Why Practice Research? Creative Writing and Recurrent Miscarriage

Sabina Dosani recently completed a PhD in Creative Writing Research at the University of East Anglia. Between the births of her two daughters, she experienced recurrent miscarriages while working as a psychiatric expert witness. As part of her PhD thesis, she wrote a memoir, Flesh and Blood, about that time. She also wrote critically about the language used in contemporary British obstetric papers on recurrent miscarriage, and in contemporary memoirs and novels in which the protagonist experiences ultrasonically-confirmed miscarriage, stillbirth or infertility.

When I told medical colleagues that I was doing a PhD in Creative Writing Research, they said things like, ‘that sounds relaxing’, or ‘it’s good to have interests outside medicine’. Creative writing wasn’t work. My PhD looked like an extended holiday. A few years ago, it’s a view I might have shared. Research, or at least the research that I believed had the power to change practice and shape policy, was data-based. And yet I reached for stories, not statistics, for my PhD. Why did I choose creative writing research methods and literary criticism?

It started with a death, or more precisely, with a series of deaths, of children I conceived, carried, but never met. During those deaths, I worked in a small team commissioned to conduct expert witness assessments of children subject to care proceedings. Almost all my professional conversations were about motherhood, mental illness and maternal attachment. In my work, I met women who gave birth to babies they were unable look after. I met children left without food, without care and without any sense of who they were and who they might count on. I visited the homes of mothers who gave birth to children they couldn’t take to school because they were too high or too sad or too afraid to leave their flats. Some mothers who had child after child removed and placed in care, and conceived another after another. At that time in my personal life, I was alternately preoccupied with any hint of possible pregnancy or with signs that might herald impending foetal death.

A brightly coloured collage/stencil-type artwork of a pregnant person next to a large old-fashioned clock face
Pregnancy. Bill McConkey. Attribution 4.0 International (CC BY 4.0)

Oddities of medical language

When I was referred to an NHS recurrent miscarriage clinic after a series of losses, obstetricians and midwives spoke in jargon familiar from medical school: products of conception, falling HCG levels, failed pregnancy. This medical terminology, especially the word ‘miscarriage’, jarred. Did it mean I was a faulty container? No clinician referred to parenthood during their scientifically precise utterance: ‘There’s no heartbeat.’ Each time I heard those words, I felt like a bereaved mother. 

Attending appointments, I increasingly noticed the oddities of medical language and of clinical consultation styles. For example, my obstetrician used military metaphors to describe his treatment plans. My immune system, he postulated, was ‘mounting an attack on embryos’, identifying them as ‘enemy invaders’. He suggested I had high numbers of cells called ‘natural killer cells’ and his proposed treatment was presented as a ‘counterattack’. Throughout that pregnancy, I lived with my husband, an army officer, on military headquarters. The politics and poetics of war were part of my life. 

So when my obstetrician used the phrase ‘natural killer cell protocol’ my first thought was that it sounded like counter-terrorism policy. Why was my treatment plan written in military language? Who might benefit from this language and who might be harmed? I spent an afternoon in a medical library, looking for answers. With scientific diligence, I collected a sample of obstetric papers. But instead of poring over data, I dissected the obstetric language, dragging a highlighter pen over war references. For example, ‘mother’s immune system attacking the embryo’, ‘prednisolone therapy as a counterattack’, ‘a more targeted treatment for recurrent foetal loss’ and ‘intravenous immunoglobulin boosts the body’s defences’. The notion of a woman’s own cells mounting an immunologically mediated attack on an enemy embryo bothered me. A woman’s womb is an unlikely setting for biological civil warfare. No mother wants her child to go to battle, least of all a battle she herself has unwittingly unleashed. Notions of attack invoke conflicts to be bravely fought, but there will be victors and losers. A further miscarriage, despite medical interventions, becomes not just a loss, a grief, but also a defeat. An obstetrician mounting a counterattack with a complex drug regime may be lured by this language into so called ‘aggressive treatment’, using unproven drug protocols, with many side effects. Is some collateral damage not inevitable in every war?

By the end of that afternoon in the library, I felt motivated to find a language that would be helpful to other women who saw themselves as grieving mothers, rather than as patients experiencing a cellular inconvenience. I began to wonder about the power of stories over statistics to change policy, and to educate midwives and medical students. I had no idea how to do this, so I went back to university. 

Memorialising foetal losses

For an essay written as part of an MSc in Medical Humanities at Kings College London, I looked at how other women from diverse faiths memorialised foetal losses. After studying rituals from Buddhists, Neopagans, liberal Jews and Christians, my interest in non-medical accounts of losses that society is not yet good at recognising grew. Towards the end of the MSc, I started reading novels and memoirs by women who experienced miscarriage, stillbirth and infertility, or whose fictional protagonists had. I planned to undertake a Medical Humanities PhD, with a literary critical focus. 

While drafting a PhD proposal and poring over funding applications, I heard the historical novelist Rebecca Stott on BBC Radio 4, reading from her Costa Prize winning memoir, In the Days of Rain (Stott 2017). It was a revelation hearing Stott’s account of growing up in a fundamentalist cult. Her framing of the story as a daughter-father narrative and her fine prose made sense of a complex and complicated childhood. I realised then that the traditional literary critical methodologies in my PhD proposal would only partially answer my research questions. Might writing memoir help me find a new form and language for my experiences? Could I use it to explore my insider-outsider status? Would it allow me to interrogate subjective experiences? I wrote to Scott, we met, and she agreed to supervise my PhD in Creative Writing Research at UEA. 

