“The Event That Was Nothing”: Miscarriage as a Liminal Event
2015; Wiley; Volume: 46; Issue: 1 Linguagem: Inglês
10.1111/josp.12084
ISSN1467-9833
Autores Tópico(s)Grief, Bereavement, and Mental Health
ResumoI remembered, then, the miscarriage, and before that the months of waiting: like baskets filled with bright shapes, the imagination run wild. And then what arrived: the event that was nothing, a mistaken idea, a scrap of charred cloth, the enormous present folding over the future, like a wave overtaking a grain of sand. —Excerpt from “A Language,” by Susan Stewart11 Stewart, Susan, “ A Language,” Poetry (2011). Retrieved from http://www.poetryfoundation.org/poetrymagazine/poem/242268 How is it possible that an event is, and is not? How can any event, properly called, be nothing? And yet Susan Stewart's fine words capture something important about the nature of miscarriage in American society. It both is and is not. It is both a source of acknowledged pain and suffering, and one swept easily away with “you can always try again” or “it could be worse.” I argue here that miscarriage is a liminal event. It is perhaps for this reason that it has been both poorly addressed in our society—it occurs in about 25 percent of pregnancies and yet 55 percent of Americans believe it is rare22 Hand, Larry, “ Misconceptions About Cause, Frequency of Miscarriage Common,” Medscape (2013). Retrieved from http://www.medscape.com/viewarticle/813084 —and enrolled in larger debates over women's reproduction. We see laws governing the behavior of pregnant women used to minimize maternal autonomy, justified by preventing fetal harm, including miscarriage. We see laws that require women to prove pregnancy loss is a miscarriage rather than an abortion. Were miscarriage better theorized, perhaps it would not so easily be enrolled in these other debates. Its very liminality and the fact that it is enrolled in these debates sheds light on the complicated network of concepts within which miscarriage lies, an event that is nothing, that is neither abortion nor pregnancy. I shall begin by discussing relevant features of miscarriage and our poor understanding thereof. This poor understanding is, itself, to be expected from a liminal event. I then clarify what I mean by “liminal” even as I establish the liminality of miscarriage. We shall see that miscarriage is liminal along four distinct but related, and perhaps inextricable, dimensions: parenthood, procreation, death, and abortion. Finally, I show how miscarriage is thus enrolled in social and moral debates which are not really about miscarriage at all but rather about the dimensions of liminality on which miscarriage lies. The interrelatedness of these dimensions makes me gravely concerned about how and whether we can improve the lives of those who experience miscarriage. To truly understand why miscarriage is so taboo and to fully grasp the identity disruption that miscarriage poses, as well as to later understand how it becomes enrolled in social debates which are not really about miscarriage, we must first understand miscarriage as a liminal event. The notion of the liminal was coined by Arnold van Gennep, a French ethnographer practicing in the early 20th century. Van Gennep focused on ceremonies of rites of passage which he divided into three phases: preliminary, liminaire, and post-liminaire. The phase of liminaire, or liminality, is one in which a member of society is transitioning from one social role into another. Van Gennep took the term from the Latin word limen: a threshold.33 Gennep, Arnold, The Rites of Passage ( Chicago: University of Chicago Press, 1961 Reprint Edition ). …the ritual ‘space’ in which one is suspended, straddling or wavering between two worlds, neither here nor there, betwixt and between settled states of self, as in rites of passage or, by extension, when experiencing illness, especially life-threatening or self-threatening illness. Liminal space is a place of ambiguity and anxiety, of no-longer and not-yet.77 Carson, Ronald A., “ The Hyphenated Space: Liminality in the Doctor-Patient Relationship.” In Stories Matter: The Role of Narrative in Medical Ethics, ed. Rita Charon and Martha Montello ( New York: Routledge, 2002), 171– 82. 