Fall 2024 Issue

Grief After Pregnancy Loss
By Scott Janssen, MA, MSW, LCSW
Social Work Today
Vol. 24 No. 4 P. 14

Men and women may grieve differently, and men’s suffering may go unacknowledged.

Carl vividly remembers the moment he and his wife, Sandra, were in the delivery room expecting the birth of their first child. “I knew something was wrong when I saw the look on the nurse’s face. When I heard the word ‘stillborn,’ it took a few seconds to register, then it was like a switch went off, and I couldn’t feel anything. Emotionally, I just went numb.”

In the weeks and months after the loss, Carl suppressed feelings of sadness, grief, and guilt, focusing instead on supporting Sandra. “I felt like I needed to be strong for her and didn’t think I had a right to be upset. She was the one who carried our baby inside her and had that heartbeat-to-heartbeat connection. Plus, I felt ashamed that I couldn’t protect her and hadn’t been able to save our child.”

In the United States, as many as one in four pregnancies end in miscarriage,1 and approximately one of every 175 pregnancies ends in stillbirth.2 Miscarriage refers to a loss before the end of the 20th week of pregnancy, whereas stillbirth refers to pregnancy losses occurring any time after, including during delivery. Neonatal death refers to the death of an infant within the first 28 days of life.

Most losses during pregnancy occur within the first three months. For that reason, symptoms indicating miscarriage may occur in women who are not yet aware they are pregnant.

Though individual responses vary, for many, grief after the loss of an infant through miscarriage or stillbirth can be intense and confusing.

The fact that such losses are often sudden and unexpected and may involve invasive medical care, as well as that they occur before parents are able to physically hold a living infant in their arms, can lead to complications during grief, such as increased risk for depression, anxiety, PTSD, and complicated bereavement.3,4

Pregnancy loss may leave parents to grieve not only the child they never had the opportunity to know and whose story they had only begun to tell (if only to themselves) but also the loss of a future they’d envisioned.

When miscarriage occurs in early pregnancy, those expecting a child may not even have informed family and friends of the pregnancy. Doing so after such a loss can feel painful and awkward. Some feel pressure to remain silent. Others find that their support networks do not know how to provide effective social and emotional support and may not recognize the significance of the loss.5

This can result in disenfranchised grief, or grief that is not acknowledged or understood by others and for which little or no social support is available, leaving parents feeling isolated without safe places to process complex thoughts, emotions, and beliefs; engage social support; or participate in grief-related rituals.

Different Ways of Grieving
Although grief after pregnancy loss can present similar challenges to men and women, there may be differences related to the nature of pregnancy, cultural expectations, and different grieving styles. The fact that a woman’s body has been physically connected to, bonded with, and protective of a pregnancy and may have been negatively affected by procedures related to a loss can be especially psychologically traumatic,6 and grief can be felt on deep somatic and emotional levels.

Existing social and mental health supports often focus on the mother, while the grief of men may go unacknowledged or dismissed. External and internal pressure for men to be “strong,” as well as cultural messages encouraging them to overcome challenges and control their emotions, can lead men to minimize or conceal their grief from others.7 They can also make it difficult for men to ask for and discourage others from offering emotional and psychological support.

According to Britta White, MSW, LCSW, a psychotherapist specializing in pregnancy loss, “Men may feel pressure to minimize or suppress their grief in order to ‘hold it together.’ They may be less likely to verbalize feelings and more likely to try to avoid grief or trauma by throwing themselves into tasks, work, or supporting a grieving partner. Some may use alcohol or substances in attempts to numb underlying emotional pain.”

A study analyzing research on the impact of pregnancy loss found that men tend to report less intense and less enduring levels of psychological distress than women do but are more likely to engage in negative “compensatory” behaviors such as increased alcohol consumption.

The analysis also found that “Men often feel that their role is primarily as a ‘supporter’ to their female partner and that this precludes recognition of their own loss. These studies also reported that men may feel overlooked and marginalized in comparison to their female partners, whose pain is typically more visible.”8

Obst et al refer to this combination of a man dismissing his grief as less important than that of a partner and an overall lack of recognition or support for his loss as a “double-disenfranchised grief in relation to the pregnancy/neonatal loss experience.”9

In general, grieving men may be less likely than women to talk about painful emotions and vulnerability. They may hold back tears, isolate themselves from others, or engage in more action-oriented forms of grief expression, such as exercising excessively or keeping busy.10

Underlying emotions like sadness, shame, or feelings of powerlessness may appear as impatience, anger, lack of concentration, emotional numbness, avoidance, or somatic symptoms like headaches or insomnia.

This masking and/or displacement of emotions, as well as the fact that men don’t share the same kind of physical connection with an expected infant, has caused some health care and mental health professionals, as well as normative cultural beliefs, to assume men do not significantly bond with an unborn child and do not grieve the loss, or that their grief is less intense.

