Nishmat's Women’s Health and HalachaIn memory of Chaya Mirel bat R' Avraham

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Pregnancy Loss & Neonatal Loss


Unfortunately, some pregnancies do not culminate in a healthy childbirth or a living baby. Many women experience at least one miscarriage during their lifetime.


Unfortunately, some pregnancies do not culminate in a healthy childbirth or a living baby. Many women experience at least one miscarriage during their lifetime. The percentage of pregnancies ending in miscarriage increases with maternal age.

If a woman has repeat miscarriages, usually defined as three or more, medical examinations are indicated to check for an underlying cause. Experiencing miscarriage after a long wait, or in the course of fertility treatment, can be particularly difficult.

The terms pregnancy loss and neonatal loss refer to a number of situations:

  • Miscarriage occurs when the body spontaneously terminates a pregnancy before it passes twenty weeks. Miscarriages early in pregnancy frequently result from genetic defects in the embryo, and they thus prevent the birth of severely affected children.
    • A blighted ovum is when a miscarriage results from an arrest of embryonic development.
  • Stillbirth refers to pregnancy loss past twenty weeks, when the pregnancy had developed normally until the loss. Pregnancy loss at later stages is more likely to be associated with problems in the uterus or the placenta.
    • Fetal Demise is a situation where a woman has no bleeding, but discovers on ultrasound that her fetus is no longer alive.
  • Neonatal Loss or death is when a baby does not survive past 28 days postpartum.

Experiencing Loss

The loss of a fetus or infant can be an emotionally wrenching experience. The anticipation experienced during pregnancy is suddenly replaced with grief, often accompanied by physical discomfort, medical procedures, and difficult choices.

If a miscarriage occurs early in pregnancy, the couple may grieve privately while the community remains unaware of their loss. In cases when the pregnancy had already become public knowledge, a couple may find themselves in the awkward situation of “breaking the news” when people ask about the baby.

A loss is nothing to be ashamed of. Being open about it with others can help marshal support. Openness also may give couples the opportunity to discuss what happened with others who have had similar experiences.

After pregnancy or neonatal loss, a woman can benefit from taking time to cry, to mourn, to pray, to talk about her loss, to rest, and to recover emotionally and physically.

Rituals

Although the laws of aveilut, mourning, do not apply after miscarriage or stillbirth and often do not apply after neonatal loss (this matter requires individual halachic guidance), there are some Jewish rituals that can be of importance for the couple.

  • When the loss is confirmed, the couple can recite the blessing “Dayyan ha-emet” “the true Judge.” This is an affirmation of faith in the face of suffering.
  • The couple can also take steps to ensure that a local chevra kadisha (burial society) washes and buries the fetus or infant in accordance with Jewish custom. Note that it is technically permissible, but not customary, to look at, photograph, or kiss the fetus or infant after loss.
  • Friends and family members may voluntarily comfort the couple. Simple words such as “min ha-shamayim tenuchamu” “may you be comforted from Heaven” can convey an important message of acknowledgment and support.
  • The mikveh immersion following miscarriage, stillbirth, or neonatal loss is halachically obligatory. It also presents an opportunity for spiritual and physical transition. A woman may choose to recite a personal tefillah during this immersion to mark what she has been through and to express her hopes for the future.
  • Especially in the case of neonatal death, the couple can light a yahrzeit candle each year.

Medical Intervention

When a miscarriage occurs early in pregnancy, the process can often be completed without medical intervention. A miscarriage sometimes happens so early in the pregnancy that it goes undetected, and the woman assumes she just had a late period.

In some early cases, though, and in later ones, a course of medication, to induce miscarriage or labor, or a dilation and curettage (D&C) or dilation and evacuation (D&E), to clean out the uterus, may be recommended. Delivery in stillbirth often resembles a live birth.

A woman experiencing miscarriage or stillbirth can ask her physician whether medical intervention is definitely required, so that she can make a decision when relevant between undergoing intervention or allowing nature to take its course.

From a halachic perspective, it is important to confirm a diagnosis of miscarriage or stillbirth before undergoing a termination procedure. Some halachic authorities require two separate tests to confirm that a pregnancy is not viable before allowing any such procedure. If the fetus is alive but seems to have a severe defect, then the couple should seek personalized halachic guidance.

In any case of stillbirth or miscarriage, with or without intervention procedures, it is important for the woman to discuss pain management with her physician. Even simple measures, such as taking Ibuprofen before undergoing a procedure, can be very beneficial.

Niddah

Either the natural bleeding of a miscarriage or birth or the uterine dilation and subsequent bleeding from a medical procedure such as D&C or D&E makes a woman like a niddah.

If the miscarriage occurs more than forty days after conception, and the gender of the fetus is either unknown, or was known to be a girl, the woman may immerse no earlier than the night following the fourteenth day from the passing of the fetal tissue or of the fetus, even though she theoretically could complete the process of counting her clean days earlier.

In practice, bleeding usually lasts longer. The amount of bleeding can vary widely, from the length of a heavy period to a number of weeks as after childbirth. Staining is also very common. Therefore, it is difficult to predict in advance when it will be possible to use the mikveh, and a couple should gird themselves for a long wait.

On the whole, the taharah process is the same as for any time a woman is niddah. The minimum wait begins with the onset of the niddah status. After all bleeding has ceased, she performs a hefsek taharah, counts shivah neki’im, and immerses in the mikveh. The moch dachuk is typically waived for women post miscarriage or stillbirth, and many suffice with only one bedikah per day of the shiv’ah neki’im. Other lenient measures may be possible upon halachic consultation.

Often, halachic guidance can help a woman reach the mikveh sooner following miscarriage. We encourage women to contact a Yoetzet Halacha or rav to discuss how best to proceed in this situation. A review of the laws of stains (see here and here) can be particularly helpful.

A miscarriage after forty days also resets a woman’s veset calendar, so she observes no more onot perishah until after her next menses.

The couple may find the restrictions on physical affection especially challenging during the time of niddah following a miscarriage, and will need to find alternative ways to express love and emotional support. It is important for husband and wife to understand that each of them might have different reactions and needs during this time period.

Contraception after Loss

The physician may allow a couple to attempt another pregnancy immediately, or recommend that they wait a certain period of time. Several factors will influence this decision, including the physician’s personal approach, how far along in the pregnancy the miscarriage occurred, and whether a surgical procedure was performed.

If a physician recommends short term contraception, the easiest method is spermicide, such as Vaginal Contraceptive Film (VCF). Spermicides are halachically permissible when contraception is allowed.

However, spermicide is only about 85% effective. Although that typically suffices following miscarriage, spermicide use should be discussed with one’s physician.

If a higher level of short-term protection is needed, a woman can explore use of a diaphragm with spermicide or a contraceptive sponge. (The diaphragm is both halachically preferred to and medically more effective than the sponge.) Condoms are not significantly more efficacious than these and are not halachically permitted for contraception in these cases.

Resources

  • Many of the organizations listed on our Fertility Resources page also offer support to couples experiencing pregnancy loss.
  • An excellent resource in Hebrew is the book Kachalom Ya’uf, by Avraham Stav (Jerusalem: Mossad Harav Kook, 2020).

 

Updated August 2020.


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