Exploring grief after miscarriage, pregnancy loss, and infant loss
Despite being relatively common occurrences, pregnancy losses.xi,xii Similarly, those that have suffered infant loss may feel that there is no one, or few people, that understand what they are going through.
Some individuals may also feel as though there is no one that they can talk to about what they are going through. Because loss and grief are often seen as uncomfortable topics of conversation, even knowing where to get evidence-based information on miscarriage and pregnancy loss can be challenging. In addition, the information available can sometimes seem conflicting. Below are some terms and definitions that may be helpful to understand.
Table 1: Summary of different types of pregnancy and neonatal loss
What are some signs of grief?
Some readers may have heard of the five stages of grief. This model for how people experience and process grief was developed by Elisabeth Kübler-Ross in the 1960xxxv and is a widely believed theory that people will go through distinct stages of denial, anger, bargaining, depression, and acceptance while grieving. However, research into grief shows that the grieving process is not so simple.xxxvi Every person will have a unique experience of loss because of factors like lived experience, personal beliefs, religious beliefs and practices, cultural background, support systems, and life stressors. How people experience grief can vary and there is no one theory about stages of grief that has been able to entirely account for how people cope with loss, why they experience varying degrees and types of distress at different times, and how or when they adjust to a life without their loved one over time.xxxvii
It is important that individuals avoid comparing their own experience to that of other people, as grief can manifest in many ways, and these manifestations can come and go over time. Mental Health Professionals’ separate grief into acute or typical grief (occurring from the loss itself to six months afterwards), and prolonged grief (from six months onwards).xxxviii,xxxix
Some of the emotional signs of grief include tearfulness and sadness.xl While some of the symptoms of grief can look like the symptoms of depression, they are distinct - normal or typical grief can be profound, but it is different from prolonged grief disorder, depression or other mental health problems .xli,xlii Feelings of anger are normal as well,xliii as is searching for reasons why a loss occurred. Grief can also manifest in physical symptoms, including insomnia and other sleep disturbances, raised blood pressure, and immune system changes.xliv Even though all these emotional and physiological responses to grief are normal, it is important to speak to a health care provider if experiencing significant changes in mood and/or physical wellbeing.
Does everyone grieve pregnancy loss?
Grief after a miscarriage
Although more research on grief after miscarriage is needed, the studies that have been completed show that many people experience intense grief after an early pregnancy loss.xlv,xlvi Sometimes a person will feel guilty about how sad they feel, as if perhaps they should not feel as bad as they would if a grown person had died, or if they had been further along in their pregnancy. It is important to remember that all expressions of grief are valid and normal, no matter when a loss occurs.xlvii Because most miscarriages occur before most people share the news that they are pregnant,xlviii it may be difficult to speak to friends and loved ones about what happened; it may be hard to announce a pregnancy and a loss at the same time.
For some, it can feel as though others downplay the experience of grief; even some physicians and care providers may appear dismissive of how that person is feeling, and not provide much information on how to cope with pregnancy loss.xlix,l,li Conversely, a person who experiences a miscarriage may not feel much, or any grief, and this is normal too.
Grief may be felt right away, weeks, months, or years later, or not at all. Sometimes special dates can provoke feelings of grief, such as the date that would have been the baby’s due date, or the anniversary of the miscarriage.lii
It can be hard to find people who validate and support the experience of grief after a miscarriage, either when it happens or later; see below for some support strategies that might be helpful. Remember, no two experiences of loss will be the same, and however grief feels is valid.
Grief after the termination of a pregnancy
When a wanted pregnancy ends in a termination, women can experience grief in the same way as if they experienced a miscarriage or other loss, with many reporting feelings of guilt or self-blame.liii Research shows that as time passes, feelings of “doubt, guilt, failure, shame, anger, anxiety, and relief” tend to diminish over time.liv However, like miscarriages, the same feelings (at varying levels of intensity) may recur in the future.
