Navigating grief and pregnancy loss through online story telling

Abstract

Miscarriage, a common experience, is uncommonly discussed in personal and professional support networks. The normal reaction of grief from a miscarriage in addition to other external factors can lead to complicated grief, a condition that has negative mental health implications on the bereaved mother. Through the lens of Worden’s tasks of meaning, a content analysis was conducted on six public blog posts in which women openly shared their grief experiences. The authors discuss the need for more training in social work practice regarding reproductive health and the intersection of reproductive health and mental health.

Keywords

Pregnancy loss grief social work in healthcare mental health

Introduction

Miscarriage, sometimes referred to as spontaneous abortion, is the loss of a pregnancy prior to 20 weeks gestation (Christiansen et al., 2005; Jurkovic et al., 2013). Miscarriage occurs in 10–20% of known pregnancies (Ventura et al., 2012). The incident rates may be higher if accounted for the early losses, which often occur before many women were aware they were pregnant (Mayo Clinic, 2019). Studies that identify early pregnancy through urinary hCG assay found that one-third of pregnancies result in miscarriage (Wang et al., 2003; Wilcox et al., 1988). The risk of experiencing miscarriage increases with age, with the rates of 20% at age 35, 40% at age 40, and 80% at age 45 (Hemminki and Forssas, 1999, Nybo Andersen et al., 2000). Experiencing consecutive miscarriages, chronic health conditions, cervical abnormalities, age, being underweight, and substance use have all been associated with increased risk of miscarriage (Arck et al., 2008; Feodor Nilsson et al., 2014; Mayo Clinic, 2019).

Symptoms of miscarriage typically include vaginal bleeding and pain or cramping in the abdomen or lower back (Wieringa-de Waard et al., 2003). Many miscarriages are caused by chromosomal abnormality (Jurkovic et al., 2013), and in most cases, there is no way to prevent the loss from occurring (Robinson, 2014).

For women who experience symptoms of miscarriage, a hospital emergency room is likely their first point of care. The emergency department is structured to primarily address medical trauma, which often leaves the psychological distress experienced by bereaved mothers and their families unacknowledged and unattended. The health appointments following the emergency care visit also heavily focus on laboratory workups and medical procedures. Approximately 10–50% of women have reported distress symptoms associated with grief, elevated anxiety, depression symptoms, including major depressive disorder within the first 4 weeks following a miscarriage (Lok and Neugebauer, 2007). Yet, in this critical time, their psychological needs are not being recognized or met through emergency and routine care (Rowlands and Lee, 2010). Previous studies have implicated the interdisciplinary, collaborative roles of medical social workers to fill in such a gap of psychosocial support. Social workers are instrumental in providing the acknowledgment of the loss, supportive counseling, psychoeducation, and resource linkage for patients and families as they navigate the unexpected pregnancy loss (Palmer and Murphy-Oikonen, 2019; Stratton and Lloyd, 2008).

Often, miscarriage is associated with secrecy and lack of support as many women have not yet shared their news of being pregnant, let alone their news of a miscarriage (Robinson, 2011, 2014; Ross, 2015). This leads to fewer opportunities to grieve with support networks, share feelings, express thoughts, or receive connections (Brier, 2008). Miscarriage loss is often thought to be an insignificant loss by the family and friends who know of the pregnancy because it ended without a child being born (Robinson, 2014). In post-miscarriage care, those who miscarry feel unsupported by medical professionals, who often minimize the psychological impact of miscarriage as they focus on the physiological products of conception (Robinson, 2011).

Miscarriage loss is linked with several psychological symptoms that can cause short-term or long-term distress. Many women experience intense yearning, preoccupation (Ritsher and Neugebauer, 2002), anxiety, guilt, depression, and self-doubt (Brier, 2008; Neugebauer et al., 1992; Robinson, 2011; Robinson et al., 1994) after a miscarriage. Women at risk of experiencing these long-lasting psychological symptoms are those who were highly invested in the baby (preparing their home, choosing a name, etc.) (Ritsher and Neugebauer, 2002), had psychiatric symptoms pre-loss, had no living children at home and were worried about infertility (Robinson, 2014). Maternal age has been shown to be a risk factor in some studies (Janssen et al., 1997) but not in others.

Despite a dearth of literature regarding miscarriage grief, it is generally known that grief is a common response (Brier, 2008). Both grief and complicated grief, two different constructs, have been associated with miscarriage. Grief is viewed as the normal reaction to loss, whereas complicated grief causes a higher degree of psychological distress (Boelen and van Den Bout, 2008; Janssen et al., 1997; Prigerson and Jacobs, 2001). Following a miscarriage, grief behaviors have been identified as preoccupation and yearning of the lost child, sadness at seeing pregnant women or newborns, guilt at not being able to protect the baby, and feeling empty (Beutel et al., 1995). Complicated grief results in a higher level of impairment with cognitive, psychological, and physiological processes (Prigerson and Jacobs, 2001; Shear and Shair, 2005).

