The Unreal World: A miscarriage in 'A Separation'

The Unreal World

"A Separation"

Hopscotch Films, Golem Distribution

U.S. release: September

The premise

Nader (Peyman Moaadi) refuses to leave Iran with his wife because his aged father (Ali-Asghar Shahbazi) suffers from Alzheimer's disease, causing a schism between the couple. She leaves him, and Nader hires a young woman (Sareh Bayat) to take care of his father, who is disoriented, incontinent and often wanders the street. When he returns to find his father on the floor, naked and barely responsive, he blames the girl and pushes her out of the house. She is 19 weeks pregnant and loses the baby. Nader is accused of murder of the baby because she claims she fell downstairs when ejected by Nader. But the real cause is murky: It later transpires that she also has been chronically abused by her unemployed, depressed and angry husband, and that she was hit by a car while looking for the old man on the street.

The medical questions

Could any of these things cause sudden miscarriage in a patient in the second trimester of pregnancy? What role could be played by psychological stress? How common is it to lose a child at 19 weeks?

The reality

Dr. Henry Lerner, assistant clinical professor of obstetrics and gynecology at Harvard Medical School and author of "Miscarriage: Why it Happens and How Best to Reduce Your Risks," says it usually takes an extraordinarily large trauma to cause a miscarriage in the second trimester. Being hit and thrown by a car is by far the most likely cause. Physical abuse with a heavy blow to the abdomen could also cause a miscarriage.

Emotional abuse and/or stress is far less likely to be the cause of a second-trimester miscarriage, Lerner says. "Many pregnant women live through war situations, divorces and deaths in the family without any appreciable increase in the miscarriage rate."

But there is some controversy here. A 2010 article in the Archives of General Psychiatry reported that depression during pregnancy (made worse by the added stressors of marital discord and poverty) may increase the risk of adverse outcomes, including preterm birth. Depression during pregnancy is common — it's experienced by 14.5% of women, says Dr. Dorothy Sit, assistant professor of psychiatry at the University of Pittsburgh School of Medicine and an expert in women's mood disorders. Such a link, if real, could be due to poor nutrition, hormonal changes or suppressed immune function, Sitt says.

It is extremely rare for a woman to miscarry at 19 weeks, Lerner says; the vast majority of miscarriages occur by 12 weeks. When a late miscarriage does occur, it's usually due to an infection, a physical defect incompatible with life or a cervix that won't stay closed.

Siegel is an associate professor of medicine at New York University Langone Medical Center. His latest book is "The Inner Pulse: Unlocking the Secret Code of Sickness and Health."

Copyright © 2019, Los Angeles Times
EDITION: California | U.S. & World