Grief after a stillbirth or perinatal loss
There is some research that exists related to grief for those who have experienced perinatal loss, which overwhelmingly shows that intense grief is common,lv,lvi,lvii but there are limitations to the research that exists. More research is needed to explore grief after a stillbirth or infant loss, and to explore how best to support those who have experienced it, as they can be at risk of developing complicated grief disorders.lviii,lix
How to cope with miscarriage, early pregnancy loss, and later-stage pregnancy loss
While everyone processes loss in their own way, and everyone experiences grief in their own way, there are some strategies below that people may find helpful along their journey.
Support groups
Sharing one’s experience with others who have also experienced pregnancy loss can help people feel less isolated and provide a safe space to discuss their feelings.lx Support groups can also be helpful for those who are pregnant after a loss and may be feeling anxious.lxi Those interested in finding a support group should seek out one from a well-established organization, such as the Pregnancy and Infant Loss (PAIL) Network in Canadalxii or Postpartum Support International in the United States.lxiii
Counseling/Therapy
Psychological interventions such as individual psychotherapy may be helpful for those who have experienced pregnancy loss. Research has shown that psychological support is beneficial for people experiencing depression or anxiety.lxiv,lxv For those that feel it is helpful, they can speak to a fertility-aware or perinatal loss trained counselor. Some examples of support organizations to consult include Postpartum Support,lxvi the PAIL network in Canada,lxvii or one can search online for local therapists who indicate experience counseling those who have experienced loss.
Journaling
For individuals that find it challenging to speak to others about their experiences, writing about their loss in a journal, with or without directed writing prompts, may be useful. This type of writing, or journaling, has been shown to be helpful for some bereaved people.lxviii,lxix
Expressive writing and gratitude journaling are two forms of journaling used in psychotherapy. While there is not much research available regarding the use of journaling as a tool to help process grief following a pregnancy or perinatal loss, it might be a way to express feelings in a safe and private manner.lxx
Although the supporting evidence is not directly related to pregnancy loss grief, the effective use of journaling to help cope with other areas of mental health, such as other types of bereavement, depression, and PTSD, has been reported.lxxi,lxxii
Rituals
There are few to no rituals to recognize pregnancy loss in most cultures, and because there is no organized recognition of the loss and grief of pregnancy loss, this type of grief is often called disenfranchised grief. lxxiii Most cultures have rituals to recognize a loss, such as a funeral or memorial service. For people who have experienced a pregnancy loss, they may feel isolated and lack a way to process their grief. One way to process grief is to create a ritual to recognize the loss and provide a structure to their mourning when one does not already exist in their culture. Rituals can vary widely, but some type of acknowledgement of the loss can be helpful in processing grief.lxxiv
Social supports
When a woman is grieving after a miscarriage, there is some research that suggests that those who have more social support and who do not have previous diagnoses of depression or anxiety are better able to cope with the psychological distress from grief after a miscarriage.lxxv Family and friends may not know what to say and may not understand grief associated with miscarriage. People may inadvertently say hurtful things, like “you’re young, you can always try again,” or “it just wasn’t meant to be,” which can cause more distress for grieving parents.
For those who already have children, they can of course understand when a parent or parents are sad.lxxvi It is important to be curious about how your child may be interpreting what is happening as they may be able to understand (or may have heard) more than you realized. Organizations such as PAIL have information on how to talk to and support children about pregnancy loss grief.
Although it is not the patient’s responsibility to educate others about loss, they can consider giving their loved ones resources about miscarriage or perinatal loss to help them better understand what they are going through, and what others can do to support that person through their grief.lxxvii
Conclusion
Pregnancy loss, whether through miscarriage, stillbirth, or infant loss, is a profoundly personal and often isolating experience. Despite its frequency, the journey through grief is unique for everyone, influenced by personal, cultural, and social factors. It is crucial to acknowledge the validity of all expressions of grief and to provide comprehensive support. Strategies such as joining support groups, seeking professional counseling, journaling, creating rituals and leaning on social support can offer significant comfort and aid in the healing process. By fostering open conversations and understanding, we can all better support those navigating the complex emotions associated with pregnancy loss.
