The taboo of miscarriage
Miscarriage is extraordinarily common, and yet remarkably easy to go through without anybody knowing. We have developed a curious social convention around early pregnancy: wait until 12 weeks before telling people, because that is when something might go wrong. The result is that the period during which pregnancy loss is most likely to happen is also the period in which many women are most likely to experience it privately. The numbers themselves can be surprising. Estimates vary depending on how miscarriage is defined and how early pregnancies are counted, but around one in five pregnancies may end in miscarriage, with the great majority of losses occurring during the first trimester. Many more pregnancies are thought to end before someone even knows they are pregnant. Miscarriage is not, in other words, an unusual reproductive event. It only feels unusually rare because so much of it happens out of sight.
Age makes a significant difference. The risk rises particularly from the late 30s onwards, largely because chromosomal abnormalities in eggs become more common with age. But miscarriage happens to younger women too, including those who are healthy, fit and seemingly doing everything “right”. For many women, the first question after a miscarriage is also the most difficult one: why?
In around half of early miscarriages, chromosomal abnormalities in the developing embryo are thought to be involved. Usually these occur spontaneously during the formation of the egg or sperm, fertilisation or early cell division. In simple terms, the embryo does not have the genetic instructions required to continue developing normally. It can be an emotionally unsatisfying explanation for something so significant, but biologically it is often a matter of chance. There are other factors associated with miscarriage. Smoking, heavy alcohol consumption, certain medical conditions, being significantly under- or overweight and increasing parental age can all affect risk. When miscarriages happen repeatedly, clinicians may investigate other possibilities, including antiphospholipid syndrome, differences in the structure of the uterus, hormonal or metabolic factors and, more rarely, genetic rearrangements carried by one of the parents.
But this is also where discussions about miscarriage can become psychologically dangerous. Knowing that some risks are modifiable can quietly turn into the assumption that every miscarriage must have been preventable. After a loss, people often search backwards through the preceding weeks. Was it the glass of wine before I knew I was pregnant? The stressful week at work? The gym? Sex? The argument I had with my partner? Should I have rested more? In most cases, there is no such moment to find. Ordinary exercise, sex, working and everyday emotional stress are not considered causes of miscarriage. Sometimes a pregnancy ends despite somebody having done everything she reasonably could to protect it.
There is, however, an interesting conversation emerging around what happens before pregnancy begins.
Rebecca Fett's book It Starts with the Egg has helped popularise the idea that preparing for pregnancy should begin not with the positive pregnancy test, but several months before conception. The title is deliberately provocative, but the biological idea underneath it is worth understanding. The egg released at ovulation has not simply appeared that month. Its follicle has been developing through a lengthy process before ovulation, and the months preceding conception therefore represent a potentially important window in reproductive health. Fett focuses particularly on egg quality and discusses nutrition, micronutrients, mitochondrial function, environmental exposures and supplements. Some of the recommendations in the book have stronger scientific support than others, and the evidence does not justify the idea that following a particular three-month regime can guarantee a chromosomally healthy egg or prevent miscarriage. Biology is considerably less controllable than that.
Still, the broader principle is useful. We often treat pregnancy preparation as something that begins once a woman is already pregnant, when there is good reason to think about reproductive health beforehand. The roughly three months before trying to conceive can be an opportunity to review nutrition, folate intake, smoking and alcohol, medications, existing health conditions and general health. It is perhaps better understood as creating favourable conditions for conception than as attempting to manufacture the “perfect” egg. There is another reason to be careful about how we talk about egg quality. Women already carry a disproportionate amount of responsibility for pregnancy outcomes. If the language of optimisation becomes too strong, an empowering message – there are things you can do before pregnancy – can very quickly become another source of guilt: If only I had eaten differently. If only I had taken the right supplements. If only I had prepared for longer. The science does not support that conclusion. And perhaps this points towards the larger problem with miscarriage. We are reasonably good at talking about its biology. We are much less comfortable talking about what has actually been lost.
A pregnancy can be six or eight weeks old and already occupy an enormous psychological space. A positive test changes the future almost instantaneously. A due date is calculated. Christmas is mentally rearranged. Someone wonders whether the spare room could become a nursery, imagines telling their parents or begins thinking about names. None of this requires a visible bump or an ultrasound photograph. Psychologically, people can travel years into the future within days of discovering a pregnancy. When the pregnancy ends, all of that disappears with it. This helps explain why the number of weeks someone was pregnant tells us remarkably little about the scale of their grief. A person may be mourning not only an embryo or fetus, but an anticipated baby, an identity, a family configuration and an entire imagined future. Yet because the pregnancy was private, the outside world may have no idea that anything has happened.
The convention of keeping pregnancy secret for 12 weeks deserves some thought for this reason. There is nothing inherently wrong with it. Some people are intensely private and would rather process a loss without having to talk about it. But “don't tell anyone until it is safe” is not a medical rule. It is a social custom. Perhaps a more useful question is not simply, When should I announce my pregnancy?, but Who would I want beside me if this pregnancy didn't continue? The answer may be nobody. It may be a sister, a close friend or a parent. The point is not that pregnancies should be announced earlier, but that secrecy should be a choice rather than something women feel obliged to maintain because miscarriage is considered too uncomfortable to discuss. Partners can also experience the loss very differently. One person has been physically pregnant; the other has experienced the pregnancy largely through imagination. One may need to talk about it repeatedly while the other becomes practical and begins looking towards the future. One may want to try again immediately; the other may be frightened to contemplate another pregnancy. Different expressions of grief are easily misinterpreted as different amounts of grief, which can create distance precisely when both people are struggling. And then there is pregnancy after miscarriage, another experience that is difficult to understand until you have lived through it. The next positive pregnancy test may bring happiness, but often not the uncomplicated happiness of the first. Symptoms are monitored. Toilet paper is inspected. Cramps acquire significance. The week at which the previous miscarriage occurred approaches like an anniversary. A reassuring scan may bring enormous relief, but sometimes only temporarily.
Once the mind has learned that pregnancy can end unexpectedly, it cannot simply return to not knowing. Perhaps this is why talking about miscarriage matters. Not because every woman should tell her story publicly, and certainly not because grief needs to become performative. Privacy and silence are not the same thing. Miscarriage can remain private without remaining taboo. The more openly we acknowledge it, the easier it becomes to understand that pregnancy loss is common, that grief after an early loss can be profound, that partners may experience it differently, and that another pregnancy does not replace the one that ended. It also becomes harder for women to carry one of the cruellest consequences of our silence around miscarriage: the belief that somehow, somewhere, they must have done something wrong.
