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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Grieving and Healing

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Grief is internal bereavement, while mourning is the external, or "public" grief.

Which emotion most closely resembles grief? Why? Love. Love is the slow development of strong bonds, while grief is the slow dissolution of those strong bonds.

"With the capacity to love, comes the necessity to mourn." Alan Wolfelt, Ph.D.

1. REVIEW OF THE PROCESS OF GRIEF:

B. Stages of Grief: (Time frames mentioned deal with a death. They can be shorter or longer.) Kubler-Ross: 1. Denial and isolation 2. Anger 3. Bargaining 4. Depression 5. Acceptance

Bowlby and Parks: 1. Shock and numbness 2. Yearning and searching 3. Disorganization and despair 4. Reorganization

Shock and numbness: Encompasses such feelings as stunned feelings, impeded functioning, emotional outbursts, short periods of concentration, resistance to stimuli. Often need to have other people make decisions for them, ie: giving the mother her baby to hold after the delivery of a stillborn, etc. Need to feel "safe" before mourning can take place. Most intense at the time of loss, gradually decreasing, but with secondary peaks again at two months and 12 months. If a person cannot feel safe, grief will be put on hold - perhaps indefinitely - but physical manifestations will eventually start showing up. These can include migraines, ulcers, certain forms of cancer, and more. Grief will come out on way or another!

Yearning and Searching: Includes such feelings as restlessness, anger, guilt, ambiguity, desiring the presence of loved one, etc. This is where many bereaved mothers will say they hear their baby crying, have arms that ache, feel fetal "kicks," and, not knowing this is normal, often are really afraid that they are "going crazy." Can easily last six - eight months, with another resurgence at 12 months. Lots of crying is done at this time, which is healthy, as tears shed during grief actually have more toxins than regular tears, and can be healing. It is not uncommon to feel like: "I'd be better off with my baby." Parents will often blame themselves and have intense feelings of guilt, and a resulting loss of self-esteem.

Disorientation and disorganization: After working through the powerful emotions of the previous "stage," many parents go through a period where they feel empty and hopeless. This is often when depression really sets in, and personal appearances may be neglected, meals not eaten, and parents are more susceptible to illness. This stage occurs around 4-8 months after the loss, and is especially difficult because by now, most people, including parents, think they "should be over it by now." Depression can be viewed as a normal response to a stressful situation. According to Dr. Alexander Lowen, depression is a recovery time for the body to rest and sleep, for the mind to relax, and for the emotions to come to the surface. Emotions need to be released, however, in an environment that understands the appropriateness of it. Expression can take many forms, such as writing, crying, yelling, singing, laughing, etc.

Reorganization: A time of "reconciliation," as parents achieve a "new normal," and are once again able to enjoy living, even though the loss will never be forgotten or the grieving ever completely "over." Parents are more easily able to make decisions, and start to reap the "rewards" of grief - strengths they didn't know they had, and the knowledge that they have survived a crisis most people think they could "never cope with." No matter a person's religion, spiritual reconciliation is essential to be able to feel truly at peace. This means that they can fit the loss into their "world view" and achieve a sense of peace regarding the loss.

     C.  Physical Manifestations:
               Can include:
           1.  Respiratory problems, often shortness of breath.
           2.  Heart palpitations
           3.  Sexual difficulties
           4.  Exhaustion
           5.  Insomnia
           6.  Headaches
           7.  Depressed immune system
           8.  Anemia
           9.  Change in appetite
          10. Crying spells 
          11. Aching arms
          12. Feelings of heaviness in the chest - crushing, suffocating sensations

2. HOW TO MOVE FORWARD IN THE PROCESS OF GRIEF

A. Physical Needs 1. Exercise: Even though it is usually hard for most bereaved parents to feel like they can even drag themselves through the day, getting exercise has definite physical and psychological benefits. Inactivity results in inadequate circulation, a poor exchange of nutrients and waste products in the tissues, a weaker heartbeat, and then greater fatigue. Exercise, on the other hand, contracts, then relaxes muscles, consumes more energy, speeding up food oxidation and the excretion process, which then stimulates the nervous, respiratory, and circulatory systems. As the respiratory rate goes up, more oxygen is taken in, and a more "alive" feeling results. Often, the time spent exercising is also a reflective time, allowing for some "grief work" to be accomplished at the same time.

2. Nutritional Needs: Grieving is a physical activity which requires that we expend a substantial amount of energy. If proper nutrients are not available, or only in small amounts, our bodies start to lose their optimal efficiency, gradually becoming depleted and leading to a state of exhaustion. If bereaved parents lose their physical strength and well-being, it becomes easier to be crippled by the grief. For many of us, a first response is to seek relief from the pain, often leading us to drugs, alcohol, sugar or other not-so-healthy comfort foods. By eliminating foods from our diets that are not very healthy, (like caffeine, sugar, heavily processed foods, etc.), and adding foods that are (like whole grains, fresh fruits and vegetables, seeds, nuts, fish, etc.), we can help ourselves in the process of grief reconciliation. Some additional "areas" to focus on include getting extra Vitamin C, B complexes, Vitamin E, adequate protein and plenty of fluids. This is hard to do! During a pregnancy, there is a very good reason to make sure that nutrition is adequate, but after a loss, there no longer seems to be any reason at all! Even if the baby is alive, and Mom is nursing, if she is also grieving, her nutrition is likely to be less than adequate! 3. Other physical needs: Rest. Sometimes a conscious effort to relax is needed to get rest, and for help in getting to sleep at night. Preventing Illness: By getting some exercise, and having good nutrition, the bereaved can make themselves less prone to illnesses. It is helpful for most parents to use soothing visualization techniques, soft music, massage, etc., as ways to keep their bodies feeling as well as possible.

