Reproductive loss¹ is a distinct traumatic event. It is not based on the threat to one’s physical self or that of another who was known, but it is the loss of someone not yet born or known, but still very much loved. Utilizing both scientific state-of-the-art knowledge and the author’s over 25 years personal clinical experience in working with this patient population, this chapter explores what makes reproductive loss a unique loss, the many forms it takes, predictors of adaptive or problematic coping and outcomes, what components of resilience can be mobilized to minimize prolonged distress, and the impact it often has on a subsequent pregnancy and postpartum. Clinical suggestions and tips for practitioners will be offered throughout the chapter to aid medical caregivers and mental health providers in addressing the needs of bereaved mothers and the whole family. This chapter starts with a description of the many aspects of reproductive loss, moves on to describing the various factors influencing coping and resilience, and finishes with elaborating on interventions and regaining one’s reproductive life after the loss.

Reproductive loss can traumatize in the usual sense of overwhelming one’s coping capacities, leaving one feeling terrified, helpless, and unable to internally process what has occurred. Inundating one’s emotional circuits, classic posttraumatic stress disorder (PTSD) typically results in attempts to assimilate the event through reliving it in dreams, flashbacks, and other reenactments, being in a heightened state of arousal with increased irritability and insomnia, and avoiding cues associated with the event and being overwhelmed (Herman 1992). Unlike most other trauma, reproductive loss usually doesn’t involve violence committed by another person. This may help explain why, in my experience, bereaved mothers do not demonstrate the detachment from others, as typically happens among those who have survived violent trauma such as rape, physical abuse, and combat casualties. In a safe setting, after some time has elapsed, the bereaved mother is often ready to share the details of her painful loss, allowing an opportunity to process it as well as to rapidly facilitate a bond with a caregiver who is prepared to empathically listen.

Reproductive loss can be traumatic in another manner. It can violate the schema we use to organize our place in the world, leaving “shattered assumptions” (Janoff-Bulman 1992) in its wake. The ways we are accustomed to viewing the world as safe, just, predictable, and benign no longer apply (Janoff-Bulman 1992). We are compelled to search for a new sense of meaning, understanding, and purpose to guide our actions (Neimeyer 2000). Reproductive loss can present a particular challenge to a sense of fairness and justice in the world because babies are not supposed to die. The natural order is upended when parents bury their offspring, not the usual other way around. Caregivers need to be able to absorb and not contest the outrage parents can feel when their world has been shattered. A father may be especially susceptible to feeling furious and helpless, not being able to protect his wife from this grief by being dealt with a tragedy that he can’t solve.

In many ways these losses are like no other (Leon 1999). It is extremely difficult to grieve someone you love but never got to know. Both the shock and ambiguity (Lang et al. 2011) of these losses can make them seem unreal. For these reasons, it can be especially valuable to encourage parents to see, hold, and get to know their deceased baby (Gold et al. 2007) in order to make the loss more real, provide memories to facilitate grieving, and, for many, identify the loss of a named family member, as a son or daughter.

Most losses entail the intolerable absence of what has been, that is, the possibility to retrospectively recall past memories of the beloved. Reproductive losses are almost entirely a prospective eradication of the imagined future with one’s child which now will not be. Even after the initial intensity of grief has subsided, a “shadow grief” (Peppers and Knapp 1980) persists at a lower ebb, temporarily heightened during anniversaries such as the due date or the birth/death date. It can be helpful for bereaved parents to know this is normal. It is not a harbinger of unresolved grief but a natural reawakening of mourning their lost child who is not there when she should be but is never forgotten.

While most friends and family appreciate the death of a family member as a loss worthy of mourning, for many a reproductive loss is minimized or disenfranchised (Lang et al. 2011) as not a genuine loss warranting grief. Bereaved parents are told to “forget about it” and “have another baby,” as if such a loss can be so simply discarded or replaced in a manner that would never be suggested for the death of an older child. Caregivers may lighten these blows by anticipating with bereaved parents that such painful comments are usually motivated by ignorance rather than malevolence, modeling the unfortunate but necessary need to educate friends and family about what support is helpful to them and what hurts.

