Women Uninterrupted is an inter-generational podcast bringing you difficult, different and uninterrupted conversations about being a woman.
This episode we ask a gynaecologist and a clinical psychologist about the physical and psychological effects of pregnancy loss.
Host: Anna Thomas Guests: Dr Shefali Tyagi & Sunanda Kolhe
Title music - The Carpet Beat:Maya Dwarka
Production: Anna Thomas
Email: editor@thehindu.co.in
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The Teen & Abortion
Shuchi Bhatt, therapist
Being pro-choice does not mean being pro-abortion.
The freedom to act to interrupt pregnancy must be considered a mental health imperative with major social and mental implications.
The psychological impact of teenage abortion can vary depending on the individual’s personal beliefs, cultural background, and social support. Young adults undergo a lot of hormonal changes during puberty. These hormones affect their moods, emotions and impulses which impacts their way of thinking about dating, sex and other decisions.
For some teens, the decision to have an abortion can lead to feelings of guilt, shame, and regret. They may struggle with self-blame and depression.
It is important to note that the psychological effects of teen abortion are not solely negative. For some young people, the experience can be empowering, and they may feel a sense of control over their reproductive choices.
From the psychological perspective, it is important to consider the individual’s unique circumstances and how that may impact their decision-making. Overall, the psychological impact of teen abortions is complex and varies from person to person. It is important to approach the issue with sensitivity and provide young people with resources they need to make informed decisions and cope with the emotional aftermath.
In every single thing we do, we choose a particular direction to take. Our life is a product of those choices. If an abortion, like any other decision we make, is a conscious and self-aware decision, it can be empowering.
Transcript
Hello, I’m your host, Anna Thomas on Women Uninterrupted. And with me I have Dr. Shefali Tyagi, an obstetrician and gynaecologist with more than 19 years of experience. Welcome, Dr. Shefali. In this episode, we are talking about what happens during pregnancy loss: both the medical and the psychological aspects. So, I asked clinical psychologist Sunanda Kolhe to join us. Sunanda specialises in mental health concerns related to women across their reproductive lifespan in her private practice. Welcome, Sunanda. I’d like to begin by asking you what is the best way family and friends can respond and react when a couple undergoes a pregnancy loss?
Dr Shefali and Sunanda
Sunanda: Well, that’s a very good question. When someone has a miscarriage, it could be quite difficult to know how to respond or react, what to say or what not to say. It’s difficult because everybody’s different, and what might be okay for someone might be upsetting for the other person. Sometimes, friends and family members are just left guessing whether to say something, or not to say something, or are scared about what to say at all. But I would say that it’s just like grieving. It’s a period of bereavement. And the way to go about it is just saying a simple, “I’m sorry,” or “I know that this is difficult for you; I do get it.” Comforting them and being compassionate, and empathetic and supporting them in their experience is important. A lot of times, friends and family members also do think that since it is a very private thing, it’s best to leave the person alone. You give them some space, but actually, sometimes that might lead to isolation. It’s best to keep in touch, drop in a text here and there, drop by, be there for them. And if at all anyone has still confusion or still is unsure about what to say, and how to react, all you can do is just sit and listen to them saying their feelings or their thoughts out. I think that’s a very validating experience for them, and it gives them a lot of support.
Anna: There is this survey that supports that - in America, of course - on public perceptions of miscarriage. The survey found that around 41% of respondents felt alone after a miscarriage happened.
Dr Shefali, I have a question from a listener. Often, we are advised by our older family members, she writes, not to announce our pregnancy. The unsaid context there is that you could lose the baby in the early stages. And then there will be lots of questions from relatives and friends, some amount of blame on mostly how the woman had conducted herself: she went to work, she used to drink, she was always stressed or even - she was lazy. What could be the real causes of early pregnancy loss?
Dr Shefali: The majority of cases of early pregnancy loss are related to the chromosomes and the DNA in the baby. If the chromosomes of 46 - 23 from sperms and 23 from egg - don’t pair together properly, there is a loss of part of chromosome: deletion, addition. Then nature generally discards it. That’s the commonest reason for pregnancy loss. Apart from that, it could be some infections in early pregnancy: if you had some fever etc; if there are some antibodies which are forming in your blood which can actually kind of start starving the pregnancy, or there could be genetic factors like the uterus shape, deformities in the uterus: all these can contribute, but they are not that prominent. Generally, your eating/drinking/travelling has nothing to do with pregnancy loss. Unfortunately, it is the woman who is blamed and they keep on questioning themselves. I do see in practice, “What did I do wrong that this happened?” But the first thing we assure you is that it was not under your control. And there is a little wisdom in the elders’ saying don’t announce it very quickly, because miscarriages are rampant. In fact, every third pregnancy will end up in a miscarriage. You can tell your parents maybe, once you test positive. Once the first heartbeat is seen at around six to seven weeks, very close family members can be told. And once you have crossed your 12th/13th week and you enter into your second trimester, it becomes relatively safer, because if the baby is genetically sound, the majority of babies will go into second trimester. After that losses can happen, but they are very rare.
