The Silenced Trauma of Late-term Pregnancy Loss

Post-traumatic Stress Disorder is usually associated with soldiers who have been emotionally scarred in battle, or victims of terror attacks. A new study shows it is equally common among women who have experienced a late pregnancy loss

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Noa Limone
Noa Limone

Three and a half years ago, during the 38th week of her first pregnancy, Hila Cohen-Eiss went in for a routine ultrasound exam. “The test was normal,” she says. “The technician just said the fetus was a little bit sleepy. I went to eat something, and when I came back to continue the test there was no heartbeat. I was hysterical, I didn’t know what was happening, I pleaded to be checked with other machines. After three different ultrasound machines, I understood that there really was no heartbeat.”

Cohen-Eiss, 32, from Jerusalem, is married and the mother of “three living children,” as she puts it. She recounts that after the frightening ultrasound results, she was rushed by ambulance to the hospital, where she went through 26 hours of labor. But in the end there was no comforting sound of a baby’s cry. The baby – whom she and her husband chose to see and to hold – was dead.

“I don’t have the feeling that I really said goodbye to him,” she says now, her voice breaking. “I don’t remember if I hugged and kissed him. I remember that we looked at him and tried to understand what was wrong. He looked totally perfect, as if he was sleeping. I was afraid to bond with him. I asked them to take him away.

“Afterward I was taken in for more surgery to remove the placenta. I woke up in the recovery room in shock and hysteria. I was taken to the ob-gyn ward and the next morning I woke up crying and screaming. My arms were searching for the baby and he wasn’t there. I sat there with my husband and we wept. I was destroyed, I felt so empty. They were sure I was going to lose my mind. They brought in a bunch of psychiatrists, but they said that my reaction was normal because my child had just died.”

When we think about post-traumatic stress disorder, we usually associate it with soldiers who have been emotionally scarred by their experiences in war. Or with victims of terror attacks and other traumatic mass-casualty events. Often, these contexts have a masculine connotation.

A new study, reported on for the first time in Haaretz, reveals another, surprising area where PTSD is common: among women who have experienced a late pregnancy loss. (The length of an average pregnancy is 40 weeks.) The findings are stunning: More than a third of the women who took part in the study were found to be suffering from full-blown PTSD. The study, conducted at Hadassah University Hospital in 2014, was headed by Dr. Danny Horesh, 40, of the Bar-Ilan University psychology department and a post-doctoral research fellow in the psychiatry department of New York University School of Medicine, and by Malka Nukrian, a nurse midwife who since 2006 has been leading support groups for women who have experienced late-pregnancy loss.

Horesh, who has been studying PTSD for 14 years, 10 of them focusing on shell-shocked soldiers, says the findings are very troubling. “To someone who researches trauma, a 32.7 percent rate of full PTSD is a horrifying figure. Percentage-wise, it’s akin to soldiers who have just returned from the worst battle. The hardest traumas of all.”

The study comprised 15 different questionnaires that were distributed to 103 subjects, whose average age was 34. They examined a number of variables related to pregnancy loss, such as: During which week of pregnancy the loss occurred, the amount of time that had gone by since the loss, if the couple had children before or after the loss. Factors relating to the effect on the couple’s marriage were also addressed. The questionnaires included a PTSD questionnaire and a clinical depression one.

Horesh says that when his team at the Bar-Ilan lab received the responses, they would first skim through them before recording and processing all the data. In case after case, they could discern almost immediately that the answers pointed to PTSD. “I’ve done a lot of different studies about PTSD,” he says, “and we could see right away that there was some very serious psychopathology here.”

Coming home empty-handed

The experiences of women who have suffered such a loss do sound highly traumatic. “Leaving the hospital empty-handed, it was just awful,” says Cohen-Eiss. “I asked the nurse to give me the disc with the pictures of the stillborn baby. I begged them to give me something that I could hold in my hand, even if not a baby carrier. But the pictures were taken after some time had gone by, and they look more like a dead body than a baby.