i Quenby, S., et al. (2021). Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet (London, England), 397(10285), 1658–1667. https://doi.org/10.1016/S0140-6736(21)00682-6
ii Linnakaari, R., et al. (2019). Trends in the incidence, rate and treatment of miscarriage—nationwide register-study in Finland, 1998–2016. Human Reproduction. https://doi.org/10.1093/humrep/dez211
iii Strumpf, E., et al. (2021). Prevalence and clinical, social, and health care predictors of miscarriage. BMC Pregnancy and Childbirth, 21(1). https://doi.org/10.1186/s12884-021-03682-z
iv McCarthy, C., et al. (2020). The general populations’ understanding of first trimester miscarriage: A cross sectional survey. European Journal of Obstetrics & Gynecology and Reproductive Biology, 254, 200-205. https://doi.org/10.1016/j.ejogrb.2020.08.042
v Linnakaari, R., et al. (2019). Trends in the incidence, rate and treatment of miscarriage—nationwide register-study in Finland, 1998–2016. Human Reproduction. https://doi.org/10.1093/humrep/dez211
vi Reinebrant, H., et al. (2017). Making stillbirths visible: A systematic review of globally reported causes of stillbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 125(2), 212-224. https://doi.org/10.1111/1471-0528.14971
vii Gregory, E., et al. (2022). Fetal Mortality: United States, 2020. National Vital Statistics Reports, 71(4). https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-04.pdf
viii Rosenstein, M. G., et al. (2012). Risk of stillbirth and infant death stratified by gestational age. Obstetrics and Gynecology, 120(1), 76–82. https://doi.org/10.1097/AOG.0b013e31825bd286
ix Rosenstein, M. G., et al. (2012). Risk of stillbirth and infant death stratified by gestational age. Obstetrics and Gynecology, 120(1), 76–82. https://doi.org/10.1097/AOG.0b013e31825bd286
x Pathirana, J., et al. (2016). Neonatal death: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine, 34(49), 6027–6037. https://doi.org/10.1016/j.vaccine.2016.03.040
xi Mergl, R., et al. (2022). Grief in women with previous miscarriage or stillbirth: a systematic review of cross-sectional and longitudinal prospective studies. European journal of psychotraumatology, 13(2), 2108578. https://doi.org/10.1080/20008066.2022.2108578
xii Heazell, A. E. P., et al. (2016). Stillbirths: economic and psychosocial consequences. Lancet (London, England), 387(10018), 604–616. https://doi.org/10.1016/S0140-6736(15)00836-3
xiii Reinebrant, H., et al. (2017). Making stillbirths visible: A systematic review of globally reported causes of stillbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 125(2), 212-224. https://doi.org/10.1111/1471-0528.14971
xiv Gregory, E., et al. (2022). Fetal Mortality: United States, 2020. National Vital Statistics Reports, 71(4). https://www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-04.pdf
xv Rosenstein, M. G., et al. (2012). Risk of stillbirth and infant death stratified by gestational age. Obstetrics and Gynecology, 120(1), 76–82. https://doi.org/10.1097/AOG.0b013e31825bd286
xvi Clement, E. G., et al. (2019). The Language of First-Trimester Nonviable Pregnancy: Patient-Reported Preferences and Clarity. Obstetrics and gynecology, 133(1), 149–154. https://doi.org/10.1097/AOG.0000000000002997
xvii Van den Berg, M. M., et al. (2012). Genetics of early miscarriage. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease, 1822(12), 1951-1959. https://doi.org/10.1016/j.bbadis.2012.07.001
xviii Kelly, K., et al. (2021). A review of stillbirth definitions: A rationale for change. European Journal of Obstetrics & Gynecology and Reproductive Biology, 256, 235-245. https://doi.org/10.1016/j.ejogrb.2020.11.015