180 , my emphasis. This betwixt-and-between-ness uncannily captures the sense conveyed by Susan Stewart in her poem “A Language” when she describes a miscarriage as “the event that was nothing… the enormous/ present folding over the future.”88 Stewart, “A Language.” This is complicated by the intense issues of personal identity and social role raised by miscarriage. For women who miscarry while gestating a wanted pregnancy, miscarriage goes far beyond a mere medical condition or event. This should come as no surprise. As John Robertson argued, procreation is morally important because “control over whether one reproduces or not is central to personal identity, to dignity, and to the meaning of one's life… being deprived of the ability to reproduce [whether through infertility or governmental restriction] prevents one from an experience that is central to individual identity and meaning in life.”99 Robertson, John A., Children of Choice: Freedom and the New Reproductive Technologies ( Princeton, NJ: Princeton University Press, 1994), 24 . This sweeping scope for the potential effect of miscarriage is borne out by research on pregnancy loss which has found that “women who do experience fetal loss are not always grieving for the loss of the fetus for its own sake, but sometimes are grieving the loss of a relationship the pregnancy facilitated.”1010 Kimport, Katrina, “ (Mis)understanding Abortion Regret,” Symbolic Interaction 35, no. 2 (2012): 105–122. 107. Procreation is not only identity-constituting, but sometimes relationship-constituting. Pregnancy loss, then, can deal profound damage to both personal identity and to interpersonal relationships. When miscarriage is treated as a medical event instead of an event with a well-understood social place, miscarriage and those who experience it are set off from society, sequestered, and occupy unclear social roles and personal identities. This, too, is a clue to its liminal nature. If a wanted pregnancy is a state in between being a nonparent and being a parent then a miscarriage halts the transition as much or more than it reverses the transition. The person who has miscarried is in the archetypal situation of “no-longer” and “not-yet,” for she will never parent the child who might have been; neither will any partner she may have. Fathers whose longed-for child never arrives due to a miscarriage also grieve, both for the loss of the child and the loss of their own identity as a father to that child.1111 Frost, Julia, Bradley, Harriet, Levitas, Ruth, Smith, Lindsay, and Garcia, Jo, “ The Loss of Possibility: Scientisation of Death and the Special Case of Early Miscarriage,” Sociology of Health and Illness 29, no. 7 (2007): 1003– 22 . Again, given Robertson's explanation of the importance of procreation to personal identity and meaning in life, this should surprise us not at all. Thus, we see that miscarriage is liminal in at least one sense: it places the once-pregnant woman, and any would-be coparent, in a space between not being a parent and being a parent with respect to that particular child who might have been. This parenthood dimension of the liminality of miscarriage is a far different experience from infertility, in which one's might-have-been children are formless. Here, there is a might-have-been child to which one stood in relation. Now, that relation can never fully manifest.1212 Because this is about becoming a parent, it is possible that this sense of liminality may also apply in cases of gestational surrogacy to the individual or couple that intends to parent the resulting child. In a normal gestational surrogacy, a child is born and the intentional parent(s) will indeed become parents. However, if the surrogate miscarries, both she and the intentional parent(s) will have had a relation to the child that might have been, without the possibility of a full parenting relation. All will be liminars; all are potentially trapped in this liminal state of becoming that never becomes. It is a state of becoming which never becomes (see Figure 1). Some individuals may wish not only to parent—or even not to parent—but specifically to procreate. Here, too, the issue becomes particularly complicated for women. As Robertson argues, both genetic contribution to a future person and gestation may constitute procreation. How is the woman who has miscarried to feel? She procreated in one sense: her genetic material, and/or her gestational capacity, have begun the process of procreation. But what happens when that process is disrupted, when it cannot be completed? What happens in the case of a miscarriage? One's genetic material, one's gestational capacity, is involved, but only incompletely. Has one procreated? Or has one not? Here, I contend, there is not only a space between not being a parent and being a parent, but also a space between not having procreated and having procreated. This has interesting implications for gestational surrogates and for genetic donors who are following the process of a pregnancy that is the result of assisted reproductive technology (ART). In the brave new world of ARTs, many persons may be betwixt and between with respect to the procreation dimension of the liminality of miscarriage (see Figure 2). The fit of the notion of liminality for miscarriage is further extended—and applies to any conceivable dimension of the liminality of miscarriage—when we consider Turner's studies of the Ndembu people. In Ndembu culture, neophytes have a physical but not social reality, and are often hidden away or disguised.1313 Turner, “Betwixt and Between,” 8. Though less formal, the isolation of women who have miscarried, and