Reproductive loss is typically an assault upon the self, resulting in a blow to one’s self-worth, particularly for the woman who so often feels her body (i.e., she) has failed (Leon 1990). Self-blame may be mitigated by finding an identified cause as well as by challenging irrational self-blame by cognitive restructuring (Kersting et al. 2011). Reproductive loss can constitute multiple attacks on self-worth (Leon 1990). The sense of omnipotence embodied in pregnancy, a vital expression of her femininity, and a defiance of mortality by projecting oneself genetically into the next generation can all be shattered by these losses. In addition to the grieving of a lost child, there is an additional dimension of grieving: lost potential and accepting the fragile vulnerability of life and limitations of mortality. At least in the immediate aftermath of these losses, women need to find other capacities to anchor their self-worth.

Because the identity of the reproductive loss is so diffuse and ill defined, it may be much more likely that this loss can revive or be conflated with prior, particularly unresolved, deaths of another child, parent, or other beloved figures (Leon 1990). This is often the case when grieving is unrelenting, showing no alleviation after a year. A previous unresolved loss may need to be reconciled first before the reproductive loss in the here and now can be addressed (Leon 1990).

Finally, reproductive loss can constitute not only a discrete loss but a disruption in the normal adult developmental stage of parenthood (Cousineau and Domar 2007). Many couples whose desire for parenthood has been thwarted by pregnancy loss and/or infertility describe feeling stuck and offtrack, as if they are running in place but getting nowhere. Interpersonal isolation compounds their sense of internal stagnation. They feel estranged and alone, cutoff from family and friends who are moving on with their lives by having children and forming families of their own. Not surprisingly, many studies report heightened grieving of reproductive losses when there are no live children (Lasker and Toedter 2000) as well as an alleviation of grief with a subsequent healthy baby (Lasker and Toedter 2000; Brier 2008). Because intolerable envy, hurt, and anger are so often evoked for bereaved mothers in the presence of infants or other pregnant women, caregivers should normalize such natural reactions and encourage avoiding those situations until the intensity of emotions has diminished.

While reproductive losses share the attributes discussed above, it is necessary to at least briefly distinguish how these losses differ among each other. More has been written about perinatal loss (defined as death after 20 weeks gestation until 7 days postpartum) than any other reproductive loss, even though its mortality rate is under 1% of all pregnancies in 2013, having decreased fourfold since 1942 (McDorman and Gregory 2015). Ironically, ectopic pregnancy, the reproductive loss least researched for its psychological impact, has a mortality rate of 2%, twice as that of perinatal loss, and reported to elicit grief as intense as that of perinatal loss (Lasker and Toedter 2003). The revolutionary change in the hospital care for perinatal loss in the past 35 years ushered in the modification of practice for all reproductive losses. Whereas in 1980 it was customary for hospitals to deny bereaved parents seeing or holding their babies, discouraging discussing or grieving this loss, advising having another pregnancy as soon as possible, and dispensing psychotropic medication to ease the emotional pain, every one of those recommendations has changed 180°. Now parents are encouraged to see, hold, and, if they wish, name their babies who died, facilitating rather than blocking grief, encouraging marital emotional sharing, and suggesting to postpone pregnancy until this loss has been sufficiently grieved. Despite substantially improved satisfaction with in-hospital care following perinatal loss (Lasker and Toedter 1994), nurses are generally perceived as the most supportive caregivers, with physicians viewed as the least (Gold 2007).

Miscarriage, defined as a pregnancy loss before the 20th week of gestation, is not infrequent (from 15 to 20% of clinically recognized pregnancies) but commonly misperceived as being more rare (about 5% or less of pregnancies) while erroneously and commonly perceived to be caused by stress (over 75%) or lifting a heavy object (64%) (Bardos et al. 2015). With the use of more frequent and higher-quality ultrasound, a woman’s maternal-fetal attachment is heightened, thereby encouraging the loss to be viewed as more like that of a baby. Satisfaction levels of caregiver support for miscarriage tend to be lower than those measures for perinatal loss (Lasker and Toedter 1994), perhaps due to the variable experience of this being the loss of a baby or fetus, making it more difficult to establish a consensual hospital protocol as used for perinatal loss. Providing options for couples in how remains are treated and/or seen may go a long way in allowing parents to feel less helpless and aiding their determining for themselves what or who was lost (Limbo et al. 2010).

