Losing a pregnancy to miscarriage or stillbirth is a traumatic event — not just for the involved mother or couple, but for the whole family. If you already have one or more children and they‘ve been involved in the excitement of pregnancy and preparations for a new sibling, breaking the news can be one of parenting’s toughest moments. The World Health Organization (WHO) estimates 10% to 20% of pregnancies end in miscarriage and that 2.6 million stillbirths take place worldwide every year. Mayo Clinic defines miscarriage as the loss of a baby up to 20 weeks. Stillbirth is defined as the loss of a baby post 20 weeks.
When it comes to telling your child about a loss, we spoke to Dr. Kate White — a Boston-based gynecologist, pioneering pregnancy loss educator and author of the book “Your Guide to Miscarriage and Pregnancy Loss” — about how to have that conversation. What steps can you take to manage the joys and risks of a pregnancy with your children? And how can a family process the grief of pregnancy loss together in a healthy way?
Mayo Clinic Press: Many people hold off on a pregnancy announcement to less-immediate loved ones and friends until after the end of the first trimester. When is the right time for a parent to tell their child or children that a new sibling is on the way?
Dr. Kate White: For adult loved ones and close friends, I favor early disclosure when it comes to announcing a pregnancy because the same people you joyously share your news with are the same people who become your support system if your pregnancy ends in a loss. However, since children are usually not a source of support for their parents — especially when they’re young — I would recommend waiting until the pregnancy progresses past the first trimester to break the news, when the risk of miscarriage decreases greatly.
MCP: How does someone start that conversation?
Dr. White: My principles for this conversation are to be clear, brief and ready to answer questions. Children don’t have the same social inhibitions as adults and if they have a question, they’re going to ask you. But with a 3-year-old, you’re going to talk about a new baby coming into the house in a very different way than with a 12-year-old — who has had some sex education and understands a little about how babies are made and born and will want a more evolved conversation. With all ages, you want to hit the basics of “There’s going to be a new baby, there is a due date but we don’t know exactly when the baby is going to come,” and then just be ready to answer questions.
MCP: Should an element of caution be built into this conversation about the potential risk of pregnancy loss?
Dr. White: No. Trying to introduce the idea that we’re pregnant and it’s wonderful — but we might lose the baby — is too much for most children to take in. It’s like car crashes. Nearly one in 100 Americans will die in a car accident — that’s an incredibly high number — but you don’t mention that risk when you get into the car to go to the grocery store with the kids.
MCP: Let’s touch on a situation where a parent or parents pursue surrogacy for parenthood. In a scenario where the parent or parents already have a child and the surrogate is now pregnant, should that conversation be run the same way?
Dr. White: Yes, run it the same way. We’re going to have a new baby. And if kids understand enough to say, “Are you pregnant?” You say, “No, there’s actually a woman who is carrying the baby for us because mommy’s body just wasn’t ready.” Or if it’s a couple who can’t biologically have kids — a same-sex marriage for example — you can say, “Daddies’ bodies weren’t made to have babies, so that’s why there’s this really lovely woman who’s going to carry the baby for us and then we get to take the baby home.” Keep it simple because the pregnancy is not happening in the home and it may be even more abstract for a child to understand.
MCP: As the pregnancy journey moves forward, is it a good or bad plan for children to be involved in medical appointments, such as ultrasound scans?
Dr. White: Every family has a different opinion on this and as a physician I support the choice of every patient. My feeling though is that appointments are boring, most of them are a lot of talking — although once you can hear the heartbeat of the baby, maybe a child can understand that. But for this to make sense to a child, they need to understand what their own heartbeat is, what a heart is, what it does. Only then can that miraculous moment when you get to hear the fetus’ heartbeat the first time, make sense to a child. Early bonding more likely happens when your child can feel the baby kick. Once you can tangibly put your hand on your mother’s belly, and feel the baby move, that is a genuine visceral connection.
MCP: After a miscarriage, how soon should you tell your kids?