its taboo nature for public discussion, is common. Consider the following. Julia Frost and colleagues examined early pregnancy loss and found that it is “clouded by secrecy” and is a “paradigmatic example of the sequestration of death, both in the sense that most women … know little about it until they experience it themselves, and in the sense that its occurrence is surrounded by secrecy and is hidden from public view.”1414 Frost et al., “Loss of Possibility,” 1004. These features are common to modern Anglo-heritage cultures’ responses to death. When an illness or event has “death salience,” as cancer and miscarriage both do, those who survive the experience have had a much closer experience with death than our culture normally encourages. Survivors may “turn inward to their deep selves in order to establish an understanding of what their life projects might become. Observers, on the other hand, find death salience hard to live with, and may turn away from the distressed survivor.”1515 Little, Miles and Sayers, Emma-Jane, “ While There's Life… Hope and the Experience of Cancer,” Social Science and Medicine 59 (2004): 3129– 1337. 1329 . I suspect this is no small feature of the liminality of miscarriage, and no small cause of its sequestration and the sequestration of those who have experienced miscarriage. Despite the frequency and commonality of miscarriage, it tends to be taboo, off limits for public discussion in a way that the ins-and-outs of pregnancy are not quite off limits. Death salience helps to explain why this is so, and is differently so from pregnancy. Helping women through pregnancy involves a great deal of social support: magazines, baby showers, unsolicited advice—however welcome or unwelcome—on how to behave while pregnant. The mere sight of a pregnant belly can elicit intimate revelations from total strangers about pregnancy, labor, and delivery. Indeed, pregnancy and motherhood are socially constructed as well as biologically constructed, and this begins as soon as those around pregnant women know they are pregnant; discursive interactions shape attachment and, even absent one's social circle knowing one is pregnant, can prepare one to become attached to the fetus, contributing to deep grief after pregnancy loss.1616 Kimport, “(Mis)understanding,” 106–07. We have clear cultural scripts for pregnancy, which is not liminal, but entails well-established social roles and interactions. Not so for miscarriage. Instead, there is a great separation between a woman who miscarries and society as a whole: “silence, isolation and uncertainty combine to augment the suffering of miscarrying women.”1717 Frost et al., “Loss of Possibility,” 1003. Miscarriage can raise not only the specter of death and thus become shrouded in secrecy, but also cause deep confusion for the survivor. Did someone die? Was there a loss of potential life or a loss of life? For many people, this is not clear. For others, it is. But the lack of social agreement puts miscarriage in a space betwixt and between death and life. All this raises a third dimension of the liminality of miscarriage related to its death salience (see Figure 3). A similar sense of liminality and resultant confusion occurs with respect to cancer, the death salience of which is strong. In discussing liminality as a major category of the experience of cancer illness, Miles Little and Emma-Jane Sayers note that an initial phase of liminality is “marked by disorientation, a sense of loss and of loss of control, and a sense of uncertainty” (1485). The liminar—a term for the person in the liminal space more general than “neophyte”—is set off from others and left, in the case of miscarriage, largely to her own devices to seek clarity and meaning. Whereas cancer survivors at least can seek the comfort of their fellow survivors through support groups, women who have miscarried often lack even this level of support. Given how little men discuss infertility,1818 Barnes, Liberty, Conceiving Masculinity: Male Infertility, Medicine, and Identity ( Philadelphia, PA: Temple University Press, 2014) . the same is true for men whose female partner or gestational surrogate miscarries a pregnancy.1919 By emphasizing women as the liminars with respect to miscarriage and merely gesturing toward coparents/progenitors, I do not mean to minimize the damage that miscarriage does to men who have begun to form father-identities in relation to a fetus, or to any coparent or coprogenitor identities with a spouse or partner regardless of gender. They, too, can be liminars with respect to miscarriage. I note that this can occur with heterosexual couples, married or unmarried, as well as with same-sex couples who contract with a gestational surrogate who experiences a pregnancy loss. For a moving description of this from the male side of the equation I recommend Amit Majmudar's fine poem, “The Miscarriage,” an excerpt from which runs as follows: “Forgive me… I was