A death or loss of a life often is associated with rituals such as a memorial or burial (Castle and Phillips, 2003; Romanoff and Terenzio, 1998). With miscarriage, there is no such established ritual, leaving the mourning parent(s) alone to make sense of their loss (Brier, 2008). It has been suggested that women should be provided an opportunity to view the products of conception, give the fetus a name, preserve or buy a memento to validate the existence of the pregnancy, or write a letter to express the dreams they had for their child (Brier, 2008; Robinson, 2014). In one study, patients who had experienced a miscarriage were randomly placed in an intervention group or a control group (Johnson and Langford, 2010). The patients in the intervention group received follow-up support from hospital staff (Johnson and Langford, 2010). Compared to the control group who received no follow-up care, the women in the intervention group felt significantly more supported and a lesser degree of despair. These results indicate that women should receive follow-up support when they are discharged from the hospital (Johnson and Langford, 2010); however, relatively few do.

In their work on bereavement, researchers Klass, Silverman, and Nickman identified that parents who have lost a child often experience an ongoing attachment to the child or a continuing bond (1996). When the loss occurs, instead of a disengaged relationship, the relationship transforms. The bereaved parents continue to experience the bonds or connections with their deceased child as they integrate the loss through their lives (O’Leary and Warland, 2013). How parents internalize and externalize the continuing bonds they have with their deceased child directly impacts their level of grief (Scholtes and Browne, 2014). Externalized bonds appear to occur in the early stages of grieving in which acceptance of the loss has not yet happened, and internalized bonds represent a more symbolic connection to the deceased with more acceptance of the death; the latter of which is associated with more positive grief outcomes (Scholtes and Browne, 2014).

Worden defines grief as a cognitive, emotional, and behavioral reaction to a death loss and mourning as the process of coming to acceptance of the loss (2018). Acceptance of the loss requires a certain amount of work. To delineate the active, intentional work of grief, Worden defines four tasks of mourning (2018). The first is to accept the reality of the loss, meaning to recognize the loss as an actual loss instead of denying it or pretending it did not happen (Worden, 2018). He explains the second stage, process the pain of grief, as the bereaved individual allowing themselves to feel all of the intense emotions they are being bombarded with (2018). The third task, to adjust to a world without the deceased, takes place across three dimensions: internal adjustments (to the self), external adjustments (to the environment), and spiritual adjustments (to the worldview) (Worden, 2018). The final task, find a way to remember the deceased while embarking on the rest of one’s journey through life, focuses on remembering the person who has died, not on being stuck with their loss (Worden, 2018).

Miscarriage loss is unique in that it is often experienced in silence or without acknowledgment. The absence of having a tangible person to mourn the missed life opportunity makes the grieving process more complex, isolating, and difficult to cope. While miscarriage has been known to have adverse psychological impacts, there are rarely medical, professional, or cultural processes in place to assist the grieving parents. In addition, miscarriage grief is not well represented in the literature, especially from the lens of continuing bonds or the tasks of mourning. This study seeks to capture the experiences of those who have had a miscarriage, identifying how miscarriage grief is processed and how parents perceive their loss.

Method

This study adopted a qualitative research approach to analyze samples of blog content about experiences of miscarriage. Blog posts are personal documents in which a first-person narrative describes an individual’s experience, action, or belief (Bogdan and Biklen, 1997). Such personal documents offer extensive opportunities compared to diary research (Hookway, 2008). Furthermore, the online “anonymity” of blogging may offer bloggers a sense of unselfconsciousness about what they write (Hookway, 2008). Qualitative methods were used because the focus was to understand and describe the experiences (Merriam and Tisdell, 2015) of women who had experienced pregnancy loss. We employed content analysis and supplemented with thematic analysis. Once themes were generated, the authors identified how themes were connected with Worden’s four tasks of mourning. The first author and conceptualizer of this study comes from a social constructivist philosophy.

Study sample and data collection

Potential blog posts were identified using purposive sampling form a Google search using the terms “pregnancy loss,” “miscarriage,” and “blog.” Blog posts were included in the sample if the following inclusion criteria were met: written by the person who experienced the pregnancy loss; the blog is about miscarriage, spontaneous abortion, or pregnancy loss; the blog was written in English. Blogs were excluded if they were not publicly available through a web search; discussed termination of pregnancy for any circumstance; were not specific to miscarriage; were specific to stillbirth. Our search took place in March 2020. We sifted through the first ten pages of search results for blog posts meeting inclusion criteria.