Dr. White: In cases of early loss, it’s reasonable to talk about it after a miscarriage is over. Miscarriages can drag out for days or weeks and it can be confusing for pregnant patients, let alone trying to explain to a child that the baby died but it’s still inside and hasn’t come out yet. It’s a lot to take in. So I think it’s best to talk about it with your child once the mother has had a D&C (dilation and curettage procedure) or passed the pregnancy on her own, and the miscarriage is complete.
If it’s a stillbirth later on in pregnancy — when the belly is visibly pregnant, and Mom’s going to have to go into a hospital — that is more challenging because you’re going to be away from your kids. If your kids go stay with grandparents for weekends very frequently, then you can send your kids to Grandma and your kids won’t know anything’s up. Then you can follow the same advice of telling your kids when you’re home and it’s all over. But if you’ve never been apart from your child and now you need to go into the hospital, you may have to start saying something then. But again, you will mostly explain what has happened when you’re home and it’s over.
My mother used to worry about me when I traveled, even into my 40s, and if I was taking a flight, she’d say, “Just text me when you get there, I don’t want to know you’re in the air because I’m going to worry the whole time.” And I think the same thing is true here: Don’t make them worry during the process, better to tell them when it’s finished.
MCP: With breaking news of a stillbirth, can the topic of death be avoided?
Dr. White: Death is a really hard thing to avoid as a human. You can try to protect your kids as long as possible, but at some point you do have to have the conversation. For preschoolers who haven’t encountered death before, parents can talk about plants — everybody gets to see the cycle of birth, life and death in flowers, in trees and bushes around them and even the bugs that are living on them. Even very young kids are aware that if they step on an ant, it dies. This helps you to explain to them that in life, things live for a while and then they stop living. It’s important not to use the word “sleep” or phrases like “went away,” because that is going to terrify the child whenever they go to sleep or you go away. You want to speak directly about what has happened but in a simple way. And then once again, let the child guide you with their questions. For kids of all ages, to explain the pregnancy loss, you should say, “The baby wasn’t healthy, and it got really sick, and it died. The doctors weren’t able to treat the baby because it was still inside. Which is different from when you and I get sick, because we can take medicines and doctors can do things to make us feel better.” You add this in because you don’t want to terrify the child about themselves getting sick and dying.
MCP: Parents can feel like they did something wrong to lose a baby, like lead too busy of a life. How can parents help themselves and their child get over this?
Dr. White: It’s important to say that it’s no one’s fault. It wasn’t that Mommy didn’t sleep enough or exercised. It wasn’t that you, anticipating a new sibling, weren’t happy about the pregnancy or you felt angry or jealous. All sorts of feelings about a new sibling are possible, especially with older kids. Kids tend toward magical thinking and can think they made the pregnancy loss happen. So, make sure you address early on that nothing any of you did or felt or thought made this happen. It just happened.
MCP: After miscarriage, how can parents best take care of their own grieving and look after their kids at the same time?
Dr. White: It’s a mixed bag having children at home when you have a pregnancy loss. Your kids serve as a reminder that pregnancy can work for you, that you can go through this process and get a baby on the other side, even if it didn’t happen this time. Pregnancy loss with a first pregnancy has an extra flavor of, “Oh my god, I don’t know if I’ll ever be a parent.” But when you’re already a parent, you know that it can work. So you have wonderful children at home that you can spend a lot of time with to remind yourself you are a parent, you have children who love you, who you love and that you’re going to be okay even if you don’t go on to have another child.
But having children at home can also remind you how much you wanted another child, especially if one of your kiddos is really little still and that can be painful. You have to balance being with your kids who need you and tapping into your support network, whether this is family or close friends. This is a time when people in your support network are often asking what they can do — but they give general sentiments, which puts the burden on the grieving person to come up with something to do. Concrete suggestions are much better, such as asking them to take your kid(s) for a period of time, whether it’s a playdate at their house or having your parents or cousins take them for a while. Don’t hesitate to get a little bit of respite care because you need to take care of yourself too.
MCP: What advice would you give to single mothers navigating a loss?