Recent research, however, has found that such bonding can be significant and often begins early in a pregnancy.11 “It’s a misconception,” White says, “that a father does not have a strong bond with the unborn child. The early stages of pregnancy can foster a powerful emotional connection within men as they envision their future as fathers. The shattering of these dreams, even at an early stage, can be devastating.”

Although men may be less openly expressive of or more apt to deny or conceal their grief, they may be more vulnerable to feelings of despair and difficulty coping in the longer term as grief goes unprocessed and/or unsupported.7

White says some men who seek counseling don’t realize they are struggling with psychological trauma and/or grief. “They may show up concerned about new behaviors that have become problematic like increasing fatigue, irritability, difficulty concentrating, or social isolation, and may need help tracing these symptoms back and connecting them with the loss of their unborn child.”

It’s important, she says, to take time to build trust and “Establish a safe, nonjudgmental space in which a grieving father can name his grief and share thoughts, emotions, and concerns at a safe pace.”

This can help a father identify patterns of avoidance (eg staying busy), self-limiting cognitions that complicate bereavement (eg, “My grief doesn’t matter”; “I just need to pull it together”), and begin to process underlying emotional and psychological pain.

Psychoeducation about grief is also important, White says. “This can help fathers understand that there is no right way to grieve and that their grief responses are valid and important. It can also be helpful in identifying strengths and positive coping strategies, as well as helping Dad release feelings of guilt if he believes the loss was due to his inability to protect or provide.”

For Carl, simply having his counselor acknowledge and validate his grief was profound. “It was like I had permission to feel what I was feeling without having to explain it, without thinking I was weak or not able to hack it. For weeks, people had asked how Sandra was doing as though I didn’t exist. It made me think my grief didn’t matter.”

Janet Jaffe, PhD, cofounder of the Center for Reproductive Psychology, says one of the core challenges of pregnancy loss is that “Losing a pregnancy is a loss of the future rather than the past.” A parent does not have memories of time with their child to look back on, stories to tell, or photographs to cherish. “With a pregnancy loss, you only have what’s in your imagination. The story you have in your head about that future child just vanishes.”4

A Reproductive Story
To help grieving parents, Jaffe uses the concept of a “reproductive story” that places the loss into a larger frame by exploring a person’s ideas, hopes, and beliefs about the meaning of pregnancy, parenthood, and parental identity, as well as how pregnancy loss may have shaken or shattered these beliefs and assumptions. This can normalize intense emotions, uncover and address problematic cognitions, build self-compassion, and allow a man or woman to place the loss into the larger context of their lives and futures. “The goal is to help clients work through their grief and loss, accept that their story can be edited and rewritten, and come away with a positive new ending.”12

Carl’s counselor helped him become aware of and start actively shaping the story he had been telling himself. “I showed up thinking I was losing it. I mean, our baby never took a single breath, but I couldn’t shake the sadness or stop second-guessing myself and the doctors. Counseling helped me realize that even though we only had a short time with our little girl, my connection was real; there was a story to tell. Once I had the story, the tears started flowing and I was able to start moving forward. Sandra and I even gathered family together and had a ritual to let everyone know our little girl’s name—Janice—and to let them know she was important to us and will never be forgotten.”

White notes that some men report relational stress with a partner after pregnancy loss. “He may be having difficulty understanding why she continues to have deep emotions and needs to talk frequently, while he gets overwhelmed by this and pulls away. This can lead to a cycle where she gets frustrated that he doesn’t ‘seem’ as upset as she is, and he pulls away even more.” She says couples may also have disagreements over the frequency of sexual intimacy in the wake of a miscarriage and whether and when to attempt another pregnancy.

Though some couples find that the shared loss brings them closer,8 for others, the stress can increase the likelihood of divorce or separation.13

Carl recalls “After our baby died, Sandra and I were on the rocks for a while. When I started seeing a counselor, I realized I’d been trying to cope with my sadness and my anger at myself and God by keeping things inside. I told myself not to upset Sandra by talking about it, and whenever she tried, I changed the subject. She thought my silence meant I didn’t care about her or our baby, which caused us to feel disconnected.”

How Social Workers Can Help
White says social workers can assist individuals or couples reporting these concerns by doing the following:

• teaching communication skills and supporting the setting of boundaries that allow both partners to feel heard and cared for;

• assessing differing attachment and communication styles and providing as well as facilitating conversations about how these styles may be influencing the relationship and the grieving processes;

• encouraging compassionate curiosity in both partners to enhance empathy and a better understanding of each other’s needs, limits, and styles;

• identifying possible gender differences in grieving styles; and

• helping normalize that a partner may not be able to give an individual all the support they need and that this is okay. It’s okay to seek and accept additional avenues of support like counseling or a support group.