Becoming a creative writer was difficult and often confusing. Medicine valorises the objective, the measurable, the categorical. Writing came with apparently no formulae and rules that could be broken, as long as I knew what those rules were and why I was breaking them. Although I had a background in medical journalism, I struggled to call myself a writer. At my probationary review, I described myself as ‘a doctor with a longstanding interest in writing’. Now, I notice the implicit hierarchy of medicine over writing in that sentence; even the form echoes my obstetric notes which describe me as, ‘this pleasant psychiatrist with longstanding asthma’. Writing was an affliction.

My PhD coincided with the pandemic, with a return to clinical practice alongside homeschooling my children. During a Zoom supervision session, Stott introduced me to a daily writing hour. Every morning, I was to close the door and stick a post-it note on the outside: ‘Only come in if you are bleeding.’ Six mornings a week, I wrote longhand, for an hour. My children came to see my writing hour as sacred and as uninterruptible as a medical consultation (my clinical practice was also remote during the pandemic). So there was a formula, after all. I began to introduce myself as a ‘writer and doctor’. 

Smithsonian American Art Museum, Transfer from the Evander Childs
High School, Bronx, New York through the General Services Administration

Flesh and Blood: crossing formal and genre boundaries

I wrote with two goals in mind: to tell the story of a medicalised pregnancy under the care of an NHS recurrent miscarriage clinic and to bring to public attention the experiences of an expert witness assessing families undergoing care proceedings in a court system that is closed to the public. Through writing, I scrutinised the medical systems I worked and had trained in and sometimes this made me feel sad, and often angry.These discoveries happened slowly, through seeing and shaping my thoughts on the page.

Flesh and Blood, named for the kinship ties examined (and often severed) in the family court, for the embodied reality of multiple miscarriages, the kin-like ties within medical teams and the camaraderie in the military, as well as the foster carers, birth parents, separated siblings and my own blended family, crosses a number of disciplines as well as formal and genre boundaries. For example, I mined my medical and maternity notes and used this personal history to compare the rigours of fortnightly ultrasound imaging with the process of medico-legal scrutiny in the family court, as well as to portray some of the unintended cruelties of these probing systems. To do the latter, I chronicle lives of families referred for expert witness assessments. I explore real themes and dilemmas, many of which are matters of public record, but names, identities, sibships, occupations and other details that could identify a family have been made up. 

These fictional lives include Noor and her baby Azhara. Noor, a migrant from Egypt, a woman depicted by healthcare services as at best unreliable and often as a liar, who apparently abandoned Azhara in hospital and found herself in court proceedings. My fictional meetings with Noor uncover the ways in which women are paradoxically hyper-visible as failing mothers, yet their emotional and practical needs are often overlooked. I examine how doctors and social workers, under time and other systemic pressures, make mistakes. 

During my writing hours, in a messy way that I still struggle to articulate, patterns emerged and recurred. For example, I knew I was taking my imagined reader on journey through my medicalised pregnancy, alongside a parallel, professional journey with fictional families eviscerated by illness, adversity and addictions. I didn’t know I would ask readers to consider what it would mean if clinics and courts were places of greater compassion, or whether emotional bonds stall the difficult and often devastating interventions designed to keep children safe, often leaving mothers in the shadows. 

When my medical friends hear that I’ve completed a PhD in Creative Writing Research, most of them say, ‘Oh, nothing to do with medicine.’ Flesh and Blood includes a chapter in which I am told that if I had a mental illness I might be ‘considered’ for a caesarean. What topsy-turvy world was this? I needed to be assessed as being clinically phobic of childbirth to be granted what I felt was the safest mode of delivery for my unborn child. The professional eyes on me, the eyes of the gatekeepers to an elective caesarean, would only be sated by evidence of a mental illness. What a different story for many mothers in the family court, who had to show that their mental illness had no impact on their parenting. 

After submitting my thesis, I worried that I had written too critically about maternity services. However, only a few weeks after submitting, the Ockenden Inquiry (Crown 2022) into maternity services of Shrewsbury and Telford Hospital NHS Trust highlighted many themes that Flesh and Blood is concerned with, including the dangers of ‘them and us’ cultures in maternity services. My first pregnancy ended in an emergency caesarean. In Flesh and Blood, I describe the NHS obstetrician telling me I am ‘not allowed another caesarean’. A low caesarean rate was trust policy, just as it was at the Shrewsbury and Telford Hospital NHS Trust, where 200 babies were stillborn and nine mothers died. Donna Ockenden, the senior midwife chairing the review concluded that the trust’s policy of deliberately keeping the caesarean rate down is to blame for these deaths, as was the prevailing culture. 

In one of my writing hours, I wrote, ‘I am supposed to end at my skin.’ Leaking uterine contents is transgressive. Writing as research has also been a transgressive act. Through creative writing, I explored how detachment comes to be widespread in medical practice. I concluded that clinical detachment, often mistaken as a hallmark of good medical practice, nurtures poor clinical judgement and does both patients and physicians a disservice. The medical system, which includes me, needs to change.

About the author

Sabina is a Visiting Research Fellow in the department of Literature, Drama and Creative Writing, University of East Anglia. She is writing a novel and continues to work part-time as a consultant psychiatrist and expert witness. 

References

Independent Maternity Review. 2022. Ockenden report – Final: Findingsconclusions, and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust (HC 1219). London: Crown. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1064302/Final-Ockenden-Report-web-accessible.pdf

Stott, Rebecca. 2017. In the Days of Rain. London: 4th Estate.

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