The Talmud has spent much time discussing the various forms that the content of a miscarriage might assume, and how this determines the ritual purity of the mother (or indeed the the status of the deceased fetus). It all began a couple of pages ago with this Mishnah:
נדה כא,א
המפלת חתיכה אם יש עמה דם טמאה ואם לאו טהורה ר' יהודה אומר בין כך ובין כך טמאה המפלת כמין קליפה כמין שערה כמין עפר כמין יבחושין אדומים תטיל למים אם נמוחו טמאה ואם לאו טהורה המפלת כמין דגים חגבים שקצים ורמשים אם יש עמהם דם טמאה ואם לאו טהורה המפלת מין בהמה חיה ועוף בין טמאין בין טהורין אם זכר תשב לזכר ואם נקבה תשב לנקבה ואם אין ידוע תשב לזכר ולנקבה דברי רבי מאיר וחכמים אומרים כל שאין בו מצורת אדם אינו ולד
…In the case of a woman who discharges an item similar to a shell ,or similar to a hair ,or similar to soil,or similar to mosquitoes ,if such items are red, she should cast them into water to ascertain their nature: If they dissolved ,it is blood, and the woman is impure with the impurity of a menstruating woman; and if not, she is pure.
In the case of a woman who discharges an item similar to fish or to grasshoppers, repugnant creatures, or creeping animals, if there is blood that emerges with them, the woman is impure with the impurity of a menstruating woman. And if not, she is pure.
With regard to a woman who discharges tissue in the form of a type of domesticated animal, undomesticated animal, or bird, whether it had the form of a non-kosher species or a kosher species, if it was a male fetus, then she observes the periods of impurity, seven days, and purity, thirty-three days…And if the fetus was a female, the woman observes the periods of impurity, fourteen days, and purity, sixty-six days…
And if the sex of the fetus is unknown, she observes the strictures that apply to a woman who gave birth both to a male and to a female. This is the statement of Rabbi Meir. And the Rabbis say: Any fetus that is not of human form is not regarded as an offspring with regard to observance of these periods, and she is permitted to engage in intercourse provided that she does not experience a discharge of uterine blood.
It all makes for very technical and detached reading, and quite honestly I have no idea to what shapes these refer. Over the decades as an emergency physician I have probably treated a several hundred women who came to the ED with an active or completed miscarriage, and never once did I see a bird, fish, or snake in the products of conception. I did however, meet a lot of sad and frightened mothers.
On today’s page of Talmud we finally discuss another aspect of the loss of a pregnancy: the emotional. Here is Rava, who explains that a fetus shaped like an animal does not preclude a later son born from the same mother to be considered as a firstborn. This is because the father would not mourn over such a misformed fetus:
נדה כג,ב
דאמר קרא [דברים כח] ראשית אונו מי שלבו דוה עליו יצא זה שאין לבו דוה עליו
“By giving him a double portion of all that he has; for he is the first fruits of his strength [ono];the right of the firstborn is his” (Deuteronomy 21:17). It is derived from the verse that the status of a firstborn applies only to a son over whose death a father would mourn.The word “ono” is interpreted homiletically based on its similarity to the word “onen”, acute mourner. This offspring that has the form of an animal is therefore excluded, as its father’s heart would not mourn over its death.
It’s the only time that the Talmud considers any emotional aspect of the loss of a pregnancy, and it hardly a surprise that when it does, it is the father’s emotions that are of relevance, rather than the mother’s. The Talmud is, after all, a record of how men viewed things. Rashi understands Rava’s statement as primarily legal rather than emotional. The father mourns, not because of the loss of a growing fetus, but because “he considers the question of inheritance.”
