The hidden grief of miscarriage

For women and their partners coping with pregnancy loss, the sense of isolation can be acute and emotionally debilitating.

Unlike with other losses, there are often no funerals or other rituals to gather with loved ones as the bereaved parents strive to process the tumult of their emotions. Their feelings might range from shame and guilt—that they somehow caused the miscarriage or stillbirth—to sadness over a future forever lost for their child and themselves, said Julie Bindeman, PsyD, a reproductive psychologist in Rockville, Maryland. Meanwhile, they must navigate a culture that’s often phobic about crying and grief and might view the loss of a pregnancy as less significant than other types of deaths, she said.

“The idea that continues to be pervasive to a degree is that the less time that you have spent with the [developing] baby, the less emotional attachment a person should have to it, and thus a shorter grieving period [is needed],” said Bindeman, a former cochair of the Committee on Reproductive Issues for APA Division 35 (Society for the Psychology of Women). “And yet what people tend not to understand is that oftentimes a pregnancy is a realization of a dream that might have started in a person’s childhood.”

Moreover, given that a miscarriage can be difficult to distinguish from an abortion, the potential stakes for those who are grieving can extend beyond the emotional following the Supreme Court’s Dobbs decision and related state laws criminalizing abortion, said Bindeman, echoing a point also made by other psychologists. “Now to have to deal with fear that you might be charged for a crime,” she said. “That’s a totally different ballpark.”

Between 10% and 20% of known pregnancies end in miscarriageopens in new window, according to the March of Dimes. Stillbirth, defined as a pregnancy loss at 20 weeks of gestation or later, occurs in roughly 1 out of every 160 U.S. pregnanciesopens in new window. These bereaved parents, particularly the mother, might live with perinatal grief that persists for years, even after the subsequent delivery of another baby, including symptoms of depression, anxiety, and trauma (Markin, R. D., Psychotherapy, Vol. 54, No. 4, 2017opens in new window). Yet researchers are only now starting to delve into how clinicians can better understand and support the individuals involved as they attempt to process the reproductive trauma and often disenfranchised grief.

How well women and their partners cope depends on various factors, including their attachment style, how they ruminate over the loss, to what extent they disclose the loss to others, and in turn how those friends and family respond, according to reproductive psychologists and researchers. (Pregnancies occur primarily but not exclusively in individuals who identify as women.) Individuals who are in same-sex relationships or who are not part of a couple might face additional challenges and stigma, depending upon the extent to which their loved ones and broader community supported their pregnancy dreams.

[Related: Healing the wounds of pregnancy loss]

Amid the isolation, a psychologist might be among the first people with whom the individuals involved speak freely, said psychologist Rayna D. Markin, PhDopens in new window, an associate professor in counseling at Villanova University and the author of Psychotherapy for Pregnancy Loss: Applying Relationship Science to Clinical Practiceopens in new window (Oxford University Press, 2024). Psychologists can provide a safe and trusting relationship, along with normalization and validation of their perinatal grief, and through psychotherapy help them over time to process and grow in the wake of the traumatic loss, she said.

That therapeutic process involves “emotional holding,” Markin said. “I hear a lot of really devastating and shocking stories of loss. It’s about the therapist being able to tolerate and join the patient in their experience of loss, which often involves sitting with the horrors of the loss without seeming overwhelmed or withdrawing. It requires being able to really hang in there with the patient.”

Holly Ann Abel first sought out therapy a few months after her daughter Magnolia was stillborn in January 2021 at nearly 32 weeks. Abel struggled with grief and depression, followed by panic attacks.

“I felt extremely isolated,” said the 29-year-old, who lives in Lawrence, Kansas. “I was surrounded by family members and friends who loved me and wanted to support me. But none of them could walk in my shoes.”

People are prone to seek therapeutic help more quickly if the loss involves a stillbirth, said Bindeman, who also serves as chair-elect for the Mental Health Professional Group of the American Society for Reproductive Medicine. When the baby is lost earlier in the pregnancy, particularly if the miscarriage occurs in the first trimester, friends or relatives may send subtle or overt messages as the months progress that the would-be parents should be on more of a recovery trajectory. Patients will say, Bindeman recounted, “I’ve been told that I shouldn’t be sad about it anymore. But I’m still sad. So what’s wrong with me?”

But research has shown that the intensity and duration of grief are not necessarily driven by the duration of the pregnancy but rather by the woman’s attachment to the pregnancy and to what extent she perceived the developing baby as a person rather than a fetus. One recent study, involving 227 women who had experienced miscarriages, found that three fourths of the women strongly perceived the pregnancy/fetus as a person (Freedle, A., & Oliveira, E., Traumatology, Vol. 28, No. 4, 2022opens in new window).

Some patients might have suffered pregnancy losses many years before seeing a practitioner but didn’t work through their emotions at the time, said Dorienna Alfred, PhD, PMH-C, a psychologist and certified perinatal mental health therapist in Gahanna, Ohio.