Infertility, inflicting about 15% of American couples (Cousineau and Domar 2007), tends to amplify all the discussed attributes of reproductive loss (Jaffe and Diamond 2011). Because there is no death, it is ambiguous, not often recognized as a bona fide loss with the couple feeling disenfranchised (Lang et al. 2011). It is much less real than discrete reproductive losses as there is no baby to grieve, except for the more nebulous imagined child. If permanent, it is the total loss of one’s wished-for biological family. Friends and family are often unhelpful or misguidedly hurtful, minimizing its profound repercussions, assuming hi-tech interventions are bound to work although only 50% of those who pursue assisted reproductive techniques (ART) ever have a live birth (Cousineau and Domar 2007). Assaults on the self can sometimes be repaired in a later successful pregnancy. While adoption enables family formation, it can permanently disrupt the traditional and normative developmental step of having biological children.

Finally there is a constellation of three reproductive losses that are all stigmatized, probably because they are all “volitional.” However, each situation constitutes an unwanted crisis, resulting in a decision often made under extreme duress with both internal and external conflict. Whatever is chosen is undesirable, only less intolerable than its alternative. Pregnancy termination for fetal anomaly (PTFA) involves ending the very much wanted pregnancy of a very unhealthy or dying baby. While this decision often evokes grief and distress comparable to perinatal loss, empathic support before, during and after the termination can help coping (Asplin et al. 2014; Lafarge et al. 2013). Additional tasks are required which include processing the traumatic news of having a baby with a severe anomaly, making an often highly conflicted decision under very tight time constraints regarding whether to continue or terminate the pregnancy, deciding whether this is the loss of a baby or fetus, and deciding how open one should be in sharing this situation and decision with others. Elective abortion is the inverse of PTFA, ending a healthy pregnancy that is very unwanted due to circumstances of not feeling able to parent this baby. A large-scale meta-study by the American Psychological Association (APA Task Force on Mental Health and Abortion 2008) reported the vast majority of women who have elective abortion do not have negative mental health consequences. However, the stigma of abortion resulting in keeping great secrecy in not disclosing to others was associated with thought suppression, which led to more intrusive thoughts and greater distress over time (Major and Gramzow 1999). An intervention designed to challenge abortion stigma by validating women’s reproductive decisions and identifying abortion misinformation was found to help women reduce their susceptibility to being judged harshly by oneself or others (Littman et al. 2009). Finally it has become increasingly recognized that the secrecy that both magnifies and is a product of the stigmatized disenfranchised grief of birthmothers who relinquish a baby for adoption needs to be forthrightly challenged. These women need to have their grief supported and sacrifice for their child’s well-being to be respected (Aloi 2009).

Many studies have sought to identify variables associated with more or less severe grief outcomes. Lasker and Toedter’s Perinatal Grief Scale (PGS) (Lasker and Toedter 2000) has become the “gold standard” of calibrating the extent of grief following this loss. In their compilation of 22 studies using the PGS, they were able to highlight the most powerful factors associated with more disturbed or prolonged distress: poor pre-loss mental health, poor social support in general and in the marital relationship in particular, being female, longer gestation, recency of loss, and not having a subsequent pregnancy (Lasker and Toedter 2000). These findings correspond well with our understanding of reproductive loss in its psychosocial context. The strain and distress resulting from these losses become more difficult to bear with more limited coping capacity due to earlier compromised mental health. Social support, especially within the marriage, serves as an important buttress for coping and buffer against stress. The more intimate and bodily relationship with the pregnancy that the mother experiences as compared to the father underscores her commonly greater grief than his. It also explains the amplification of that grief as gestation lengthens along with the baby’s greater presence and mother’s attachment to her. The nature of grieving with distress subsiding over time explains why this is usually a time-limited process rather than an ongoing pathological state. Finally the developmental disruption and assault on self-esteem resulting from these losses can both be repaired by a subsequent pregnancy.

An important advance over the usual stage model of bereavement in which resolution of grief is based on completing a sequence of phases is the dual process model of coping with bereavement (DPM), a template for grieving which privileges elements of coping as much as aspects of grieving (Stroebe and Schut 2010). In this process, the bereaved oscillates between the dual poles of active grieving and restoration of functioning. Elements of coping include attention to life changes, trying out new things, distracting oneself from grief, and taking on new roles and relationships. These facets of coping are as indispensable to resolving loss as the painful grief work of remembering the deceased and sufficiently detaching in order to find a new place in a changed world (Stroebe and Schut 2010). This model captures the phenomenological sense of grieving as being intermittent, in waves, as one yearns and aches for the beloved, but then shifts, even in the early period of intense grief, to coping in the world of daily tasks, especially parenting surviving children.