מי שלבו דוה עליו - לב אביו מתאבל על מותו הוא דחשיב לענין נחלה:
His heart mourns: The father’s heart mourns over the death of the fetus because he considers the question of inheritance
The epidemiology of Miscarriage
A miscarriage is a pregnancy that ends spontaneously before the fetus has reached a viable gestational age. There is no hard cut off, but this usually equates both clinically and legally to a human pregnancy that ends before 24 weeks of gestation, and as a review article on the epidemiology and medical causes of miscarriage pointed out, “human reproduction is extraordinarily wasteful.” One estimate is that “78% of fertilized eggs fail to result in a live birth and that the vast majority of these losses occur before the clinical diagnosis of pregnancy.” In other words, most women loose a pregnancy and never know they were even pregnant. Others suggest the rate of miscarriage is about 15-20%, generally occurring before 12 weeks gestation. Whatever the actual number, chances are that either you have had a miscarriage, or you know someone who has. We are blessed with four children. Our first pregnancy ended in a miscarriage.
“Sporadic miscarriage is the most common complication of pregnancy, and one in four of all women who become pregnant will experience pregnancy loss. The vast majority are early, occurring well before 12 weeks of gestation... The incidence of clinically recognizable miscarriage in general population studies has been consistently reported as 12-15%- but this figure is just the tip of the iceberg of total reproductive loss.”
The emotional cost of miscarriage
Since many women turn to the emergency department when they have a miscarriage, let’s start with an old paper looking at loss and grief in this population, a consecutive sample of 44 women. About three weeks later 82% felt a sense of loss, and two thirds “experienced some limitation with daily functioning.” Importantly, even the mothers who did not want the pregnancy experienced a feeling of loss.
A Swedish study published last year looked at a larger population of 103 women and 78 of their male partners. They used a few different tools, including the Revised Impact of Miscarriage Scale (RIMS), the Perinatal Grief Scale (PGS) and the Montgomery Asberg Depression Rating (MADRS-S). As measured by all of these tools, the emotional experience of the miscarriage was more pronounced in women. They were more likely to describe the miscarriage as resulting in “isolation or guilt,” and a “devastating event.” For the women, active grief and coping difficulties were reduced after four months, but the feeling of despair remained the same. For the men, all three factors, (active grief, difficult coping and despair) were reduced after four months compared to one week. Women without children, women who had experienced a previous miscarriage and women undergoing infertility treatment showed significantly more grief than women with previous children. The researchers also noted that the fact the women had more negative emotional consequences after a miscarriage than men can affect the relationship of the couple, “and therefore, the men should not be neglected during treatment of miscarriage.”
And things can quickly worsen. The overall risk for an episode of major depressive disorder following a miscarriage is about 2.5 times that of other women. Specifically, 11% of women who miscarry experienced an episode of major depressive disorder compared with about 4% of other women.
How about the fathers?
Since Rava specifically addressed the mourning process in a father, let’s look at a study of the psychological impact of stillbirth specifically on fathers, published in the British Journal of Psychiatry in 2006. It questioned 38 pregnant couples whose previous pregnancy had ended in stillbirth, and compared them with 38 pair-matched controls. The couples were assessed six weeks, six months and one year after the loss. It was a small study, so caution is needed in generalizing, but it found that
Fathers experienced higher levels of depression than controls across all assessments.
Mothers had higher levels of psychological symptoms than fathers at every assessment, although the difference did not reach the level of significance.
Symptoms largely remit after the birth of a live child, although mothers continue to be more vulnerable than fathers to ongoing psychological morbidity.
Parents’ levels of symptoms to run in tandem rather than for one of the partners to ‘carry’ the burden of symptomatic distress for both parents, or for one of the partners (typically the father) to feel that they have to deny their grief in order to remain strong in the face of the other’s distress.
Finally, the researchers found that for fathers there was a trend for better outcomes associated with conceiving again within a year of the stillbirth. “It is possible that these are chance findings,” they wrote, “but it is also possible that fathers and mothers have different needs in relation to this decision. Whereas mothers need time to mourn and recover before becoming pregnant again, fathers’ levels of depression and anxiety may increase as more time elapses before there is a real prospect of becoming a parent again. If this is the case, then there are implications for the advice that parents should be given about the timing of a subsequent pregnancy in the best interests of both partners.”