“When I got home,” she continues, “his room was all ready and waiting for him. The clothes were folded in the drawers and the baby carriage was there too. It was enormous heartbreak. It still is. It felt like a gaping hole suddenly opened up in the earth and we fell crashing down.”

On top of that, it’s not easy to deal with other people’s reactions, says Cohen-Eiss. “People who heard what happened often didn’t know what to say. They meant well, but when they told me things like, ‘You’ll get over it’ or ‘You’re still young,’ it only exacerbated the pain and the anger. After three months, I had to go back to work. I would come in early so as not to run into anyone and then shut myself in my office,” says Cohen-Eiss.

Three months later, she became pregnant again, this time with twins. “It was a very anxious pregnancy. It was very hard, physically and emotionally,” she says. “I felt like all eyes were upon me, that it was up to me to right this wrong – that I had delivered a dead baby instead of a live one.” In her 32nd week, she gave birth to a boy and a girl. That was two years and 10 months ago. When the twins were 14 months old, Cohen-Eiss became pregnant for the third time. She says all of the post-trauma surfaced during this pregnancy. “I had nightmares, flashbacks, relentless memories. Every pregnancy checkup was extremely stressful for me. I was afraid that the people close to me would experience another trauma, so I didn’t talk about any of the tests I had, not even with my husband. It was like I was bracing myself to lose the pregnancy at any moment.”

Her anxiety over a possible repeat of the trauma prevented Cohen-Eiss from “connecting” to the pregnancy. “It was almost like I wasn’t participating in it. I didn’t want to find out the gender. When I would come in for an ultrasound, it was in the same room where I found out the first baby had no heartbeat. I didn’t sit in the waiting room, so I wouldn’t have to look at the other pregnant women. They had me scheduled to do the test for the heartbeat in the same room and on the same date that we lost the baby. So I came in the day before. Even now, when I’m driving on the road we took to the hospital and an ambulance passes by, I freeze up. I have to pull over. That trip became a recurrent nightmare.”

In her third pregnancy, Cohen-Eiss gave birth in her 34th week. “There is no doubt in my mind that, because of all the tension and anxiety, I didn’t make it to the 38th week in either of the pregnancies that followed the loss. I didn’t want to get to that week,” she says sadly. “My baby girl was very sweet, and she didn’t cry either. They laid her on me right away but I started screaming that she wasn’t crying, that they had to do something. I absolutely panicked.”

Today, thanks to psychological and psychiatric therapy, and also thanks to a support group for women who have suffered the same kind of loss, Cohen-Eiss says she is doing better emotionally. “Two months after the delivery, I was invited to come to a support group at Hadassah. There were five women there, all with similar stories.” Being with people who had been through the same experience was what “helped me the most to cope. We still meet sometimes, together with our children who were born afterward. We’ve been through it all together.”

Nonetheless, even now she is not free of feelings of guilt and failure. “I’m not the same person I used to be,” she says. “My outlook on life has changed. The innocence is gone. The optimism is gone.”

Adding to her tribulations, she does not even know for certain where her baby is buried.

How did that happen?

“They had us sign the burial papers very quickly, at the most stressful time. At first I was told that the baby would be buried together with an adult who died the same day. I was horrified. Then they suggested that the hospital take care of the burial, so of course I agreed. How could I have dealt with that? But I feel like I never said goodbye. I feel like I wasn’t a good mother to him in his final moments.

“People don’t understand. They ask me, ‘You’re still hung up on it? You haven’t gotten over it yet?’ But I had a child and he’s gone, and he was everything to me.”

Severe levels of depression

When Horesh began looking into the subject of PTSD following late pregnancy loss, he found that practically no research had been done on this in Israel (there has been some, but not much, in other countries). “On the research level – nothing, and on the clinical level – way too little,” he says. In the few studies that were done, he explains, “a relatively small group of women were interviewed about their experience. This is important and I do not mean to be dismissive at all, but these are not the kinds of studies from which one can draw statistical conclusions.”

