Abstract
In the UK, miscarriage affects one-in-five pregnancies and is described as the loss of a pregnancy before 24 weeks gestation. Today women receive medical and psychological help from early pregnancy assessment units, often after referral by their GP with pain or bleeding. Miscarriage is not new, throughout history women and their families have experienced the trauma of miscarriage, historically referred to as abortion. Culture and religion still affect our thoughts about miscarriage today. A lack of knowledge about pregnancy loss led to some peculiar beliefs. Here we take a look at some historical discourse on miscarriage, from magical amulets to blasphemy, Tudor queens and criminal activity.
Ancient worlds
In Ancient Egypt, the Gods and spirituality played a significant role in health. For pregnant women one of the most important Goddesses was Isis, who symbolised fertility and pregnancy. Isis was believed to have inserted rolled papyrus in the shape of a knot into her vagina acting as a plug to prevent miscarriage of Horus, her son. Pregnant women would mimic this act to keep their pregnancies safe. Uterine magic was commonly practiced, the uterus was believed to be a separate entity within the body and magic attempted to control its unpredictable behaviour. Primarily spells and prayer were used to control the timely opening and closing of the uterus, thus preventing miscarriage. Magical beliefs also encouraged the use of amulets cast with protective spells inserted into the anus or vagina to protect the pregnancy (Robins, 1993).
More fearful tales came from Ancient India, with stories of demons and devils that could inhabit a womb. The Atharva Veda Hindu text describes the demonic Kanva, or ‘devourers of offspring’. The blood-stained sheet of a woman who had miscarried held the demon and could be passed on to others. Sheets would be left at the roadside in the hope that an impoverished woman would take the sheet, and hence, the Kanva demon would be transferred to her. Karma propagated a belief that bad actions in a past life cause miscarriage in the present life (Wujastyk, 1999).
Middle ages
In the European Middle Ages, an increasingly pious culture placed more blame and restrictions on mothers during pregnancy, requiring bed rest and confinement. Fright, blaspheming, strong emotions, sneezing, riding in a carriage, heavy lifting, and being conceived under bad planetary alignment were all thought to cause miscarriage.
Even the Tudor family was unable to escape miscarriage. King Henry VIII’s second wife Anne Boleyn had a miscarriage in the second trimester with her son. Court documents from the time blame Anne, shocked after receiving news of her husband being in a riding accident. Letters written by Imperial Ambassador Eustache Chapuys suggest the miscarriage was caused by Anne’s own inability to have children or her fear of Henry’s interest in Jane Seymour. Anne had two miscarriages following the birth of their daughter Elizabeth and 4 months later Anne was beheaded on charges of treason, adultery and incest.
Jane Sharp, a famous midwife from the 17th century, wrote The Midwives book in 1670, containing remedies for preventing miscarriage based on the physician Nicholas Culpeper’s Directory for Midwives. Sharp suggested drinking physic – a wine boiled with thyme, and eating juniper berries every morning to prevent miscarriage. However, Nicholas Culpeper did attribute some blame to men, offering that weak sperm could cause miscarriage. Sadler, another physician, described the connection between the heart and the uterus and recommended avoiding fear ‘as it the heart would then forsake the womb, thus allowing cold to strike it and caused the ligaments retaining the baby to collapse’ (Evans, 2014).
Victorian era
The Victorians continued the tradition of maternal blame for miscarriage with incredibly detailed descriptions of prohibited activities. These included overreaching a hanging picture, riding a bicycle, tooth extraction, bathing in the sea, using a sewing machine and being excessively happy.
The 20th century
Sources from the early-20th century in the UK established a link between miscarriage, working class women and criminality. The middle class propagated the belief that miscarriage was a working-class problem and that much of it could be ascribed to illegal abortions (Brooke, 2001). Doctors believed that women were more likely to present for medical care if they had an illegal abortion and developed complications (Elliot, 2014). They believed that working class women experiencing a natural miscarriage would not present. Only women secretly wishing for miscarriage to avoid the economic and physical costs of pregnancy would present. A prominent surgeon in 1950 claimed that 90% of pregnancy loss was likely caused by induced abortion (Davis, 1950). In stark contrast, a 1915 survey of the female working classes found that lack of rest and poverty were most commonly believed to cause miscarriage (Women’s Co-operative Guild, 1915).
During World War I with large population losses, the opinion on pregnancy loss started to change with greater importance placed on the fetus and antenatal care (Elliot, 2014). The opinion of doctors changed, with provision of treatment for recurrent or habitual miscarriage that included plugging of the bleeding, ergot and surgery (Elliot, 2014). In the 1930s, hormones were beginning to be understood. Doctors started to trial hormones to prevent miscarriage, indicating a change in medical culture to help prevent pregnancy loss (Elliot, 2014). By the 1950s, antenatal ultrasound was developed, providing visual evidence of pregnancy loss for the first time.
Throughout the 20th century the changing attitude towards miscarriage established a distinct medical specialty and the establishment of early pregnancy assessment units in the 1980s. Charities have since been established, such as the Miscarriage Association and Ectopic Pregnancy Trust, offering advice and support for patients. In 1997, the Royal College of Obstetricians and Gynaecologists recommended a change in terminology from spontaneous abortion to miscarriage and early pregnancy loss.
Although we hope in our modern healthcare system not to apportion blame to for miscarriage, some patients still hold on to a belief that they may have caused their miscarriage. The predominant emotions in women after miscarriage are self-blame and guilt, potentially leading to mental health problems. Research has shown an increased risk of anxiety (28–41%), post-traumatic stress disorder (up to 39%), and depression (27%) after miscarriage (Cumming et al., 2007; Janssen et al., 1996; Lok et al., 2010; Prettyman et al., 1993).
Take for example the ‘12-week rule’. Women are often told not to tell anyone they are pregnant until the dating scan at 12 weeks gestation, in case miscarriage occurs. However, consider what effect this can have once miscarriage happens. Not telling friends, employers, or family narrows a woman’s support network and may make it much harder to deal with the loss (Bansen and Stevens, 1992).
The taboo of pregnancy loss still exists. Many women avoid open discussion of their loss in a society that focuses on life rather than loss during pregnancy. Whether or not these modern beliefs originate in our dark history, today we must openly support and care for women who experience miscarriage. As doctors, we have a duty to encourage a conversation about pregnancy loss and to bring the issue to the forefront of early pregnancy care. We must look after our patients’ wellbeing. Simply raising pregnancy loss in discussion with patients recognises that it happened. Asking if the patient is okay can make a difference. Breaking the silence around miscarriage is an important barrier to overcome. It will help to remove the stigma and taboo that may still surround pregnancy loss.