JOURNAL OF WOMEN’S HEALTHVolume 17, Number 3, 2008© Mary Ann Liebert, Inc.DOI: 10.1089/jwh.2007.0505

Grief Following Miscarriage: A Comprehensive Review of the Literature

NORMAN BRIER, Ph.D.

ABSTRACT

Objective: The literature exploring the relationship between miscarriage and grief is sparse.This paper summarizes the literature on grief subsequent to an early miscarriage to elucidatethe nature, incidence, intensity, and duration of grief at this time and to identify potentialmoderators.

Methods: An electronic search of the Medline and Psych Info databases was conducted.Studies were selected for inclusion if they related to early miscarriage, used a standardizedmeasure to assess perinatal grief, and specified the assessment intervals employed. Qualita-tive studies were included when helpful to develop hypotheses.

Results: Descriptions of grief following miscarriage are highly variable but tend to matchdescriptions of grief used to characterize other types of significant losses. A sizable percent-age of women seem to experience a grief reaction, with the actual incidence of grief unclear.Suggestively, grief, when present, seems to be similar in intensity to grief after other typesof major losses and is significantly less intense by about 6 months. Few conclusions can bedrawn in regard to potential moderators of grief following a miscarriage.

Conclusions: Although additional research is clearly needed, guidelines for coping withgrief following miscarriage can be based on the data available on coping with other signifi-cant types of losses. Given the range of potential meanings for this primarily prospective andsymbolic loss, practitioners need to encourage patients to articulate the specific nature of theirloss and assist in helping them concretize the experience.

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INTRODUCTION

AMISCARRIAGE, OR SPONTANEOUS ABORTION, is apsychologically challenging event. Unlike

the loss of other family members, the grieving in-dividual has had few direct life experiences oractual times with the deceased to review, remem-ber, and cherish. There is no publicly acknowl-edged person to bury or established rituals tostructure mourning and gain support, and, often,relatively few opportunities are present to ex-

press thoughts and feelings about the loss due tothe secrecy that often accompanies the earlystages of pregnancy. When others do know aboutthe loss, they often fail to appreciate its impact orminimize it, making comments such as, “It wasnot meant to be” or “It is for the best.”1–7

Although there is increasing acceptance that amiscarriage represents a significant loss experi-ence,4 the empirical literature relating grief tomiscarriage continues to be limited by several sig-nificant problems. The term “grief” itself tends to

Department of Psychiatry and Pediatrics, Albert Einstein College of Medicine of Yeshiva University, Children’sEvaluation and Rehabilitation Center, Bronx, New York.

be poorly and inconsistently defined.8,9 Thescales used to measure grief following miscar-riage have varied in their reliability and validity,the breadth of signs of grief that are measured(for example, at times including markers of de-pression and at times yearning for the lost preg-nancy and baby), and the definition of the centralconstruct underlying measures of perinatal grieftend either not to be specified or to vary acrossscales.10,11 In addition, the assessment intervalsused in studies have ranged widely. As the in-tensity of grief is significantly affected by the pas-sage of time,12,13 the use of varying assessmentpoints confounds results. In addition, some stud-ies have measured grief while symptoms are be-ing directly experienced, whereas other studiesmeasure grief retrospectively so that descriptionsof grief are primarily based on recall. Finally,pregnancy loss in studies of grief is sometimesviewed as a unitary category in which distinc-tions between early and late miscarriages, ectopicpregnancies, stillbirths, and neonatal deaths areblurred.

Consequently, this review comprehensivelysurveys the literature on grief following miscar-riage. It emphasizes studies that have focused ongrief in regard to early miscarriage, specified theassessment intervals used so that the time sinceloss can be considered, and used a reliable andvalid measure to assess prenatal grief. Qualitativestudies are included when the results can be em-ployed to develop hypotheses. The purpose ofthis review is threefold: to elucidate the nature ofgrief following an early miscarriage; to determinethe incidence, intensity, and duration of grief atthis time; and to identify the variables that po-tentially moderate its intensity and duration. Asa result of this analysis, clinicians will be betterable to understand the nature and course of theirpatients’ grief following miscarriage and therebybetter help patients cope. Patients, in turn, will bemore likely to feel that the import of their loss isrecognized and understood and be able to acquireclearer expectations as to what they are likely tofeel and for how long.

First, the terms grief and miscarriage are de-fined. Next, the nature, duration, and intensity ofgrief following miscarriage are discussed, in-cluding differences in grief associated with gen-der. Key moderators are then noted. In the finalsection, the research and clinical implications ofthe review are described.

MATERIALS AND METHODS

An electronic search of the Medline and PsychInfo databases was conducted covering the pe-riod from January 1966 through January 2007 us-ing the keywords miscarriage, spontaneous abor-tion, pregnancy loss in combination with grief,mourning, and bereavement. Further searcheswere then carried out using references cited in theidentified papers. Searches were not circum-scribed by date or by language if an English ab-stract was available. Studies were subsequentlyincluded in the review if the majority of womenin a study sample (i.e., at least 51%) experiencedan early miscarriage (i.e., before the 20th week ofgestation), a standardized measure of perinatalgrief was used, and assessment intervals wereclearly specified. Qualitative studies, as noted,were included when helpful in formulating hy-potheses.