wondering… whether to console you/ if I consoled you it would make the loss/ your loss.” Majmudar, Amit (2005), “ The Miscarriage,” Poetry. Retrieved from http://www.poetryfoundation.org/poetrymagazine/poem/175619 The once-pregnant woman is caught between being a parent and not being a parent. If she has a would-be coparent, whether male or female, the social status of miscarriage reinforces isolation and then both liminars are caught betwixt and between. This isolation is typical of liminal states or events, and a typical experience for a liminar. This brings us to another key aspect of liminality, a temporal one identified in discussions of disability as a liminal state. Kristi Kirschner raises this in considering new-onset disability, as illustrated by the case of a 17-year old boy whose spinal cord injury while playing in a pool resulted in quadriplegia: “the past is irrevocably gone, the future hard to imagine. ‘Old normal’ can't be regained, ‘new normal’ hasn't yet arrived.”2020 Kirschner, Kristi, “ Liminal States: The Challenge of New-Onset Disability,” Atrium: The Report of the Northwestern Medical Humanities and Bioethics Program 2 (2006): 1– 3 , 6. Such disabilities not only present issues at onset, but can result in persons who occupy a liminal state not just temporarily but permanently. Jeffrey Willet and Mary Jo Deegan argue that chronic disability may well trap disabled persons in a liminal state. The liminal stage is supposed to be a transition between two socially viable positions; for the chronically disabled in a society constructed around the able, there is no socially viable position. There is only “a confusion of all the customary categories.”2121 Turner quoted in Willet and Deegan, “Liminality and Disability.” For women who have miscarried, movement out of the liminal can also be problematic since the states between which they found themselves were related to procreation and parenting, and specifically creating or parenting that particular child, as well as to death and life. As I have indicated, we have well-practiced scripts for clear social events such as birth (“Congratulations!”; “Welcome, baby X!”; “Sleep whenever you can!”). These incorporate people into society and shared experience. But we have no such incorporating scripts for miscarriage. Insofar as we have scripts, they tend to be dismissive or to reinforce the sequestration and isolation of both miscarriage and the liminars. The colloquial response which urges women who have miscarried to “try again” or seeks to console by saying “you can always have another” is, I think, not necessarily a lack of compassion even though it is often interpreted that way. Through the liminal framework, we can come to see it as a hamhanded way of attempting to usher the liminar toward a stable state. In this case, that of a parent after all. But, alas, a parent of a different child. The unfulfilled relation remains unfulfilled. The loss remains unaddressed, somewhere between death and life. The liminar remains liminal. Being trapped in liminality is often excruciating for liminars, especially because of the isolation it entails. For Willet and Deegan, the solution to the permanent liminality of chronic disability is for liminars to engage in what Turner called “communitas,” in which liminars treat each other as equals regardless of any status differences before the transition. Willet and Deegan provide the example of a blind woman who looks forward to going to national conventions for the blind or disabled not just because it allows her to act on her political convictions but because she feels a strong relationship to strangers who share with her the experience of disability. From this follows mutual aid and support and the ability to build self-concepts of normality. Willet and Deegan argue that these help group members to actively discover and construct identities different from those given them by society. Alas, persons who miscarry suffer an attenuated ability to build communitas. Many women say that it was only after they miscarried that they discovered how many people they knew had, themselves, miscarried. However, even this does not enable effective communitas. The taboo nature of miscarriage and the inability to easily identify others who have miscarried outside of one's immediate social circle hinder the ability to form connections, to mobilize, to “actively discover and construct identities.” The lack of cultural scripts to draw upon in order to deal with miscarriage further hinders the ability to form communitas, or even to access public and community support from beyond the shared-experience group of women who have miscarried, assuming that one even has access to that. Because of the sequestration of miscarriage, some never do: Dr. Zev Williams tells of once caring for two sisters, both of whom had miscarried and neither of whom knew it of the other.2222 Hand, “Misconceptions.” We have seen the case for