So Horesh decided to pick up the gauntlet. He searched for health-care professionals who could collaborate with him, and found midwife Malka Nukrian at Hadassah Hospital. “I had been present at a lot of deliveries of women who were in advanced stages of pregnancy and had to terminate the pregnancy for various reasons, and I could feel their emotional distress, in addition to the physical distress,” says Nukrian.

In 2006, she founded the first support group at the hospital. “We’ve led more than 70 groups at this point. They are for six or seven women, and meet once a week,” she says. “The goal is to process the experience of the loss, to normalize the feelings and give legitimation to the grieving process, and to their feelings in general.”

Over the years, she noticed that women were reporting similar types of reactions, but there were no questionnaires or studies specifically describing these phenomena. When Horesh contacted her, Nukrian was eager to work with him.

Working together, Horesh and Nukrian were able to apply research tools developed from study of other forms of PTSD to women who had experienced a late-stage pregnancy loss. All had been Hadassah patients: About half had participated in the support groups, the rest were listed in hospital records.

Horesh says the conservative definition of a “late-stage pregnancy” begins at the 20th week, “but I can tell you that we are now analyzing the data, and to this end, we are looking at the 13th week and beyond. If you ask me, the threshold could be set even earlier. On the whole, when you get into double digits of weeks of pregnancy, which is the stage where you’ve started to really picture it and you’ve started telling people and so on, that could definitely be considered a late stage.”

In Horesh and Nukrian’s study, on average, pregnancy loss occurred at the 28th week. For 42 percent of the women, the loss occurred between weeks 30 and 40. According to Horesh's data, 86 percent of the women in the study essentially experienced a stillbirth.

What is PTSD?

Post-traumatic stress disorder is relatively newly recognized, having entered the DSM (Diagnostic and Statistical Manual of Mental Disorders) in 1982. Since then it has been the subject of a vast amount of research, in Israel too. “We’re a PTSD powerhouse,” says Horesh, “but only in terms of war-related trauma.”

Clinical diagnosis of PTSD depends on the appearance of four main types of symptoms: 1) intrusion symptoms, such as recurring memories and flashbacks; 2) avoidance symptoms, such as attempts to avoid trauma-related thoughts and feelings, as well as the place where the trauma occurred; 3) alterations in arousal or reactivity, such as trouble sleeping and concentrating, or excessive irritability; and 4) negative alterations in cognition and mood – that is, persistent negative beliefs about the world, feelings of alienation, inability to experience positive emotions, and other depression-like symptoms.

Horesh explains that there are two accepted methods for diagnosing PTSD. The stricter of the two, hewing closely to the DSM, requires the appearance of a minimum number of symptoms from each of the four categories; that the disturbance persist for at least one month, with the patient exhibiting a significant functional decline. This is a binary type of diagnosis – either you have it or you don’t. According to this stricter diagnostic method, the study by Horesh and his colleagues finds a 19 percent rate of full-blown PTSD among women who have suffered late-pregnancy loss, not 32.7 percent.

“This is a high rate of PTSD in any event,” he says, “and one that can certainly be likened to the more ‘classic’ post-traumatic populations. PTSD is a chronic disorder,” he goes on. “It must last for at least a month. But usually it lasts much longer. It has all kinds of fluctuations. It can spontaneously resolve. It can spontaneously worsen. A person can recover and then it can come back.”

Are there different PTSD profiles in general for men and women?

“The profile question is an interesting one, but I don’t have enough data to answer it. I can say something about the rate, which is that it’s about twice as high among women as in men, and that’s something that transcends borders.”

That has to do with the type of trauma that women are exposed to, compared to men, right?

“Yes. Women are subjected to sexual assault at a much higher rate than men, for example. For men, violent assault is more common. And then there’s the question – If I take men and women who were exposed to the same trauma, will I still see these differences? Some studies say that the differences are canceled out, while others say they’re not. From a comprehensive reading of the literature on the subject, I can say that women have a heightened vulnerability.