xix Tavares Da Silva, F., et al. (2016). Stillbirth: Case definition and guidelines for data collection, analysis, and presentation of maternal immunization safety data. Vaccine, 34(49), 6057-6068. https://doi.org/10.1016/j.vaccine.2016.03.044
xx NICE. (2019, April 17). Ectopic pregnancy and miscarriage: Diagnosis and initial management. Retrieved August 9, 2024, from https://www.nice.org.uk/guidance/ng126
xxi Kolte, A. M., et al. (2015). Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group. Human Reproduction, 30(3), 495-498. https://academic.oup.com/humrep/article/30/3/495/659554?login=false
xxii Kolte, A. M., et al. (2015). Terminology for pregnancy loss prior to viability: a consensus statement from the ESHRE early pregnancy special interest group. Human Reproduction, 30(3), 495-498. https://academic.oup.com/humrep/article/30/3/495/659554?login=false
xxiii ACOG practice bulletin No. 200: Early pregnancy loss. (2018). Obstetrics & Gynecology, 132(5), e197-e207. https://doi.org/10.1097/aog.0000000000002899
xxiv Wu, H. L., et al. (2017). Misoprostol for medical treatment of missed abortion: a systematic review and network meta-analysis. Scientific reports, 7(1), 1664. https://doi.org/10.1038/s41598-017-01892-0
xxv And file:///C:/Users/Sorton/Downloads/ICMART_dex234%20(1).pdf
xxvi Annan, J. J., et al. (2013). Biochemical pregnancy during assisted conception: a little bit pregnant. Journal of clinical medicine research, 5(4), 269–274. https://doi.org/10.4021/jocmr1008w
xxvii Kelly, K., et al. (2021). A review of stillbirth definitions: A rationale for change. European journal of obstetrics, gynecology, and reproductive biology, 256, 235–245. https://doi.org/10.1016/j.ejogrb.2020.11.015
xxviii Stillbirth Collaborative Research Network Writing Group (2011). Causes of death among stillbirths. JAMA, 306(22), 2459–2468. https://doi.org/10.1001/jama.2011.1823
xxix Barfield, W. D., & Committee on Fetus and Newborn (2011). Standard terminology for fetal, infant, and perinatal deaths. Pediatrics, 128(1), 177–181. https://doi.org/10.1542/peds.2011-1037
xxx Barfield, W. D., & Committee on Fetus and Newborn (2011). Standard terminology for fetal, infant, and perinatal deaths. Pediatrics, 128(1), 177–181. https://doi.org/10.1542/peds.2011-1037
xxxi Perrone, s., et al. (2021). Sudden Infant Death Syndrome: Beyond Risk Factors. Life, 11(3), 184. https://doi.org/10.3390/life11030184
xxxii Pathirana, J., et al. (2016). Neonatal death: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine, 34(49), 6027-6037. https://doi.org/10.1016/j.vaccine.2016.03.040
xxxiii Rosenstein, M. G., et al. (2012). Risk of stillbirth and infant death stratified by gestational age. Obstetrics and Gynecology, 120(1), 76–82. https://doi.org/10.1097/AOG.0b013e31825bd286
xxxiv Barfield, W. D., & Committee on Fetus and Newborn (2011). Standard terminology for fetal, infant, and perinatal deaths. Pediatrics, 128(1), 177–181. https://doi.org/10.1542/peds.2011-1037
xxxv Kübler-Ross, E. (2011). On Death and Dying. Scribner. Retrieved from https://www.perlego.com/book/778497/on-death-and-dying-pdf
xxxvi Stroebe, M., et al. (2017). Cautioning Health-Care Professionals. Journal of Death and Dying, 74(4), 455-473. https://doi.org/10.1177/0030222817691870
xxxvii Zisook, S., & Shear, K. (2009). Grief and bereavement: what psychiatrists need to know. World psychiatry : official journal of the World Psychiatric Association (WPA), 8(2), 67–74. https://doi.org/10.1002/j.2051-5545.2009.tb00217.x
xxxviii O'Connor M. F. (2019). Grief: A Brief History of Research on How Body, Mind, and Brain Adapt. Psychosomatic medicine, 81(8), 731–738. https://doi.org/10.1097/PSY.0000000000000717
xxxix American Psychiatric Association, D. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi/book/10.1176/appi.books.9780890425596