miscarriage as a liminal event along three dimensions, parenthood and procreation and death, discussion of which is taboo. We have seen the case for conceiving of women who have miscarried, and sometimes their partners, as liminars struggling in isolation to make meaning out of miscarriage. This positions us to now see how “the event that was nothing,” and the women who experience it, become focal points for social discourse on reproduction. This will also lead us to the fourth dimension of miscarriage as a liminal event. Miscarriage's liminal nature and its corollary sequestration make it all too easy to enroll women who have miscarried, and their families, in related political and moral debates. These include debates over abortion, and over how much control society should be able to exert over the behavior of women with wanted pregnancies who wish to carry to term. A clinical term for miscarriage, “spontaneous abortion,” reveals some of this liminality. Specific clinical descriptors for types of miscarriage include “complete abortion,” “incomplete abortion,” “inevitable abortion,” “infected (septic) abortion,” and “missed abortion.”2323 Storck, Susan, “ Miscarriage,” Medline Plus. National Institutes of Health (2012). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001488.htm Treatment guidelines are almost entirely clinical; whether women receive bereavement counseling is not standardized. Interviews with women who had miscarried indicate such terms are deeply alienating and consider medical use of them to be “insensitive,” particularly when hospital staff attempt to use them as a clinical euphemism while discussing a miscarriage with the woman who has just experienced one, given the “stigma and moral confusion” surrounding abortion.2424 Frost et al., “Loss of Possibility,” 1005. Colloquially, miscarriage may be described as a “lost pregnancy” or a “failed pregnancy.” This is only slightly better than clinical use of the term “abortion,” for while it also entails a degree of agency on the part of the pregnant woman, here it is an issue of omission rather than of commission. A lost pregnancy must have been lost by someone; someone must have failed for there to be a failed pregnancy. Such attempts to comfort are all too easily converted into a devastating subject-verb-object: “I lost the pregnancy” or “I lost the baby.” Thus we see that miscarriage stands in a fourth liminal space between the fraught social categories of induced abortion and pregnancy (see Figure 4). A thing such as miscarriage is poorly understood because it is so little spoken of and because it is sequestered due to the dimensions on which it is liminal. A thing poorly understood but too-like states or events which we believe we understand is quite likely to be drawn into debates over those other states or events. And so we see how the liminality of miscarriage leads to a paradox: that we speak of it little and yet that we can speak of it to such disastrous effect. Miscarriage, if better theorized, might not be so easily brought into these larger debates over women's reproduction and responsibility for reproduction. We should be able to see that, while it is liminal with respect to these four dimensions, it is nonetheless distinct from the poles of each. Even though it is likely by its nature to remain ontologically a liminal event, it—like long-term disability—can gain much from further theorizing. They are thus laws which enroll miscarriage in the abortion debate (1 and 2) and laws which enroll miscarriage in debates over the control of pregnancy (3). We have already seen that miscarriage is a liminal event between the well-defined social categories of abortion and pregnancy. That it would thus play into laws pertaining to both is nearly a foregone conclusion; that it would do so without careful reflection by the law's framers is a result of its undertheorized and sequestered state. We must examine these laws in some detail to see not only that miscarriage's liminality is in play, but also the damage it can do when deployed unreflectively. Let us begin with laws which enroll miscarriage in the abortion debate. The first set of these involves laws which require women to prove that a pregnancy which does not go to term is not due to an abortion. In 2009, Virginia state Senator Mark Obenshain—who ran for Virginia Attorney General in 2013—authored a bill that, on one reading, would have required Virginia women to “report miscarriages to police or risk legal penalties, including as much as a year in jail.”2525 Perry, Susan, “ Failed Virginia Bill on Miscarriages Reveals Ignorance about Women's Health,” MINNPOST (2013). Retrieved from http://www.minnpost.com/second-opinion/2013/05/failed-virginia-bill-miscarriages-reveals-ignorance-about-womens-health This reading requires one to believe that persons might misinterpret a clause requiring the woman who miscarried, or someone acting on her behalf, to report her name