B. EMOTIONAL NEEDS: 1. Normal grief includes, but is not limited to, the following: - There is no right or wrong way to grieve! - Partners almost always deal differently with their grief, and that's OK. - Grief cannot be avoided, only delayed or disguised. - Everyone is entitled to having feelings! Parents and other grievers need to give themselves "permission" to feel them. - It is normal to find comfort in nurturing. This may be stroking a kitten, brushing someone's hair, rocking, holding a baby doll, etc. - It is normal to find comfort in being nurtured. - It is normal to grieve past losses. - It is normal to be irritable; try to reduce your stress by finding constructive outlets (writing, drawing, working with clay, Play-Doh, punching pillows, yanking weeds, screaming and yelling (in the shower?!), and talking). - It is normal - and OK - to be happy sometimes! - It is normal to feel isolated. - It is normal to feel impatient with grief. You are tired of feeling bad and want to feel better! Remember to allow time for the process. - It is normal to feel like you'd be better off dead - what is there to live for, after all - but it is important to get help if you feel concerned about it, or start making plans to end your life. - It is normal to think about the baby often, and what "might have been." - It is normal to feel the baby's presence. - It is normal to hear the baby cry. - It is normal to feel fetal kicks. - It is normal to have aching arms. Many mothers feel like they need something to cuddle. This can be a doll, a kitten, an older child, or any number of things. - It is normal to feel like a changed person. - It is normal for mothers to feel like their partner is not "really" grieving. - It is normal to feel like you'll never be "back to normal." This is actually true, since it will never be "the same," but a new normal. - It is normal to feel jealous of pregnant women, and to feel like it's almost impossible to be around close family &/or friends who have babies and you don't. - It is normal to worry about your spouse &/or remaining children dying. It is also normal to become very protective of the loved ones still with you. - It is normal to search for something you "must" have done to cause this - either something you did during the pregnancy, or as punishment for past sins, etc. Forgive and love yourself! Most problems are not preventable. - It is normal for partners to feel like they are "required" to give much more than they feel capable of. - It is normal for partners to feel like they are carrying an enormous weight - everyone expects them to "be strong!" - It is normal for partners also to feel like they have "failed." 2. Sharing: Most bereaved parents feel a need to share their loss and their feelings, although some can work through their grief effectively on their own. The most supportive friends and relatives are those who understand that the loss is significant and tragic. Parents will find out about "true" friends, and those that will turn away. Unfortunately, they will be subject to "unsettling" remarks. It is helpful to know that while most people mean well, they are unsure what to say and the offense is inadvertent. However, it is still offensive! As parents feel up to it, they can use those opportunities to educate those who would make such remarks! Many parents find comfort in support groups, especially those specifically designed for those experiencing perinatal losses, such as SHARE. Counseling can also help, provided the counselor recognizes normal grieving as healthy, and not pathologic, and understands the uniqueness of any kind of perinatal loss, whether or not a death is involved. Healthcare workers can provide a significant source of comfort, or can be a cause of "additional" pain. Hopefully we as midwives, doulas and others will always be helpful and supportive to our clients!

3. Expressing: It is vital for bereaved parents to be able to express their feelings! Again, it is vital that they feel "safe" in doing so. Expression can be verbally, in written form, artistically or physically. Yelling, screaming, talking it out, even singing are all forms of verbal expression. Writing is often very therapeutic, whether it is an angry letter (it doesn't have to be mailed!), writing in a journal, or other forms of writing, like poetry. Drawing can also be a therapeutic outlet, especially if the bereaved parents can distance their "conscious mind" from their creativity. Creating in other forms can also be beneficial, such as working in clay, or other media. One of the most powerful expressions of grief you can find is in the sculptures done by Julie Fritsch. After a full-term stillbirth of her son Justin, she was able to release her emotions through sculptures. Those sculptures are pictured in her book, "The Anguish of Loss." This is an excellent way to bring some of those emotions to the surface where they then can be released! There are other moving works of art, poetry, writings, and songs created from grief. Physical expression of grief can take the form of vigorous exercising, intense housecleaning, punching pillows and more. Expression of grief is crucial to the healing process.

RESOLUTION/RECONCILIATION How to know when reconciliation is being reached: - Bereavement experts suggest completing the following processes over the months and years following a death, so that grief can successfully be reconciled into the "new normal." (Adapted from Empty Cradle, Broken Heart.) * Acknowledge your loss. * Understand as much as possible about how the loss occurred. Do you have an explanation you can accept, whether proven or not, or do you still wonder? * Accept all your feelings. * Experience the hurt and sadness. * Change your expectations for the future. * Readjust to life without the baby you envisioned, (whether the loss was of the "real" baby, or of the fantasy baby) including finding ways to be happy. * Change your emotional investment in the baby that is no longer alive. * Form a new relationship with your baby. * Think of your baby realistically. * Maintain an appropriate connection to your baby. * Reinvest your emotional energy.

- The following checklist, adapted from When a Baby Dies, may help parents recognize that they are coming to terms with their loss. Over time, they will be able to "check off" more and more of the following items. [] I am now able to laugh without feeling guilty. [] I pay attention to my personal appearance. [] I enjoy being out with friends for an evening. [] I am able to feel pleasure in sexual experiences. [] I am able to sit quietly by myself, and think of things other than my loss. [] I take an interest in current events and the news. [] I feel like I can effectively parent my remaining children. [] I am able to do the daily tasks that I am used to performing. [] I look forward to outings, trips, and special events. [] I am once again involved in activities that I participated in before the loss. [] I am now able to talk about the loss without showing strong emotion. [] I feel like the fog has lifted. [] I am able to pay attention to my surroundings (beautiful scenery, the taste of food, etc.) [] I am able to get a good night's sleep and awaken refreshed. [] I am able to concentrate on work and conversation. [] I am less forgetful and better able to think clearly. [] I can recall past events. [] I feel stronger and more in control (less like an open wound, better able to cope with others' comments, etc.) [] I am able to deal with the minor crises and normal stresses of everyday life without feeling panicked, frantic, or excessively worried. [] I feel that there is meaning to my life. [] I am now able to look back on what happened and feel that something good came out of the tragedy. [] I am able to fit the loss into my view of spirituality.

3.HOW DO WE HELP?

Special Considerations for Doulas: Being With a Family As They Experience an Unexpected Outcome:

Doulas are oh-so-important when families are experiencing the shock of an unexpected outcome! This may be a cesarean after a long, difficult labor, a child born with disabilities or even the death of the baby. Our role as doulas at any birth are to provide physical and emotional support to the laboring woman and the other people she has chosen to support her. In the event of an unexpected outcome, this becomes even more important. We can help the family through this crisis situation. We can explain what is happening (as much as we are able), by being with the family, and by encouraging them to begin the grieving process.

We can do this by gently talking to them about what "most people feel" or what "most people do" in situations similar to theirs.

If the woman that you are providing doula services for has experienced the death of her baby and now must labor to deliver that baby, there are some additional, specific things to know. First, be familiar with the areas on what the normal responses of grief entail. Then, you need to know how to emotionally help someone who is experiencing a miscarriage, stillbirth, delivery of a disabled baby, etc. (take pictures, have Mom and Dad hold the baby, etc.) Next, be aware that are definitely issues that arise during the labor. If the baby is stillborn, the issue arises of whether or not that mother will have her labor induced or will it start spontaneously. Again, 80% or more of all stillbirths occur before labor begins, so she will need help in this decision-making process. Some mothers want to "get it over with" as soon as possible, while others want to have some extra time to grieve and "adjust" to their baby being dead before it is actually time to deliver. The doula can offer a listening ear, go over pros and cons of each approach and then support the family and their careprovider in whatever path they choose. Another issue likely to come up is that of pain relief. Some mothers whose birth plan was for an unmedicated birth may very well choose to have an epidural. After all, the baby is no longer affected by whatever medication she chooses, and the numbness of the epidural often matches the numbness in her heart. Some women will choose to continue with the same birth plan and experience the labor completely. These Moms will go into the "laboring mind response" and will not be as aware of their surroundings as a Mom with an epidural. An important role for the doula in this type of birth would not only be the normal "doula duties" but also carefully noting times and events of Mom's labor. This is important in helping the mother "reconstruct" her birth completely and accurately. The doula needs to be aware that whatever birth plan Mom has made and chooses to follow, there are some distinct aspects of labors for stillborn babies. It is common for labor to be long, for there to be plateaus on a frequent basis, and generally slow progress. Pushing is often very difficult - after all this is the last few moments this Mom will have that baby with her. Calm, encouraging, supportive words and gestures are very important! So is patience! This baby will come, but Moms just need time.

