More pregnant women died and stillbirths increased steeply during the pandemic, studies show.

A nurse helping a pregnant woman at a hospital in Paris last November.

By Apoorva Mandavilli

More pregnant women died, experienced complications or delivered stillborn babies during the pandemic than in previous years, according to an analysis of 40 studies in 17 countries published on Wednesday in the journal Lancet Global Health.

Pregnant women face a heightened risk of severe illness and death if infected with the coronavirus. But the researchers, in Turkey and the United Kingdom, wanted to assess collateral damage from the pandemic on pregnancy and delivery, and so excluded from their analysis those studies that focused only on pregnant women who were infected.

Reviewing data on more than six million pregnancies, the investigators found evidence that disruptions to health care systems and patients’ fear of becoming infected at clinics may have led to avoidable deaths of mothers and babies, especially in low- and middle-income countries.

Data from a dozen studies showed that the chances of a stillbirth increased by 28 percent. And the risk of women dying while pregnant or during childbirth increased by more than a third in two countries: Mexico and India. A subset of studies that assessed mental health showed that postpartum depression and anxiety were also heightened during the pandemic.

Nearly six times as many women needed surgery for ectopic pregnancies — in which a fertilized egg grows outside the uterus — during the pandemic than before. Ectopic pregnancies can be treated with medications if detected early, so the results suggest that the surgeries may have resulted from delays in care.

The analysis did not find differences in other conditions associated with pregnancy, like gestational diabetes or high blood pressure, or in the rates of cesarean sections or induced labor.

The rates of preterm birth also did not change significantly during the pandemic in low- and middle-income countries. But in high-income countries, preterm births fell by nearly 10 percent.

The drop may be a result of changes in health care delivery and in pregnant women’s behavior during the pandemic, the researchers said, indicating that the pandemic has exacerbated disparities between low- and high-income countries.

Complete Article HERE!

How Jewish Rituals Helped Me Mourn My Miscarriage

By

I had a miscarriage this summer — and it broke me in more ways than I could have imagined. At my nine-week appointment, I discovered, to my complete surprise, that I was experiencing a “missed abortion” – a pregnancy loss in which I’d had no miscarriage symptoms whatsoever. Not only did I have to make medical decisions while in shock, but I also struggled intensely to make sense of what I was feeling emotionally and spiritually.

With help, I recognized that I was deep in the throes of grief. Jewish tradition provides an incredible structure for mourners to grieve the death of a loved one. Yet nothing is prescribed for my miscarriage grief. When grieving, it can be harder to make any decision, large or small. I craved a prescription for what to do; that might have left me with fewer heart-wrenching decisions.

Nonetheless, I found healing and comfort in adapting Jewish rituals and traditions.

In honor of October being Pregnancy and Infant Loss Awareness Month, here are some of the lessons I learned:

  1. Jewish tradition teaches that we are not obligated to mourn a miscarriage or even the death of a baby who lives less than 30 days. In fact, we are taught that up through 40 days after conception (this would be just under 8 weeks pregnant in today’s terms, since counting begins at the woman’s last period, not at conception), the embryo is considered to be merely water (Yevamot 69b). This does not describe the emotional reality of many pregnant women or couples. Even in those early weeks, the connection to the embryo can be incredibly deep. And yet I recognize that mourning a miscarriage is not the same as mourning the death of a child or an adult. I didn’t lose a baby that I’d held. I didn’t even lose a fetus. I lost an embryo (the transition from embryo to fetus happens in the 11th week), but that embryo was supposed to make me a mother. That embryo was supposed to grow into a fetus. I would have delivered a baby, named and held my child. That embryo had a due date. I had a timeframe sketched out already for when I would start looking at daycare options.
  2. The specific grief of a miscarriage is different but still very real. In order to cope with my grief, I needed to mourn. The ancient rabbis likely believed that having a prescribed set of mourning rituals for a miscarriage may have been a burden, since families could experience multiple miscarriages.
    Today, too, families may experience one or more miscarriages. While miscarriage rates may or may not have changed since rabbinic times, many things have changed: birth control has led to less pregnancies; at-home pregnancy tests help women find out that they are pregnant much earlier than even several decades ago; because of ultrasound technology, pregnancies feel much more “real” when a future parent sees an embryo or a flickering heartbeat at a fairly early stage. All of this leads to pregnant people (and their partners, if applicable) who are more likely to experience grief when losing a pregnancy. The Perinatal Grief Scale was developed in 1988 to help clinicians diagnose and care for their patients’ grief. What if certain rituals of mourning were opportunities to grieve, instead of a potentially weighty obligation placed on the family? Michael I. Norton and Francesca Gino, faculty at Harvard Business School, conducted experiments to measure the impact of mourning rituals. They determined that rituals are incredibly effective in reducing grief because they allow mourners to regain a sense of control, at a time when it feels like they have lost any semblance of control of their world. For me, rituals like burial and mikveh also helped me find a sense of validity in my grief. I needed concrete physical acts that also stemmed from Jewish tradition to help me recognize that my loss was real and mattered, both in my own eyes, and perhaps more importantly, in the eyes of Jewish tradition.
  3. Rituals may be traditionally absent, but Jewish rituals, modified from other contexts, are emerging. Not everyone marks time and life cycle through Jewish liturgy and ritual, but I do. Each person will find what is meaningful for them in coping with a miscarriage. In the first few days, I felt compelled to have a way to externalize my pain. 