and the location of fetal remains to police within 24 hours of a “fetal death” occurring without “medical attendance.” In fact, this may seem prima facie reasonable. According to Obenshain's campaign manager, Obenshain had in mind not targeting women who miscarried, but rather ensuring that fetal deaths were not due to infanticide or illegal abortion and instead due to stillbirth or miscarriage. To his credit, the bill was “stricken at the request of patron,” meaning that Obenshain himself pulled it after the unintended consequences for women who miscarried had become clear.2626 Whack, Errin, “ In Race for Virginia Attorney General, Abortion Debate Takes on Greater Intensity,” The Washington Post (June 25, 2013). Retrieved from http://www.washingtonpost.com/local/va-politics/in-race-for-virginia-attorney-general-abortion-takes-on-greater-intensity/2013/06/25/4b122118-d9bf-11e2-9df4-895344c13c30_story.html This law, though part of an attempt to regulate fetal death, was judged by its own author to be too sweeping in scope. So why bring it up? The proposed law and its downfall, exemplify how difficult it is to separate the liminal event of miscarriage, or its close cousin stillbirth, from debates over abortion. The United States is not the only nation in which the liminal status of miscarriage comes up against the brick wall of the abortion debate. In El Salvador, women who suffer miscarriages or stillbirths are sometimes suspected of inducing an abortion and can be jailed for murder. Take Glenda Cruze, a 19-year-old El Salvadoran suffering severe abdominal pain and heavy bleeding in 2012. Doctors said she had lost the pregnancy; she had been unaware she was pregnant given that a pregnancy test had been negative, her weight had not changed, and she had continued to menstruate. Four days later, she was charged with aggravated murder: the hospital had reported her to the police for a suspected late-term abortion. She was convicted and sentenced to 10 years in jail. In the judge's ruling, he said she should have saved the baby's life.2727 Lakhani, Nina, “ El Salvador: Where Women May Be Jailed for Miscarrying,” BBC News (October 17, 2013). Retrieved from http://www.bbc.com/news/magazine-24532694 El Salvador has a total ban on abortion; between 2000 and 2011, more than 200 women were reported to the police for suspected abortions, 49 of whom were convicted with 7 more convicted since 2012.2828 Ibid. A lawyer who has worked with 29 of the incarcerated women, Dennis Munoz Estanley, says that only one intentionally induced an abortion whereas the other 28 were all jailed for murder without any evidence beyond suffering from obstetrical complications. One advocate says many El Salvadoran women who suffer miscarriages or complications during pregnancy are “too afraid to seek medical help.”2929 Ibid. The implications for the liminality of miscarriage in a zero-tolerance-for-abortion setting are predictable, and the ethical fallout is distressing. In addition to these sorts of laws which would require women to prove that a miscarriage was a “spontaneous abortion” rather than induced abortion or face harsh consequences, we should consider an entirely different sort of law which enrolls miscarriage in the abortion debate due in large part to its liminal status with respect to pregnancy and abortion. These are laws or informal policies which allow health care providers to opt out of, or constrain them from participating in, treatment for miscarriages because of its resemblance to abortions. Let us first consider policies—supported by conscientious objection laws—which allow providers to opt out of training in techniques that are used to treat incomplete miscarriages because these same techniques are also used in abortions. Within months of Roe v. Wade (1973), states began considering laws that would allow health care providers to exert a “right of conscience.” Such a right extends now to the federal level, where federal funding can be withheld from hospitals that punish providers for refusing to participate in medical procedures such as abortion which the provider finds morally objectionable, on grounds of personal conscience. In part because of such laws, some medical schools have seen fit to allow students to “opt out” of training dilation and curettage (D&C), a common technique for a surgical abortion, and indeed to opt out of all abortion training.3030 Rogers, Beth, “ Secret Practice: The Struggle to Integrate Abortion Training Into the Medical School Curriculum,” The New Physician 58, no. 8 (2009). Retrieved from http://www.amsa.org/AMSA/Homepage/Publications/TheNewPhysician/2009/1109FeatureAbortion.aspx D&C is also used after “incomplete abortions,” not induced abortions at all but rather miscarriages in which material from the pregnancy remains trapped inside the uterus of the woman who suffered a miscarriage. In addition, 44 percent of m
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