Pictures and videotape are absolutely invaluable. Even if the video camera were set up on a tripod in the corner for most of the labor will capture images that Mom and Dad will treasure as they move through the grieving process. As doulas help encourage the parents to hold, name and cherish their baby, she can then move off to allow the family their time while she takes pictures. Honestly, you can never have too many! Again, it is important to be familiar with the above section of "how to help." Follow-up with that family is crucial! Every day the first month would not be too often! Remember that as the family moves through the grieving process, support is so important! It would not be unusual to follow-up with that family on a regular basis for at least one year.

Ideas for Specific Types of Losses
Miscarriage:
     *  Be aware that most women grieve over a miscarriage, though some will only grieve a little, or not at all.
     *  Be aware that most men want information about miscarriage and what they can do for their partner.
     *  Use the terms miscarriage, not abortion, baby, not "products of conception," etc.
     *  In subsequent pregnancies, acknowledge that parents may fear another miscarriage.
     *  It may be appropriate to suggest an ultrasound to reassure parents that a subsequent pregnancy is viable.
     *  Recognize that many women feel guilty about a miscarriage.  Please reassure them!
     *  Make a special effort to meet with the parents for a follow-up visit 4-6 weeks after the loss.
     *  Listen, listen, listen!
     *  Remember, as Sherry Jimenez says, "What is a miscarriage, but an early stillbirth?"
     *  Let parents know that there are resources for obtaining ways to memorialize the miscarried baby/babies, such as
     miniature coffins, tiny clothes, etc.

Sometimes suggestions need to be made, and sometimes the doula or midwife needs to physically help the parents. This can mean giving the baby to his or her mother if she "can't decide," taking photographs for the parents, etc., even if it means "holding" them until a later date and more. The following are helpful for the parents:

     *  Follow your heart!!!  Ask for what you want, and just let your heart be your guide.
     *  Naming the baby
     *  Expressing feelings
     *  Taking pictures.  Lots and lots and lots!  One of the most frequent regrets of parents is that they didn't take enough. 
     Take pictures of the baby being weighed, measured, footprinted, dressed, held by each member of the family, etc. 
     Remember the video camera as well.  It can be set up on a tripod in the corner and no one will need to "run" it.
     *  Saving mementos - ID bands, lock of hair, blanket or clothing baby was in, a special blanket, etc.
     *  Seeing and holding the baby.  It helps to unwrap the baby, in order to have a "full" memory.  If the baby has been
     dead for a little while, parents will need to be prepared for skin fragility, etc.  If the baby has been in the NICU, often
     it is possible to remove all "machinery" and let the baby die in a loving embrace.  It is OK to ask for the baby even a
     day or two later, and it's OK to want to hold the baby more than once.  If this is the case, however, the parents do need
     to know that their baby will be cold.  Even if the baby is "deformed," experience of other bereaved mothers has shown
     that imagination is worse than reality!  Mothers and fathers are able to focus on the positive aspects of their baby. 
     Holding their baby is a precious memory.
     *  Being able to put away baby things themselves, when they feel ready.  Friends and family should not try to do this!
     *  Making final arrangements.  Some parents have taken their baby home with them to have memories of the baby
     there, and as an opportunity to have friends and relatives over.  Remember, death too, throughout time, has generally
     been a family affair, mostly taken care of at home!  Generally, letting the hospital "take care of it" is not very pleasant,
     and leaves the family without a "memorial," whether that is the memory of a service, a gravesite, ashes, etc.  Please
     don't have a service, or funeral without the mother!
     *  Allow parents to have time together just the two of them, or with the baby.
     *  If one parent strongly does not want to see the baby, and the other does, that's OK.  One parent can have the needed
     time alone with the baby and take the desired pictures.
     *  Blessing or baptizing the baby.
     *  The need to inform family and friends.  Sending birth/death announcements is one way.  Obituaries are another. 
     Phone calls can be used to inform a few important people, and ask them to inform others.
     *  The option of staying on the "maternity" floor, or moving to another.  There are advantages and disadvantages to
     both.
     *  Dad staying with Mom at the hospital.  Even if this is not "usual," it is almost always "permitted."
     *  How long to stay in the hospital.  Often, physical recovery can occur "better" at home, and short stays are common.
     *  Autopsy.  One consideration is that over 60% of all stillbirths are from unknown causes.
     *  Cremation or burial  (see memorial service)
     *  Moms need to be prepared for "normal postpartum" experiences, including lochial flow, hormonal changes, and
     lactation.  Some mothers may welcome suggestions to decrease their milk supply, while others want to feel that milk
     come in.  Either way, it is often a painful, sometimes bittersweet reminder of their loss.
     *  Leaving the hospital.  Moms sometimes need something to carry something in their arms as they leave the hospital. 
     Others may find that the need empty arms, since empty is how they feel.

Helpful things to say: * "I'm so sorry." * "How are you doing with all this?" * "This must be so hard for you." * "What can I do for you?" (Although from experience, this is really not so helpful, as the reply is almost always, "Oh, nothing.") * "I'll be over with dinner on _____." * "I'm here, and I want to listen." * "Tell me about (baby's name)." * Anything that affirms their grief, and values their baby. * Crying with them as you share your grief with them.

Things not to say: * "I know just how you feel." (Like heck you do!) * "Be thankful you already have a healthy child." * "You can always have another." * "It's for the best." * "You have an angel in heaven." * "This is nature's way of weeding out defective ones." * "I've known other people who've handled this well; they never cried." * "At least you know you're fertile." * "You're lucky it happened now instead of six months from now - you didn't know the baby yet." * "At least your loss was final. When our house burned down, for months we kept remembering more things we were missing." * Anything that makes light of the baby or the loss, including trying to find "blessings" from the loss. Most people will eventually reach the point of resolution where they can look back and acknowledge some "blessings" from their loss. That is for them to discover, though, and not have it pointed out, which often makes parents feel like they should be grateful for experiencing the loss! * "You must be really special, strong people - I could have never handled it" * "One upmanship" stories. These don't help! * Changing the subject every time they want to talk about the loss. * Being so distraught yourself that parents feel an obligation to comfort you!

4.WHAT ABOUT ANOTHER PREGNANCY?

