Symbolic annihilation through design: Pregnancy loss in pregnancy-related mobile apps

Data collection

The data collection followed an iterative process and led to the analysis of a set of 166 unique apps.

Data analysis

Pregnancy-related Apps’ Features

In response to RQ1, our analysis led to four main feature categories: (1) tracking; (2) information, tips, and advice; (3) reminders and planning assistance; and (4) social connection. While some of the tracking features also included information and tips, we included them under tracking because that was their main functionality and framing. We provide percentages for each individual code and the larger categories.

Pregnancy loss in pregnancy-related mobile apps

To investigate how pregnancy loss was accounted for to answer RQ2, we divided apps into three groups: (1) those that actively and explicitly included pregnancy loss (18%), (2) those that passively included pregnancy loss (10%), and (3) those that excluded pregnancy loss, meaning they did not mention it in any way (72%). Our findings show that even when loss is accounted for, it is rarely done in a way that is sensitive to the needs of those experiencing it. For example, some apps that claim they allow logging pregnancy loss do so without naming the event and simply let the user “exclude the cycle,” without any acknowledgment or providing any resources for coping or moving forward. Others that allow logging the loss delete the pregnancy and its associated data once the loss is recorded. Others hide the option to report a loss, so it is difficult to know that is even a feature. For an example, see Figure 1.

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Figure 1.

These are screenshots from the “I’m Expecting—pregnancy App,” counted as explicitly including pregnancy loss. However, once a loss is logged, the user sees the page on the left, including a message of being sorry for the loss. The app ignores the significance of this loss and states that there are tools when the user is “ready” to “get back on track,” assuming that “getting back on track” is the only thing they need. If the user selects “yes” they are directed to download a sister app to help them track their cycles and conceive, with the background saying “We’re so sorry.”

Active inclusion refers to including features such as options to log a pregnancy loss, informational articles on topics such as identifying warning signs of a loss, articles on coping with the emotional aspects of a loss, and forums for conversations about loss. Active inclusion means directly engaging with pregnancy loss (in contrast to passive inclusion described next) through the app’s features and designs.

Logging a pregnancy loss often meant going into the settings of the apps, which were sometimes very hard to find, and entering the loss into the pregnancy data. This would sometimes mean that the app would delete all the data related to that pregnancy, as if it never happened. This would also mean that the individual would not be able to use that data in conversations with healthcare providers or others.

Passive inclusion of pregnancy loss refers to loss is not being directly addressed in the app’s features but present in the system through mentions in generic (not loss-specific) forums by users, or in a way in which the user would not come across the topic unless actively searching for it. In these apps, the concept of pregnancy loss was only accessible after in-depth exploration and was not attainable to the average user.

Exclusion of pregnancy loss means that there is no mention of pregnancy loss. Apps in this category did not include loss in passive or active ways.

Pregnancy loss: from books to the mobile technology landscape

In her feminist account of pregnancy loss in America, Layne (2002, 2003) describes how the rhetoric of the women’s health movement in books, magazines, and educational resources portrays birth scenarios and pregnancy as idyllic and rosy, and how negative outcomes such as loss are erased.

First, Layne (2003) argues that the movement’s attention to the cruciality of women being in control of their bodies contributes to both stigma and blame by the self and others when desired pregnancies do not have happy endings, highlighting an “American moral obligation to always be happy, a hegemonic narrative preference for narratives of linear progress, for stories with happy endings, and a culture of meritocracy which holds individuals responsible for misfortune” (p. 1889). In parallel, we argue that dismissing loss in pregnancy-related apps exacerbates the stigma associated with loss.

Second, Layne (2003) posits that emphasis on happy endings aggravates the experiences of those whose pregnancies do not end happily. Such an emphasis is present in feminist women’s health activism and biomedical approaches to pregnancy. She argues that the women’s health movement has systematically marginalized negative reproductive outcomes. Furthermore, books and classes erase and neglect experiences of loss. For instance, Our bodies, Ourselves (often referred to as the “bible for women’s health”) segregates negative outcomes, sometimes excludes them, or groups them in chapters on “some exceptions to the normal child bearing experience” (Layne, 2002). This dictates what is “normal” and what is not. Our findings highlight parallels in the mobile app landscape regarding both how loss and other stigmatized reproductive experiences are addressed. For example, we found that many apps included pointers to external resources on topics such as STDs, abortion, or adoption, signaling that these do not belong in a space dedicated to pregnancy management.