The authors sought only personal blog posts that were written by one person who had experienced the pregnancy loss. Blog sites from associations, organizations, service providers, or blogs sharing other’s stories were excluded. We reviewed posts from these types of sources and found the posts to be indirect discussions of miscarriage or pregnancy loss, medicalized in nature, and lacking the personal narratives that were vital to this study. The initial search yielded nine blogs that met inclusion criteria. One was excluded due to a non-viable hyperlink. One was excluded because it shared multiple stories from other women and were not inclusive of the blog owners personal experience with miscarriage. One other blog was excluded due to the brevity of the discussion of several miscarriages. It was determined there was not enough data to contribute to the study. Once identified, the blog post specific to miscarriage from six blogs were included in this analysis.

Ethics

Ethical dilemmas and controversies associated with the emergence of online tools is not novel and discussions center on ethical guidelines for conducting research in online spaces such as blogs (Hookway, 2008). Hookway, posits that there is no consensus among social scientists regarding informed consent or permission from bloggers. Furthermore, there are debates surrounding “what is private versus public” within the internet realm. Walther (2002) posits that archived material on the internet is publicly available and consent is not warranted while others suggest that while publicly accessible, online postings are written with an expectation of privacy and thus consent should be obtained (Elgesem, 2002). Finally, Waskul and Douglas opine that there is no clear cut way to identify public versus private within online interactions. As described by Hookway (2008: 105) “blogging is a public act of writing for an implicit audience. The exception proves the rule: blogs that are intrepreted by bloggers as private are made friends only. Thus accessible blogs may be personal but they are not private.” Additionally, the authors utilized the blog posts as the research material and not the blogger, an important distinction. As cited in Wilkinson and Thelwall (2011) “Web-based objects like social network sites, bulletin boards and blogs are all, in principle, electronic documents (Ess and Committee, 2002). Research involving such public web documents without contacting their authors is not human subjects research (Enyon, Schroeder, and Fry, 2009) and can therefore avoid even triggering the need for consideration by university ethics committees” Because the ethical discourse surrounding online research is vastly different, the authors sought approval from the Institutional review board.

Approval to conduct the study was submitted to the institutional review board of all authors’ institutions. Given the blogs were publicly posted, institutional review board approval concluded that the authors did not need to proceed with IRB review as the purpose of the blogs were to be publicly available for individuals to find was not needed. Additionally, the purpose of the blogs as stated outwardly by the bloggers themselves were to make this information available to others in an attempt to education, inform, and de-stigmatize the experience of miscarriage.

Data analysis

The first and second author worked collaboratively to analyze the contents of the first three blog posts using open and focused coding, constant comparison, and memo-writing. The initial stage of coding consisted of the first two authors reading the first three blog posts in their entirety. We used open coding and memoing to create codes. Next, we discussed what we were seeing in the data and then developed a codebook based on our reading and consensus of the first three blog posts. Collaboratively, the first two authors interrogated the code names and definitions for each code. We worked together to identify places of overlap and differences in our understanding of the codes. This was an interactive process in which the first two authors used open and focused coding on 50% of the data to create a well-defined codebook which contained the most recurrent and salient initial codes (Charmaz, 2014). The next step, once the initial codebook had been established was to code the remaining blog posts. The first author analyzed the remaining three blog posts. The authors met to review the final three blog posts and discuss any questions or issues that arised during the coding process. Once the research team reviewed the memos and coding, we agreed that there were no new codes emerging from any one blog post and agreed to conclude our data collection.

Researcher bias

During the codebook development and coding phases, the authors practiced reflexivity to challenge their thoughts, and beliefs about the experience of miscarriage. The practice of reflexivity was important within this particular study as each author has personal experience with pregnancy loss. The first two authors experienced loss differently and were able to challenge each other’s initial thoughts about the experience of pregnancy loss. Each author maintained their own document that served as an “audit trail” (Carcary, 2009) in which notes regarding coding decisions and thoughts or emotions regarding the data were recorded and shared among the research team.

Results

The findings are organized into Worden’s four tasks of mourning: (1) Accept the reality of the loss; (2) Work through the pain and grief; (3) Adjust to an environment in which the deceased is missing; (4) Emotionally relocate the deceased and move on with life.

Acceptance

The first task of mourning is the acceptance of the loss. Within our data, we identified two key themes that we identified as accepting the loss. When individuals experience loss, there may be a period of time when the loss is recognized but not fully accepted. Accepting the loss is characterized as “taking in” the loss such that the individual who has experienced the loss must recognize the importance of the loss including the relationship with the deceased and the impact of the loss on the self.

Education

Upon learning that they were experiencing miscarriage, most of the bloggers sought out more information about miscarriage and what to expect. Several bloggers described looking to Google to answer their questions, reading medical articles and other online sources such as chat threads between women who had previously experienced miscarriage. Another blogger noted that while the miscarriage was difficult, they were looking forward to an upcoming doctor’s appointment because they would be able to learn more about what was happening in their body.

