The month of October is Pregnancy and Infant Loss Awareness Month. In particular, October 15th is Pregnancy and Infant Loss Remembrance Day. The sad fact is that too many families are affected by a pregnancy loss, stillbirth or early infant loss. The grief when a loss occurs has no bounds and remains significant and deep, even if there are future children that join the family after a loss has occurred. Societal expectations are for families to move on, get over it and have things quickly return to "normal." The reality is that this is next to impossible and the grief and other emotions get hidden away, pushed down and inside, which can exacerbate feelings of sadness, loneliness and depression.

In the 14 plus years that I have been teaching, loss has been an event that happened rarely, but in the past two years, it has sadly been a regular event in my classes. Just recently, a friend and colleague lost her baby shortly after birth and my heart is still heavy for all that she and her family have experienced and still move through. The burden is heavy for those grieving and I, like many others, are left to wonder why.

I decided to consult with some Lamaze Certified Childbirth Educators and ask their expert advice on how they discuss this difficult topic, and how they have handled the situation when it has come up. Finally, I asked them to share some advice with others, to help all of us be prepared if we experience this as an educator.

I wish to thank the following educators for sharing their knowledge.

• Deena Blumenfeld ERYT, RPYT, LCCE, FACCE
• Diana Petersen M.Ed, CD(DONA), LCCE
• Elizabeth Mendoza, LCCE
• Kathryn M. L. Konrad, MS, RNC-OB, LCCE, FACCE
• Melinda Delisle, LCCE
• Robin Elise Weiss, PhD, MPH, CPH, LCCE
• Sheri Deveney CD(DONA) BDT(DONA) LCCE
• Stacie M. Bingham, LCCE, (CD(DONA), LER

How do you talk about loss during your childbirth classes?

Elizabeth Mendoza: I include talking about loss in the discussion about unexpected outcomes. I read the "Welcome to Holland" essay or have clients pick cards of unexpected outcomes and then we discuss how to deal with unexpected situations, such as expressing grief, finding support, etc.

Sheri Deveney: I spiral discussion with respect to loss throughout the series. I found that dedicating a specific segment was too intense for parents and that they didn't seem to recover fully from that discussion. Taking it in smaller chunks have been more effective

Kathryn Konrad: Concern about past loss or potential loss often comes up when discussing fears. History of pregnancy loss or fear of infant loss is a common unspoken concern. As an educator, when I bring the issue of pregnancy or infancy loss I can see the relief on many families faces. They want to ask questions but are afraid to bring broach it. This leads to a discussion of what to look for and warning signs.

Melinda Delisle: I start by mentioning that we need to discuss a sensitive topic that I wish we didn't have to talk about. I use much the same wording as the beginning of my spiel above, but expand it to share that it has happened to couples in my classes. I also mention that our culture tends to not really respect the loss of babies, especially before birth, but it is a big deal, and it is ok to grieve. I briefly mention some ways that parents cope ' spending some time with their baby, making memories right away, talking with other parents who have experienced loss, etc. and offer some resource links. I emphasize that if something happens unexpectedly, to make SURE that they get pictures and footprints, and spend at least some time saying goodbye. They might not want photos at the time, but they will almost certainly want them later. I wrap up with another encouragement to have a short discussion with their partner, and an assurance that losing a baby at this point is unusual, and they will probably not need this personally. Then we do a positive birth story relaxation and take a break.

How do you find the balance between being accurate and realistic, and preparing them just in case with not frightening families?

Robin Weiss: You don't go into details. You just say it happens. It's usually not anyone's fault, but you do what you can and people have been there and will be there for others who experience it.

Kathryn Konrad: I discuss discomforts and warning signs in terms of a traffic light. Green light is common discomforts- heartburn, difficulty sleeping, constipation. Yellow light is warning signs to call their healthcare provider- burning on urination, lower back pain, swollen feet. Red light is warning signs to go to the birthplace- decrease (or loss) of fetal movement, bright red bleeding, constant abdominal pain. This allows participants to ask questions and gives them answers they can act on if needed.

Melinda Delisle: I thought that I was finding a good balance in the beginning by at least mentioning the topic and a local support group. I was wrong. After I had a couple lose their nearly full-term baby, I started approaching it differently. I try to keep the total time spent on the topic to no more than 5 minutes. If I know that someone in the class has lost a baby, I let them know in advance when we will be discussing it, and give them the option of sharing briefly if they want to. I also ask if they want me to let the rest of the class know any of their story or not. I find that most couples with a prior loss prefer to not be in the room during this part of the class.

I admit that I tend to use euphemisms a lot in this part of the class, and avoid terms that are either too personal (ie, if your baby dies/d) or too clinical (i.e, infant mortality, neonatal loss). I am not sure if it helps or not, but it seems right to my sense of empathy.