When an immediate relative dies, the mourner tears their clothes or wears a kriyah ribbon. I chose to let my nail polish chip away naturally over the coming weeks instead of taking it off my fingernails once it started to chip. I looked unkempt and that felt appropriate. People should know that something was awry. I whispered kaddish once while tears streamed down my face – it felt both rebellious and cathartic. I realized that I needed a burial of sorts, echoing how we address a loved one who has died. 

With the help of Sinai Memorial Chapel, I arranged to bury my embryo, unmarked, near newly planted trees in a cemetery. I chose not to be present for it, but it was comforting to know that it was returned to the earth. I also visited the site a few weeks later with a friend and buried a piece of paper on which I’d written my due date, and some other dates that would no longer be shared with this baby – I had envisioned a baby costume for this Purim, and had imagined that this Passover would be my first as a parent. None of this was halachically prescribed or encouraged but these acts helped me say goodbye.

 

Some new Jewish rituals for mourning a miscarriage suggest planting a sapling. But for me, this didn’t seem fitting. A sapling would grow into a larger plant, but my baby-that-should-have-been was never going to grow. While I yearned to one day be able to grow a different pregnancy, that wasn’t what I wanted out of this ritual. I needed a ritual that was solely about loss before I could begin to think about new life again.
  4. The cultural norm is to keep the pregnancy quiet through the first semester — but that’s not always helpful. Miscarriages are common, but it feels incredibly lonely.* The Jewish community has a superstitious relationship to the evil eye: if you tell others about your blessing (of pregnancy), the evil eye might overhear and change your luck. Soon after the first trimester, you start to show, and the secret is out, so the concern about the evil eye lessens a bit then. When I miscarried, only a small group of people knew about my pregnancy. How could my tight-knit Jewish community support me through this trauma when only a handful of people knew that I was pregnant? We have been trained to not publicly reveal pregnancies until we are past the first trimester, and yet that first trimester is when 75-80% of miscarriages occur. And they happen more than we realize. 20-30% of pregnancies end in a miscarriage, and the statistics only increase as women continue to have children into their late 30s, 40s, and beyond.   One the one hand, the more people you tell about your pregnancy, the more people you feel like you need to ‘un-tell’ should you, God forbid, miscarry. On the other hand, those people are the ones who can hold you – feed you, check in on you, and let you fall apart with them. 