Physical body

Discussion related to the physical body was prevalent and ranged from mentioning the physical process of experiencing a medical procedure for the miscarriage “For me, I had to carry our miscarried baby for two full weeks before I was able to have a D+C which meant a full surgery, anesthesia, and those sweet little hospital mesh undies that everyone who has a baby tells you about. I remember being angry that I was walking out in those undies without a baby in my arms and an empty womb.” Others discussed feeling pregnant for several weeks after the miscarriage conversely, some bloggers noted how quickly their body felt more normal again in the sense that they weren’t experiencing pregnancy symptoms. For some the lack of pregnancy symptoms was the first indication that something was wrong while others thought they had overcome the symptoms more quickly than others but still assumed the pregnancy was viable: “The miscarriage happened on a Thursday evening. The Sunday prior I had woken up feeling wholly like a new woman. The cloud of nausea and exhaustion had lifted entirely. I felt like myself again. My energy was back, my mood was stable. I could eat and drink as I pleased. I returned to yoga and my morning walks. I could do this!” One blogger spoke about how quickly her physical body returned to normal but the emotional aspect took much longer: “My body was back to normal in less than a week, but it took me nearly 6 weeks to truly feel myself again on the inside. I can’t say I got over it, I don’t think you do, but I am able to accept that it happened to me, without any shame.” Although the physical experience differed for the bloggers, the physical aspect of the miscarriage was a common discussion point.

Pain and grief work

The second task of mourning is working through the pain and grief. Importantly, the pain associated with the loss can vary between and within grievers and that a wide-variety of emotions may be felt during the grief process. We have identified two additional themes that encompass this task.

Support

The concept of support was described in every blog post. The bloggers discuss the phone calls and conversations they had with friends and family about their loss. One blogger said “What surprised me was that of this small group, nearly every single woman would tell me that she too had a miscarriage, or two. It certainly felt like more than 25%.” One blogger sought out indirect support by reading others stories of miscarriage and stated this helped her to know she was not alone. But the discussion of support came with other emotions and expectations of others that led to frustration and more complex feelings associated with the miscarriage. “I also admit that I wanted to feel the support of others, to let people know that there was a baby that we loved, but now it was no longer. I felt support and I felt love, but I also felt frustration. I realized I had invisible expectations of people and when they didn’t meet those expectations, I felt bitter. It was my first experience with how people handle things like miscarriage, and how most people have no idea how to react or what to do for you. I can only blame myself for not being more open with what I needed at the time.” This blogger was certainly not alone in feeling frustrated and isolated by how others were unsure to react after hearing the news. At least two others noted a similar experience. These discussions of support were often followed with pieces of advice about how to support those who have experienced loss.

Emotional symptoms

The emotional experiences of miscarriage are directly related to working through the pain and grief of miscarriage. It is clear through each person’s writing that emotions felt during and after the miscarriage are intense and often exist simultaneously with multiple complex emotions. This is how one blogger described the process: “The grief and gravity of it all will come in waves. Somedays you will stay afloat, somedays it will suck you in, just know that your baby was blessed to belong to you and someday you will be reunited.” The bloggers discussed intense emotional experiences describing the days and weeks after their miscarriage as being a “blur of deep sadness” and feeling “devastated and empty inside.” Bloggers spoke about the loss of identity, sometimes personality as they were trying to understand their emotions: “I felt weepy and lost, like an identity I had worked so hard to accept and embrace no longer fit.” Another common emotion was loneliness and isolation: “Initially I felt very alone. I felt like this terrible tragic thing was happening to me and had never happened to anyone else.” The bloggers spoke about feeling guilty for experiencing a miscarriage, guilt of when or how the miscarriage occurred (like on Christmas) and the guilt they felt for not being able to sustain the pregnancy. Another common experience was to hash over all their decisions and shame themselves for that “cup of coffee” or the way they slept or from exercising. Some discussed feeling ashamed that they resented seeing happy families on the street. One blogger described the emotions afterward as grasping for a reason, attempting to feel gratitude and accepting the feelings of loss and defeat.

Adjust to the new environment

Task three of Worden’s tasks of mourning is to adapt to the environment in which the bereaved person is missing. One new theme emerged that connects to the task of adjustment to the new normal. In addition, the theme of “education” from task one again resurfaced her in task three.