Grief defined

Grief refers to the affective, physiological, andpsychological reactions to the loss of an emo-tionally important figure14,15 and typically in-cludes severe and prolonged distress.16 There isa lack of consensus as to what constitutes normalgrief.18 For example, the American PsychiatricAssociation’s Diagnostic and Statistical Manual(DSM-IV)19 does not note what a typical grief re-action is. Instead, the DSM-IV describes a set ofsymptoms that are not characteristic of a normalgrief reaction, such as excessive guilt, suicidalideation, and feelings of worthlessness.

Various authors have attempted to delineatewhat constitutes normal grief by describing thesigns and symptoms that are typically present inthe bereavement period.20–23 Prigerson et al.,9,22

for example, described a holistic set of character-istics of grief as part of their effort to distinguishcomplicated and normal grief. Organizing the de-scriptors into affective, behavioral, cognitive, andphysiological categories, they noted that, affec-tively, people are depressed, despairing, dejected,angry, and hostile. Behaviorally, they tend to actagitated and fatigued, cry spontaneously, and aresocially withdrawn. Cognitively, they are preoc-cupied with thoughts of the deceased, have neg-ative self-judgments, feel hopeless and helpless,have a sense of unreality, and experience mem-ory and concentration problems. Physiologically,

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there is a loss of appetite, sleep disturbance, en-ergy loss and exhaustion, somatic complaints,and physical complaints often similar to what thedeceased endured.9,22 Yearning, or a deep long-ing for the deceased, has been identified in a re-cent study as the most salient element of griefamong 233 individuals who were administeredthe Inventory of Complicated Grief-Revisedscale.23

Explanatory frameworks to help understandthe nature of grief tend to emphasize attachmenttheory.24 According to attachment theory, grief isa natural product of an individual’s continuingattempt to foster proximity with the object of at-tachment and minimize separation from him orher. As will be described, this perspective may beespecially helpful in understanding an individ-ual’s tendency to experience a strong sense ofyearning for an anticipated, mostly imagined re-lationship following miscarriage. Initially, ac-cording to attachment theory, there are energeticreactions to the absence of proximity after a losscomposed of searching and protest and, subse-quently, passive responses suggesting the begin-ning of a process of disengagement from the at-tachment figure.20,24,25

A Stage Theory of Grief is often used both toorganize the individuals’ reactions to loss23,24,26,27

and to address the duration of grief. Most stagetheorists propose an initial stage of numbnessand disbelief, followed by a stage of separationdistress during which yearning for the deceasedis primary, then a period of sadness and despair,and a concluding phase of recovery and reorga-nization.23,28 Empirical support for this sequenceof stages was recently demonstrated in a longi-tudinal study of 233 bereaved individuals as-sessed over a 24-month period.23 Additionally, allthe salient distressing characteristics of grief werefound to peak within 6 months,23 consistent withJacobs’ review28 of normal and pathological griefin which he noted that the normal grief processseems to be appreciably completed within 6months after the loss of a loved one.

Miscarriage defined

Miscarriage, or spontaneous abortion, is thenatural termination of a pregnancy before the fe-tus is considered viable.1,29 Roughly 15%–20% ofrecognized pregnancies end in miscarriage,30,31

with about three quarters occurring before the

12th week of gestation.32,33 Although cliniciansgenerally consider pregnancies that spontane-ously terminate prior to the 14th–16th weeks ofgestation to be miscarriages,1 the time framesused in research studies have ranged, most typi-cally, from up to 20 weeks of gestation1 to 27weeks of gestation.7,34 Miscarriage rates rise dra-matically with age, from about 27% for womenaged 25–2930 to about 40% for women aged 4035

to about 75% for women aged �45.36

Instruments and methodologies used to assess the presence and intensity of grief following miscarriage

Empirically, studies specifically designed toelucidate the essential characteristics of grief fol-lowing a miscarriage, incorporating operationaldefinitions of grief and miscarriage, representa-tive samples, and a comparison group of subjectswho had experienced other types of losses, couldnot be located. What is available as a basis for elu-cidating the nature of grief at this time are stud-ies describing the development of self-reportscales designed to quantitatively measure thepresence and intensity of perinatal grief10,11,37–39

and qualitative studies of the experiences of wo-men who had a miscarriage.40–43

As will be apparent, the measures developedto assess grief following miscarriage differ interms of the types of symptoms of grief they in-clude and their comprehensiveness. In addition,although some of the scales to be described havebeen developed based on a factor analysis of itempools, others have been derived based on thescale author’s theoretical or clinical perspective.

The Perinatal Grief Scale (PGS)38 was one of theearliest instruments developed to assess the in-tensity of grief following a miscarriage. The scalewas based on an established measure, the TexasGrief Inventory.13 The items selected for this scalewere derived from the authors’ clinical experiencewith people who had lost a close friend or relativeand was intended to measure grief-related behav-iors and feelings, such as sadness, searching for thedeceased, crying, and yearning.38,46 Toedter et al.38

interviewed parents who experienced a perinatalloss and modified the wording of items based onthese interviews. A condensed version of the scalewas also developed.39

Factor analytical studies of the PGS have iden-tified three subscales: active grief, difficulty cop-

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ing, and despair. Nikcevic et al.37 also adjustedthe Texas Grief Inventory for miscarriage and, ina study of 227 women who suffered a miscarriageprior to the 14th week of gestation, again founda three-factor solution: pure grief, grief-relatedemotions, and perceived adjustment and func-tioning since the miscarriage. High reliability(Chronbach’s alpha � 0.90) and construct valid-ity for this scale were found in an initial studydemonstrated by significantly lower scores re-ported in women who became pregnant.37