When I did tell people who didn’t know that I had been pregnant, I had to tell them three secrets at once: (a) I decided to try to become a parent (b) I had been elated that I got pregnant (c) I am now crushed because I had a miscarriage and now I need you to be gentle with me. Sharing pregnancy news – whether about a new pregnancy or a pregnancy loss – is an incredibly vulnerable act. Don’t be too afraid of letting people know before you cross the first-trimester finish line, if those people would not only celebrate with you but also support you through your fears or even a loss. Let’s change the stigma around revealing a pregnancy while it is still uncertain. The uncertainty doesn’t go away entirely until you hold a baby in your arms.
  5. A miscarriage is related to, but not identical to, infertility. Trying to get pregnant again may feel intensely different than before. 
For weeks, I couldn’t shake the feeling that I’d done something to cause this, even though I was reassured again and again that running too much or taking a redeye or that sip of coffee would not cause me to miscarry. 
People told me that it was a good sign that I was able to get pregnant. While there might be medical truth to that, as much as I wanted reassurance that I would eventually, God willing, be able to carry a pregnancy to term, I need to mourn this particular loss – this particular baby-to-be that I carried and would never become a baby that I could hold in my arms. I went to the mikveh before I tried again, so that I could acknowledge that my body, which was supposed to create life, had in fact held a sort of death. I needed to immerse and wash that away in order to be ready for new life again.
  6. A miscarriage is not (always) the same as being sick. 
My mental and spiritual health were compromised, but thankfully, in my particular situation, I was never worried about my physical well-being. This may not be true for other women, but I did not want to benschgomel (a call-and-response moment during an aliyah to the Torah, often said when you survive a potentially life-threatening experience) both because of this gratitude for my health throughout and because I was not sure that I wanted to acknowledge my miscarriage quite so publicly. 

I associate gomel with surviving in the face of fear, but I had not been afraid. Instead, I had been devastatingly sad.
  7. When in shock and grief, decisions are exponentially harder. Prescribed rituals or other things to do or not to do can help you move through that. 
When an immediate family member dies, Jewish tradition prescribes very specific and concrete changes in order to grieve the life lost. 

I have been working on compiling resources for rabbinic colleagues to help their communities mourn miscarriages, perinatal losses, and neonatal deaths, but there isn’t a definitive set of do’s and don’ts. In the midst of what can be a deeply chaotic and heart-wrenching experience, rabbis can help by developing a concrete set of ways to mourn. Had I been steered toward taking several days to fully grieve in a way that parallels shiva, I believe that I would have healed more easily.

Grieving my pregnancy loss was incredibly challenging. And yet, a foundation in traditional Jewish mourning rituals eventually helped me find ways to adapt them that felt honest and appropriate for miscarriage. As I moved through each day, I also found myself experiencing deep, profound gratitude for the people in my life who showed up for me over and over again.

May we find ways to cushion the pain of pregnancy losses with community, ritual, and tradition.

Complete Article HERE!

Getting Back to Sex After Pregnancy Loss

Though your body might be ready to return to sex after a miscarriage, are you?

By Jessica Zucker

How soon can you have sex after experiencing a pregnancy loss? It’s a common question among women of childbearing age, considering that up to 20 percent of pregnancies result in miscarriage and approximately 1 in 100 in stillbirth. There’s not a standard — or straightforward — answer. Generally, physicians counsel patients to wait until they feel ready. But readiness for a woman and her partner can depend on a number of physical, and emotional, factors.

“From a medical and practical perspective, the primary thing is to ensure that the pregnancy has passed completely, the cervix has closed, and that there isn’t an increased risk of causing infection in the uterus,” explained Zev Williams, M.D., Ph.D., chief of the division of reproductive endocrinology and infertility and an associate professor of obstetrics and gynecology at Columbia University Irving Medical Center. “The timing for this depends on how far along the pregnancy was at the time of the loss and how quickly the woman’s body recovers.”

A couple’s romantic readiness is another question altogether.

Emotional roadblocks are a big factor: Women may feel reluctant to engage in sexual intimacy while still grieving their loss. Miscarriage can also change a woman’s relationship with her body, and what sex represents to a couple might shift. If this seems hard to understand, it is: I am a psychologist specializing in women’s reproductive and maternal mental health, and I didn’t fully comprehend how complex returning to sex could be until I experienced a second trimester miscarriage firsthand. Then I understood all too well: There’s no one-size-fits-all answer.