Both parents and caregivers need to know that subsequent pregnancies are often very difficult. Much helpful information can be found in the book entitled Still to be Born by Schweibert and Kirk. This is a great gift to give to clients who are planning another pregnancy. Typically, there are two reactions: "I want to get pregnant right away," and "I don't ever want to be pregnant again," without having any "middle ground." There are advantages and disadvantages to waiting, and to not waiting. However, bereaved parents need a chance to come to terms with the ending of their relationship with the baby that died before they can want "just any baby" again. The "replacement child" syndrome is real, but there are two main problems associated with it. The first is that parents delay their grief until after the new baby comes, or, they think that by having another baby right away, they won't have to grieve at all. This definitely complicates the postpartum period with the new baby! These parents may find themselves unable to relate to this new child because the baby's arrival may open unhealed wounds from the previous baby's death. The second problem that occurs is that the subsequent child can end up with an identity problem. He or she will be unable to be the "perfect" child that he or she is replacing, thus making it difficult for the parents to love this child as much as the dead baby, who is perfect. "If your mother dies, people don't say "you can always have another mother". Then why is it all right to say you can always have another baby if your baby dies?" (Schweibert et al., 1993)

Parents considering a subsequent pregnancy usually have more intense concerns than those who have not experienced a loss such as theirs. First of all, there is the fear that this child will die too. After all, their last baby wasn't supposed to die, either, so what is there to prevent another loss? Those who have not suffered such a loss may make comments such as "lightening never strikes twice," or "you've paid your price; I'm sure everything will be fine." Couples who have experienced such a loss, however are not as easily convinced, and often see themselves as "marked" or singled out for tragedy. Another complicating factor may be guilt. The parents may wonder if they will be punished for past mistakes - an abortion or the decision to place a child for adoption, ambivalent feelings at the beginning of the pregnancy, or some other "sin" they committed. They may also feel guilty about not having been "perfect" during the last pregnancy (didn't take their vitamins, smoke/drank/used drugs, ate too much junk food, etc., etc.) Or, they may feel angry and betrayed because they were perfect!! Life is so unfair!

Parents may then ask, "How long should we wait before we have another baby?" There is no set answer, as time is only as valuable as you make it in progressing through grief. People can spend years without doing any real grief work, or they may be able to move through the bulk of their grieving in a matter of months. It is generally recommended that parents wait at least six months before planning to conceive again, although the mother physically will be ready before that. It is certainly all right for parents to wait longer than that if they do not feel ready. Some suggestions that Schweibert and Kirk give are for parents to ask themselves these questions:

     - How do I feel about holding other people's babies that are the same age my child would have been?
     - What do I think when I see other pregnant women?
     - What will it be like to deliver in the same place where my dead (or handicapped, etc.) baby was born?
     - What is it like walking through the baby department at the store?

Next, parents will have to think about who will be their care provider for this pregnancy. Hopefully, their midwives, doulas and other careproviders will have helped them enough that they will be comfortable discussing this issue with them. Mothers will have to consider what level of care they require for a safe outcome. Will going to the same care provider be more or less comforting? How do the fathers feel? Where will the mothers feel the most safe? Some mothers will only feel "safe" with as "high-tech" care as possible, regardless of their previous beliefs. Some will want to avoid technology, either because they fear it, or because they understand now that there are no guarantees! Some problems will most likely "risk-out" a mother for a home birth, a birth center birth, or even a vaginal birth. Others were once-in-a-lifetime (we hope!) occurrences and they can continue with the same support as before. Other times, women may benefit from dual care providers - an obstetrician and a midwife.

Once mothers find out that they are actually pregnant again, emotions are often jumbled. On the one hand, they are often excited to be pregnant; on the other they are scared to think going through another loss. Some women contemplate abortion because the fear of losing this baby also is just so overwhelming. Many women do not share the news of their new pregnancy with as many people, or as soon as they did before. Some mothers may be almost fanatic in their desire to do everything perfectly this time around, while others may have a much more laid-back attitude, since they did everything right last time and it "didn't work." The truth is some of these pregnancies will be "easy" and some will be quite burdensome. Although these new moms-to-be may crave assurances that everything will be all right, they know and we know that there are no guarantees in life. There are some commonsense things that every pregnant woman should do to ensure the best possible health for her unborn child (excellent nutrition, no smoking or alcohol, moderate exercise, etc.). We all know people who broke the rules and had babies that were fine. This does not mean, however, that their baby would not be adversely affected by not using common sense, and following the guidelines for good health and good "baby-building." Some parents may experience difficulty in their sexual relationship. Many feel guilty for "having fun" when their baby is dead, and once another pregnancy has occurred, many will avoid sexual intercourse to keep from hurting the baby. Rationally, most parents know that sexual relations and even orgasm are OK during pregnancy, but irrational fear often accompanies pregnancies that follow losses! We need to reassure parents that it is normal to experience contractions after orgasm and/or nipple stimulation. We can suggest that a condom be worn if they are concerned about the prostaglandins in the semen. We can also try to reassure them that unless there are definite medical reasons not to, intercourse is fine throughout pregnancy. Abstinence (usually short-term) may be advisable in the case of a mother with a history of miscarriages, or, pre-term deliveries, undiagnosed vaginal bleeding or a placenta previa, or chronic infection of the reproductive tract. Long-term abstinence can have negative side effects, too! Loving, touching, kissing, fondling, or just being close are all part of lovemaking, and for some couples, this will be sufficient. It is important for caregivers and partners not to assume that everyone feels the same way they do, however, and open communication remains essential!

There are some times that will be particularly hard on these expectant mothers. Being familiar with them can help us as caregivers to be there in times of need, and even "anticipate" difficult times. These times include:

     1.  The first trimester, especially if the mother has had one or more miscarriages in the past.
     2.  The first time they hear the baby's heartbeat, as they may be remembering their dead baby's heartbeat.
     3.  Having an amniocentesis or other test done, then waiting for the results.
     4.  Not feeling the baby as soon or as often as the mother thinks he or she should.
     5.  The time in pregnancy when there was the first indication of a problem with the baby's health.
     6.  The anniversary date of their baby's birth and death (not always the same date!), or last due date.
     7.  Holidays, just because they remind mothers that they were already supposed to have a babe-in-arms.

