The hierarchy of grief - guest blog from Beth

Guest blog by Beth

There are few places on the internet that I’ve found as warm and as welcoming as baby loss support groups on Facebook. There is so much compassion, solidarity and advice to be found there that enduring friendships are often formed, and the loneliness and isolation that many bereaved parents feel is chipped away. Even here, however, there is an elephant in the room, which is only occasionally acknowledged: the hierarchy of grief. 

The hierarchy of grief is the belief that the impact of a baby’s loss correlates with the length of the pregnancy. This is something that is rarely talked about, but it was made explicit a few weeks ago, in one of the baby loss groups I belong to on Facebook. A grieving mother had posted her feelings about the word “miscarriage”. She had lost her baby close to 20 weeks, and felt that the word was totally inadequate to convey the experience that she had gone through, in giving birth to a baby who was very small, and yet recognisably a baby. She was arguing that “miscarriage” should be used only to describe first trimester pregnancy loss, and whilst this is a thought process I can sympathise with, I can also understand why her post upset a great many people. I don’t in any way mean to attack that poor woman. Having lost babies before 6 weeks and after 12, I can confidently say that the experience is very, very different. But stating that difference should not at all minimize the suffering of those who have experienced the former, and that is something that must be stated clearly and often. 

The distinction is, of course, ultimately a medical one. Before 24 weeks in the UK (20 in the US), pregnancies are not considered viable unless the baby is born alive. If the baby is not born alive, the pregnancy is considered to have been miscarried, and the baby has no legal status and does not receive a birth certificate. After 24 weeks, a baby who is not born alive is considered to have been stillborn, and is registered in accordance with the legal processes in place to register live births.

This is obviously devastating for families who lose their babies just before 24 weeks; that a couple of extra days or weeks would have conferred the legitimacy and weight of legal registration, and the much less problematic label of “stillbirth”. Moreover, and I am open to correction here, as I haven’t experienced either, but it strikes me that the process and impact of a 24 week stillbirth is not very different from a 42 week one. Both will involve labour and delivery, naming, legal registration, and probably a funeral. On the other hand, a miscarriage at 6 weeks is extremely different from one at 23 weeks. At 6 weeks, the sex of the baby will not be known, their remains may not be identifiable, and it is much more likely that the pregnancy will have been a secret. At 23 weeks, a baby can be dressed, named, photographed, and their existence is less likely to have been shrouded in secrecy. Leaving aside the word miscarriage, which I think there are serious with, this difference does pose a lot of problems. For this reason, many bereaved parents and those who work with them, choose to say that babies lost to late miscarriage were “born sleeping”, to avoid the medical terminology entirely. 

But I feel that one of the main problems here is not that that the word “miscarriage” is used to describe two very disparate experiences, but that it simply does not seem to carry connotations of serious physical and emotional trauma. It’s assumed to be the loss of “a cluster of cells”, described merely as heavy bleeding, or even a heavy period. There is the assumption that no identifiable tissue will be lost, and that it is the body’s way of dealing with ‘mistakes’ that happen at conception.

There are two obvious problems with this conception of miscarriage. The first is that it isn’t accurate, in terms of conceiving all miscarriages as the same- either in terms of experience or cause. And the second is that it isn’t accurate in its assumption that even the earliest losses cannot be extremely traumatic, either physically or emotionally. 
The problem of society conceiving of miscarriage as “just bleeding”, and as the sad but ultimately unavoidable consequence of things that go wrong at conception, is that the experiences of women which differ from this are minimized and side-lined. In many ways, the “1 in 4” campaign is excellent; it unites women who have experienced baby loss in all of its awful forms, and makes them feel less isolated in their grief. But the flipside of highlighting the normality of baby loss is that it allows the suffering that accompanies it to be minimised. Oh, you lost a baby? So did my best friend/brother’s girlfriend/next door neighbour. This normalization can be insidious, because while these people might have been through a process that was physically akin to yours, they also might not. And even if they have, that absolutely does not mean that their experience was akin emotionally to yours.

The simple fact is that some women find miscarriage extremely difficult, irrespective of gestation, while others cope better. And this comes down in large part, the evidence suggests, to what’s called the maternal assignment of fetal personhood. This means the extent to which the mother regarded the baby as a person in their own right, and not just as the lost potential for a baby. Some people may prevent themselves from feeling that their baby was a person, in order to protect themselves from the grief associated with a loss. This is obviously easier to do in pregnancies where the baby has not yet taken on a visibly human form, or when the mother is not exposed to that form (for instance due to surgical management). Others may simply feel that they have lost a pregnancy, rather than a baby. In theory, this means that a woman who loses a baby to a chemical pregnancy at 4 weeks could feel grief equal to or greater than a woman who loses a baby to full term stillbirth, if the former had assigned greater personhood to her baby than the latter had to hers. 

To perpetuate the hierarchy of grief, where later gestation is considered to correlate with greater grief and trauma is therefore to create a culture in which many bereaved parents will not be supported as they should. The formal systems needed to support parents grieving early loss will not be, and indeed are not, in place. And to compound this, informal support networks will not be capable of recognising the extent to which they are needed. It’s in this kind of context that parents who have lost a baby find alienation and isolation in social networks instead of consolation. In which they are told they must be “disappointed” (a word that is stunningly inadequate to describe the depth of pain that baby loss can cause), that what will be will be, or are reassured that they can try again when all they want is the baby they had lost. 

To some extent, this hierarchy of grief is established by the medical and legal differentiation of miscarriage and stillbirth. But it is also perpetuated all the time. By hospitals who reserve access to services such as bereavement midwives and rainbow clinics to parents who have experienced later loss. And also, however inadvertently, by parents who reject the notion that their experience of late miscarriage or stillbirth can have anything in common with those who have lost a baby at an earlier stage. As I said earlier, I appreciate more than most people that there is a huge difference in these experiences, but we can compare them without ranking one as worse- more traumatic, more upsetting, more legitimate, than the other. At the end of the day, we are all bereaved parents, and none of us knows what the others are going through. There is no point in comparison; only solidarity can help. 

You can read Beth's story here and follow her on Instagram here.