The PGS has been criticized for both overem-phasizing feelings related to the “lost baby” at theexpense of other potential grief-related feelings,such as yearning for the lost pregnancy,7,37 andfor overlapping too greatly with markers of de-pression.7 With regard to reliability, in a reviewof a decade of research with the PGS based on 22studies and a sample of 2485 participants, com-putation of Cronbach’s alpha indicated very highinternal consistency. Adequate convergent valid-ity has also been consistently demonstrated in theassociation of the scale with markers of mentalhealth, social support, and marital satisfaction.42

To better distinguish grief following a miscar-riage from depression, Beutel et al.10 developedthe Munich Grief Scale. They modified and short-ened the PGS based on a review of the literatureand their own clinical observations. They foundthe Munich Grief Scale to be composed of severalsubscales, including sadness, fear of future loss,guilt, anger, and searching for meaning. Theynoted that feelings of missing the baby, painfulmemories of the loss, and difficulty relinquishingthe hopes for, expectations of, and fantasies aboutthe unborn child were important elements to bemeasured. Adequate reliability was reportedalong with adequate validity based on the scale’sassociation with scales of depression, anxiety,and physical symptoms.

Hutti et al.40 developed a scale to measure grieffollowing a miscarriage, entitled the PerinatalGrief Intensity Scale (PGIS). The scale was theo-retically derived to predict grief intensity and wastested on a convenience sample of 186 womenwho suffered a miscarriage before 16 weeks ofgestation in the previous 12–18 months. The threefactors they identified as predictive of grief in-tensity following a miscarriage were the realityof the baby and pregnancy within, the congru-ence between the actual miscarriage and the wo-man’s standard of the desirable (i.e., wish for ababy), and the ability of the woman to make de-

cisions or act in ways to increase this congruence.The PGIS, in an initial validation study, demon-strated acceptable reliability (alpha coefficient of0.82) and construct validity. All three subscaleswere significantly correlated with self-report ofgrief intensity and length of grieving.40

Finally, a recently developed, narrow measureof grief following a miscarriage, derived from areview of the theoretical, clinical, counseling, andresearch literature, is the Perinatal BereavementGrief Scale (PBGS).11 An initial validation studydemonstrated high internal consistency and test-retest reliability. The scale is designed to measuregrief following reproductive loss based on thedegree to which the individual yearns for the lostpregnancy and lost baby. The intensity of grieffound on the scale is associated with the indi-vidual’s desire to maintain an attachment withthe baby and the degree of investment the indi-vidual has had in the child. Convergent validitywas demonstrated by its association with mea-sures of attachment and investment in the child.The use of yearning as the key construct to de-velop the scale is validated by the recent longi-tudinal study of bereaved individuals, noted ear-lier, in which yearning was found to be the mostsalient psychological response to natural death.23

Qualitative studies of the experience of mis-carriage have varied widely in their methodology(i.e., questionnaires, interviews, and nonstan-dardized Likert scales) and in their sample sizes(i.e., from 6 to 294 subjects).41,43–48 Initially, asense of shock and unreality is described, fol-lowed by feelings of confusion over the suddendisappearance of a maternal role, and disap-pointment over the loss of an anticipated fu-ture.44,45,48 The intensity of grief is described assimilar to the intensity of grief individuals expe-rience after other types of significant losses, suchas that of a family member.41,43 Also describedare symptoms of stress, sadness, depression,guilt, and self-blame.43,45,47,48

Based on this review of the items included instandardized measures developed to assess peri-natal grief, descriptions of grief following mis-carriage are highly variable but, on the whole,seem to match descriptions of grief used earlierto characterize other types of significant losses.Thus, yearning, sadness, crying, fatigue, appetiteand sleep changes, preoccupation with the loss,and guilt seem to be commonly noted. When guiltis present, it tends to be specifically linked to self-blame for failing to protect the baby from pain

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and death.8 Particularly evident in the qualitativestudies noted, the yearning evident as part of agrief reaction following miscarriage is primarilyprospective and centers on a longing for an an-ticipated future and set of expectations, plans,and hopes. Thus, grief after miscarriage seems, inlarge measure, to involve distress over the loss ofa symbolic, as opposed to an actual, relationship,one constructed in idiosyncratic fashion from themourner’s imagination based on her uniqueneeds and wishes. Again, particularly evident inthe qualitative studies, grief following miscar-riage seems to involve multiple elements of loss,of being a pregnant woman, a mother, and amember of a relatively larger family, with the in-tensity of grief attached to each element seemingto vary from mourner to mourner.

Incidence, intensity, and duration of grieffollowing miscarriage

The literature in regard to incidence rates, in-tensity, and duration of grief following miscar-riage is extremely sparse. With regard to inci-dence rates, the literature is composed primarilyof qualitative studies that lack a clear operationaldefinition of grief and use varying time intervals,formats, and measures. As a result, the incidenceof grief reactions following miscarriage reportedin these studies has varied widely.

Results, for example, of an early, impression-istic study of 22 women who had experienced aspontaneous abortion found that all the womendisplayed typical signs of grief based on clinicalcontacts,49 as did almost all the women (96%)who were provided support and counseling aftera miscarriage in a miscarriage clinic.50 As both ofthese qualitative studies involved individualsseeking counseling, the incidence of grief is likelyto be elevated. In another qualitative study, us-ing data obtained from 44 women treated for mis-carriage, about 2 weeks later, on average, 82% ofwomen were said to feel a sense of loss, and 77%experienced some limitations in daily functioningas a result of that loss.51 Finally, in an empiricalstudy employing a matched community controlgroup, 125 women were assessed with the Mu-nich Grief Scale shortly after a miscarriage thathad occurred before the 20th week of gestationand again at 6 and 12 months. Twenty percent ofthe sample had only a grief reaction, 12% had adepressive reaction, 20% had a combined de-pressive and grief reaction, and 48% had no

change in their emotional reactions.3 Thus, al-though a sizable percentage of women seem toexperience a grief reaction following a miscar-riage, the actual incidence of grief at this time isunclear.