Anna: The usual reasons people criticise women: she exercises too much; sometimes, it could be that “I saw her swimming” or “I saw her horse riding,” and that there was stress. Is stress a reason?
Dr Shefali: I wouldn’t say that. Stress might indirectly manifest. But then we cannot put a number on the amount of stress that can lead to pregnancy loss. Some people are really stressed. Now, I’ve had a patient whose husband had a cardiac arrest at 24 weeks. The baby is doing well; it didn’t lead to a miscarriage. What can be more stressful than that? And we have office stress, or people who are homemakers without too much stress, still having a miscarriage. I don’t think stress might be a very strong contributor. But of course, we tell you to remain as stress-free as possible in pregnancy,
Anna: What are the signs of pregnancy loss?
Dr Shefali: Once you test positive, we ask you to do a blood test called beta HCG. If the values of beta hCG are extremely low, our antennae go up and we want to kind of monitor the rise of beta HCG. Many a time, it is not appropriate: how it should double in 48 hours - that goes a little off track. That itself gives an indication that this pregnancy might not do well. Later, once we do the early pregnancy scan around six-seven weeks, we see a lot of difference in the date as compared to the growth of the baby. Sometimes the baby’s not seen or is very small; the heartbeat is not seen or there’s a big gap or the heartbeat is very low; there’s a big bleeding sitting inside. All these are early warning signs. And physically, the woman herself can have bleeding, which can be threatening. Anytime you have bleeding in pregnancy, it should be checked immediately.
Anna: What are the non-surgical options available to treat early pregnancy loss? What happens when you miscarry?
Dr Shefali: There used to be a treatment called expectant miscarriage treatment where we did not do anything. Nature took its own course and after a few weeks the bleeding started and the whole thing came out. This happens occasionally now also, but it’s a very unpredictable type of treatment. Working women and those who have a fast-moving life cannot keep waiting for weeks for bleeding to start. Whether it will be a complete miscarriage is another question. Nowadays expectant treatment is not generally offered. We do have medicines nowadays, which can be the medical treatment for miscarriage where the medicines alone will start irritating the uterus and push the products out. And then we check on the ultrasound whether it’s a complete miscarriage or not. It is important that the miscarriage has to be totally complete. There should not be a part of the pregnancy left inside the uterus; it can lead to complications later on.
Anna: What is the recovery process; how fast can you go back to work? How many days does recovery take?
Dr Shefali: In both medical and surgical procedures, the recovery is fairly fast. Medicine is a little tougher because it is painful. And after a week, we generally get to know whether it’s a complete abortion or not. So that is a slightly prolonged procedure. Perhaps you can budget two days for rest in medical termination and maybe one day’s rest in surgical termination where the recovery is quite fast.
Anna: How soon can women get pregnant again after a loss?
Dr Shefali: I believe they should wait for at least two periods before they plan again. Two to three months is the required gap between pregnancy loss and planning for the next.
Anna: Sunanda, I’d like to ask you: how can a partner help in coping with miscarriage or an abortion?
Sunanda: I think there are two ways here, two very important ways. There are multiple ways actually, in which a partner can help, but the most important ones being providing support in the form of, you know, if the partner wants to vent and talk about her feelings, then it’s very important for the partner to validate those feelings, and be comforting towards her. The second thing would be communication. I think that is very important: an open form of communication between both, where the woman obviously feels safe, in a space where she understands that she can share her feelings with her partner without being judged or, you know, or a comment being passed that would kind of upset her. I think that is very supportive. Open communication and being supportive, being comforting and just listening to her; being there for her. I think that’s very important.
Anna: Would anger be one of the reactions?
Sunanda: Anger in the woman?
Anna: Yes,
Sunanda: Yes. The common feelings are feelings of guilt, loneliness, anger, helplessness, hopelessness, loss of control, loss of trust in her own body and anxiety, could be depression, as well.
Anna: So that’s a natural cycle.
Sunanda: Yes, it’s very common to feel these emotions, but only unless they kind of start interfering, significantly, and clinically, in the daily functioning, if the intensity is high, and they are more frequent, and lasts for a longer period of time than the usual, like, more than six months, then you must speak to a mental health counsellor, or a specialist.