She also has authored a book about her own experience, Pregnant With Promise: A Spiritual Journey of Pregnancy, Bedrest, and Childbirthopens in new window (Works of Faith, 2019). Psychologists should routinely ask new patients about their reproductive history as part of the intake process, she said, even if they are coming in for seemingly unrelated reasons. In her intake forms, Alfred asks about any history of pregnancy, including the number of live births, as well as any infertility treatment. When patients do report a prior loss, psychologists should not move along without asking additional questions, Alfred said. These might include, “In what ways does your loss affect you now? What was your experience of grieving that loss and having support?”

Adopt a trauma lens when working with these patients, suggested Elia E. Villalobos Soto, PsyD, PMH-C, a clinical health psychologist in Tampa, Florida, who also is a board member of the Women’s Health Interest Group of APA Division 38 (Society for Health Psychology). “These experiences can be traumatic,” she said. “If it happened in a hospital setting, ask how did they feel in that moment. Maybe they felt like no one was listening to them.”

It’s also important for psychologists to gain a sense of the broader cultural context around pregnancy and parenthood, whether that’s rooted in religious faith or ethnic/racial heritage, Villalobos said. For instance, the Hispanic/Latino culture can place a particularly high value on child-bearing, she said. “That’s why it’s taboo sometimes to talk about the loss or infertility issues.”

The urge to “fix” the grief of pregnancy loss is a human tendency, even among psychologists, Alfred said. She pursued certification as a perinatal mental health therapist after her son Joshua was born too early at 19 weeks, followed by difficult pregnancies.

“And, quite honestly, if you’ve had a loss that really is unimaginable, you may not be OK,” said Alfred, who has two living sons. “As a psychologist, we have to learn to hold space for people who just are not OK.”

Abel said her first therapist tended to offer strategies that seemed to minimize her emotions. They were still meeting when Abel learned that she was pregnant again with her living daughter, Marigold (“Goldie”), who is now 2.5 years old. Her anxieties and fears ramped into hyperdrive. “I very much felt like it was my full-time job to keep this baby alive,” she said.

When Abel tried to share her acute pregnancy fears, the therapist suggested unrealistic strategies that Abel felt didn’t address the scale of her worry and grief. She stopped seeing the therapist after she realized that she was dreading the appointments.

Along with coping with often disenfranchised grief, bereaved parents might also be suffering from reproductive trauma, said Agata Freedle, PhD, an assistant professor in the counseling program at the University of Missouri–St. Louis and a counselor educator. “Because we don’t believe that children should die before their parents, it shakes our core beliefs or assumptions,” she said.

In research involving 227 women who had experienced miscarriage, Freedle looked at what coping strategies and resilience factors contributed to their posttraumatic growth, exploring the relationship between self-disclosure of the loss, positive social reactions, and rumination. Freedle and her research colleague found a correlation between self-disclosure and the positive social reactions that the women received in fostering their posttraumatic growth. Moreover, deliberative rumination—a cognitive process in which the individuals attempt to integrate the traumatic experience into their life narrative over time—mediated the relationship between positive social reactions and posttraumatic growth, according to the study’s findings (Traumatology, Vol. 28, No. 4, 2022opens in new window).

Psychologists can also help patients work through how the pregnancy loss has impacted their lives in other ways, Markin said. For instance, a doctor might have become adept at suppressing feelings of trauma and loss to cope with treating terminally ill patients. But in the wake of a miscarriage, she might find herself suddenly overwhelmed by feelings of trauma and loss and realize that her typical coping strategies were no longer working, Markin said.

When the baby’s death occurs after the first trimester, or the baby is stillborn, the parents might decide to gather with loved ones for a funeral or other type of ceremony, said Abel, who now works with bereaved parents. But even in the absence of traditional rituals, patients can develop their own ways to mourn or remember their babies, such as creating jewelry or filling a memory box, psychologists said. (While some couples might describe their pregnancy as a baby, others might refer to it as a fetus, and the psychologist should defer to the language that the patient prefers, Bindeman noted.) Or patients might find it helpful to write a letter to the baby who has died to help them better crystallize what or whom they are mourning, Markin said.

“Oftentimes patients will express sorrow, regret, or guilt about not being able to keep their baby safe,” Markin said. Other times, she said, they might write about their sadness over a future forever lost. “‘I’m sorry I never got to hold you. I’m sorry that we never got to celebrate the holidays together. That I never got to see you crawl. I never got to hear your first words.’”

Freedle, who started her pregnancy loss research after experiencing two miscarriages, also sought out therapeutic help. Over time, she has built a memory box that includes a pregnancy test, an ultrasound picture, and a poem that she received from hospital staffers. She also carries with her the memories of her two lost babies on a necklace chain, from which hangs a nest with two eggs nestled within.

Researchers understand even less about the impact of the loss on the male partner in heterosexual relationships, and the experiences of gay and transgender men have been largely overlooked in research studies. One systematic review, which identified 29 studies, found that men were less likely to have intense and long-lasting negative psychological outcomes than their female partners but more likely to engage in compensatory behaviors, such as increased alcohol consumption. One common coping mechanism involved avoidance behaviors, such as emotionally withdrawing or immersing themselves in work (Due, C., et al., BMC Pregnancy and Childbirth, Vol. 17, 2017opens in new window).