Making sense

This theme is closely tied to others but is described as encompassing the labor of processing the timeline in which the miscarriage happened. Throughout every blog, the author describes the sequence of events detailing the start of the pregnancy, to the recognition of the miscarriage, the physical experience, and the process afterward. In each of the blogs it is as if the reader is taken to the setting in which the miscarriage took place. One woman described the bathroom of a family members house on a specific day, while another discusses the day she remembers feeling well and the miscarriage occurring a few days later. Others recount the exact amount of time it took for their menstrual cycles to return or how soon after they felt comfortable attempting to become pregnant again. We have also included the spiritual discussions brought up by bloggers in this theme. Spirituality was used as both a form of support but also primarily as a means to make sense of the experience and begin to heal: “What I’ve learned in the last year is that while I may want to control everything in my life, there are some things that are truly up to a higher power (God, The Universe, whatever you want to call it). I know 100% that we’ll be parents and I just have to be ok with waiting a while longer. There are days when I accept that and there are days when I sob just thinking about it. But in my heart and my gut, I know that we’ll be ok.”

Education

In task one we discuss education as a means of learning more about what to expect. In task three we come back to this theme as it functions here as well. Throughout the process of writing and discussing their journeys, most of the bloggers discuss the startling amount of women who experience miscarriage. Some of them identify as one in four which is the number of women who experience miscarriage. In many of the blogs we reviewed, the blogger comes back to how common miscarriage is and begin to identify as one these statistics. The information provides solace in knowing they are not alone but also raises the question regarding why they did not know how common miscarriage was prior to experiencing their own. This question almost always leads the blogger to mention that this is why they decided to share their story, they did not want others to feel alone, they wanted to provide support and speak out which leads to the final task.

Emotionally relocate the deceased

The fourth mourning task is to emotionally relocate the deceased and move on with life. In other words, task four is to find a way to stay connected with the deceased that does not hinder one’s ability to live. In this task, the main theme we identified was the actual blogging process in itself which we have called speaking out.

Speaking out

We view the act of creating a blog post dedicated to discussing their miscarriage as a way for the blogger to accept the loss. Many of the bloggers discuss that while they will never forget about the child they lost, they want to turn this pain into something that will help others experiencing pregnancy loss: “I’m not writing it for sympathy or to be looked at as a victim. I’m writing it because the few and far between posts like this helped me get through the last year in surviving a miscarriage.” Another woman writes this: “Why can’t we talk about this? I know that in the media most functions of the female body are glossed over with white imagery, blue fluids and pills as solutions. We can choose to open that conversation. Miscarriages happen. They are traumatic, uncomfortable, messy and heartbreaking. They have happened to women we know and love - and we may never know about it.” It appears that in speaking out, the bloggers are making it less taboo and creating support networks for other women. In this sense, it is if they have accepted their experiences and moving toward the future in spite of their loss.

Discussion

Miscarriage is a common pregnancy loss occurring before 20 weeks gestation and affecting ten to twenty-five percent of confirmed pregnancies (Ventura et al., 2012). Women who experience miscarriage often report symptoms of depression or anxiety (Lok and Neugebauer, 2007; Mutiso et al., 2018). Scholars also point out that women who experience miscarriages often suffer from complicated grief (Kersting and Wagner, 2012). This grief is further compounded when the bereaved mother feels unsupported in her loss (Robinson, 2011, 2014). As shared in the blogs, women who miscarry struggle to find ways to understand and express their grief. For women who miscarry, there are gaps that exist between the physiological loss of a fetus and the tasks of acceptance. The bloggers sought to fill these gaps by publicly sharing their grief stories, which they identified as helping them with acceptance. When women miscarry, they need to be connected to other ways of processing and accepting their grief. An example of coping with grief is through storytelling. Journaling is often used as a therapeutic tool recommended to clients as a means to story-tell in a personal capacity. More recently, the internet has provided a new avenue to journal and storytelling capability through blogging sites which have become relatively popular in the last decade. The use of blogs has become more common and used for a wide-variety of health-related concerns (Anderson et al., 2017).

Storytelling through blogging provides an individual an opportunity to express their personal experiences and can play an important role in helping individuals navigate difficult health-related experiences (Keim-Malpass et al., 2013; McWilliam, 2009). Using blogs may serve as a means of navigating the meaning of loss and process to the grief, both of which are effective coping behaviors. Not only does the use of the internet allow individuals to share their personal experiences, blogging allows outsiders to enter into the world of the author, gather knowledge, and perhaps find comfort in knowing they are not alone in the experience. This is especially relevant as it pertains to pregnancy loss. However, the use of online groups, including blogs, has yet to be widely studied for its effectiveness in reducing psychological distress. It is important to acknowledge that these informal virtual forums present great potential in serving as a resource for those without access to mental health treatment or those experiencing stigma related to the loss while also providing an avenue for others to tell their stories.