Whereas many studies have examined factorsthat might moderate the intensity of grief fol-lowing a miscarriage, three studies could be lo-cated that focused on the overall, relative inten-sity of grief following a miscarriage. Paton et al.52

administered the PGS to 58 women 4–6 weekspostmiscarriage and found highly elevatedscores. Similarly, Nikcevic et al.37 administeredthe Texas Grief Inventory adjusted for miscar-riage to 207 women who miscarried prior to 14weeks and obtained mean scores as high as thescores of people who had lost a close relative. Fi-nally, Hutti et al.40 administered the PGIs, devel-oped specifically to predict intensity of grief re-sponse to early pregnancy loss, to a conveniencesample of 186 women who had experienced amiscarriage before 16 weeks of gestation in theprevious 12–18 months. Roughly three fourths ofparticipants reported moderate to intense griefreactions. Thus, based on this limited literature,when a grief reaction occurs following a miscar-riage, it seems to be relatively elevated. Further,again suggestively, the intensity of grief follow-ing a miscarriage seems to be similar to the in-tensity of grief after other types of significantlosses.

Several studies have attempted to answer thequestion: How long does grief endure followinga miscarriage? using changes in the intensity ofgrief over time as a marker. Deckhardt et al.53 ad-ministered a standardized questionnaire to 86women who experienced a spontaneous abortionshortly after a dilation and curettage (D & C) andagain at 7, 13, and 24 months. For the majority ofwomen, grief continuously declined prior to theinitial follow-up assessment at 7 months. Simi-larly, Beutel et al. carried out two studies ad-dressing the issue of duration of grief. In a lon-gitudinal study using the PGS with 86 womenwho had an early miscarriage, grief reactionswere found to gradually decline and significantlydiminish by 6 months,10 and in a controlled fol-low-up study, 56 couples completed the MunichGrief Scale at 6 and 12 months postmiscarriage.Grief scores significantly declined after 6 monthsfor both men and women.3 Nikcevic et al.,37 in aprospective, longitudinal study administered theTexas Grief Inventory adjusted for miscarriage to

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143 women who had a pregnancy loss between10 and 14 weeks. Grief scores were significantlylower at 4 months compared with 4 weeks post-miscarriage. Finally, Hutti et al.,40 in a validationstudy of the PGIS with 186 women who experi-enced a miscarriage before 16 weeks, found thatthe moderately intense grieving most partici-pants reported lasted less than 6 months, withabout one half grieving less than 3 months. Thus,the available data indicate that there is a signifi-cant reduction in the intensity of grief by about 6months postmiscarriage, suggesting that the du-ration of grief following pregnancy loss is simi-lar to the duration of grief after other types of sig-nificant losses.23

One variable that seems to affect the durationof grief following a miscarriage is a subsequentpregnancy.7 Cuisiner et al.,54 for example, ad-ministered questionnaires to 2140 pregnant wo-men in a prospective study. Subsequently, 227lost a baby by miscarriage (85%) or perinataldeath (15%). These women were then adminis-tered the PGF at four postloss assessment inter-vals. The women who had a subsequent preg-nancy by the time of these assessments displayeda significant decrease in grief levels comparedwith women who as yet had not conceived. Sim-ilarly, Nikcevic et al.55 used the Texas Grief In-ventory, adjusted for miscarriage, with 207 wo-men who had an early pregnancy loss. Grieflevels in women who became pregnant followinga miscarriage were significantly lower than grieflevels of women who had not become pregnant.Franche56 compared the level of active grief, dif-ficulty coping, and despair in 25 women (andtheir partners) who had become pregnant after apregnancy loss with the level of active grief, dif-ficulty coping, and despair in 25 women (andtheir partners) who had not become pregnant.Women who were pregnant experienced signifi-cantly lower levels of despair and difficulty cop-ing. Grief intensity, however, remained high forboth groups, suggesting that a subsequent preg-nancy seems to lessen the active, impairing effectsof grief while mourning still continues. Thus,these studies are somewhat consistent in indicat-ing that the duration of grief following miscar-riage is relatively shorter in women who becamepregnant by the time of assessment comparedwith women who do not become pregnant. In ad-dition, these studies suggest that key elements ofloss following miscarriage include the loss of theroles of pregnant woman and mother so that

when these roles are reestablished, symptoms ofactive grief lessen.

Gender and intensity of grief following miscarriage

An area in which there has been a fair amountof research relates to gender-specific differencesin the intensity of grief following a miscarriage.Although a variety of standardized grief assess-ment instruments were used, along with widelydifferent sample sizes and assessment intervals,men were found to experience significantly lessintense levels of grief for a shorter period fol-lowing a miscarriage than women in eight of theeleven studies that could be located.57–64 Of thethree studies that produced somewhat contradic-tory results, two used only a male cohort andcompared scores on the PGF with norms for wo-men. Men’s and women’s scores were found tobe comparable following miscarriage.65,66 Com-paring men’s scores with test norms rather thanwith their female partners’ scores limits thestrength of the conclusion, in that time intervalssince loss are not controlled. The remaining con-tradictory study, which found higher levels ofgrief in 39 men relative to their female partnerssoon after the miscarriage and comparable levelsat 2–4 months postmiscarriage, is also limited, inthis case by the small size of the sample.67 Thus,the overall trend of these findings supports thecommonsense expectation that a woman’s griefis relatively more intense than a man’s followinga miscarriage because she carried the pregnancybiologically, has a greater psychological attach-ment as a result, and, therefore, experiences theloss more powerfully.