Horesh suggests as well that, “There are studies showing that sex hormones are related to PTSD susceptibility. Other studies show differences in coping mechanisms. As science sees it, classic female coping is based upon emotion, while classic male coping is based on problem-solving; men have a greater tendency to seek out a mission. Traditionally, emotion-based coping – the tendency to reflection, to crying, everything that is inter-psychological in dealing with the event – causes greater psychological vulnerability in general, not just with women.

“Within all this, there are whole worlds of coping that are extremely interesting, like a variable that’s called ‘monitoring versus blunting.’ Evolutionarily speaking, women tend to actively monitor their environment. In the event of a trauma, when there is a lot of destruction or external impact, this tendency also opens them up to a lot of pain. Men, on the other hand, tend to withdraw into themselves and avoid the world outside somehow. Consequently, after a trauma, they end up much lonelier, but they also absorb less pain.

“There are cognition studies that show women’s post-traumatic cognitive responses tend more toward self-blame. And new studies being done about fear conditioning show that this occurs much more rapidly with women than with men.”

The effect on relationships

Horesh and Nukrian’s study had several key findings. First, that a very high rate of women who have experienced late pregnancy loss suffer from PTSD – 32.7 percent by the less stringent calculation method and 19 percent by the more stringent method. A second major finding was that 34 percent of the subjects in the sample reported moderate to severe symptoms of depression.

Horesh explains that clinical depression is divided into three levels – minimal, moderate and severe, “but even ‘minimal’ is not something that you or I would wish to experience. And ‘moderate’ is not a very apt description either. It’s clinical depression in every way,” he says. The study also looked for the simultaneous appearance of PTSD and depression, known in professional terms as comorbidity. “In the study, we found something that is also frequently seen in the trauma literature in general, which is that depression and PTSD tend to go hand in hand, at a very high rate,” Horesh says. “In our study, among women with moderate depression, 46 percent also had PTSD. But the most startling finding was that among women with the most severe depression, 100 percent had PTSD as well. In other words, we’re identifying a highly vulnerable, deeply suffering subgroup: These are women who are in a profound depression, who could be suicidal, and at the same time they’re reporting severe PTSD symptoms. These women will find it extremely difficult to function. I don’t even want to think about how they function as mothers if they still have kids at home.”

One aim of the study was for data analysis to make it possible to identify at an earlier stage women who are at risk of such severe comorbidity. “It is of the utmost importance to try to do an initial assessment of women following pregnancy loss – maybe when they are still in the ob-gyn ward in the hospital – to try to identify who is most vulnerable, and to offer help and referrals for follow-up treatment,” he stresses.

Horesh says the initial data analysis showed that intrusive symptoms such as nightmares and flashbacks were the most dominant group of PTSD symptoms found among the study’s subjects. “That didn’t surprise us very much, considering the ‘graphic’ nature of the trauma of pregnancy loss. It may be called a ‘still’ birth, but when you really look at it, a lot of the women in our study experienced sights and sounds and smells and sensations of a traumatic nature.”

Another important finding relates to the dyadic nature of the trauma of pregnancy loss. “We started out with the premise that this is not just an individual trauma,” says Horesh. “The couple’s relationship is also a significant dimension in this. We looked at different measures, such as the degree of coherence and agreement between the couple; the level of conflict between them; the degree of expressiveness between them. We also looked at how open the woman was to sharing her feelings with her partner – about the pregnancy loss specifically, and in general. Men were not included in this study – everything was reported from the woman’s point of view. That will be the next step for us – to look at men too.”

What did you discover about the role relationships play in this?

“From the initial findings, one can certainly say that the quality of the relationship is inversely related to the level of psychopathology following pregnancy loss. In other words, the better and more stable the relationship, the lower the level of psychological distress. Of course, this is a correlative study, so we don’t know what preceded what, but we can speculate – based upon previous studies that we’ve done and seen – that the influence is bidirectional: the relationship is affected by the syndrome, and vice versa.”