The study of pregnancy loss blogs has numerous implications for practice with women and families for healthcare providers, including social workers. The narratives are derived from the experiences of women and the desire to grieve, heal, and support others experiencing pregnancy loss. Pregnancy loss is a common experience that is underdiscussed and understudied in relation to the grief experience. Throughout the themes, there was an underlying desire to understand what was happening, had it happened to others, how often does it happen, and can the individual persist after pregnancy loss. This leads the authors to further question the availability of resources to individuals experiencing pregnancy loss and, perhaps, the needs to further integrate pregnancy loss education into reproductive training, social work, and prenatal visits. For those working with pregnancy loss survivors, the authors suggest linking survivors to established infant loss bereavement organizations (see Table 1), developing local support groups, connecting survivors to peer mentors, and journaling as a means to assist the survivor with navigating the grief process. Furthermore, we recommend that all women who have experienced miscarriage loss be referred to a mental health professional who specializes in reproductive issues.

Table 1.

Resources for practitioners and grieving parents.

Organization	Web site
Postpartum support international	www.postpartum.net/get-help/loss-grief-in-pregnancy-postpartum
The compassionate friends	www.compassionatefriends.org
The MISS foundation	www.missfoundation.org/grieving
Miscarriage hurts	www.miscarriagehurts.com
Empty arms	www.emptyarmsbereavement.org
TEARS foundation	www.thetearsfoundation.org
Resolve	www.resolve.org

The findings of our study demonstrate that formal and informal support networks are needed to support women through the grief tasks. For example, in providing formal supports, medical staff assisting the patient with the physiological outcome of a miscarriage can provide information on the emotional aspects of grief following an early pregnancy loss. Friends and family can offer the informal supports by validating the miscarriage as a real loss, despite not having grown the baby full term. Social workers in medical and clinical settings can help connect grieving mothers to professional supports. If grieving mothers desire to hear the stories of how others have worked through their miscarriage grief, they can be directed to blogs and other forms of online supports.

The way in which the bloggers discuss miscarriage resembles how Silverman and Klass believe we never fully get over a loss. Such phenomenon is demonstrated by statements made by several bloggers as they reflect on their loss and make meaning of their experiences of motherhood as it relates to loss. This is evidenced by research that suggest psychological distress after pregnancy loss may persist up to 3 years after the event (Blackmore et al., 2011; Lok and Neugebauer, 2007; Nynas et al., 2015) and furthered acknowledged by the bloggers themselves who shared the feelings of grief and loss while discussing the complexity of motherhood after loss, pointing to a need for psychological interventions that address pregnancy loss. Through the lens of Worden’s four tasks of meaning, this study suggests that there are ways for women to make meaning of their loss, including journaling, which can be beneficial with both grief and complicated grief.

Currently, the evidence for psychological interventions related to pregnancy loss remains preliminary and lacking robust research (Murphy et al., 2012). Interpersonal psychotherapy (Johnson et al., 2016), cognitive behavioral therapy (Nakano et al., 2013), bereavement counseling (Simpson et al., 2015), and supportive counseling (Kong et al., 2014) are the few face-to-face therapeutic interventions with limited supporting evidence and have not yet been replicated. We support the extension of addressing pregnancy loss in healthcare and providing adequate training and resources to providers to help alleviate the burden of loss from women and their families.

Our study is not without limitations. The demographic characteristics of individuals cannot be ascertained due to the nature of the blogs. The digital divide poses a threat to those able to regularly access internet at home or otherwise; as such, geographics cannot be described. Thus, individuals from rural or underserved individuals may not have been included in this study. Furthermore, the study does not include the voices of those who have experienced miscarriage and were unaffected or relieved by the loss. However, the study presents several strengths. To the authors’ knowledge, this is the first study to analyze the use of blogs related to coping with pregnancy loss. Additionally, recall bias is not a concern in the data, given the nature of the blogs as opposed to a traditional interview or focus group. Finally, there is potential for the results of the study to present a large impact despite the limitations. The study provides intimate knowledge of the grief process and associated feelings of loss as it pertains to pregnancy loss—a topic widely underdiscussed among women and healthcare providers. The themes described in the study (physical body, support, emotional response, making sense, education, speaking out) apply to the experiences of the women writing the blogs and to those who have openly discussed pregnancy loss through other means such as twitter, the lived experiences of some of the authors, and, more recently as seen in celebrity interviews. The themes also apply to our clinical practice experience, which has focused on helping women heal from miscarriage and child loss as a necessary step in preparing for adoption. The themes identified in the present study speak to the met and unmet needs of those who have experienced or are currently experiencing pregnancy loss. The findings of the present study present an opportunity for healthcare providers a means to understand the complexity of pregnancy loss, the emotional toll, and the need to provide treatment through therapy or other means acceptable to the patient.

Conclusion

Through the use of public blogs, we conducted a qualitative analysis of what the grief experience is like for women who miscarry. Because of the general lack of discussion and research on miscarriage, many women feel isolated and alone as they struggle to face the loss of their fetus. Bloggers use their platforms to process, educate and connect. Most of the bloggers in our analysis shared their stories as a way to help them work through their grief. They also sought to help open public discussions for the benefit of other grieving mothers. They freely gave advice to those seeking to comfort grieving women: “Don’t try to explain it, don’t tell them about your friend who went on to have many healthy babies, don’t belittle the experience, don’t tell them that things happen for a reason, just be with them.”