Dr. White: I’m a big believer that there’s the family you’re born into and the family you make. And some of us are blessed to have robust, dual families and some have one or the other. This is a time where if you are used to being a strong, independent person managing things on your own, it is okay to reach out for help and take these offers. People are desperate to help you. When people say, “Tell me what I can do,” they mean it, because everybody wants to fix your sadness. And, of course, they can’t. It will make people feel better though if you give them something to do. And it doesn’t have to be taking care of your kid, it can be walking your dog or getting you groceries. When I had my stillbirth, the best thing anyone did for me was my office chipped in to get me a housekeeper for the two months of my bereavement leave. Not having to worry about cleaning my toilets during those two months was like the best gift anyone ever gave me. Let people help you. It’s not that people in crisis want to be alone, they just don’t want to be a burden on the people they love. So I want to send a message to single mothers going through pregnancy loss: Your support network loves you and they are grieving with you, let them help you. Single parents or not, everyone needs that advice.
MCP: Some families have a ritual or ceremony to mark a miscarriage — and it’s more common for families to have a ceremony or service to mark a stillbirth. What role should your kids play?
Dr. White: If you have any rituals or ways of memorializing the pregnancy, let the kids be involved. It’s not typical to have open casket wakes with a stillbirth, but if you do a funeral or you’re burying the baby, or if you have a ceremony at the beach or at a park or plant a tree — whatever it is — let your kids take part because it really is a loss for the whole family.
MCP: Are there any obvious warning signs parents can look out for that their kids are not coping with the pregnancy loss?
Dr. White: Sadness, anger, guilt, acting out, are all normal when kids are processing. The presence of negative emotions is not in itself a red flag, it’s grief. And children cycle through it the same way the rest of us do. Part of this experience is us accepting that you can’t fix your own broken heart and you can’t fix how your kids are feeling. Part of this is tolerance for the grieving process. But you are also looking out for when emotions start to interfere with how they’re doing in school or interfering with their relationships. Everybody has sad days and anxious days but once it’s rendering your kid nonfunctional, that’s when you want to get extra help.
MCP: Is it a good idea to let your child’s school know that there has been a pregnancy loss at home?
Dr. White: I think it’s a really good idea. It’s twofold: I’m a big believer in disclosure around loss because it helps break down stigma — and it helps garner support for that person and sometimes from unexpected places. Your child’s caregiver, your child’s teacher — I’m not saying you have to tell the person at the checkout at the grocery store — but the people who are in your life … it is pivotal for them to know. Not only so they can support you in some way, but they’re going to understand or keep an eye out on what’s happening with your kids. How often are kids asked to sketch a picture of their family in school? And if the child draws something disturbing, it helps the teachers to have context so they can help the child through.
MCP: The parents move on, try for a baby again, get pregnant and the first trimester passes. Does the conversation about a new sibling being on the way now require caution due to the recent pregnancy loss?
Dr. White: Kids may make the connection and ask if they do. It’s okay to talk about what happened before and what may happen this time. A conversation might include something along the lines of: “Life is uncertain and we’re going to hope that everything is going to be okay. But there’s a chance it might not be.” A similar but simpler way to say that would be: “We’re pregnant again and we’re really hopeful we’re going to get to take a baby home.” Little kids may not make the connection to the last pregnancy. They may keep seeing this as a brand-new thing. But older kids will likely say, “What if you lose the baby again?” To which you say, “We’re hoping for the best, but we can’t control what happens.”
MCP: With pregnancy loss in all forms, how can a family best move through the grieving and healing process together?
Dr. White: Don’t try to hide your sadness because the kids will know. Expressing emotion and teaching children feelings of sadness are normal and that it’s OK to feel that way when something sad happens is an amazing lesson. Not only is it easier for you not to have to hide, but it’s a really good lesson for the kids. Get your kids back to their routine as fast as possible because kids thrive on routine. Do whatever you need to do to get through the loss — which may include a lot of doctor visits and the kid going to a lot of child care or going to someone else’s house — but as soon as you can, get them back to their routine. If you usually do bath and bedtime stories and tuck them in and that got disrupted by going to the hospital, get back to that as soon as you can. Routines tell them they are safe and loved and they are OK and their parents are okay and everything’s going to be okay.
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