Finally, the parents are in the "final countdown" to this new baby's birth. Many will find it difficult to prepare the nursery, or use the same baby clothes intended for their now deceased baby, while others may have no trouble "going through the motions," but have a hard time really believing that they may actually get to a hold and parent a real, live, healthy baby. Some couples will choose to take childbirth classes again, or for the first time, but many who do find it difficult to be a room with other couples who are "blissfully ignorant" of the grief of losing a precious baby. Again, as we educate our clients, let's make sure we at least cover a little of "unexpected outcomes!" There are things that mothers and their partners can do to help make this birth as special as possible, without looking upon labor as a necessary evil, governed by an embittered past. Learning or relearning relaxation is definitely helpful, to say the least! Being educated about the birth process also helps, and we as caregivers can offer continual assurances that birth does indeed work. This should be done both during the pregnancy and during the labor. There are many ways to help mothers gain confidence, as most mothers who have experienced a loss are at least somewhat afraid that their bodies will fail them again (even if they really didn't "fail" in the first place). Some helpful suggestions for working with these mothers are positive affirmations, healing guided imageries, creative birth journaling (as detailed in the book "Creating a Joyful Birth Experience" by Capacchione and Bardsley). Remember that the last few weeks of pregnancy are long for every pregnant mother, but even more so for the bereaved mother. Even if she has worked hard at not "succumbing" to medical interventions, many are greatly tempted to get the "jump" on nature and want to induce labor, or even schedule a C-Section to finally get that baby here alive. It can seem difficult to keep on even a somewhat even keel emotionally, and anxieties are probably heightened. Facing these anxieties head on can help diminish them. Encourage the moms to talk about their fear for the upcoming labor, talk through the previous labor and delivery experience, visit the hospital, if applicable, where the previous birth took place, or where this one will. It is also useful to have these moms write out a "birth plan," even for a home birth, so there is no misunderstanding between laboring mom and careprovider. It can also be helpful to plan on making the baby's birth-day as special as possible. Surrounding herself with loving, supportive people can definitely be an asset for the laboring mom! Taking pictures and even tape recording the baby's first cries help add "validity" to this important event. Pictures offer tangible evidence of the birth. The parents can go back over these pictures and "recapture" their parts of their birth that they can't remember because they were too involved or too afraid to allow themselves to fully experience the birth. Planning a birthday party is also fun, especially if there are older children who have also lived through the previous loss or losses.

The baby is finally here, safe and sound and now everything is fine, right? Maybe. Some parents who experienced the death of their firstborn find themselves grieving anew because they now know what they lost in the death of their child. Others find themselves quite lonely for their dead baby or babies, as they rock and nurse their new baby. Many parents feel like they are "just waiting" for something catastrophic to happen to their babies - childhood diseases becoming fatal, SIDS, some undiagnosed congenital problem, etc. It is quite common for these new mothers to find themselves continually on the verge of tears in the first few days after the birth. These alternate between tears of relief and joy that this new baby is here safely, and tears of sadness over the past loss. Plus, they all deal with the same hormonal adjustments and sleep deprivation that any post-partum mother does! Again, being able to talk things out is enormously helpful. Sometimes the midwife or doula may fill this role; at other times it may be a trusted and supportive friend or relative. It also helps some parents to have a patient, understanding pediatrician who does not brush off any worries or concerns as insignificant. Finally, these new moms need to be kind to themselves! They need to let others pamper them, and not to worry if they feel a "little crazy at times." They will adjust! For those parents who have experienced a pregnancy loss of any type, a sense of a "loss of innocence" is usually felt. Knowing they will never take a pregnancy and subsequent healthy baby for granted will always "color" the lives of anyone touched by loss. Sometimes lightning does indeed strike twice. Parents need to ask themselves if they are ready to face that possibility. Of course, no one ever wants to face loss again, but there is a point after which it changes from "absolutely impossible" to "hard, but we'd survive." One very difficult reality that parents sometimes face after a loss is the inability to get pregnant. It can be really hard to end childbearing on such an "unpleasant" event. Support groups such as SHARE and even RESOLVE often discuss this topic, and parents can find lots of comfort in knowing there are others who feel the same way as they do.

After a loss, parents, and especially mothers, find themselves being very protective of their living children, and any that are born to them after the loss. This is normal, but some mothers need help in "letting go" enough that they and their children can live normal lives.

Being Doula for a Mom Who Has Had a Previous Loss:

This situation also has some unique attributes. As a doula, you should be aware of the emotional issues that come up in pregnancies following a loss, namely fear. This is something that is best addressed during the pregnancy, so it does not "interfere" with the birth process. Your prenatal interview may be longer that most as you talk with this Mom about her feelings about her last birth. Some Moms can put off grieving until they are either pregnant with, or have given birth to their next baby. If so, be ready for a long, difficult labor, as she will be spending some of that time "processing" some of her emotions. Most of the information that applies to Moms experiencing a VBAC, or mothers who have been victims of sexual abuse also applies here. Understanding those issues allows doulas (and other careproviders) to be prepared with many helpful suggestions and techniques. These may include giving warm, nurturing, continuous touch, aromatherapy, guided imageries, talking about the fear or many other things. Doulas supporting Moms after a loss will be doing lots and lots of reassurance. This can include, but is certainly not limited to, pointing out the differences between this labor/birth and the last one, more fetal monitoring, and helping to create a safe space for Mom (and Dad) to release fear and grief. Understanding that use of anesthesia to "block" sensations may be more common, especially in women who have not really been able to process through their grief. They want everything numb! Once the baby is actually there, there may be a sense of shock and disbelief that things are OK! There are times when this "shock and numbness" extends into early parenting and bonding is negatively affected. These are Moms (or Dads, grandparents , siblings, etc.) who do not want to open themselves up to love and trust because they know if a loss occurs, the grief is excruciatingly painful. In other words, to try and avoid feeling intense grief if a loss should occur, they avoid feeling love and joy as well. Doulas can continue providing reassurance, support, caring and understanding in helping Moms learn to "let go" and feel able to love again. Don't give up! Occasionally, professional counseling is beneficial and desirable. Supporting a woman during a pregnancy and birth after a loss brings to the forefront all the best of what a doula is and does. Providing a safe environment, nurturing, loving, supporting and reassuring are the essence of being a doula!