Through the lens of Worden’s tasks of grieving, these blogs demonstrate how women experiencing miscarriage grief can go from needing to accept the reality of the loss, working through pain and grief, adjusting to an environment without the baby, and finding a way to emotionally relocate their lost fetus.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Aubrey E Jones

References

Anderson

Hundt

Dean

, et al. (2017) “The church of online support”. Journal of Family Nursing 23(1): 34–54.

Arck

Rücke

Rose

, et al. (2008) Early risk factors for miscarriage: a prospective cohort study in pregnant women. Reproductive Biomedicine Online 17(1): 101–113.

Beutel

Deckardt

von Rad

, et al. (1995) Grief and depression after miscarriage. Psychosomatic Medicine 57(6): 517–526.

Blackmore

Côté-Arsenault

Tang

, et al. (2011) Previous prenatal loss as a predictor of perinatal depression and anxiety. British Journal of Psychiatry 198(5): 373–378.

Boelen

van den Bout

(2008) Complicated grief and uncomplicated grief are distinguishable constructs. Psychiatry Research 157(1–3): 311–314.

Bogdan

Biklen

(1997) Qualitative Research for Education. Boston, MA: Allyn and Bacon.

Brier

(2008) Grief following miscarriage: a comprehensive review of the literature. Journal of Women’s Health 17(3): 451–464.

Castle

Phillips

(2003) Grief rituals: aspects that facilitate adjustment to bereavement. Journal of Loss and Trauma 8(1): 41–71.

Carcary

(2009) The research audit trail – enhancing trustworthiness in qualitative inquiry. Electronic Journal of Business Research Methods 7(1): 11–24.

10.

Charmaz

(2014) Constructing Grounded Theory. 2nd ed. London: Sage.

11.

Christiansen

Nybo Andersen

A-M

Bosch

, et al. (2005) Evidence-based investigations and treatments of recurrent pregnancy loss. Fertility and Sterility 83: 821–839.

12.

Elgesem

(2002) What is special about the ethical issues in online research? Ethics and Information Technology 4(3): 195–203.

13.

Eynon

Fry

Schroeder

(2017) The ethics of online research. The SAGE handbook of online research methods 2: 19–37.

14.

Feodor Nilsson

Andersen

Strandberg-Larsen

, et al. (2014) Risk factors for miscarriage from a prevention perspective: a nationwide follow-up study. BJOG: An International Journal of Obstetrics and Gynaecology 121(11): 1375–1385.

15.

Hemminki

Forssas

(1999) Epidemiology of miscarriage and its relation to other reproductive events in Finland. American Journal of Obstetrics and Gynecology 181(2): 396–401.

16.

Hookway

(2008) `Entering the blogosphere’: some strategies for using blogs in social research. Qualitative Research 8(1): 91–113.

17.

Janssen

HJEM

Cuisinier

de Graauw

, et al. (1997) A prospective study of risk factors predicting grief intensity following pregnancy loss. Archives of General Psychiatry 54(1): 56–61.

18.

Johnson

Langford

(2010) Proof of life. Critical Care Nursing Quarterly 33(3): 204–211.

19.

Johnson

Price

Kao

, et al. (2016) Interpersonal psychotherapy (IPT) for major depression following perinatal loss: a pilot randomized controlled trial. Archives of Women’s Mental Health 19(5): 845–859.

20.

Jurkovic

Overton

Bender-Atik

(2013) Diagnosis and management of first trimester miscarriage. BMJ: British Medical Journal 346: f3676–f3676.

21.

Keim-Malpass

Baernholdt

Erickson

, et al. (2013) Blogging through cancer. Cancer Nursing 36: 163–172. DOI: 10.1097/NCC

22.

Klass

Silverman

Nickman

, et al. (eds) (1996) Continuing Bonds: New Understandings of Grief. Taylor and Francis.

23.

Lok

Neugebauer

(2007) Psychological morbidity following miscarriage. Best Practice and Research Clinical Obstetrics and Gynaecology 21(2): 229–247.

24.

Mayo, Clinic (2019) Miscarriage. Retrieved from: https://www.mayoclinic.org/diseases-conditions/pregnancy-loss-miscarriage/symptoms-causes/syc-20354298 (accessed 14 December 2020).

25.

McWilliam

(2009) Patients, persons or partners? Involving those with chronic disease in their care. Chronic Illness 5: 277–292. DOI: 10.1177/1742395309349315

26.

Merriam

Tisdell

(2015) Qualitative Research: A Guide to Design and Implementation. Francisco, CA: John Wiley and Sons.