xl Zisook, S.,et al. (2014). Bereavement: course, consequences, and care. Current psychiatry reports, 16(10), 482. https://doi.org/10.1007/s11920-014-0482-8
xli Bui, E., et al. (2012). Pharmacological approaches to the treatment of complicated grief: rationale and a brief review of the literature. Dialogues in Clinical Neuroscience, 14(2), 149–157. https://doi.org/10.31887/DCNS.2012.14.2/ebui
xlii Mergl, R., et al. (2022). Grief in women with previous miscarriage or stillbirth: a systematic review of cross-sectional and longitudinal prospective studies. European journal of psychotraumatology, 13(2), 2108578. https://doi.org/10.1080/20008066.2022.2108578
xliii Cacciatore J. (2013). Psychological effects of stillbirth. Seminars in fetal & neonatal medicine, 18(2), 76–82. https://doi.org/10.1016/j.siny.2012.09.001
xliv Buckley, T., et al. (2012). Physiological correlates of bereavement and the impact of bereavement interventions. Dialogues in clinical neuroscience, 14(2), 129–139. https://doi.org/10.31887/DCNS.2012.14.2/tbuckley
xlv Brier N. (2008). Grief following miscarriage: a comprehensive review of the literature. Journal of women's health (2002), 17(3), 451–464. https://doi.org/10.1089/jwh.2007.0505
xlvi Mergl, R., et al. (2022). Grief in women with previous miscarriage or stillbirth: a systematic review of cross-sectional and longitudinal prospective studies. European journal of psychotraumatology, 13(2), 2108578. https://doi.org/10.1080/20008066.2022.2108578
xlvii Meaney, S., et al. (2017). Experience of miscarriage: an interpretative phenomenological analysis. BMJ open, 7(3), e011382. https://doi.org/10.1136/bmjopen-2016-011382
xlviii Quenby, S., et al. (2021). Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet (London, England), 397(10285), 1658–1667. https://doi.org/10.1016/S0140-6736(21)00682-6
xlix Filippa, S., et al. (2024). Do miscarriage care practice recommendations align with individuals’ needs?: A scoping review. Contraception, 136, 110448. https://doi.org/10.1016/j.contraception.2024.110448
l Quenby, S., et al. (2021). Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet (London, England), 397(10285), 1658–1667. https://doi.org/10.1016/S0140-6736(21)00682-6
li Brier N. (1999). Understanding and managing the emotional reactions to a miscarriage. Obstetrics and Gynecology, 93(1), 151–155. https://doi.org/10.1016/s0029-7844(98)00294-4
lii DeMontigny, F., et al. (2017). Women’s persistent depressive and perinatal grief symptoms following a miscarriage: The role of childlessness and satisfaction with healthcare services. Archives of Women's Mental Health, 20(5), 655-662. https://doi.org/10.1007/s00737-017-0742-9
liii Maguire, M., et al. (2015). Grief after second-trimester termination for fetal anomaly: A qualitative study. Contraception, 91(3), 234-239. https://doi.org/10.1016/j.contraception.2014.11.015
liv Geerinck-Vercammen, C. R., & Kanhai, H. H. (2003). Coping with termination of pregnancy for fetal abnormality in a supportive environment. Prenatal diagnosis, 23(7), 543–548. https://doi.org/10.1002/pd.636
lv Obst, K. L., et al. (2021). Factors contributing to men's grief following pregnancy loss and neonatal death: further development of an emerging model in an Australian sample. BMC pregnancy and childbirth, 21(1), 29. https://doi.org/10.1186/s12884-020-03514-6
lvi Goldstein, R. D., et al. (2018). The Grief of Mothers After the Sudden Unexpected Death of Their Infants. Pediatrics, 141(5), e20173651. https://doi.org/10.1542/peds.2017-3651
lvii Mergl, R., et al. (2022). Grief in women with previous miscarriage or stillbirth: a systematic review of cross-sectional and longitudinal prospective studies. European journal of psychotraumatology, 13(2), 2108578. https://doi.org/10.1080/20008066.2022.2108578