Furthermore, we found that pregnancy-related apps include features around information, tracking, reminders, and social contact. These meet some important needs during pregnancies (Lupton and Pedersen, 2016). However, most apps do not account for needs of pregnancies that do not end happily. For example, apps include mood tracking. Individuals experiencing loss often experience depression and post-traumatic stress disorder (Neugebauer and Ritsher, 2005); yet, any accounting for the emotional toll of loss occurs through separate forums or links to external sources if at all. Such design sends the message that when a pregnancy loss occurs, a user must cope with the loss “outside” of these spaces they have used to manage the pregnancy up to that point.

As reviewed, other prior work suggests that pregnancy-related apps tend to reinforce dominant narratives about “good” (expecting) motherhood (Brady and Guerin, 2010; Madge and O’Connor, 2006) and linear ideal reproduction scenarios. Discussions in this work do not include pregnancy loss, but discuss other limitations, such as how apps are gendered and heteronormative, depict what “good” (expecting) motherhood is like, and instill blame for not meeting the expectations of a “good” (expecting) mother (Thomas and Lupton, 2016), or exclude partners (Peyton and Wisniewski, 2020). We show how these apps also portray and design for happy endings rather than potentially undesired yet realistic turns that a pregnancy can take.

The politics of pregnancy-related apps

In his foundational essay “Do artifacts have politics?” Winner (1980) argues that technologies have “political properties.” By “politics,” he means “arrangements of power and authority in human associations as well as the activities that take place within those arrangements” (Winner, 1980: 123). He asserts that “specific features in the design or arrangement of a device or system could provide a convenient means of establishing patterns of power and authority in a given setting” (Winner, 1980: 134). Simply put, technologies and their features include possibilities to order human activity in certain ways to push certain agendas forward. Winner uses the example of bridges over Long Island highways that would not allow buses to drive through. Their design enforced a certain political agenda and social effect: limiting the access of low-income and racial minorities to certain spaces (Winner, 1980).

This offers a useful a lens for revealing the politics of pregnancy-related apps that our findings highlight. We suggest that these apps’ politics assert whose needs are central and whose are marginal (and therefore lack authority and power), as communicated through design. Specifically, we empirically show that pregnancy-related app designs assert that tracking, information, reminders, and social contact are important during some pregnancies. The finding that pregnancy-related apps include these features resonates with prior work (e.g. Peyton and Wisniewski, 2020), although terminologies may be different. However, our key contribution is empirically showing how these features particularly focus on healthy pregnancies. We show how accounting for users’ needs falls short when a pregnancy loss occurs and when a linear pregnancy is disrupted. We suggest that these apps inherently position linear, rosy pregnancies as the authoritative narrative and shape how loss is experienced by ignoring the needs and existence of users who experience losses.

Symbolic annihilation through design

In this section, we argue that ignoring pregnancy loss through the design of pregnancy-related mobile apps, even unintentionally, impacts those who experience loss through symbolic annihilation. We call this impact symbolic annihilation through design.

Symbolic annihilation was first introduced by feminist media scholars in the 1970s. Gerbner and Gross (1976) noted that representation in the fictional world implies social existence and absence in it leads to symbolic annihilation, associating symbolic annihilation with absence. Later, Tuchman (1979, 2000) expanded on Gerbner’s definition. Through an analysis of traditional mass media content (i.e. television, magazines, newspapers), Tuchman (2000) argued that through ignoring women or representing them in stereotypical roles, the mass media symbolically annihilate women. Tuchman’s conceptualization of symbolic annihilation includes omission, trivialization, and condemnation. Such annihilation reinforces stereotypical conceptions of the affected individuals and helps maintain social inequities (Gerbner and Gross, 1976; Tuchman, 2000).