Horesh cites several important points concerning the relationship indices used in the study. “At this point, it appears that of all the indices, consensus – or agreement – is the most significant as a protective factor against psychological distress. After a crisis, the family as a whole, and the couple, need calm. No matter what, the couple has experienced a major upheaval, and it looks like the more they can feel like a team again, the better off they’ll be.

“We also looked at whether it helped or hurt that the woman shared her feelings with her partner. We found that there were two main feelings for which emotional sharing was linked to reduced distress for the woman: guilt and shame. There is a long tradition of literature on guilt and shame, both in trauma literature and the literature on grieving and loss. We saw ‘survivor guilt’ and thoughts about ‘What I could have done differently during pregnancy,’ and so on. There are also [emotional] experiences connected to ‘flawed’ or ‘imperfect’ motherhood, to a ‘failed’ pregnancy. These are two themes that it is very advisable to take into account in therapeutic interventions after pregnancy loss.”

One intriguing bit of analysis had to do with women in whom comorbidity was found. “If we said that a good relationship in general reduces depression over time, in couples where the woman suffers from both depression and PTSD, it seems that support from the partner actually heightened the symptoms.”

How do you explain that?

“Because support can also feel stifling. There are studies showing that people with PTSD often just want to be left alone. For someone who wants to avoid things and not talk about it, ‘support’ can increase the distress. This is very specific, but it means that from the standpoint of clinical thinking we have to look at the woman’s entire psychopathology. The distinction between the disorders is very important.”

Horesh notes with dismay the popular notion in this country that childbirth – whether normal or traumatic – and miscarriage are perceived as an experience solely belonging to the woman, not the couple. “Around the world, there is much literature about the husband’s place after a normal birth as well as after a pregnancy loss. But in Israel, you will hardly find any articles or data about this.” Similarly, he laments that in Israel there is no couples-therapy model following such experiences of loss.

Faith and PTSD

Other variables examined in the study were the number of children already in the family (the more children a woman had, the less she appeared to suffer psychological trauma related to the loss); the woman’s age (younger women were found to be more vulnerable to psychological trauma); the amount of time that had passed since the loss (the closer the proximity to the event, the greater the distress). The latter finding is not surprising, but it does have important implications for treatment of the trauma. “In the first months after the loss there is a more vulnerable period in which many women find themselves without sufficient support,” says Horesh.

Another variable considered was whether the woman had experienced a previous pregnancy loss, or losses. “In the study, the average was two previous losses per woman. So a large portion of our sample had experienced pregnancy loss before. What’s interesting is that there was no clear correlation between the occurrence of previous losses and PTSD, but there was a correlation with depression – and it was a negative correlation. In other words, women who had previously experienced pregnancy loss were more ‘immune’ to depression after the current loss.”

Another provocative finding relates to religious faith. The researchers found that women at the far ends of the religious spectrum – the most secular and the most Orthodox among the Jews – were the most immune to trauma, while women who fell somewhere in the middle of that spectrum were more vulnerable.

“The preliminary interpretation is that when you come into the traumatic event with a firm ideological and/or religious basis, whatever it is, you are better equipped to cope,” Horesh says. Bear in mind, though, that nearly all the women in the study were Jewish – since non-Jewish women make up a smaller percentage of patients at Hadassah Hospital and also showed less willingness to take part in the study, so there were not enough of them to provide a meaningful statistical sample.

Unusually, Horesh also says the study did not include a control group, which in this context would have been women who had a normal birth. But even the term “normal birth” is not straightforward, as it encompasses many types of deliveries – including natural childbirth, vacuum delivery, caesarean section – and these, in turn, are divided into many subtypes. Moreover, a “normal” birth can also be traumatic.

Horesh notes, “Generally, the field of pregnancy is gradually opening up to trauma researchers. In Britain, for instance, there are some very impressive teams of researchers studying birth trauma, and they are also working on validating a post-trauma questionnaire that is specific for childbirth.”