Several qualitative differences between men’sand women’s grief have also been noted. In astudy comparing couples’ reactions to miscar-riage, men were found to cry less, be less dis-tressed when seeing other pregnant women, andhave less need to talk about the loss.59 In a sec-ond study using an interview format with 20 malepartners, a high level of confusion as to appro-priate behavior and a belief that men need todeny their own feelings of grief for their partner’ssake were noted.68 Men’s grief following a mis-carriage was found to be moderated by severalvariables, including the vividness of their im-agery of the fetus based on exposure to an ultra-sound scan65,66 and length of pregnancy in onestudy69 but not moderated by length of preg-

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nancy in another.65 An important caution whendiscussing distinctions between men’s and wo-men’s affective reactions to miscarriage is thatthese differences may reflect differences in the ex-pression of emotion generally rather than affec-tive reactions to miscarriage per se.7

Moderators of grief and miscarriage

Based on the literature reviewed, the natureand intensity of individuals’ reactions to preg-nancy loss seem to vary. The factors that are gen-erally seen as moderating the direction andstrength of the relationship of bereavement andgrief include the nature of the relationship be-tween the bereaved and the deceased, the specificneeds and wishes the individual associates withthe relationship, the extent to which the deceasedis an important part of the bereaved individual’smental representation of the world, the way theindividual deals with emotional challenges andexpresses emotions typically, and the reactions ofsignificant others to the loss.8 These general fac-tors are used as an organizing schema to make asomewhat arbitrary division of the potentialmoderators identified in the literature on miscar-riage and grief.

Nature of the relationship. As noted, given theprimarily prospective, symbolic nature of the re-lationship between the bereaved and the de-ceased in a miscarriage, the degree to which theindividual experiences the pregnancy and rela-tionship to the developing fetus as real and ges-tational age are two factors that have been notedin the literature as possibly affecting the natureand intensity of grief after a miscarriage. Fetalimaging techniques, experiencing fetal move-ment, and such concrete actions as naming thebaby and purchasing items for the baby increasethe likelihood that the deceased will be experi-enced as real. In addition, these experiences arelikely to result in memories of actual times withhim or her,70 increase the likelihood that he or shewill be perceived as a baby rather than as a fe-tus,71 increase maternal attachment,7 and, as aconsequence, ought to increase the intensity ofgrief following the loss.

The empirical studies relating the perceived re-ality of the pregnancy and the nature and inten-sity of grief following a miscarriage are extremelylimited. The reality of the pregnancy has beenidentified as a factor in the three-factor solution

found by Hutti et al.40,71 when developing thePGIF. Based on a convenience sample of 158 wo-men who had experienced a miscarriage before16 weeks of gestation in the prior 12–18 months,the more individuals had perceived the preg-nancy and baby as real prior to the miscarriage,the more intense was their level of grief.

With regard to the effect of viewing an ultra-sound, contradictory results have been reported.Puddifoot and Johnson66 administered the PGFand the Vividness of Visual Imagery Scale to 158male partners of women who had miscarriedprior to the 25th week of pregnancy. Men whohad viewed an ultrasound were found to havesignificantly more vivid images of their unbornchild and higher levels of grief than male part-ners who had not seen an ultrasound. Ritsher andNeugebauer,72 however, found a lack of associa-tion between viewing an ultrasound and level ofgrief.7 Some of the contradiction in findings maybe explained by differences in the methodologyused in the two studies. Whereas Ritsher andNeugebauer72 noted if an ultrasound wasviewed, Puddifoot and Johnson66 measured notonly if an ultrasound was viewed but also the de-gree to which vivid images resulted from theviewing. The latter may be more important inpredicting the psychological impact of the loss.

Relatively higher levels of yearning after preg-nancy loss after experiencing fetal movement orquickening have been reported in the one studythat could be identified.11 In this validationstudy of the PBGS, a sample of 304 women whoexperienced a miscarriage (approximately threequarters before 16 weeks and the rest before 27weeks) were assessed at 2 weeks, 6 weeks, and6 months postmiscarriage. Women who felt thefetus move had significantly higher PBGSscores. Support was also found for a significantpositive association between PBGS scores andsuch actions as naming the baby, thinking ofwhat has been lost as a baby, making changes inthe home in anticipation of the baby’s arrival,and purchasing items for the baby. Ritsher andNeugebauer11 considered these actions to be re-flections of parents’ investment in the preg-nancy, and they are also likely to enhance thereality of the baby and increase the number ofconcrete events that have occurred and can beused to create memories of the baby. Thus, giventhe limited and somewhat inconsistent nature ofthese findings, there is only partial support forthe proposition that the more an individual ex-

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periences the pregnancy as real, the more in-tense is his or her level of grief.

Length of gestation is another factor thought toincrease the reality of the pregnancy, based on thecommonsense assumption that the longer thepregnancy, the greater the number of opportuni-ties there would be to experience the baby’sreality (e.g., fetal movement, ultrasound) and,therefore, the stronger the attachment to the baby.Again, very few studies could be located thathave focused specifically on the relationshipsamong gestational age, grief, and miscarriage.Further, the studies that could be located variedmarkedly in design, sample size, definitions ofpregnancy loss, assessment instruments, and as-sessment intervals. Not surprisingly, therefore,the results are highly inconsistent.