Other scholars have used the concept of symbolic annihilation to articulate how marginalized groups such as Native Americans (Merskin, 1998), Black women (Coleman and Yochim, 2008), LGBTQ individuals (Venzo and Hess, 2013), and Muslims (Mir and Paschyn, 2018) experience symbolic annihilation in traditional mass media. Others have examined symbolic annihilation of historically marginalized groups in community archives (Caswell, 2016) and games, as an example of new digital media (Huntemann, 2015).

We build on this work and expand the concept of symbolic annihilation to mobile apps. We argue that symbolic annihilation can occur through technology design, which we call symbolic annihilation through design, similarly reinforcing stereotypes about phenomena or individuals and sustaining social inequities like marginalization and stigmatization. Specific to pregnancy loss, exposure to messages through media impacts beliefs, values, attitudes, and expectations (Paik and Comstock, 1994). Stigma, lack of acknowledgment, and the absence of pregnancy loss in our societal repertoire exacerbate the loss experience (Silverman and Baglia, 2015). Symbolic annihilation of pregnancy loss through design is harmful and invalidating to those who experience losses, perpetuates stigma surrounding loss, and reinforces normative narratives about pregnancy and pregnant individuals’ experiences. While we focused on pregnancy loss inclusion within pregnancy-related apps to develop the concept of symbolic annihilation through design, we suggest that the concept is useful for interrogating how technologies (fail to) consider certain groups’ needs, especially those experiencing marginality and stigma.

Design to combat symbolic annihilation

We advocate that pregnancy-related apps should directly engage with pregnancy loss through their design. Winner (1980) states that “to recognize the political dimensions in the shapes of technology does not require that we look for conscious conspiracies or malicious intentions” (p. 125). Similarly, we do not suggest that there are malicious intentions in designing these apps. Layne (2002) argues that pregnancy loss and other negative reproductive outcomes should be at the center of women’s health agendas. Given our findings and that technologies have been appropriated and designed for managing reproductive health, feminist media design should also account for unfortunate experiences.

We advocate that pregnancy-related apps should center both individuals whose pregnancies proceed as expected and those whose pregnancies take undesired turns, rather than subjecting the latter to symbolic annihilation through design. How such technological inclusion would look should be determined using participatory methods (Schuler and Namioka, 1993) that engage with individuals who use pregnancy-related apps, both those who have and have not experienced losses. However, we maintain that any such designs should not perpetuate and amplify the stigma associated with loss, and should instead raise awareness and educate all—not just those who experience loss. Pregnancy-related app design should be aligned with the needs and values of those impacted by pregnancy and its complications, including and beyond loss.

Pregnancy loss as situated within a range of gendered silenced experiences

Pregnancy loss is situated within a broader range of gendered, silenced, experiences. As Layne (1997) argues, pregnancy loss is subject to what Foucault (1990) calls the “triple edict of modern puritanism—‘taboo, nonexistence, and silence’”. Layne references Foucault: “There is not one but many silences, and they are an integral part of the strategies that underlie and permeate discourses” (p. 27). In this view, silence is part of the discourse, rather than being separate from it. In this section, we situate pregnancy loss within a range of silenced discourses and experiences (e.g. traumatic birth stories). We build on the “intensified motherhood” theory (Hays, 1998) to illustrate how symbolic annihilation through design is problematic, how it can be a useful lens in other silenced contexts, and how it is situated within intensified motherhood ideologies that keep everything but positivity at bay (Das, 2019).

Examples of silenced experiences beyond loss include infertility (Becker, 1994; Letherby, 2002a, 2002b), abortion (Harden and Ogden, 1999), having children when diagnosed with HIV (Barber et al., 2019), or feeding children formula milk (Lee, 2008). Even desiring pregnancy is stigmatizing for some, such as those approaching menopause, LGBTQ individuals, women with disabilities, single women, or women in not socially approved relationships (Campbell, 1999; Lorber and Moore, 2007). Silencing contributes to marginalization and lack of agency and control. Indeed, pregnant individuals have historically been subject to control and surveillance (Oakley, 1984). In fact, activism and scholarship in relation to breaking gendered silences has been central to feminism (Selimovic, 2020). Motherhood and reproduction in particular have been key, and yet contested, themes in feminist discourse (Neyer and Bernardi, 2011; Peterson and Engwall, 2013).