Experiences of miscarriage after one week and four months. Three questionnaires, the revised impact of miscarriage scale (RIMS), the perinatal grief scale (PGS) and the Montgomery–Asberg scale (MADRS-S) was used for measurements after one week and four months for women (n = 64) with miscarriage and their male partner (n = 64). For comparisons between different time points, Wilcoxon’s Signed Ranks Test was applied. For comparisons between men and women, Mann U-Whitney’s test was applied, P < 0.005 was considered significant difference. From Volgsten, H. Jansson C. et al. Longitudinal study of emotional experiences, grief and depressive symptoms in women and men after miscarriage. Midwifery 2018. 64. 23–28.
Bonding with the unborn fetus
Although it may be hard to believe, there was a time when pregnant mothers did not carry around an ultrasound image of their growing fetus. However, studies of the perceived reality of the pregnancy and the nature and intensity of grief following a miscarriage are extremely limited. It seems intuitively obvious that the more an individual had perceived the pregnancy and baby as “real” prior to the miscarriage, the more intense would be their level of grief, and this is indeed what has been found. However there have been contradictory studies with regard to the effect of viewing an ultrasound. One study of men who had viewed an ultrasound found that they had significantly more vivid images of their unborn child and higher levels of grief than male partners who had not seen an ultrasound. Another study found no difference, leading to the conclusion that “the effect of ultrasound on maternal attachment and the possible influence of ultrasound on bereavement reactions after perinatal loss await further systematic investigation.”
The Rules of Mourning and the Emotions of Mourning
Based on several passage in the Talmud, Maimonides ruled that there are no mourning rites after a miscarriage or for an infant that dies within thirty days of its birth. And this is codified in the Shulchan Aruch, the Code of Jewish Law (Yoreh Deah 374:8).
הלכות אבל א, ו
הַנְּפָלִים אֵין מִתְאַבְּלִין עֲלֵיהֶן. וְכָל שֶׁלֹּא שָׁהָה שְׁלֹשִׁים יוֹם בָּאָדָם הֲרֵי זֶה נֵפֶל. אֲפִלּוּ מֵת בְּיוֹם שְׁלֹשִׁים אֵין מִתְאַבְּלִין עָלָיו
We do not mourn for a fetus. Anything which does not live for thirty days is considered as a fetus.
The scholar Meir Bar Ilan has suggested that the infant mortality rate in Israel during period of the Talmud was around 30%. Given this, perhaps it made psychological sense to limit mourning rites for this most vulnerable of populations. Perhaps. Mercifully, things are different today, and there are new and creative rituals that might fill the vacuum left in traditional Jewish law. In 1996 the Conservative movement published a responsa titled Jewish Ritual Practice Following a Stillbirth, which noted that “contemporary rabbis and halakhic bodies cannot continue to treat a still-birth as non-event.” The same, surely, is true of a miscarriage.
In a few weeks we will learn the following Mishnah (Niddah 5:3, 44a):
תִּינוֹק בֶּן יוֹם אֶחָד… וַהֲרֵי הוּא לְאָבִיו וּלְאִמּוֹ וּלְכָל קְרוֹבָיו כְּחָתָן שָׁלֵם
a day-old infant…in relation to his father and to his mother and to all his relatives, is like a fully-fledged groom [whose death is deeply mourned].
This Mishnah is the record of another tradition, one which, with great care and sensitivity, understood that a miscarriage or neonatal death has meaning for a father and mother far greater than may be reflected in any legal decision.
“I gave birth to seven children, but I had a lot of miscarriages, maybe twice as many as my children, ... My first miscarriage, which was before I had children, was very hard for me. I awoke with shuddering pain. everyone was outside, and I cried hysterically. . . .
Afterward I learned that if a woman undergoes a miscarriage, it is actually a fetus that comes to repair something, and blessed be God. He chose a woman who observes the commandments, to keep the holiness of the soul. . . . That really encouraged me.”
