Termination of pregnancy for medical reasons: a decision with no good option

The image is still on the screen. The doctor stopped talking a few seconds ago, but nobody in the room moves. Then she asks something that seems completely beside the point: “Can I stay here a little longer?”

This is how it begins for many people. With a scan result saying that something has gone seriously wrong with a pregnancy that, until yesterday, was a joy. Sometimes it is a condition with which the baby could not survive after birth. Sometimes a condition that would mean severe illness or suffering. Sometimes the mother’s health or life is at risk. And then comes the moment when a decision has to be made about something nobody would ever want to decide.

Termination of pregnancy for medical reasons is a loss that is spoken about even less than other pregnancy losses. This post is not about whether such a decision is right. It is a decision made by the people who live it, with their doctors and in line with their own values. This post is about what happens afterwards — and about why grieving after it can be so lonely.

A decision with no good option

When people describe this moment, they often use the same sentence: “There was no good choice.” It is not a choice between good and bad, but between two kinds of pain. Continuing the pregnancy knowing what it will bring. Or ending it and carrying that decision onwards. Each path has its price and neither is without loss.

Then there is time. Decisions are often made within a few days, sometimes in circumstances where complex medical information has to be understood quickly. People remember corridors, waiting rooms, phone calls with relatives, searching online in the middle of the night. All of this at a time when they ought to be in shock — and they are.

An important boundary: the medical questions that come up belong with your doctor. What the result means, what the options are, what will happen to your body, what it means for any future pregnancy — talk all of this through with your gynaecologist and the team looking after you. It is right to ask as much as you need, even more than once. In this post I stay with what is my field: what happens to the person and to their relationships.

What research tells us

There is not much research on the emotional consequences, but what exists paints a similar picture. A team led by the German researcher Anette Kersting followed women for 14 months after a termination for fetal anomaly. In a significant proportion of women, symptoms of grief and traumatic stress were still marked more than a year later.

A Dutch team led by Marianne Korenromp followed women for longer. Most of them eventually adjusted well, but in a minority the distress persisted. Among the factors associated with a harder course, they found doubt during decision-making and the feeling that their partner had not been a support. This matters, because these are things that can be influenced — more on that later.

Qualitative research, in which women describe their experience in their own words, adds another layer. The British researchers Lafarge, Mitchell and Fox, in a review of such studies, showed that women often experience this as a traumatic event, that they struggle with sadness and guilt at the same time, and that what often hurts most is the silence of those around them. Some said they had never told anyone the whole story.

Grief that goes unacknowledged twice over

In 1989 the psychologist Kenneth Doka introduced the term disenfranchised grief — grief for a loss that those around you don’t recognise as a real loss, or don’t acknowledge out loud. There is more on this in The grief nobody acknowledges. Pregnancy loss in general often falls into this category, as described in Pregnancy loss: the grief others don’t acknowledge, and you will also find a short explanation in the knowledge base under pregnancy loss.

With a termination for medical reasons, the lack of acknowledgement can be double. First, because it is a pregnancy loss that others often don’t know about or don’t take seriously. Second, because the loss was a decision. People are afraid of being judged, so they say nothing. Or they tell only part of it — “we lost our baby” — which is true, but not all of it. And then they cannot talk about the part that eats at them most.

Some don’t even allow themselves to grieve. “I made the decision myself. What right do I have to be sad?” The thought is understandable, but it isn’t true. A decision doesn’t erase love for the child you were expecting. Sadness and the decision exist side by side, because they were both already there in the moment of deciding.

Guilt is not the same as responsibility

Guilt is often the loudest voice after a loss like this. It comes back as questions: What if we had waited for one more scan? What if they were wrong? What if it would have been all right after all? Did I do something wrong for this to happen at all?

It helps to tell two things apart. Responsibility means: I made a decision and I carry it. Guilt means: I did something wrong. People often mix them up. You can carry responsibility for a decision without that decision being a mistake. You decided in circumstances you didn’t choose, with the information you had at the time, out of love and care — for the child, for yourself, for your family.

Guilt is explored in more depth in Guilt after a loss: “I could have done more”, and the knowledge base has short explanations of guilt and regret. The difference matters: regret can also simply mean wishing things had been different — and that doesn’t mean you chose wrongly.

The time before the decision

Korenromp and colleagues’ research shows that doubt during decision-making is linked to a harder course later on. That doesn’t mean doubt must be suppressed. It means it is good if doubt has room — if you can say it out loud before you decide, and don’t carry it alone.

If this moment is still ahead of you, here are some things people later name as important:

• Ask your doctor everything that isn’t clear to you, even if you feel you have already asked. Write your questions down in advance.
• Ask how much time you have. Sometimes there is more time than it seems in the first shock, sometimes less. It is good to know.
• Ask what is possible in terms of saying goodbye, keepsakes and rituals — the options differ from place to place, and you often have to ask for them.
• Talk to each other, not only about the decision but about what you feel. A decision a couple makes together is carried differently later on.

The knowledge base tool questions before a big decision may help here — not to tell you what to choose, but to help you hear more clearly what matters to you.