Nukrian, with her many years of experience in the delivery room, backs this up. “I’ve seen live births where there is post-trauma. And this is the next study we plan to do.”

New legislation

Nukrian has worked to get pregnancy loss legally recognized as a major life event that can have an impact on married and family life. In the previous Knesset, she advised the chairwoman of the Committee on the Status of Women, Aliza Lavie, on amending a law. “The [original] law stated that in the event of pregnancy loss from the 26th week onward, women were entitled to a payment from the National Insurance Institute and maternity leave. I told [Lavie] about the support groups, about how we saw that women who lose a pregnancy at an earlier stage go through the same experience, and that many of them are forced to return to work after just a week or two. I met with her, together with a woman who had experienced pregnancy loss, and we wrote a very strong position paper. Last year, the cutoff was changed from the 26th week to the 22nd."

Nukrian says she recently went to the Knesset to ask that the eligibility threshold be further lowered to the 16th week. “We haven’t received an answer yet, but we presented the issue of PTSD and how it impacts both members in the couple, and we said that both the man and woman should be able to obtain therapy.” There are various independent organizations that offer therapy in connection with stillbirth in Israel, but not one unified center.

“We ought to have treatment centers for couples who experience pregnancy loss,” continues Nukrian. “Or to expand the women’s health centers in the hospitals and health maintenance organizations so they can also provide a holistic therapeutic approach for both the woman and her partner. And these services need to be made available to women who live far from the major cities, too,” she adds. Another important aim is to boost public recognition of the legitimacy of the grieving process.

Unbearable guilt

Five years ago, when she was in her 19th week of pregnancy, Yael Eisenberg, 43, went in for a routine amniocentesis test.

Estimates of the risk of complications associated with the test range from just 0.5 percent to 1 percent. But for Eisenberg, a married mother of three from Nes Tziona, the statistics were of no use. “Three days later I started to bleed,” she recalls. “An infection developed. I was hospitalized for two weeks at Assaf Harofeh [Hospital, Tzrifin], and every day they checked the condition of the amniotic fluid in the womb. When I was in my 21st week the doctor told us my chances of giving birth were very low, and that if the baby was born there was a high risk she would be born with a severe birth defect or would not survive. He strongly recommended that we terminate the pregnancy.”

For Eisenberg, having to make that decision to terminate added an unbearable sense of guilt on top of the feelings of grief and loss. “For a long time, I carried around this feeling that I was a murderer,” she says.

“Before they started with the procedure, I begged the doctor to still give it a chance. But they said the infection in the womb could spread throughout my body very rapidly and that I was in danger. I underwent a D&C under full anesthesia. It’s physically more risky that way, but emotionally at least you don’t go through the trauma of a stillbirth.”

Still, the experience was traumatic enough. “I was a complete wreck when I came out of there. A week later, I was lying on the therapist’s couch,” recalls Eisenberg, adding, “It affects everything – [including] your self-image. I was furious at myself, at my body that was supposed to hold and nurture this baby and that betrayed me. I had eating binges, which is a way to punish the body.”

And she says other people’s reactions didn’t make it any easier. “There’s a big difference in people’s minds between a baby that is born and then dies, and a baby that dies in the womb. So they say things to you like, ‘You’ll get over it,’ or ‘You’ve got two kids at home.’ They mean well, obviously, but society doesn’t allow you to mourn, and that hurts.”

For several weeks after the abortion, Eisenberg still looked as if she were pregnant. “People ask you when you’re due, and when you say you’re not going to be giving birth, it kills you. You find yourself with breasts that are dripping milk, and at the same time the tears are streaming down, because it rips your heart out.”

It was also a big blow for her marriage to absorb. “For my husband, since I had been in mortal danger, as soon as I left the hospital he felt relieved. His attitude was, we just thank God and keep going. He didn’t really understand the grief I was feeling. Our intimacy was seriously affected, too.”