27.

Murphy

Lipp

Powles

(2012) Follow-up for improving psychological well being for women after a miscarriage. The Cochrane Database of Systematic Reviews 3(3): CD008679.

28.

Nakano

Akechi

Furukawa

, et al. (2013) Cognitive behavior therapy for psychological distress in patients with recurrent miscarriage. Psychology Research and Behavior Management 6: 37–43.

29.

Neugebauer

Kline

O’Connor

, et al. (1992) Depressive symptoms in women in the six months after miscarriage. American Journal of Obstetrics and Gynecology 166(1): 104–109.

30.

Nybo Andersen

A-M

Wohlfahrt

Christens

, et al. (2000) Maternal age and fetal loss: population based register linkage study. BMJ: British Medical Journal 320(7251): 1708–1712.

31.

Nynas

Narang

Kolikonda

, et al. (2015) Depression and anxiety following early pregnancy loss: recommendations for primary care providers. The Primary Care Companion for CNS Disorders 17(1).

32.

O’Leary

Warland

(2013) Untold stories of infant loss: the importance of contact with the baby for bereaved parents. Journal of Family Nursing 19(3): 324.

33.

Palmer

A. D.

Murphy-Oikonen

(2019) Social work intervention for women experiencing early pregnancy loss in the emergency department. Social Work in Health Care 58(4): 392–411.

34.

Prigerson

Jacobs

(2001) Traumatic Grief as a Distinct Disorder: A Rationale, Consensus Criteria, and a Preliminary Empirical Test. Available at: https://psycnet.apa.org/record/2001-18149-026 (March 10, 2022).

35.

Ritsher

Neugebauer

(2002) Perinatal bereavement grief scale. Assessment 9(1): 31–40.

36.

Robinson

(2011) Dilemmas related to pregnancy loss. The Journal of Nervous and Mental Disease 199(8): 571–574.

37.

Robinson

Stirtzinger

Stewart

, et al. (1994) Psychological reactions in women followed for 1 year after miscarriage. Journal of Reproductive and Infant Psychology 12(1): 31–36.

38.

Robinson

(2014) Pregnancy loss. Best Practice and Research Clinical Obstetrics and Gynaecology 28(1): 169–178.

39.

Romanoff

Terenzio

(1998) Rituals and the grieving process. Death Studies 22(8): 697–711.

40.

Ross

(2015) “I think it”s self-preservation’: risk perception and secrecy in early pregnancy. Health, Risk and Society 17(5–6): 329–348.

41.

Rowlands

Lee

(2010) ‘The silence was deafening’: social and health service support after miscarriage. Journal of Reproductive and Infant Psychology 28(3): 274–286. DOI: 10.1080/02646831003587346

42.

Scholtes

Browne

(2014) Internalized and externalized continuing bonds in bereaved parents: their relationship with grief intensity and personal growth. Death Studies 39: 75–83. DOI: 10.1080/07481187.2014.890680

43.

Shear

Shair

(2005) Attachment, loss, and complicated grief. Developmental Psychobiology 47(3): 253–267.

44.

Simpson

Lee

Lionel

(2015) The effect of bereavement counseling on women with psychological problems associated with late pregnancy loss. Journal of Asian Midwives 2(2): 5–20.

45.

Stratton

Lloyd

(2008) Hospital-based interventions at and following miscarriage: literature to inform a research-practice initiative. The Australian and New Zealand Journal of Obstetrics and Gynaecology 48(1): 5–11. DOI: 10.1111/j.1479-828X.2007.00806.x

46.

Ventura

Curtin

Abma

, et al. (2012) Estimated Pregnancy Rates and Rates of Pregnancy Outcomes for the United States, 1990-2008. National Vital Statistics Reports. Hyattsville, MD: National Center for Health Statistics, 60. No. 7.

47.

Walther

(2002) Research ethics in Internet-enabled research: human subjects issues and methodological myopia. Ethics and Information Technology 4(3): 205–216.

48.

Wang

Chen

Wang

, et al. (2003) Conception, early pregnancy loss, and time to clinical pregnancy: a population-based prospective study. Fertility and Sterility 79(3): 577–584.

49.

Wieringa-de Waard

Ankum

Bonsel

, et al. (2003) The natural course of spontaneous miscarriage: analysis of signs and symptoms in 188 expectantly managed women. The British Journal of General Practice : The Journal of the Royal College of General Practitioners 53(494): 704–708.

50.

Wilcox

Weinberg

O’Connor

, et al. (1988) Incidence of early loss of pregnancy. The New England Journal of Medicine 319(4): 189–194.

51.

Wilkinson

Thelwall

(2011) Researching personal information on the public web: methods and ethics. Social Science Computer Review 29(4): 387–401.

52.

Worden

(2018) Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner. New York, NY: Springer.