The couple: two losses in one story

In Korenromp and colleagues’ research, the feeling that one’s partner was not a support emerged as one of the factors in a harder course. But often it is not that the partner doesn’t want to be a support. It is that the two partners grieve differently and don’t recognise each other in their grief.

The woman lived the loss in her body. Her partner lived it beside her — and it often seems that his grief has no place. People ask how she is. Hardly anyone asks him. And he often takes on the role of the one who has to hold up, sort things out, make the calls, answer the questions. When the time comes when he might grieve, it feels too late, or as though he isn’t allowed to, because she is the one who really lost.

On top of this, a couple can drift apart in how they experienced the decision. One was more certain, the other less so. One accepted it faster. What goes unsaid can come back later as a reproach: “You wanted it this way.” That is why talking about it — how each of you experienced the deciding, not only the loss — is one of the most important steps afterwards. More on how couples cope with loss each in their own way in Grieving as a couple.

This is how such a conversation might sound a few months later (a composite, not a real person):

“You got back on your feet so fast. As if it didn’t even touch you.”
“Someone had to. You couldn’t get out of bed.”
“But you never cried. Not once.”
“I did. In the car, before work. Every day for the first three weeks. I didn’t want you to have to carry me as well.”

Whom to tell — and how much

One of the hardest questions after a loss like this is a simple one: what do I say when someone asks? Colleagues who knew about the pregnancy. Relatives. An older child who was looking forward to a little brother or sister.

You don’t have to tell anyone everything. You can choose different levels: to some people you say only that you lost the baby. To some you say it was a serious illness. There may be a few people you tell everything. That difference isn’t a lie, it is a boundary. What matters is that there is at least one person — a partner, a friend, a therapist — with whom you can talk about the whole story. Women in qualitative studies often describe how it was precisely the silence about the whole experience that isolated them most.

If you have an older child at home, they deserve a simple, true explanation suited to their age — without details they cannot understand, but also without made-up stories. How to talk with children about death is covered in How to talk to a child about death – by age.

Exercise: a letter you don’t have to send

This exercise is for the time when the first shock has passed but the sadness hasn’t yet found words. Do it when you have an hour of quiet and someone you can call afterwards if it gets hard.

1. Choose whom you are writing to. The child, yourself at the moment of the decision, or your partner. There is no right addressee — choose the one who feels closest right now.
2. Begin with what you wished for. What kind of pregnancy, what kind of child, what kind of future. Grief begins with acknowledging what was lost.
3. Write down how you decided — and why. Not to defend yourself, but to hear your own reasons. They are often full of love that guilt hides.
4. Write down what still hurts or what you don’t know. Including questions that have no answer. They can stay questions.
5. End with a sentence you want to keep. Something you will carry with you. Keep the letter, destroy it or read it to someone you trust — whatever feels right to you.

If too much comes up while you are writing — thoughts that overwhelm you, or a body that won’t settle — stop. You don’t have to finish it in one day.

Where this post doesn’t apply

I don’t want to give the impression that everyone must go through a long, hard grief after a loss like this. Korenromp and colleagues’ research shows that most people eventually adjust well. Some feel above all clarity when they decide. Some feel relief alongside sadness — because the suffering the child would have gone through was spared, or because the uncertainty is over. Relief is not a sign that you didn’t love your child. It is one of the feelings that come with a loss like this, and not something that needs to be hidden.

Nor is there one path for everyone. Some need a ritual, others don’t. Some talk about the loss a great deal, others little. Grief doesn’t move through stages — why not is explained in The stages of grief are a myth. And people lean on different sources — faith, nature, making things, community. It isn’t my place to judge which is the right one.

You do need help, though, if after several months the distress isn’t easing: if you can’t sleep, can’t work, avoid everything that reminds you of pregnancy, or are flooded by images from those days. Then turn to your doctor, who can refer you on. When a loss needs professional help is described in more detail in When loss needs professional help. If thoughts come that you can’t go on living, don’t wait: in Slovenia, the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am), the Samaritans helpline in Slovenia on 116 123 (24 hours a day), and in immediate danger 112.

When the next pregnancy comes

For many, a moment comes when questions about a new pregnancy open up. The medical ones — how likely it is that the condition will recur, which tests make sense — belong with your doctor, and perhaps with genetic counselling if it is offered to you. The emotional ones are often harder than people expect.

Every scan can bring back the memory of the one at which the news was given. Joy is cautious, sometimes not allowed at all until it is “safe”. And people often feel guilt about a new pregnancy too — as if by being happy they were betraying the child who isn’t here. A new pregnancy doesn’t replace the child you lost, and it doesn’t have to. There is more about this time in Pregnancy after loss: the fear that lasts until birth.

I see people in person in Ljubljana, in English or Slovenian — individually or as a couple. You don’t need to have the words ready. It is enough that you come.

What to remember

• Termination of pregnancy for medical reasons is a loss, even though it was a decision — sadness and the decision exist side by side.
• Responsibility for a decision is not the same as guilt. You decided in circumstances you didn’t choose.
• The silence of others and the feeling that your partner isn’t a support make grief harder; it helps to talk about the whole story with at least one person.
• Partners often grieve differently — the one who “held up” has lost something too.
• Medical questions belong with your doctor; seek help if the distress isn’t easing after several months or if thoughts come that you can’t go on.