I always end this short 'presentation' with an assertion that it is unusual to lose a baby at this point, so chances are that they have nothing to worry about. I encourage them (again) to have a short discussion with their partner about it to cover any 'what ifs,', then put it out of their minds because they probably won't need it. I also always do this topic right before a positive birth story relaxation session and a break, so we re-orient everyone's brain to positive thoughts, and so that anyone who needs a bit of extra personal conversation with me can talk to me.

When a family in your class has experienced a loss, was this communicated to other families? How did that happen and what was the response?

Stacie Bingham: I had another situation where the parents asked if they could come back to the class reunion after their loss (which happened after the series was over). Of course I don't want people to feel uncomfortable, and I also know the value in having your experience of birth and loss acknowledged. I welcomed them, and I asked them to come about 30 minutes after the initial start. This way I made sure all attendees heard first the situation (in case they weren't aware), and they could decide if it was too much for them to stay; everyone stayed. It was a tearful, painful, and very bonding reunion. This family shared their birth experience with all of us. They held other babies. They received hugs, support, and friendship. This class stayed particularly tight, getting together often, and celebrating when this family, 5 months later, got pregnant again and then gave birth to their lovely baby girl.

I have also had the situation where some class members knew each other in real life of through social media. When their baby, at 32 weeks, was born still due to a placental abruption, it absolutely was something we had to address. I threw out the class plans for that week, and we had a discussion. In anticipation of this I asked one of our providers if she could be present to help me address questions and offer more support for these families who would suddenly feel shocked and vulnerable.

Robin Weiss: I tell them as soon as possible, preferably in person. I usually bring a card for everyone to sign. This is a small touch that both parties have, over the years, said was meaningful. The first time I had to do this was class three of my very first childbirth class ever. While it was really frightening at the time, it was a blessing in disguise. It's now just a part of every training I do, I'm not worried about talking about loss these days.

Deena Blumenfeld: The first time I had a student with a loss it was very early in my career. I was a prenatal yoga teacher, not yet teaching Lamaze. The mother had lost her baby at 28 weeks. She'd been a regular yoga student in a large class. She'd notified me that she wouldn't be coming to class anymore and we cried on the phone together. I asked her permission to tell the other students since I knew they'd ask about her, as everyone had become close. She granted me permission to tell them, as she wanted the support from the group.

When the prenatal yoga class began, I had everyone sit and I told them, directly, what had happened. I then facilitated a meditative, healing circle for this group, as opposed to our usual class. It was raw and open that day, but the love of the group was vast.

Kathryn Konrad: Unfortunately, pregnancy and infancy loss has occurred in my classes. When it occurred in course of the series I asked the family what, if anything, they would like me to share. The family was close to the rest of the class and wanted me to share their story. It was difficult to share the loss with my class. The class noticed a missing family and asked about their absence immediately. I told them what the family wanted to share- the baby died in utero and was born shortly after. There was no indication of what happened to the baby that lead to their death. The class was upset but came together to bring flowers and meals to the family. They became a wonderful support for one another. In other instances, a family experienced infancy loss by SIDS just prior to a class reunion. They called to tell me about their loss and asked that I not discuss it during the class reunion. I honored their wishes.

What did you do to support the family after you heard?

Stacie Bingham: I reach out to families after a loss. I have found some are eager to have me come over, to show me their baby's things, to share their story and pictures. I cry with them -- it can't be helped. I try to leave them with that support link -- to let them know I am always around. My sister lost my nephew, and I will share personal feelings or thoughts from that experience; I find it can help them open up more when they see I had a personal connection they can link to. During that process, I collected many, many ideas of how to help a family experiencing miscarriage or infant loss, and I share that resource with them.

Robin Weiss: I contact them right away to ask if I can join them. So many ask: "What can I do?" They don't know. I have a wealth of information I never wanted to have, but I know who to talk to and what funeral homes don't charge for baby funerals, and where you can buy a single grave versus utilizing a space already owned.

Sheri Deveney: I went and had tea with the mother the week after the baby died. I took her a copy of Tear Soup and a necklace with the imprint of tiny feet and a blue jewel. She showed me his nursery and we sat and cried together. She said she craved talking to me because I was part of the last plans for his birth; the happy plans. She wanted to feel that comfort of our time together. Because she worked at the local hospital as did her partner, she felt she needed someone outside that support network that was only connected through planning for her birth. I remember acutely the first day that her mailbox was empty. She called and was sobbing so hard that she couldn't talk. I waited. When she was able she told me that it meant everyone else had gone on with their lives and she was still stuck in this loss

Do you stay connected with the family after this is all done? Do you go to a service if there is one?