Anna: How would you advise a minor who comes to you with a pregnancy she did not intend to happen? What process do you go through there?
Sunanda: Yeah, that’s a very important and a very sensitive question. A minor would mostly come with the parents, right. So, it’s going to be the family who will come. First of all, we do individual therapy with the minor, and then we would do some sort of educational therapy, psycho-educate the parents and therapy with the parents. Later, we will get both of them together to have a conversation. When it’s individual counselling for the girl, I think some of the important things would be the empathetic attitude of the counsellor, no hostility, non-judgmental attitude and being genuine. I think that is also another thing that’s very important: being really able to understand what she’s saying and where she is coming from. And, as Dr Shefali and you also said earlier, a lot of times, self-blame takes over. It is very important for the therapist to address that self-blame and regret: “It’s okay, you know, it’s alright that it’s happened.” But, of course, future measures can be taken to prevent it. When we’re speaking with the parents, it’s more about educating them about the natural course of emotions and the behaviours that the minor might show and might be feeling. Educating them around that and how to handle those behaviors and those feelings and whatever gestation phase the girl is in; what happens around that period, and how all of them can combine and result in whatever emotions or behaviours or personality traits that she’s showing. Finally, when we get both of them together, it’s basically both parties communicating with one another and trying to be on the same page. So that’s the goal: that both of them should be on the same page.
Anna: Dr. Shefali here, she has a diploma in medical law from NLSIU and I would ask her this: In 1997, I discovered I was pregnant with my second baby. At my first visit to the gynaecologist, she asked if I’d like a sex determination test. Amniocentesis, she called it. Quite confused, I asked why. And she said, your first child is a daughter; you have a girl. And she said, many of our patients ask for a test because they don’t want a girl again. Dr. Shefali, I never went back to that clinic again. And I have no excuses for not reporting it. How should a common citizen react when she finds out that sex determination with an intent to abort a female foetus is happening at some place? Do I file an FIR? Do I report it to the Medical Council on their website?
Dr Shefali: Nowadays, it’s absolutely illegal to even ask for a sex test. So maybe at a week before delivery, people ask because obviously, that curiosity is there. A nine-month pregnant lady would ask: now I can’t do anything, Doctor - can’t you tell me now? But it’s a big no. In Indian law, the doctors are jailed and the licenses are taken away if it is found out that sex determination is being done. There is a very strict PCPNDT Act. All the people who have ultrasound machines have to have that registration, the license, and it has to be displayed everywhere that sex determination is not done. In smaller places, maybe in small towns of India, it’s still being done, but that is absolutely illegal. And this is basically a jailable offense. You can file a FIR and later report to MCI. This practice has to absolutely stop in India. In the metros, nobody will even utter…even our doctor colleagues…we don’t say what sex are you carrying; it’s always a surprise for all of us.
Anna: It took till 2022 for our country to give equal abortion rights to both married and unmarried women up to 24 weeks. What are the legal changes you look forward to that will give a woman absolute right to her bodily integrity in her reproductive lifespan?
Dr Shefali: Certainly, India is far ahead in abortion law as compared to rest of the world. In Europe, they will not even scan - like whatever deformed baby you have, please bear with it. They’re not going to even talk about termination. We have been very liberal, and unmarried women have as much as right as married women to abort; it has been there forever from 1971, that medical termination act, but from 20 weeks to 24 weeks is recent, which is actually a big advantage because many anomalies develop over time. At 19 weeks, they are in the developmental phase, and we have a suspicion. And then suddenly the 20-week deadline comes in: you can’t do anything after that. And, you know, you will wash your hands off and say, I can’t do illegal termination. Now thankfully, the Supreme Court has extended that guideline to 24 weeks. We now have time to check it out, confirm, take a second opinion and be very sure that there is an abnormality in the baby and it has to be terminated. That way, I think India has done fairly well. And terminating beyond 24 weeks: most of the people are aware and educated nowadays; they have a fair idea by 24 weeks that they are pregnant. After that, I think it’s one-off cases where they want to terminate - but it should actually not be allowed. It’s not that safe for the mother and baby: baby is not fully viable but baby will still be born alive at that time. And if you don’t resuscitate, it is so heartbreaking, that struggle to live, crying for a few hours. It’s not humane and not fair. 24 weeks is a good enough time, I think.
Anna: Thank you, Dr. Shefali, and Sunanda. If you have questions on this episode, write to us at this email: editor@thehindu.co.in with the subject line: Women uninterrupted. For anxiety and other mental health concerns, call Kiran the 24/7 toll free National Mental Health Helpline at 18005990019. Signing off on this episode of the Women Uninterrupted podcast brought to you by The Hindu.