5. Multiple Losses

Parents who have experienced a loss worry about another loss. Most times, the odds are on their side, but they always know that they have beat the odds once and could do it again. What happens to parents who do "beat the odds" and have multiple losses? For one thing, it becomes harder and harder to hope a pregnancy would actually end in a live, healthy baby! Many parents report increasing difficulty in coping with each new loss. The healing that is necessary becomes harder and harder to achieve, as the past losses are grieved for again, plus the latest loss. The resources that parents drew on for their first or second loss seem to offer less comfort, less reassurance. The ability to recover sometimes disappears completely. A persistent, unshakable feeling of depression and despair pervades every part of their life, although the acute pain has lessened. If a woman has experienced multiple losses, she becomes more and more likely to "build walls" around her emotions, so as not to get her hopes up. As mentioned above, numbing yourself to grief also means numbing yourself to joy as well. Partners often find themselves doing the same "protecting" of their own emotions. Many times mothers feel that their partner was not emotionally involved in the pregnancy. This is often true. Even if a pregnancy does eventually result in a live baby, Dads are often able to hold back on emotional investment until after they see a live baby. This can obviously lead to intensifying the problems experienced in a subsequent pregnancy after a loss (or losses). Cynicism can be a common side effect following multiple losses. Now you "know" that you are marked, singled out, and that nothing will ever go right again in your life. This can lead to a breakdown in the relationships with others! Sometimes, there are answers available in the medical community, such as DES exposure, maternal infections, etc. Most often, however, there are no known reasons for multiple losses. This is especially true if the losses are of a "mixed" type - that is, they are not all the same type of loss. Each couple must decide for themselves how long to keep trying, and how much they can "handle." Many women do go on to have a "successful" pregnancy after numerous losses. Others decide that the pain of possibly losing another pregnancy is more than they could bear and stop trying. Still others experience losses, then a child, then more losses, and another child, etc. Statistically speaking, the more losses a woman has experienced, the less likely it is that she will achieve a successful pregnancy. Remember, though, that these are only statistics! Emotionally, multiple losses are very difficult. You get the feeling of being "kicked while you're down." Reassurances mean almost nothing. However, support is still very important!! Doulas and midwives can support women in multiple losses by many of the same things mentioned previously. However, these women are less likely to have much success in positive affirmations, imageries, etc. They can often develop the very deep-seated belief that birth does not work! Still, loving support during any pregnancies, losses and subsequent decision-making is so helpful! It is hard to allow yourself to hope when you have been disappointed (to put it mildly) so many times before. Hope is healing, however! Parents grieving multiple losses will need someone to "watch over them," to help them, support them, perhaps even guide them as they move through grief to acceptance, wherever that may be.

"Life and death are intrinsic parts, one of the other. If we can unravel a little of the mystery of life, we can know and understand a bit more of death. We can begin to recognize and honor our eternal connections with our children - connections that begin with their conception. We can consciously share ourselves with our children, from the moment we know they exist. The richness of relationship we begin to build will only enhance and grace the ties that endure beyond death, whenever it comes. Death cannot destroy that which always lives.

We cannot recall our children from their new lives in death, nor can we recover other childbearing losses now gone from us. Yet we can honor the eternal love we feel for our children, and they for us, by transforming our ended beginnings into new beginnings. Beginning today." (From the book Ended Beginnings by Claudia Panuthos and Catherine Romeo.) Grief is very much like labor. Only one person can make the journey, but loving support makes the path an easier one to trod.

RESOURCES

SUPPORT GROUPS:

AMEND (Aiding a Mother Experiencing Neonatal Death) 4324 Berrywick Terrace St. Louis, MO 63128 (314) 487-7582

THE COMPASSIONATE FRIENDS P.O. Box 3696 Oak Brook, IL 60522-3696 (708) 990-0010 A self-help organization of bereaved parents who have lost children of all ages. Local chapters.

PARENT CARE, INC. 9041 Colgate St. Indianapolis, IN 46268-1210 Offers information, referrals, newsletter, and other services to families, parent support groups, and professionals concerned with infants who require intensive or special care at birth.

PEN-PARENTS PO Box 8738 Reno, NV 89507-8738 (702) 826-7332 Support network of grieving families who have experienced pregnancy losses or the deaths of young children. Pen-Parents provides an opportunity for bereaved parents to talk about their child(ren) through the newsletter. Pen-Grandparents is another referral of Pen- Parents. For information contact Mary Nell Saunders, PO Box 3304, Jasper, AL 35502 (205) 384-3053

PREGNANCY AND INFANT LOSS CENTER 1415 East Wayzata Boulevard, Wayzata, MN 55391 (612) 473-9372 A national non-profit organization that offers literature, newsletter, local and national support group information, parent-to-parent peer support group program, and professional training on miscarriage, stillbirth and infant death. This is a great resource/

RESOLVE, INC. Box 474, Belmont, MA 02178 (617) 484-2424 Support, resources, education and information concerning infertility. Publishes newsletter, has many local chapters.

RTS BEREAVEMENT SERVICES (formerly Resolve Through Sharing) LaCrosse-Lutheran Hospital 19190 South Avenue, LaCrosse, WI 54601 (608) 785-0530, ext. 3675 Provides information on local and national parent support groups; training for professionals on counseling and follow-up of families who have experienced miscarriage, stillbirth, or newborn death, and offers literature for parents, healthcare providers, and clergy.

SHARE (A Source of Help in Airing and Resolving Experiences) National SHARE Office, St. Joseph Health Center, 300 First Capitol Drive, St. Charles, MO 63301-2893 (314) 947-6164 SHARE is a national, non-denominational parent support organization that offers parents a place to express their feelings after the death of their baby. Great newsletter and referral to local support groups.

THE SUDDEN INFANT DEATH SYNDROME ALLIANCE 10500 Little Patuxent Parkway, Suite 420, Columbia, MD 21044 (800) 221-SIDS or (301) 964-800 Disperses information to parents, families, professionals, and the general public about SIDS. Publications and newsletter.

Contact your local children's hospital, or the pediatric unit at the local hospital for information about parent support groups for families dealing with children with various problems, including prematurity, genetic disorders, and more.

PUBLISHERS: Call or write for information or catalogs.

BOULDER COUNTY HOSPICE, INC. 2825 Marine Street, Boulder, CO 80303 (303) 449-7740 Sells Death of a Dream by Donna and Roger Ewy.

CENTERING CORPORATION Box 3367, Omaha, NE 68103-3367 (402) 553-1200 Besides its own publications, Centering provides a non-profit network for distributing supportive grief literature from other sources. Great resources available for people experiencing grief from any source.

CREATIVE MARKETING Human Services Division 2631 North Grand Avenue, East, Springfield, IL 62702 (217) 528-1756

NATIONAL MATERNAL AND CHILD HEALTH CLEARINGHOUSE 38th and R Streets, N.W., Washington DC 20057 (202) 625-8410 Offers free, single copies of A Guide to Resources in Perinatal Bereavement. The guide is a selected and annotated list of resources that provide information and support to bereaved parents.

PERINATAL LOSS 2116 N.E. 18th Avenue, Portland, OR 97212 (503) 284-7426

PRAIRIE LARK PRESS Box 699-W, Springfield, IL 62705 (217) 544-6464, ext. 5727

WINTERGREEN PRESS 3630 Eileen Street, Maple Plain, MN 55359 (612) 476-1303

SUGGESTED READING

* = Highly recommended!

*Allen and Marks (1993) Miscarriage - Women Sharing from the Heart A wonderful book that will help anyone who has experienced the grief of a miscarriage to realize that they are not alone! Tender sharing from mothers, fathers, grandparents and siblings, this book will touch your heart, and hopefully help lead you down the path to healing.

Arnold, J., and Buschman, P. (1983) A Child Dies, A Portrait of Family Grief Gemma, MD, Aspen Publications Personal account of grief.

Barney, A. (1993) Stolen Joy - Healing after Infertility and Infant Loss Baltimore, MD, Icarus Books A book of poetry and prose about surviving infertility and then infant loss.

*Berezin, N. (1982) After a Loss in Pregnancy New York, Simon and Schuster Very good book about grieving and healing.

