You're right—if patients ran the hospitals, D and Cs and all the other procedures that surround miscarriage and stillbirth would take place as far from the maternity wing as possible. But it's the medical profession that's in charge. And from the point of view of many of its members (many as in not all—to the exceptional doctors and midwives and nurses out there, please know that we're rooting for you), pregnancy loss has two things going against it: boredom and mystery. The surgery that we experienced as shattering was ho-hum from the perspective of the doctors who performed it. At the same time, the reasons why we were lying on the table instead of cheerily ordering maternity clothes were out of their reach, in other than the most general terms. My husband said that getting a D and C was like going to an auto body shop—a matter of fixing a mechanical failure without getting into the details of what caused it. The day before, the obstetrician told us that most early pregnancy losses are the result of a genetic defect. (Sometimes the brakes just don't work right, ma'am.) When we asked if he was planning to do any tests to see if that was the case with this miscarriage, he looked surprised. One, two, even three miscarriages are no cause for concern, he told us. Go home. Don't worry.
That response may make perfect sense as a matter of allocating resources. Why should my health insurer have to spend money to uncover the cause of a minor medical event that in all likelihood will turn out to be a blip on my fertility screen? The problem with doing nothing, though, is that sometimes determining the cause of one miscarriage helps to prevent more of them. From the point of view of the doctor or the insurer, waiting out another cycle of loss is no big deal. But if you're the woman who has lost one or more pregnancies and is frantically wondering whether you're fated to become a "serial miscarrier" (another unfortunate, heart-sinking term), every piece of take-it-easy, wait-and-see advice is a torment.
I don't know enough about either the state of medical knowledge or the cost-benefit tradeoffs to defend or attack the current standard of care. But I suspect that the science of miscarriage and its cousin, infertility, isn't really a science at all. A friend whose sister has been trying to get pregnant for a year and a half recently told me that her sister had finally gotten a diagnosis that made her feel better because at least now what was happening to her had a name—"unexplained infertility." No irony intended. Infertility treatments help women get and stay pregnant. Yet there's so much about reproduction that we still don't know or can't fix. And in the meantime, women on the receiving end of everything from "just keep trying" to IVF face months or years of uncertainty and heartache.
I guess I do have one small, unprofound suggestion. Until doctors have better scientific tools at their disposal, they should use the basic tool they do have: human kindness. Obstetricians and fertility specialists can offer the kind of emotional support that makes you feel like you're not coming off an assembly line—the kind that the midwives in my obstetrics practice gave me and that your doctor gave you. And they can do a better job of asking women what they want in terms of testing and treatment and of explaining why certain options aren't warranted, if, in their judgment, the timing or circumstances aren't right.
The rest of us can also try to pick up on the cues that women give when they've recently lost a pregnancy or suffered a fertility disappointment. I didn't equate my miscarriage with a death—the longing I felt for my not-to-be-born babies, however real, wasn't like missing someone I'd known and loved. But I really appreciated the cross-country call that I got from a rabbi in California I'd worked for years ago. He said that he was sorry to hear about my loss and that he wanted me to know that there were Jewish texts—scant, but still—that I could draw on. The best one was from the Book of Ruth. "I went out full, but empty has God returned me," Naomi tells the women of Bethlehem when she returns to their city after a long absence. She's not talking about a miscarriage: She has lost her husband and two grown sons. But she could be, as Lois Dubin points out in a wonderful essay from the collection Reading Ruth, edited by Judith Kates and Gail Twersky Reimer.
In fact, the image of being "returned empty" speaks to a lot of life's worst moments, I think. It means beginning again the hard work of filling ourselves up, in whatever way we can. You and I are blessed to be filling again with babies. And despite our previous losses, with hope.
Dahlia, I wish for you all the joys of motherhood—the salt with the honey, the vinegar with the wine. Thank you for writing to me.