Bindeman warns couples that while they might grieve similarly during the acute phase, over time they might process their emotions in different ways that can lead to one feeling isolated or lonely. Some people are more intuitive grievers, openly expressing feelings, while others might be more instrumental grievers, disappearing into a project like woodworking to feel productive, she said. “It can be really difficult when you have a couple, and each of them has one of those tendencies.”

When the miscarriage happens before the couple has shared their pregnancy with loved ones, they might grieve in their own isolated bubble, placing a heightened importance on the relationship’s resiliency, psychologists said. One qualitative study, based on a total of 18 interviews with six couples following a miscarriage, found reason for optimism despite the inherent stress. All six couples, who were interviewed both together and individually, reported greater strength in their relationship in the wake of the loss, and five of the couples felt the experience “brought them closer” (Heifner, A. R., Family Relations: Interdisciplinary Journal of Applied Family Science, Vol. 70, No. 1, 2021opens in new window).

In another study, Freedle surveyed 244 women, most of them in heterosexual relationships, to gain insights into their interactions with their partner following a miscarriage or stillbirth. The analysis found that women who already had a secure attachment style prior to the loss showed higher levels of dyadic coping—a process in which both partners are mutually engaged in coping—and higher levels of posttraumatic growth (Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 16, No. 2, 2024opens in new window). In short, they were more willing to lean on their partner, gaining emotional or logistical support, Freedle said.

The pregnancy loss can also impact the couple’s sexual life, something that psychologists should ask about, said David Allsop, MS, CFLE, a doctoral candidate in psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia. “The meanings behind sex may have changed,” he said. “Maybe it used to be something positive and now it’s a painful reminder of their loss.”

In a recent study, Allsop and research colleagues compared sexual well-being levels in both partners of 103 couples who had experienced a pregnancy loss in the prior 4 months to a control sample of 120 couples with no history of pregnancy loss. They found that gestational individuals and their partners in the pregnancy loss group were less sexually satisfied than their control counterparts. But they did not differ from the control group in terms of sexual desire, and, in fact, partners of gestational individuals were less distressed about sex than partners in the control group (Archives of Sexual Behavior, Vol. 53, No. 1, 2024opens in new window).

Individuals in same-sex relationships face additional challenges following loss, even if their broader community supported the pregnancy, psychologists said. “A challenge for same-sex couples is that family building is always an inherently intentional process—you can’t just casually try again,” said Sarah Holley, PhD, a psychologist and a health sciences assistant clinical professor who works at the Center for Reproductive Health based at the University of California, San Francisco and studies risk factors for psychological distress during fertility treatment.

When working with these bereaved couples, psychologists should guard against applying any heterosexual framing to make assumptions in terms of the individuals’ emotional reactions or roles within the relationship, Holley said. They should also step carefully in terms of well-meaning efforts to problem solve, such as suggesting to a woman in a same-sex couple that maybe her partner should try carrying the baby next time instead, she said. “The whole process they decided for a reason, and there are feelings that go along with being the carrier or whose eggs to use,” she said. “And it’s not an interchangeable system—there was a reason they made the choices that they made in the first place.”

Parents’ grief involving perinatal loss can recede over time but can still extend for years afterward, potentially overlapping with when they conceive again, according to a recent review that identified seven related studies (Donegan, G., et al., Midwifery, Vol. 121, 2023opens in new window). Addressing unresolved grief and trauma is particularly important given the high likelihood of a subsequent pregnancy, Freedle noted. “If you have unresolved PTSD, anxiety, or depression, that has the potential to impact future pregnancy and your relationship with the future child,” she said.

Some individuals suffer more than one miscarriage, though it’s rarer, with fewer than 5 out of every 100 people having two miscarriages in a row, according to the American College of Obstetricians and Gynecologists. For people who have weathered one or more losses, that next positive pregnancy test can understandably reignite fears and anxieties related to prior losses, Bindeman said. No longer do they have any naivete about the risks involved with every pregnancy, she said.

“Anxiety is a feature, not a bug,” Bindeman said. “If someone who is pregnant after loss isn’t anxious, I’m worried about them. I wonder if they’re disassociating from the pregnancy.”

Bindeman reminds patients that although they have experienced a loss, not all pregnancies end in that manner. She works to keep them focused on the here and now and develop related mantras, such as: “Based upon what I know today, I am still pregnant.”

Abel lost another baby, delivered during a miscarriage in the first trimester, after her daughter Goldie was born. By then, she was already working with her current therapist, who helped her reconnect with her body, learning to tie her grief to physical symptoms. These days, she helps others walking in her shoes. She wrote a children’s book, Some Babies, and works for Return to Zero: HOPE, a nonprofit organization for bereaved parents that provides resources for health professionalsopens in new window.

With time and therapy, Abel has learned to wade into and breathe through the ocean of her grief without being pulled under by it. “But it’s also OK to get in the water and to experience all of these feelings,” she said, “because where there’s grief, there’s love. And sometimes if we honor our grief, that’s when we feel the most love. I know for me, that’s how I parent my babies is by honoring them.”