Berg, B. (1981) Nothing to Cry About New York, Seaview Books Personal account of repeat miscarriage and this mother's journey through grief.

Borg, S., and Lasker, J. (1981, 1990) When Pregnancy Fails Boston, Beacon Press A book written to offer comfort to women and their families suffering after the death of their baby. The authors both suffered the loss of their first babies, and have interviewed many other women with similar experiences.

Centering Corporation (1989) Dear Parents - Letters to Bereaved Parents Omaha, NE, Centering Corp. A book of sharing thoughts, ideas, feelings, advice and care for parents who have had a child die. These "from-the-heart" letters are powerful and caring, and certainly acknowledge how hard it is for any parent to lose a child of any age.

Cohen, M. (198 ) An Ambitious Sort of Grief: Diary of pregnancy and neonatal loss Liberal Press Personal account of this mother's journey through loss and grief.

*Cohen, M. (198 ) She was Born. She Died. Centering Corporation A collection of poems by a mother who lost her infant daughter at 44 hours of age. Raw emotion is in these poems - she knows what grief is!

Cohen, N; 1991 Open Season: A Survival Guide for Natural Childbirth and VBAC in the 90's, This book pulls no punches in talking about birth in America today - a 25% Cesarean rate average, 90% episiotomy rate, women mostly medicated, continuously monitored and kept in bed, and talks about reclaiming our "birthright" as women.

Cohen and Estner, 1983 Silent Knife, A powerful, thoroughly documented book that should be read by everyone connected with childbirth. It was written to help give women the knowledge and confidence needed to birth their babies vaginally, even after one or more previous cesareans. Also see Nancy Cohen's second book, Open Season.

*Davis, D. (1991) Empty Cradle, Broken Heart: Surviving the Death of Your Baby Golden, CO, Fulcrum Publishing A very good, helpful book on how to survive the death of your baby.

DeFrain, J. (1986) Stillborn: The Invisible Death Lexington Book

Diamond, K. (1991) Motherhood after Miscarriage Holbrook, MA Bob Adams, Inc. The author is an expert in genetic research and has experienced several miscarriages herself. She has written a book that explores why miscarriages happen, and what can be done to prevent them.

Dodge, N., and Lamb, Sr. J.M. (1985) Sharing with Thumpy (workbook) Springfield, IL, Prairie Lark Press Coloring book for children bases on "Thumpy's Story".

Dodge, N., and Lamb, Sr. J.M. (1983) Thumpy's Story - A Story to Color Springfield, IL, Prairie Lark Press A book of dealing with the death of a young sibling from "Thumpy, the bunny's" point of view. Appealing to children, it answers many of the questions and concerns they may have when a sibling dies.

Donnelly, K. (1982) Recovering from the Loss of a Child New York, Macmillan Publishing

Erling, J., and Erling, S. (1986) Our Baby Died. Why? Wayzata, MN, Pregnancy and Infant Loss Center A booklet designed to help children resolve their grief over the death of a baby sibling. Includes feelings and pictures by other siblings, and places for your child to express themselves.

Erling, S., et al. Self Care (1989) Wayzata, MN, PILC (booklet) Booklet for grievers on how to take care of themselves and make their recovery a little easier.

Ewy, D., and Ewy, R. (1984) Death of a Dream: Miscarriage, Stillbirth, and Newborn Loss New York, E.P. Dutton, Inc.

Freeland, A. (1990) Journey to Motherhood (personal account) New York, Prentice Hall Press One mother's personal account of her journey through loss and grief on the way to motherhood.

Friedman, R., and Gradstein, B. (1982) Surviving Pregnancy Loss Boston, Little, Brown, and Co. This book contains descriptions and first-hand accounts of reactions common to pregnancy loss, as well as practical approaches to coping with the intense emotions of such a loss. Contains lots of resources for parents.

*Fritsch, J., and Ilse, S (1988, 1992) The Anguish of Loss Long Lake, MN, Wintergreen Press (Also available as a slide show) This book is a "visual expression of grief and sorrow" of the author's experience with her stillborn son. There is poetry and sculptures that Julie created as an articulation of her grief. This book reaches out and grabs you! This really is what grief feels like!

Gaffney, D. (1988) The Seasons of Grief: Helping Your Children Grow Through Loss New York, New American Library

Gunderson, J., Harris, D. (1990) Quietus - A Story of a Stillbirth Omaha, NE Centering Corporation A booklet written by the mother and grandmother of a stillborn baby. Very personal account of the grief and anguish that comes with such a loss.

Gryte, M. (1988) No New Baby Omaha, NE, Centering Corporation (for children) A booklet for boys and girls whose expected sibling has died. Good for miscarriage, stillbirth and early infant death.

*Ilse, S. (1990) Empty Arms: Coping with miscarriage, stillbirth, and infant death Long Lake, MN, Wintergreen Press This wonderful book is for all parents who are or have experienced a perinatal loss. Sherokee offers many practical suggestions for getting through the shock of having your baby die, and help with all of the decisions that must be made at that time. It also provides support for the lonely days ahead. Highly recommended!

*Ilse, S (1994) Precious Lives, Painful Choices, Long Lake, MN, Wintergreen Press Excellent resource for parents who have discovered that their unborn baby has one or more problems. Sherokee discusses the option of inducing labor immediately or going to term. The information is presented in a non-judgmental tone and has moving accounts from women who have lived through this experience.

*Ilse, S (1989) Presenting Unexpected Outcomes: A Childbirth Educator's Guide Long Lake, MN, Wintergreen Press An excellent resource with great ideas on how to broach the sensitive subject of grief and loss. Does not apply only to childbirth classes, but is beneficial to doulas and midwives and others who care for childbearing women.

*Ilse, S., and Burns, L. (1985) Miscarriage: A Shattered Dream Long Lake, MN, Wintergreen Press A complete book dedicated to miscarriage, the grief associated with it, getting through it and thinking about a "next time". It answers common questions families have about miscarriage, and lists a large number of resources parents can turn to for further support.

Ilse, S., Burns, L. Erling S. (1984) Sibling Grief Wayzata, MN PILC (booklet) A guide to helping children through grief over the loss of a baby sibling. In booklet form.

Ilse, S., Erling, S., et al. (1986) Planning a Precious Goodbye PILC A booklet designed to help plan a memorial service for a beloved baby, regardless of the age when lost. Includes poetry readings, service ideas, song suggestions and more. A nice help!

Ilse, S., Leininger, L. (1985) Grieving Grandparents Wayzata, MN, PILC (booklet) A booklet for grandparents whose grandbaby has died. Acknowledges the "double" grief that grandparents feel - losing their grandbaby, and watching their child suffer as well.

Jimenez, S. (1982) The Other Side of Pregnancy Englewood Cliffs, NJ, Prentice Hall Well written book about the "dark" side of pregnancy.

