have to give a place to the loss. As far as motherhood is concerned, and this is ethically important, closure is necessary.
If you are going to continue looking for pregnancies later on, you have to give that pregnancy a place. It is quite common that, sooner or later, the woman ends up relating the loss to a baby.
Q: What is the professional consensus on how to deal with perinatal mourning?
A: Any mental health professional must work with the issues that the patient brings to them, and can never influence them with beliefs or aspects of personal conscience.
We work with the suffering of the person, but when you dignify a life, you dignify the mother and her emotions, she alone makes the journey of dignifying her own process.
It also often happens that people leave the therapy as they experience improvement, so maybe I don't see the closing of the whole cycle either.
Regarding tools, there is more and more spirituality in psychology. Not religious, but in general. And the whole approach to grief is surrounded by a lot of spirituality.
It is not the same to think that the baby has a soul, a body and a spirit, as it is to think that it is a sack of almost human cells, as some say.
To understand that that embryo, that foetus, that baby has value in itself because it is a miracle in itself, and that it doesn't matter how long it has lived, but that God has set his eyes on that baby, and that he has chosen that man and that woman to be the parents of that baby, changes everything.
The fact that we can trust that we will be reunited with our lost baby, and that there is a God in whom fatherhood and motherhood dwells, who understands my suffering, welcomes it and sustains it.
We will not come to understand what has happened here, but we can trust that God has a much bigger plan and rest in that. In terms of professional tools, it is unparalleled to be able to approach the process with that perspective.
Q: In your experience, how are such cases generally handled in the church?
A: They are simply not handled. I know it is the same with other issues, and I don't want to make this issue the banner of what doesn't work in evangelical churches. I think that socially, this is a very invisible issue, and our churches are a reflection of what is happening outside.
Furthermore, the idea that God gives and God takes away is very widespread, and it seems that mourning has to be integrated quickly. Grief is not overcome, it is integrated and becomes part of our life.
But one thing that helps to integrate grief properly is to be able to share and talk about it, thus validating that loss, so that when it is not named, not mentioned, not asked, the faith community is not working.
In the pulpit, abortion is only mentioned when it has to do with the voluntary termination of pregnancy. And so on with other things, such as infertility and the stories of Isaac and Samuel. There are many other realities within the family that are not being addressed.
Q: What could churches do?
A: We need to create spaces, certainly not with the whole community, but small groups of trust where we can be accountable and share what is happening to each other. We must provide a climate of enough trust to be able to talk about our desires for fatherhood and motherhood.
Seeing certain responses in the church, when we go through a process of perinatal mourning or infertility again, the anguish, the fear, and the impact on our own faith in marriage during this process is huge, and we live it alone, because we don't want to feel invalidated in our emotions.
That's why we have to create those spaces of trust where we can be vulnerable on an emotional level.
We must also be very careful about what we say because, although we are brothers and sisters and members of the same spiritual family, our words are not lost in the wind. Some comments are not only made in the context of the church, but they are intensified there.
Language is very important. When we begin to name things, we begin to give them the value they have.
When preaching about suffering in marriage, it can also talk about the pursuit of pregnancy or pregnancies that don't work out, in addition to finances, pornography, or unchurched children. By naming them, we validate the pain and perhaps people may dare to share it in those spaces and with those people they trust.
Q: Are there any biblical insights that especially renew you, given the reality of the perinatal mourning cases you often deal with?
A: For me, as a psychologist, the text of James 1:5 is very important: "If any of you lacks wisdom, you should ask God, who gives generously to all without finding fault, and it will be given to you" (NRSV, 1960). It encourages me to return again and again to the source of wisdom and truth, which is God.
Jesus is a very good example for me of this emotional acceptance and support. When he accompanies Martha and Mary at Lazarus' death, or when he is writing on the ground and they brought him the adulterous woman. I can ask God for wisdom again and again and he will give it to me without reproach.
It also helps me very much to think that as a church we are called to be salt and light. And in the midst of the pain, the suffering, the brokenness of the world we live in, we really do have a message of hope to give, regardless of what has happened.
I have been working as a perinatal psychologist for a few years now, since I specialised, but I have also worked in a prison context since 2008, especially in cases of gender-based violence and with very violent crimes. And I see the dignity of the human being in every look, not because that person deserves it, but because I see that it is God's work.
It is very important for me to be able to convey a message of hope in any circumstance, even in those that each of us has brought upon ourselves, or in those consequences of bad decisions that are now being paid for.
Something I often repeat to the people who visit me is that their pain is important. And it really does. Understanding where that suffering comes from has to do with the essence of the human being. That pain has consolation.
The statement in Psalm 139:16 is very special to me, especially for Christian couples: "Your eyes have seen my embryo".
The idea of our existence is already spiritual in itself. To understand that a baby who has died in the first weeks has significance in the mind of God, and therefore has importance in the history of the world, brings a lot of comfort.