Despite research attesting to the intensity of grief after pregnancy loss and plentiful corroborating data from counselors and grief specialists, harmful stereotypes persist. These include a belief that miscarriage and stillbirth are not real losses, grief related to pregnancy loss is short-lived and not as serious as other losses, men are not meaningfully attached to their future children during pregnancy and therefore do not grieve, and/or women are the ones who go through pregnancy loss while men simply observe it from the outside.

Social workers in settings where pregnancy loss and neonatal death occur are in positions to dispel these misconceptions, assess for underlying grief, and provide psychological intervention. When a miscarriage or stillbirth occurs, or if news needs to be delivered during a medical appointment, White encourages professional staff to be as inclusive of male partners as possible. “Include both the dad and mom in all decision-making regarding the baby unless notified otherwise. If memorial items are being offered, include a photo of Dad holding baby or handprints of Dad and baby together, and offer both Dad and Mom alone time with their baby.”

Medical and mental health professionals, she says, should be conscious about their language so as not to unintentionally imply that a woman’s grief is deeper or more real than a man’s or that it’s a man’s job to place his feelings on hold to focus on supporting his partner.

Most research into the psychological and emotional impact of pregnancy has focused on heterosexual, cisgender couples and individuals. Little focus has been given to factors like gender identification and gender expression, grief of same-sex couples, grief after the loss of a surrogate pregnancy, and the potential intersection of grief and gender with race, religious/spiritual beliefs, or socioeconomics.

Those studies that encompass the grief of men suggest that they may be more likely to dismiss their grief as unimportant, focus on supporting a partner, suppress troubling emotions, and/or attempt to distract themselves by staying busy or using negative coping such as increased alcohol consumption.

Though responses to miscarriage and stillbirth vary with the context and meaning an individual ascribes to the loss, grief is a normal and common response. Unfortunately, these losses are often unrecognized and unacknowledged, with no shared rituals to mark the loss and few safe places to process one’s grief and construct a coherent, meaningful story about losing an unborn child. This can leave men and women grieving in isolation, questioning the validity of their grief, and unaware of the origins of symptoms like anxiety, depressed mood, or indications of posttraumatic stress.

Social workers who understand the potential challenges and difficult relational and cultural dynamics facing those who have survived a loss through miscarriage or stillbirth can be vital supports for men like Carl. “It was like a weight off my shoulders when I found a counselor who understood what I was dealing with. It helped me understand why I was feeling the way I was feeling, to know it was normal, and that there was a way to heal. It meant the world to me.”

— Scott Janssen, MA, MSW, LCSW, is a hospice social worker. He frequently writes about issues related to PTSD and is a member of the National Hospice and Palliative Care Organization’s Trauma-Informed Care Work Group.

References
1. Dugas C, Slane VH. Miscarriage. Treasure Island, FL: StatPearls Publishing; 2020.

2. Data and statistics on stillbirth. Centers for Disease Control and Prevention website. https://www.cdc.gov/stillbirth/data-research/index.html. Updated May 15, 2024.

3. Kersting A, Wagner B. Complicated grief after perinatal loss. Dialogues Clin Neurosci. 2012;14(2):187-194.

4. Weir K. Healing the wounds of pregnancy loss. Monitor on Psychology. 2018;49(5).

5. Bellhouse C, Temple-Smith MJ, Bilardi JE. "It's just one of those things people don't seem to talk about..." women's experiences of social support following miscarriage: a qualitative study. BMC Womens Health. 2018;18(1):176.

6. Farren J, Jalmbrant M, Falconieri N, et al. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. Am J Obstet Gynecol. 2020;222(4):367.e1-367.e22.

7. Puddifoot JE, Johnson MP. Active grief, despair and difficulty coping: some measured characteristics of male response following their partner's miscarriage. J Reprod Infant Psychol. 1999;17(1):89-93.

8. Due C, Chiarolli S Riggs DW. The impact of pregnancy loss on men’s health and wellbeing: a systematic review. BMC Pregnancy Childbirth. 2017;17(1):380.

9. Obst KL, Due C, Oxlad M, Middleton P. Men’s grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model. BMC Pregnancy Childbirth. 2020;20(1):11.

10. Janssen JS. Understanding the way men grieve. Social Work Today website. https://www.socialworktoday.com/archive/exc_0816.shtml. Published August 2016.

11. McGarva-Collins S, Summers SJ, Caygill L. Breaking the silence: men’s experience of miscarriage. An interpretative phenomenological analysis. Illness, Crisis & Loss. 2022;32(2).

12. Jaffe J. Reproductive trauma: psychotherapy for pregnancy loss and infertility clients from a reproductive story perspective. Psychotherapy. 2017;54(4):380-385.

13. Gold K, Sen A, Hatward R. Marriage and cohabitation outcomes after pregnancy loss. Pediatrics. 2010;125(5):e1202-e1207.