Of the studies that found a positive relation-ship, Toedter et al.38 report a significant positiveassociation between gestational age and grief aspart of their initial development and validationstudy of the PGF. It is important to note, how-ever, that the sample of 194 subjects includes wo-men who had experienced fetal and neonataldeaths as well as spontaneous abortions. Thus,the range in gestational age was much greaterthan would be the case if only women who mis-carried were included. Similarly, Theut et al.73 re-port a positive association between gestationalage when women miscarry and unresolved griefduring the subsequent pregnancy and postnatalperiod. Again, however, 16 of their 25 subjectshad miscarried, and the rest had experienced still-births and neonatal losses. Further, the study em-ployed a retrospective design so that subjectswere recalling losses that had occurred at vary-ing times in the last 2 years.

Goldbach et al.,57 in a follow-up study at 1 and2 years postloss based on earlier research with thePGS, also found a positive association betweengestational age and grief in 138 women whoseloss occurred on average at 16.5 weeks, as didJanssen et al.74 in a longitudinal, prospectivestudy. Janssen et al. sent a questionnaire to 2140women within the first 12 weeks of pregnancy.Of these, 227 women subsequently miscarriedand were reassessed four times over an 18-monthperiod using the PGS. Duration and intensity ofgrief were positively associated with the lengthof the pregnancy. In addition, Franche56 reporteda positive association between gestational ageand symptoms of active grief based on the re-sponses of 60 pregnant women with previous

miscarriages or perinatal deaths and 50 of theirpartners using the PGS. Fifty-one percent of thewomen in the sample had a loss in the firsttrimester, and the mean gestational age at thetime of loss was 17.5 weeks. Complicating the im-plications for miscarriage per se, however, is that15% of the sample had a loss in the thirdtrimester, and 5% had neonatal deaths. In addi-tion, the assessment on average occurred 15.1months after the loss and during a subsequentpregnancy, when thoughts of the earlier loss mayhave been rekindled.

Of the studies that found a lack of associationbetween gestational age and grief following mis-carriage, Peppers and Knapp75 found no rela-tionship between the intensity of grief and timeof loss in 65 women who had a pregnancy loss.The implications of these results are weakened bythe widely varying time intervals between theloss and the time the intensity of grief was as-sessed, and results are confounded in regard tomiscarriage by the inclusion of women who ex-perienced relatively late losses in the form of still-births and neonatal deaths in the sample.Deckardt et al.53 found a lack of association be-tween gestational age and grief. Standardizedquestionnaires were administered to 86 patientswho had experienced a spontaneous abortionshortly after they miscarried and subsequently at7, 13, and 24 months. Intensity of grief was foundto be unrelated to gestational age. Finally,Cuisinier et al.76 compared the effect of gesta-tional age on grief in early pregnancy loss (i.e.,before 20 weeks) and in late pregnancy loss (i.e.,stillbirth). Based on a sample of 143 women whoexperienced either a miscarriage or a stillbirth,gestational age was not found to be associatedwith the intensity of grief in early miscarriage butwas associated with the intensity of grief in lossesthat occurred late in the pregnancy.

Aside from the clear need for systematic study,what can be inferred from these contradictory re-sults? One possibility is that as the range in ges-tational age is relatively restricted in miscarriage,with three quarters occurring before the 12thweek of gestation,32,33 gestational age is less likelyto have a powerful effect on grief when womenwho have experienced a miscarriage are studiedexclusively.77 Alternatively, gestational age maynot be a primary marker of the strength of thebond or reality of the pregnancy in early miscar-riage. Bowlby24 described attachment as the de-gree to which an individual experiences an af-

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fective connection and sense of involvement withthe loved individual, object, or symbol. Perhapsthe degree of psychological attachment present inan early pregnancy loss is not dependent on theliteral passage of time. In support of this possi-bility, many women are found to have a strongattachment as soon as the pregnancy is known,70

and the majority of women have mental repre-sentations of the fetus by about 10 weeks even inthe absence of independent verification throughfetal imaging.3

Needs and wishes the individual associates with thepregnancy. The particular needs and wishes theindividual associates with the pregnancy oughtto impact the duration and intensity of grief fol-lowing a miscarriage. Maternal age, often con-sidered a potential indicator of values and goalsthe individual is likely to have in regard to child-bearing, and number of prior losses are factorsmentioned in the literature that might define themeaning of the pregnancy to the bereaved and,thus, impact the duration and intensity of griefsubsequent to a miscarriage. With regard to age,grief symptoms generally associated with the lossof loved ones are greater in younger age groupsperhaps because coping with death at youngerages tends to be more difficult, given that the lossis likely to be more sudden (i.e., more likely to bedue to accidents and less likely to be due to dis-ease) and, therefore, more unexpected.17

No studies could be located specifically relat-ing grief, maternal age, and miscarriage, butNeugebauer et al.78 studied the relationship be-tween maternal age and signs of depression ina cohort of 229 women, and no association wasfound. Because symptoms of grief and depres-sion are particularly difficult to distinguish inthe first 2 months postloss,19 the fact that 72% ofthe women in the cohort were assessed in thefirst month postloss provides support for a lackof association between grief and maternal agebut still leaves open the possibility that a differ-ent result might be found if grief were directlyassessed. In the same study, Neugebauer et al.78

also did not find that the number of prior re-productive losses had a significant effect on theincidence of major depression 1 month after amiscarriage. Based on their review of the litera-ture on affective reactions and miscarriage, Klieret al.7 concluded that prior pregnancy loss doesnot seem to have a significant effect on the psy-chological consequences of miscarriage (defined

primarily by studies measuring depressive re-actions).