lviii Kersting, A., & Wagner, B. (2012). Complicated grief after perinatal loss. Dialogues in clinical neuroscience, 14(2), 187–194. https://doi.org/10.31887/DCNS.2012.14.2/akersting
lix Goldstein, R. D., et al. (2018). The Grief of Mothers After the Sudden Unexpected Death of Their Infants. Pediatrics, 141(5), e20173651. https://doi.org/10.1542/peds.2017-3651
lx Gold, K. J., et al. (2022). Online Support Groups for Perinatal Loss: A Pilot Feasibility Study for Women of Color. Cyberpsychology, behavior and social networking, 25(8), 534–539. https://doi.org/10.1089/cyber.2021.0304
lxi Côté-Arsenault, D., & Freije, M. M. (2004). Support groups helping women through pregnancies after loss. Western journal of nursing research, 26(6), 650–670. https://doi.org/10.1177/0193945904265817
lxii Sunnybrook Pregnancy and Infant Loss Network. (2024, April 16). Peer support programs. PAIL Network. https://pailnetwork.sunnybrook.ca/programs-for-parents/
lxiii Postpartum Support International (PSI). (2023, March 16). Loss & grief in pregnancy & postpartum. https://www.postpartum.net/get-help/loss-grief-in-pregnancy-postpartum/
lxiv Hunot, V., et al. (2007). Psychological therapies for generalised anxiety disorder. The Cochrane database of systematic reviews, 2007(1), CD001848. https://doi.org/10.1002/14651858.CD001848.pub4
lxv Ijaz, S., et al. (2018). Psychological therapies for treatment-resistant depression in adults. Cochrane Database of Systematic Reviews, 2018(5), Article CD010558. https://doi.org/10.1002/14651858.CD010558.pub2
lxvi Postpartum Support International (PSI). (2023, March 16). Loss & grief in pregnancy & postpartum. https://www.postpartum.net/get-help/loss-grief-in-pregnancy-postpartum/
lxvii Sunnybrook Pregnancy and Infant Loss Network. (2024, April 16). Peer support programs. PAIL Network. https://pailnetwork.sunnybrook.ca/programs-for-parents/
lxviii Lichtenthal, W. G., & Cruess, D. G. (2010). Effects of directed written disclosure on grief and distress symptoms among bereaved individuals. Death studies, 34(6), 475–499. https://doi.org/10.1080/07481187.2010.483332
lxix Frattaroli, J. (2006). Experimental disclosure and its moderators: A meta-analysis. Psychological Bulletin, 132(6), 823–865. https://doi.org/10.1037/0033-2909.132.6.823
lxx Sohal, M., et al. (2022). Efficacy of journaling in the management of mental illness: A systematic review and meta-analysis. Family Medicine and Community Health, 10(1), e001154. https://doi.org/10.1136/fmch-2021-001154
lxxi Sohal, M., et al. (2022). Efficacy of journaling in the management of mental illness: a systematic review and meta-analysis. Family medicine and community health, 10(1), e001154. https://doi.org/10.1136/fmch-2021-001154
lxxii Taking Pen to Hand: Evaluating Theories Underlying the Written Disclosure Paradigm. Clinical Psychology: Science and Practice, 11(2), 121–137. https://doi.org/10.1093/clipsy.bph062
lxxiii Doka, K. J. (2002). Disenfranchised grief: New directions, challenges, and strategies for practice.
lxxiv Wojtkowiak, J., et al. (2021). Ritual in Therapy for Prolonged Grief: A Scoping Review of Ritual Elements in Evidence-Informed Grief Interventions. Frontiers in psychiatry, 11, 623835. https://doi.org/10.3389/fpsyt.2020.623835
lxxv Lee, C., & Rowlands, I. J. (2015). When mixed methods produce mixed results: integrating disparate findings about miscarriage and women's wellbeing. British journal of health psychology, 20(1), 36–44. https://doi.org/10.1111/bjhp.12121
lxxvi Supporting siblings after pregnancy or infant loss. (n.d.). Sunnybrook Pregnancy and Infant Loss Network. https://pailnetwork.sunnybrook.ca/wp-content/uploads/2020/02/PAIL-Book3-Sibling-final3.pdf
lxxvii Sunnybrook Pregnancy and Infant Loss Network. (2024, May 2). Resource library. PAIL Network. https://pailnetwork.sunnybrook.ca/resource-library/
