For a reproductive psychologist, problems like miscarriage and infertility are regularly seen in the consulting room. A situation that presents itself less frequently is when a mother and her partner terminate a pregnancy for medical reasons (TFMR).

Pregnant woman looking out a window - Helping Clients Through a Pregnancy After Termination for Medical Reasons

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TFMR is a commonly used term for an abortion when the fetus carries an adverse diagnosis identified either through prenatal testing or ultrasound. In very rare situations, the mother’s physical or mental health makes carrying the pregnancy to term risky leading the mother to decide to terminate. The TFMR may occur by D&C, D&E, or an induction leading to labor and delivery.

These are wanted pregnancies. When the parents receive news of a poor prenatal diagnosis, they often react with shock, disbelief, sadness, and anger.

These moments are often experienced as traumatic by the parents. The mother and her partner must make a decision whether or not to carry a baby to term that may have any number of medical complications or special needs. One of the reasons we see fewer people presenting with TFMR is due to shame and stigma stemming from our culture’s views on abortion.

For the past 6 years, I have seen individual women and couples who have terminated a pregnancy for a medical reason. I work with them individually and in a support group format. From my work with these individuals, several themes have emerged in terms of reasons for choosing abortion in the case of an adverse prenatal diagnosis. Some of the reasons include preventing suffering, a lack of resources (either financial or emotional or both), concern about the effects on existing children, and quality of life concerns for the baby.

Even in “clear-cut” situations where the baby’s quality of life would be severely diminished, clients struggle with feelings of guilt, shame, anger, and sometimes doubt about whether or not they made the right decision. I often hear, “I know it was the right decision for us and for the baby, but I still feel guilty.” Other clients are plagued by the “what-ifs.” “What if the doctors were wrong?” Or, “What if this was a miracle baby?”

Many women would like to become pregnant again after a TFMR.

These individuals are ready to be parents and are often frustrated that the pregnancy did not work out as planned. As with other types of perinatal losses, there is fear of a repeat occurrence of the same problem or fear of a new problem. Women often feel they are unlucky to be the one person out of hundreds or thousands to receive a rare diagnosis.

Feeling unlucky does have implications for a subsequent pregnancy. Sometimes, women and their partners will want more certainty in a subsequent pregnancy in the form of diagnostic testing like CVS or amniocentesis. Conversely, some women feel that they can’t possibly risk a miscarriage and will skip the diagnostic, invasive testing in favor of an earlier, noninvasive screening tool, like the first trimester screen, or the cell-free fetal DNA testing.

There are many choices to make in a subsequent pregnancy.

You clients may easily make these decisions or may agonize over them. Your role as therapist is to support them in whatever decision they make and guide them to make choices that feel right to them. Sometimes this means helping them advocate for themselves with medical professionals.

In a subsequent pregnancy after TFMR, bereaved parents often feel as if no choice is the right one. You can empathize with this feeling and let them know that they are doing the best they can under difficult circumstances. Women may seek out visits with their obstetrician or midwife more frequently because they are in need of reassurance that the baby is doing well. Most experienced care providers are fine with this. Be sure not to pathologize the client’s need for such reassurance. She is trying to do the best she can for her baby even if her fears are unfounded.

What is unique about being pregnant after TFMR is the experience of contradictory feelings.

While excitement concurrent with fear are experiences had by any parents who have experienced a perinatal loss, feelings of guilt and shame concurrent with excitement or optimism emerge more sharply in women who have terminated a pregnancy for medical reasons.

When these feelings of guilt and shame emerge in session, it is crucial to pay close attention. The client is not necessarily saying that she feels she made the wrong decision. However, she may be experiencing a feeling of having done something “wrong,” which is often a product of our society’s taboo against abortion. Even though it is a legal procedure, there are restrictions in each state. The narrowing of women’s options (in the form of legislation designed to make abortion less accessible to women) serves to perpetuate shame and stigma around a procedure that has historically been very controversial. A client’s religious beliefs may also contribute to their sense of guilt or shame. In other, more complicated situations, a woman who has had a history of abuse, trauma, or body image difficulties will struggle even more with the decision to TFMR. For women with a history of body image concerns or disordered eating, the additional weight gain may cause distress as they feel that they had already gained some weight in the prior pregnancy but are now left with “nothing to show for it.”

Eventually, with a sensitive therapist who is knowledgeable about the issues surrounding TFMR, a woman can work through her complex and sometimes contradictory feelings and get to a place where she feels more accepting of the fact that there is risk inherent in any pregnancy. Highlighting her strengths and courage in making a very difficult decision may serve to bolster her self-esteem and resolve to get through a new pregnancy. She needs someone with kindness and compassion to guide her through what is for many, a trauma. She also needs someone who will be attuned to her history and be able to understand how the TFMR fits into the larger narrative of a person’s life. While we acknowledge that we are limited in what can do for women in a subsequent pregnancy after TFMR, our reliable, soothing presence can make a big difference to a woman who is living week to week, day to day, minute by minute, watching and waiting for something to go wrong in her subsequent pregnancy.

The clients of mine who have made the biggest gains in therapy are the ones who can transform their narrative of loss.

The TFMR, while always sad, becomes for some clients, a source of pride in being able to make a good decision as a parent. For many women, it represents the first big decision a person makes as a mother. When the client can frame the decision to TFMR as one made out of love, then she is in a better position to feel self-compassion rather than self-hatred or shame.

Each client is unique and will present differently depending on individual history and life factors. Be mindful of important milestones and dates for women. Even if one easily become pregnant again, anniversaries for the prior pregnancy are significant and can cause distress, especially the estimated due date and the one year anniversary of the termination procedure.

On a final note.

Clinicians working with individuals and couples who have made the decision to TFMR should do a self-assessment to acknowledge one’s own opinions and biases about the issues of abortion and TFMR keeping in mind that views sometimes evolve over time. A safe, judgment-free atmosphere is crucial to the client’s healing. Consultation with trusted colleagues is always recommended and can be a wonderful way to practice good self-care in the face of challenging clinical work. For clinicians who have experienced a TFMR of their own, consultation with colleagues are especially important as clients’ situations raise many complicated feelings in the clinician that are important to separate from the client’s experience.

Staying open to the client’s experience of this loss as well as some specific knowledge about TFMR and what it entails will go a long way in helping these clients through a new pregnancy.  We are in a good position to help with managing all the feelings that arise during that nine month period to ensure the best possible outcome for the parents and for the baby.

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