Extent to which the lost relationship is an impor-tant part of the bereaved individual’s mental repre-sentation of the world. Investigations as to whetherthe importance of the pregnancy and the de-gree to which it was desired impact level of grief have produced mixed results. Ritsher andNeugebauer,11 in a validation study of the PBGS,assessed at 2 weeks, 6 weeks, and 6 months post-loss the relationship between degree of invest-ment in the pregnancy and intensity of grief in304 women who suffered a miscarriage prior to28 weeks. Women who desired the pregnancyand seemed more invested in it (indicated, for ex-ample, by endorsing such items as, I had startedthinking of a name; I think of the loss as a baby;I bought things for the baby) had significantlyhigher PBGS scores. Beutel et al.,3 on the otherhand, administered standardized independentmeasures of grief and depression to women whoexperienced a spontaneous abortion. Ambiva-lence toward the pregnancy was significantly as-sociated with an increase in depressive symptomsbut not associated with intensity of grief reac-tions.

The number of living children an individualhas at the time of miscarriage has also been usedas a marker of the importance attached to thepregnancy, based on the assumption that the ab-sence of living children is associated with a rela-tively greater desire for children and, as a result,a greater investment in the pregnancy. Janssen etal.,74 in a longitudinal, prospective study, evalu-ated 227 women using the PGS on four occasionspostloss. A highly significant positive relation-ship (0.01) between intensity of grief and the ab-sence of living children was found. Similarly, wo-men without any children had significantlyhigher PGF scores when assessed at 4 months, ina follow-up study of 88 women who miscarriedprior to 18 weeks.79 Inferential support was alsofound in the study by Neugebauer et al.,78 notedearlier, that examined the likelihood of major de-pressive disorder (MDD) following miscarriage.When the 229 women who had miscarried wereadministered the Diagnostic Interview Schedule,the risk for an MDD was significantly elevated inwomen who had miscarried and who were child-less relative to a comparison group of womendrawn from the community. Again, as has beennoted, as 72% of the cases of MDD in this study

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began within the first month after loss, thesesymptoms are likely to overlap with symptomsof grief. Thus, based on these sparse data, the re-lationship between investment in the pregnancyand intensity of grief is inconsistent, whereasstudies related to the absence of living childrenat the time of miscarriage seem consistent in in-dicating relatively higher levels of grief in womenwho do not have living children.

Preloss coping capacity. How well an individualhas coped with emotional challenges has beenconsidered a potential predictor of how well heor she will cope with a current emotional chal-lenge, such as miscarriage. Thus, an individual’shistory of high level of emotional distress and thepresence of psychiatric symptoms were expectedto be associated with relatively more enduringand intense grief following pregnancy loss.Janssen et al.74 directly addressed this question ina prospective longitudinal study. They used theDutch Personality Inventory and informationabout low self-esteem, general and social inade-quacy, and aggrievedness to assess preloss “neu-rotic personality,” defined as relatively high lev-els of emotional distress. Women who had arelatively high degree of neurotic personality andpreloss psychiatric symptoms had relativelyhigher levels of grief based on the PGS. This result is consistent with Lasker and Toedter’s re-view80 of 22 studies that used the PGS and in-cluded an examination of the relationship be-tween mental health, as indicated by scores on awide-ranging set of psychiatric symptom ratingscales, and pregnancy loss (including miscar-riages, stillbirths, induced abortion, neonataldeath). Intensity of grief was positively related tothe presence of psychiatric symptoms.

Social support. Many studies have demon-strated that social support is associated with im-proved adjustment following negative lifeevents81 and may be related to an individual’spersonal appraisals of support rather than the ac-tual supportive behaviors of others.82 There issome evidence that social support may facilitateadjustment after pregnancy loss generally80 bylessening the intensity and duration of stress,17

but no studies examining the effects of social sup-port on grief following miscarriage could befound. Because many people wait until the endof the first trimester to announce a pregnancy, po-tentially supportive associates in the individual’s

social network may not even know about eitherthe pregnancy or the miscarriage and, therefore,may not be able to offer comfort. Thus, the im-portance of enlisting social support after miscar-riage is an important question that awaits furtherstudy.

One specific form of social support that hasbeen posited as a factor in better coping with ad-versity is participation in a religious commu-nity.81 The literature on the relationship betweenparticipation in religion and coping with be-reavement is inconsistent, however, ranging frompositive to no difference to poorer coping amongthe religiously bereaved.17 Again, no studiescould be located examining the relationship be-tween religious participation and grief followingmiscarriage. Religious participation not only canaffect social support, but it also can affect the in-dividual’s belief system and potentially facilitategrieving by allowing the individual to attach ameaning as to why a loss has occurred.

Integrative summary

The literature relating grief to miscarriage is ex-tremely sparse, and as a result, few clear and con-sistent results are evident. Suggestively, the af-fective and behavioral reactions that typicallyoccur following miscarriage seem similar to theaffective and behavioral reactions that typicallyoccur following other types of significant losses.At the same time, grief following miscarriageseems somewhat distinct from grief that typicallyoccurs following other losses in the preponder-ant emphasis on times ahead rather than re-membered times. Thus, after a miscarriage, theindividual seems to dwell on images of an antic-ipated future and the hopes and dreams aboutwhat was to be rather than on past experiences.Yearning after a miscarriage also seems some-what different in that it is primarily centered onthe individual’s mental construction of a rela-tionship and future rather than actual, past, di-rectly shared experiences.