Scholars have theorized silencing of a range of women’s experiences within gendered frameworks, such as “intensive motherhood” (Hays, 1998). Intensive motherhood is a central concept in the sociology of motherhood. It describes the ideology that mothering is child-centered, emotionally absorbing, labor-intensive, and financially costly. Modern-day Western society sees “intensive mothering” as required of a “good mother” (Hays, 1998).

Prior work has examined representations of birth, infertility, and related topics in the media (Benedictis et al., 2019; Tyler and Clements, 2009), for example, finding that women are shown to not have control over their birth interventions on TV (Benedictis et al., 2019). In the online context, Das (2017) shows how traumatic and difficult birth stories are silenced, highlighting an aversion to sharing and hearing difficult stories. Das argues that pregnancy is a “disciplinary body project” which women are instructed to enjoy, where, for example, a mother who does not feel pain, or bears pain but does not call it pain or take pain medication, is celebrated. Das (2019) describes how in online groups “ideal birthing women” who “attended classes, practiced affirmations, listened to self-hypnosis tapes, [and] practiced movements with [their] birth partner[s]” intentionally avoided women who sought to share difficult birth stories (p. 21). Das theorizes aversion to sharing and hearing difficult birth stories online as an aspect of intensive motherhood. Part of intensive motherhood is keeping everything but positivity at bay, where only positive birth stories must be told and heard (Das, 2019). Lupton (2013) argues that intensive motherhood and a society that holds women responsible for pregnancy outcomes leads to motherhood’s beginning prior to birth, which as we describe below, becomes even more complicated when a loss occurs.

Building on the work described here, we argue that the intensive motherhood ideology extends to pregnancies that lead to losses and partly shapes the loss discourse as well as how loss is accounted for in mobile apps. As our findings show, the once-pregnant person is left on their own to cope with the loss and experience harm from mobile apps largely organized around an expected child, rather than an expecting person. As such, we argue that symbolic annihilation of loss through design and the features that pregnancy apps include unrelated to loss (e.g. tracking, information, reminders, and social contact) are in part shaped by the intensive mothering ideology: A “good” and “responsible” mother uses these features to cater to the unborn child while the pregnancy is in progress. The once-pregnant and expecting person’s needs are no longer a subject that matters to these apps’ designs once the pregnancy has taken an undesired turn. Butler asks fundamental questions about what “matters”: “what qualifies as bodies that matter, ways of living that count as ‘life’, lives worth protecting, lives worth saving, lives worth grieving” (Butler, 1993: 16). Interrogating mobile apps’ treatment of pregnancy loss as a silenced and gendered experience articulates mechanisms through which such “mattering” is demonstrated through design, and ways design can render visible a wider range of experiences that matter but that the societal, including the socio-technical, discourse represents as not mattering.

Further examining the contexts within which socio-technical systems account for a range of silenced experiences (e.g. infertility, abortion) is an area for future work, and a first step to paving the way to better designing these systems. Through a deep focus on one silenced experience, we provide the lens of symbolic annihilation through design that we anticipate will be useful for interrogating other silenced experiences in socio-technical systems’ design.

Limitations and opportunities

While we sought to include all relevant apps, it is possible that we missed some. For example, it is possible that the recommendation algorithms that showed us other relevant apps through our search queries, have missed some relevant apps that exist but did not show up in our search either; or that there were apps that do not use any of the keywords we used. That said, the likelihood of these scenarios practically is low. While each was independently analyzed by two coders and then discussed to reach 100% agreement, it remains possible that the coders missed some features or coded some incorrectly. We included apps that were free and in English; it is possible that paid apps or those in other languages include features not surfaced in our data. However, given the steps taken, our core arguments regarding the importance of accounting for loss in pregnancy-related apps and the dire lack of its inclusion currently, as well as the concepts we develop, still hold. Finally, future work could explore how experiencing symbolic annihilation through design in one platform (e.g. pregnancy tracking app) might relate to one’s way of engaging (or lack thereof) in others (e.g. social media).