When Eisenberg had to terminate her pregnancy, the law did not provide for National Insurance Institute support and maternity leave for women whose pregnancy ended before the 26th week. Instead, she had to go back to work a week after leaving the hospital.

“Because I didn’t give birth to a live baby, there was no legitimacy to processing the difficult experience I’d just been through. But there was a baby. I felt her kicking, I had a name picked out for her already; I was already talking to her. You have this whole fantasy in your head too, and all of a sudden it’s over.

“When I got married, I wanted a very big family,” she continues. “And after this happened, my husband didn’t want to hear about it. Luckily, I got pregnant again unexpectedly. But along with the joy, the next pregnancy was filled with crazy amounts of stress and anxiety. Especially during the amniocentesis – when I had to take tranquilizers – and also the whole month before the birth I was panicking. Even the way you relate to the child is not as free and relaxed. Because you’re so anxious.”

After the psychotherapy Eisenberg went through following the termination, and participation in the Hadassah support group (“The other women in the group helped me the most in this whole thing”), the one-time lawyer decided to become a therapist herself. She now works with women who have experienced pregnancy loss, and also leads workshops in creative writing.

“I took this loss and turned it into a basis for growth,” she says. “I now understand that this baby wasn’t meant to be born. But that she came to wake me up, to make me become a therapist, because that is my true calling.”

‘Akin to a war’

Why is it that in Israel – a country in which pregnancy, birth and family have such a central place, and in which trauma research is so advanced – there has been so little research on pregnancy loss and its treatment implications? Dr. Horesh believes one reason for the neglect is that this kind of trauma is “not heroic.”

“PTSD has always been more intertwined with politics than any other psychiatric disorder, because it’s a disorder that derives from the outside situation,” he says. “Schizophrenia comes from the inside, as do depression and bipolar disorder to a large extent. Israel lives on heroic traumas. And I’m not belittling that. It is truly the tragedy of our country. But it doesn’t justify the lack of attention to other traumas.”

Horesh is also part of a team that is researching trauma in poor neighborhoods in the United States in relation to violent assault. “If someone were to research trauma in poor neighborhoods in Israel, like Neve Sha’anan or Shapira [in Tel Aviv], or in the Bedouin sector, for instance, I promise you they would find higher PTSD rates there,” he says. But no such research is being done in Israel. “Civilian life here doesn’t count, so the trauma of everyday life isn’t given any weight either. Pregnancy loss is that kind of trauma. It’s a civilian and not a military thing; it’s part of everyday life rather than something ‘heroic,’ and it’s experienced by women and not men. So it’s at a disadvantage in all these ways. And so the resources aren’t there. But to judge from the percentages that were revealed in our study, it’s very much akin to a war.”

Dr. Ronit Leichtentritt of the social work school at Tel Aviv University has done research on all forms of late-term abortions in Israel. The women she interviewed described what a horrible experience it was – both because of the way the medical system pushed them to terminate the pregnancy, and because they felt compelled to keep quiet about their decision, fearing societal disapproval. The women also said that following the late-pregnancy termination, they felt tormented for years to come. They also felt like Israeli society is sending a clear message to women: It’s your responsibility to give birth to nothing but healthy children. Also that there is no societal recognition for their loss, a loss that it wants them to keep quiet about – leaving them isolated as they struggle to cope with their trauma and the guilt that comes with it.

What changes would you like to see in the way this subject is handled in Israel?

“First of all, I would like to see the issue get attention, to shake up the system and institutions. We can’t be a society that gives such a central place to the idea that ‘children equal joy’ and to children’s shops and children’s play centers, etc., without also acknowledging these other sides of it. There needs to be some kind of paradigm shift.

“Also, on the practical level, psychotherapy today is moving in the direction of personalized medicine. The idea is that the same illness is manifested differently in different people, and so should be treated differently as well. The treatment methods for trauma are constantly changing, too, and new treatment models are continually being constructed. We need to have treatment models for women and couples who have experienced pregnancy loss, and within that there should be a range of treatment options.”