With regard to the percentage of individualswho experience a grief reaction following a mis-carriage, no clear guidelines are possible. Theavailable literature does suggest that grief reac-tions are common and similar in intensity to grieffollowing other types of losses. In addition, likegrief following other types of losses, grief aftermiscarriage seems to abate in intensity by about6 months and to diminish when a subsequent

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pregnancy occurs. Gender differences in relationto grief following miscarriage are evident, withmen seeming to experience less intense and en-during grief than women.

Although many variables have been studied todetermine their role as moderators of the inten-sity and duration of grief following miscarriage,few clear conclusions can be drawn. There is par-tial but inconsistent support for an association be-tween perceiving the pregnancy as real and grieffollowing miscarriage and inconsistent supportfor an association between gestational age andgrief when other forms of pregnancy loss are ex-cluded from study and only miscarriage is con-sidered. The effects of two variables that mightimpact the desire to have a child, maternal ageand number of prior reproductive losses, havenot been studied specifically in regard to griefand miscarriage. A lack of association, however,is suggested based on studies of depressive reac-tions in the first 2 months following a miscarriage,a period in which grief and depressive reactionsoverlap. Studies examining other variables thatmight bear on the relationship among grief, theimportance of the pregnancy, and the degree towhich the pregnancy was desired have producedmixed results. For example, the absence of livingchildren is suggestively but inconsistently asso-ciated with the intensity of grief following mis-carriage. Somewhat consistent results are foundwhen level of grief after miscarriage and the pres-ence of prior psychiatric symptoms are studied,with preloss coping capacity seeming to be pre-dictive of level of grief. Finally, the absence ofstudies on the effects of social support and reli-gious participation on level of grief followingmiscarriage prevents any conclusions from beingdrawn.

Research and clinical implications

Additional research is clearly needed to ad-dress the many important questions that havebeen either not examined or insufficiently exam-ined. In particular, additional research is neededto further clarify the nature of grief following mis-carriage, the incidence of grief reactions, and thedegree to which maternal age, number of priorpregnancy losses, amount of social support, therole of cultural beliefs, and religious participationmoderates the intensity of grief subsequent tomiscarriage. Ideally, these studies would employa literature-based, operational definition of grief;

a consistent interval to define when a pregnancyloss is considered a miscarriage; standardizedmeasures of grief specific to pregnancy loss inwhich scale items are keyed to the definition ofgrief used; representative samples; and stan-dardized assessment intervals.

Clinically, the paucity of clear information asto the incidence, characteristics, and duration ofgrief following miscarriage suggests that practi-tioners can offer only suggestive guidelines as towhat constitutes an adaptive or typical reactionto miscarriage. When an individual’s reactionsseem to be typical, the similarity in the results ofstudies examining the duration and intensity ofgrief following miscarriage and the duration andintensity of grief following other types of signif-icant losses supports using the general literatureon grief to help guide patient expectations. Forexample, women who miscarry can be advisedthat their grief is likely to ebb by about 6 months23

and that a subsequent pregnancy is likely to beassociated with a diminution in grief.7 By offer-ing these general guidelines and comparing grieffollowing miscarriage to grief following other sig-nificant losses, the clinician is indirectly provid-ing validation, when needed, that a miscarriagehas a high level of significance for most peopleand that strong feelings of grief are expectable.

Given the range of potential meanings that in-dividuals attach to the pregnancy, motherhood,and loss after miscarriage, clinicians need to helppatients articulate their “personal legacy of theloss.”83 For example, clinicians can ask when theindividual first began to wish for a child (or nextchild), what she was hoping for or anticipating,and for descriptions of special moments that haveoccurred during the pregnancy and for imagesand fantasies that the individual has had aboutthe expected future with the child. By helping thepatient to put his or her thoughts and feelingsinto words and then helping organize these ideasinto a coherent whole, patients may experiencean increased sense of control. In addition, the pa-tient may be better able to share his or her feel-ings and thoughts with others, thereby facilitat-ing support.

Finally, given the primarily prospective, sym-bolic nature of loss in miscarriage, clinicians canfacilitate grieving by helping the patient con-cretize the experience. Clinicians might ask pa-tients if they have named the baby, inquire as tothe name, and, with permission, use the namewhen discussing the loss. Developing ways to

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memorialize the baby can also help increase thereality of the loss and create mementos and mem-ories. Clinicians can suggest that patients placematerial goods bought for the baby in a keepsakebox, along with, for example, the sonogram anda letter the individual might write describing thehopes and dreams that she or he had for the baby.Clinicians can also assist in designing a memor-ial service that structures and concretizes theevent, provides validation that a significant losshas occurred, and establishes an opportunity forothers to acknowledge the loss and offer support.In addition, the memorial service may be valu-able in marking time, providing a means to indi-cate the end of one phase and the beginning of anew one.84

DISCLOSURE STATEMENT

No competing financial interests exist.

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Address reprint requests to:Norman Brier, Ph.D.

Clinical Professor of Psychiatry and PediatricsAlbert Einstein College of Medicine of

Yeshiva UniversityChildren’s Evaluation and Rehabilitation Center

1410 Pelham Parkway SouthBronx, NY 10461

E-mail: brier@aecom.yu.edu

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