Sheri Deveney: I did for the first year. She would call out of the blue and I'd hear a squeak on the other end of the line and I knew she'd had a bad day. She felt like this was her whole life now'¦ being the mother of the baby born still. She wanted to tell me how her partner was shutting down and how nobody at work would look her in the eye. She wanted me to come with her to his grave and to admire the view they had chosen for him. She needed to tell me about the letters they put in his casket and about his bright red hair. I listened and never winced. I leaned in and stayed connected until she no longer needed me The calls got further and further apart until I got the joyful call that another son had been born, healthy, strong and miraculous.

Robin Weiss: I absolutely go to the service. I feel like I was one of the few people who got to know their child through them coming to classes. It puts me in a very special spot. I try to drop them notes and call or email a few times in the first weeks and feel them out for what they want after that. I do send a card around the due date if the baby was born early, and the anniversary of the baby's death.

Kathryn Konrad: Pregnancy and infancy loss are difficult topics. But loss is often a source of fear. We need to discuss loss with families. Acknowledge the concerns and the previous losses. Be open to the discussion and to provide information as needed. Keep a list of local and online support groups and counselors to refer families to. Have someone you trust you can discuss the personal feelings you may have surrounding loss. This may bring a flurry of emotions for educators as well- sadness, anger, grief, are all normal responses to pregnancy and infancy loss. Care for your own emotional health too.

What would you want to tell other educators about dealing with this sensitive subject? Any words of advice?

Elizabeth Mendoza: It's not something anyone wants to talk about, but on the rare chance that it will happen, it's important to be prepared. Connect with resources now so you're in the know if the need arises.

Robin Weiss: Try not to be concerned about talking about. Doing it BEFORE you HAVE to address it is always easier. Grab a LCCE friend and practice, even if just on the phone. Attend some trainings in your area from perinatal hospices, etc.

Sheri Deveney: I would tell them to take every workshop they can on loss. Don't avoid it. It's hard, its emotional and its taxing but it's so vital. I had avoided all that sadness as an educator and I so wished I hadn't when this event happened. Luckily I had colleagues that were seasoned and they got to work schooling me in real time. I'm forever grateful to them.

Deena Blumenfeld: Go easy and never make assumptions about how you think your students will feel or react. Remember that they are grown-ups. Grown-ups can handle more than you think they can. If you approach the subject with fear and trepidation, then that's what your students will take away from your teaching.

With regards to how to discuss stillbirth and loss - weave it in with your other teachings. You mention it with postdates, C-section, cord around the neck, emergency birth, SIDS, etc. If you list it as one of many possible outcomes and don't necessarily emphasize it, you safely plant the seed without growing the fear.

Diana Peterson: Swallow your own emotions and feelings surrounding the loss and reach out to the family, even if it makes you uncomfortable. Don't shy away. When my friend lost her husband a few years ago, she said text and emails were greatly appreciated but phone calls were too much, so I usually take her advice and text or email first. Acknowledge that they gave birth and are parents. Use the baby's name and ask how they chose it. Ask who the baby looked like. Avoid platitudes. Don't assume religious beliefs. 'Comfort in and dump out.' As a childbirth educator who got to know this family, it's OK to have your own feelings and be upset! But offer support and comfort to the family and then find another outlet to share your own distress.

Kathryn Konrad: Pregnancy and infancy loss are difficult topics. But loss is often a source of fear. We need to discuss loss with families. Acknowledge the concerns and the previous losses. Be open to the discussion and to provide information as needed. Keep a list of local and online support groups and counselors to refer families to. Have someone you trust you can discuss the personal feelings you may have surrounding loss. This may bring a flurry of emotions for educators as well- sadness, anger, grief, are all normal responses to pregnancy and infancy loss. Care for your own emotional health too.

Stacie Bingham: I would just say address all things with love and not fear. We need to strike the balance between offering helpful information and crossing the line into TMI or disaster stories. Sometimes brevity is key. When you hold the stories of others in your head and heart, it is important to respect privacy, to ask if you can use a helpful detail of their experience, or something that could be beneficial for a class of expectant parents. For example, I had a woman state she had a feeling something was off, but she was concerned her provider would judge her as being a worried first-timer so she kept her feelings to herself. Incidentally, I also tell families their providers work for them -- it doesn't matter what insurance they have if they are married, their religion, their education -- they have the right to present concerns to their provider and get an answer they are satisfied with. Never be afraid to reach out to another childbirth educator, or a doctor, midwife, or nurse who you feel might be able to lend personal support to you as you work your way through this.

Here are some prior Science & Sensibility blog posts that can offer further resouces and information on this topic

Now I Lay Me Down to Sleep Photography; Honoring the Babies Whose Stay Was Too Short

The Role of the Childbirth Educator During a Perinatal of Infant Loss

Ideas for Commemorating Pregnancy and Infant Loss Awareness Month

Honoring Henry Dean: A Mother Shares Her Journey After the Stillbirth of Her Son

What has been your experience with loss for families attending your childbirth classes? Please share your wisdom and experiences in our comments section below.

images: Vicki Zoller

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