“There are no guidelines with regard to telling patients what to expect about returning to sex after miscarriage. Routinely, we don’t discuss sex after loss unless patients bring it up,” said Jessica Schneider, M.D., an ob-gyn at Cedars Sinai Medical Center in Los Angeles. “There’s research about how safe it is to get pregnant again after a loss, but not about sexual function or satisfaction.” And the fact is, sexual function and satisfaction can, and do, change.

I talked to several women about their experiences around sex after pregnancy loss to find out how they approached returning to intimacy. (The women preferred their last names not be used due to privacy concerns.)

Some women, like Ash, 36, felt ready to have sex right away. After experiencing a stillbirth, she turned to sex for healing. “It was a way to feel powerful in my body,” she said. “I felt like my body had failed me, and sex was a way to get that back.” There was one caveat though: She didn’t want to risk another pregnancy. “It felt better to engage in sexual acts that couldn’t result in one.”

Trying to get pregnant again is a sensitive topic medically and emotionally. The World Health Organization’s official stance is to wait six months before attempting another pregnancy. Recent research, however, suggests that having sex sooner doesn’t have a negative effect on future pregnancies and could actually help success rates.

“The doctor told us to wait until we were comfortable,” said Maria, 26, who has had four miscarriages. “It was nerve-wracking to return to sex. I think because I was terrified of getting pregnant again and losing it or not getting pregnant again. It was challenging mentally.”

It’s understandable to feel conflicted, but the odds of future success are good: Up to 85 percent of women who experience a pregnancy loss, and 75 percent of women who have had multiple losses, go on to have a healthy pregnancy.

Shame and self-blame can enter the bedroom after pregnancy loss and create trouble where there previously was none. Hanan, 27, thought she was ready to have sex again immediately after a stillbirth, though her doctor told her to wait six weeks. She said she felt arousal and the desire to have sex, and engaged with her husband in everything other than penetrative sex, while waiting for medical clearance. But the first time they had intercourse, she wasn’t prepared for her emotional reaction. “I cried so much after the first time. I felt very guilty,” she said. “My body wanted to, but my brain didn’t. It felt selfish and immoral — like I should have been celibate while grieving.”

These thoughts are especially challenging for women who are actively trying to conceive again. “I did not want to initiate sex after my loss, but at the same time, I did want to get pregnant again,” said Maggie, 32. “My vagina became a constant reminder of the loss.”

Some women said they resented their bodies for a perceived failure. “After my miscarriage, I couldn’t be with anyone for over a year,” Zachi, 27, told me. “The fact that my body failed impacted the way I felt sexually afterward. I carried the baby emotionally, long after physically.”

While a 2015 survey found that 47 percent of respondents who had experienced a miscarriage reported feeling guilty about it — and nearly three-quarters thought their actions may have caused it — the reality is that chromosomal abnormalities are the explanation in about 60 percent of miscarriages. Pregnancy loss cannot be prevented.

If you’ve been trying to conceive for a long time, sex following a pregnancy loss can become especially fraught — even unappealing.

“After my first miscarriage, we only had sex to conceive. It started to feel like a task,” said Gina, 30, who has experienced infant loss and two miscarriages. “That mentality compounded after my second miscarriage and killed all sexual desire for me.”

Sonali, 33, who has lost four pregnancies, had difficulty returning to the very place she got pregnant. “Sex with your other half in the bed where you conceived the babies you lost is so triggering,” she said.

“Sometimes, I’m thinking about where I’d be in my pregnancy now; how I wouldn’t be able to have sex in this position,” Maria said. “It makes me feel guilty to feel great, when I should be seven months pregnant and uncomfortable.”

Pregnancy loss can have unintended positive impacts on a woman’s sexuality, too. Zachi said that she is more assertive in her sex life because of her miscarriage. “I have to listen to my body now,” she said. “It becomes painful not to. I am a lot more sure in what I want.” A miscarriage ultimately brought Maggie and her husband closer together, she said. “During the loss, I felt like I was on an island,” she remembered. “The first time my husband and I had penetrative sex, I cried from relief, because I felt so re-connected to him.”

Having and enjoying sex again is really about one thing — personal readiness — which is what I tell my patients. It’s O.K. to feel grief and sexual desire simultaneously. “Moving on” is not a prerequisite for pleasure.

Complete Article HERE!