Johnson. J., and Johnson, S. Children Die Too Centering Corporation Helpful booklet of grieving the loss of a child.

Johnson, J., et al. (1983) Miscarriage Omaha, Centering Corporation Booklet about the unique pain of miscarriage.

*Johnson, J., et al. (1985) A Most Important Picture Omaha, Centering Corp "A very tender manual for taking pictures of stillborn babies (including miscarried babies) and infants who die." Wonderful!

Johnson, J., et al. (1992) Newborn Death Omaha, NE, Centering Corporation A booklet for parents on what to do right after a small baby dies. (Gather mementos, hold the baby, etc.)

*Kohn, I., Moffitt, P, and Wilkins, I (1993) Silent Sorrow - Pregnancy Loss Delta Publishers This helpful book examines such issues as why men and women grieve differently, the impact pregnancy loss can have on a career, personal experiences and dealing with loss in the context of religion. Has a good section on subsequent pregnancies.

*Kushner, H. (1981) When Bad Things Happen to Good People New York, Schocken Written by a rabbi, this excellent book discusses "adversity" from a theological perspective. Warm and caring, this is a great one to have!

Lamb, Sr. J., (1989) Bittersweet: Hello, Goodbye Prairie Lark Press (this is a comprehensive planning resource for funeral/memorial services for infants.) A resource in planning farewell rituals when a baby dies, this book contains information on ideas that have worked for other parents. Religious orientation. *Limbo, R., and Wheeler, S. (1986) When a Baby Dies: A Handbook for Healing and Helping Resolve Through Sharing, LaCrosse Lutheran Hospital, LaCrosse, WI A very helpful book containing checklists for those involved in having a baby die, whether a parent, other family member, friend, clergy or healthcare provider. Good discussion of the grief process, and suggestions for helping the bereaved to heal from such a loss.

*Linn, E. (198 ) I Know Just How You Feel: Avoiding the Cliches of Grief The Publisher's Mark, PO Box 3969, Incline Village, NV 89450 Ever wonder what to say to someone who has experienced sorrow or tragedy in their lives? Don't want to say anything for fear of saying something wrong? This book lists many of the common phrases people say and why they are hurtful. It can give us all insight in how to best approach a grieving person, like simply saying, "I'm sorry".

*Madsen, L (1994) Rebounding From Childbirth: Toward Emotional Recovery, Bergin and Garvey This book is the first to focus exclusively on the mother's feelings about a difficult birth. For the woman who experiences her birth as being traumatic, very often her feelings of anger, grief, failure and disappointment get little or no acknowledgment. The author is a professional counselor and a mother who experienced a traumatic birth herself. She guides the reader through some essential steps for healing.

*Manning, D. (1984) Don't Take My Grief Away from Me San Francisco, Harper and Row for Insight Books A book for anyone personally experiencing a loss, or supporting a friend or family member who has. It points out the necessity of grieving. We need to acknowledge the losses in ours and others lives, not downplay or ignore them. By doing so, we can all move toward resolution.

Menten, T (1991) Gentle Closings: How to Say Goodbye to Someone You Love Philadelphia, PA, Running Press Book Publishers

*Panuthos, C. (1984) Transformation Through Birth New York, Bergin and Garvey (Has an excellent chapter on healing childbearing losses.) A supportive book for women desiring uplifting, empowering birth experiences. You are given at least a glimpse of how to protect the integrity of your birth, and perhaps begin to share those resources with other birthing women.

Panuthos, C., and Romeo, C. (1984) Ended Beginnings: Healing Childbearing Losses New York, Bergin and Garvey Publishers, Inc. This sensitive, sharing book is for women who have experienced a childbearing loss, and their families. This book addresses losses such as miscarriage, stillbirth, prematurity, traumatic birth , cesarean section, babies born with disabilities and more. It addresses what we need to heal, and helps us through that journey.

Pregnancy and Infant Loss Center (1986) Tiny Baby PILC (Booklet on miscarriage) Booklet of poetry about miscarried babies.

Rich, L. (1991) When Pregnancy Isn't Perfect New York, Penguin Books Written for women who are having complications with their pregnancies. This book discusses in easy-to-understand terms what is happening and why with various complications that can befall pregnant women.

Rothman, B. (1986) The Tentative Pregnancy Harrisonburg, VA, R.R. Donnelley & Sons Co. Book discussing the impact of prenatal testing - especially amniocentesis - and the maternal-infant bond that develops during pregnancy. Discusses the "burden of choice" mothers face when told their baby has a defect.

Sanders, C. (1992) How To Survive The Loss Of A Child, Prima Publishing Written by a psychologist specializing in bereavement, and herself a bereaved mother, this book is a wonderful help for understanding grief and helping you to heal. The author provides reassurance, talks about many of the different emotions that accompany the journey through grief, and helps us understand what we can do to heal.

Schaefer, D., and Lyons, C. (1986) How Do We Tell the Children? A Parent's Guide to Helping Children Understand and Cope When Someone Dies New York, Newmarket Press

Schiff, H. (1977) The Bereaved Parent New York, Crown Publishers Discusses grief and healing after the death of a child.

*Schweibert, P., and Kirk, P. (1985) When Hello Means Goodbye Portland, OR, Perinatal Loss A booklet meant for parents whose babies have died. This is often the booklet handed out to parents in the hospital, and is mostly geared toward the decision-making that must take place immediately after a death. There are pictures sensitively shared, and encouragement to get to know the baby by holding, naming, photographing, etc.

*Schweibert, P., and Kirk, P. (1989) Still To Be Born Portland, OR, Perinatal Loss If you have experienced a childbearing loss, such as miscarriage, stillbirth or an infant death, and are considering another pregnancy, or are already pregnant, this book is for you! The authors talked to many bereaved parents in the same situation and then address several issues, such as letting go of the child you lost, and especially, how to live through another pregnancy.

Semchyshyn, S., and Colman, C. (1989) How to Prevent Miscarriage and Other Crises of Pregnancy New York, Macmillan Publishing Co. This book has a lot of good information about why women may miscarry and suggestions to help avoid a repeat occurrence.

Viorst, J. (1971) The Tenth Good Thing About Barney New York, Atheneum Children's book about dealing with grief. A young boy has to come to terms with his feelings - including anger - after his dog, Barney, dies.

Wolfelt, A. (1983) Helping Children Cope With Grief Muncie, IN, Accelerated Development, Inc.

Holly Richardson is a certified doula, a certified childbirth educator and a bereaved mother. She has experienced 18 miscarriages, including one in the second trimester. She has given birth to four children, two of whom have extensive disabilities. She and her husband Greg have also adopted three children. They have also experienced the tragic death of one of their daughters at age 5 1/2. Holly has been teaching workshops to midwives and doulas about the process of grieving and healing since 1992. She is always available to answer questions, or just to lend a listening ear. She can be reached at 801-224-3564, or by writing to her at 645 West 350 South, Orem, UT 84058.