Construction of Meaning in Pregnancy Loss: Qualitative Study with Brazilian Couples

Construção de Significados na Perda Gestacional: Estudo Qualitativo com Casais Brasileiros

Construcción de Significados en la Pérdida Gestacional: Estudio Cualitativo con Parejas Brasileñas

Abstract

We investigated the process of meaning construction in pregnancy loss in 11 Brazilian couples. The reports were submitted to inductive and deductive thematic analysis using the categorization system from the integrative model of meaning construction in grief. Regarding the original dimensions of the model (Sense-making of death, benefit from the experience of loss, and identity change), there was a lack of meaning for death, perception of strengthened bonds within the couple as a benefit, and parenting as an identity project. We propose an additional dimension (Meaning-making process) that includes gender differences, lack of social recognition, and emotional intensity of the experience. As for coping strategies, spirituality and the search for peers were identified, especially in social media. After a pregnancy loss, the process of meaning construction proved similar to that of other types of loss, validating this experience. We discuss the implications of the category system used in this study.

Keywords:
spontaneous abortion; grief; beliefs; parenting

Resumo

Investigou-se o processo de construção de significados na perda gestacional em 11 casais brasileiros. Os relatos foram submetidos à análise temática indutiva e dedutiva, utilizando o sistema de categorização do modelo integrativo de construção de significado no luto. Em relação às dimensões originais do modelo (Sentido para a morte, benefício na experiência de perda e modificação da identidade), constatou-se falta de sentido para a morte, fortalecimento de vínculo do casal como benefício e parentalidade enquanto projeto identitário. Foi proposta uma dimensão adicional (Processo de construir significado) que incluiu diferenças de gênero, falta de reconhecimento social e intensidade emocional da experiência. Enquanto estratégias de enfrentamento, identificou-se espiritualidade e busca por iguais, especialmente nas mídias sociais. O processo de construir significados na perda gestacional mostrou-se semelhante ao de outros tipos de perdas, validando esta experiência. Foram discutidas as implicações do sistema de categorias utilizado.

Palavras-chave:
aborto espontâneo; luto; crenças; parentalidade

Resumen

Se investigó el proceso de construcción de significados en la pérdida gestacional en 11 parejas brasileñas. Los informes fueron sometidos a un análisis temático inductivo y deductivo, usando el sistema de categorización del modelo integrador de construcción de significado en el duelo. En cuanto a las dimensiones originales del modelo (Significado para la muerte, beneficio en la experiencia de pérdida, cambio de identidad), se encontró falta de significado para la muerte, fortificación de lazos de la pareja como un beneficio y la parentalidad como un proyecto de identidad. Se ha propuesto una dimensión adicional (Proceso de construcción de significado) que incluye diferencias de género, falta de reconocimiento social e intensidad emocional de la experiencia. Como estrategias de afrontamiento, se identificó la espiritualidad y la búsqueda de los iguales, especialmente en las redes sociales. El proceso de construir significado en la pérdida gestacional demostró ser similar al de los otros tipos de pérdida, validando esta experiencia. Son discutidas las implicaciones del sistema de categorías utilizado.

Palabras clave:
aborto espontáneo; luto; creencias; parentalidad

Introduction

Pregnancy loss (PL)¹ is a crisis with traumatic potential (Krosch & Shakespeare-Finch, 2017), which challenges the natural order of life and, therefore, what is expected in a grieving process (Wheeler, 2001; Worden, 2013). Unlike those who are bereaved by other forms of death, those grieving by PL have few memories with the deceased person and do not often practice burial or other rituals that promote social support and mourning. (Brier, 2008). Due to secrets or the fear of societal non-recognition of the loss, it is often found that it is difficult to share thoughts and feelings openly (Worden, 2013). Compared to other forms of bereavement, the common sense is that PL is less stressful and of quicker resolution (Lang et al., 2011).

The most frequent complication during pregnancy is PL (Meaney, Corcoran, Spillane, & O’Donoghue, 2017). Despite being common and having a high psychosocial and economic impact, there is a reluctance to discuss this issue on the global agenda (Frøen et al., 2011). In Brazil, the fetal mortality rate (FMR) was 9.5 / 1,000 births in 2015; this index has been stationary since 2000 in the country and every region of Brazil (Barros, Aquino & Souza, 2019). However, Barros, Aquino, and Souza (2019) also point out that the FMR considers only the PL that occurred after the 22nd full week of pregnancy, in addition to underreporting and lack of available information.

Family resilience, or the dynamic adaptation mechanisms and potential posttraumatic growth, may be activated in the face of challenges, such as a loss (Walsh, 2016). According to Walsh (2016), the systemic view of resilience shifts the conventional emphasis of individual characteristics to interactional mechanisms, introducing the family as a functional entity since family processes serve as mediators for all members’ adaptation. In this perspective, Walsh (2016) proposes key processes for understanding family resilience, which involve their belief system, organization patterns, and family communication processes. The current study focuses on the domain belief system, which includes finding meaning in adversity, adopting a positive outlook, and integrating transcendence and spirituality in response to the challenge to which the family is subjected.

Searching for meaning after a loss is expected (Franqueira, Magalhães & Ferés-Carneiro, 2015) and is considered an essential aspect in the grief experience for different theories (Gilles, Neimeyer, & Milman, 2014). In particular, Gilles and Neimeyer (2006) proposed an integrative model for the construction of meaning in grief, based on a constructivist perspective, which aggregates aspects of the Attachment Theory (Bowlby, 2004), cognitive theories of trauma and coping (Janoff-Bulman, 1989), and the Dual Process Model of Coping (Schut & Stroebe, 1999). In this integrative model, the effort to find, create or reconstruct meaning is the central element. According to Gilles and Neimeyer (2006), bereaved individuals engage in three activities to reconstruct meaning after a loss: i) making sense of death (ability to attribute a cause or reason for death); ii) finding benefit in the loss experience (derive benefits from the event to recognize some positive value of the loss); and iii) undergoing identity change (changes in the roles assumed by the mourners and creation of new life goals). These three activities are good predictors, for example, of the severity of grief (Gilles et al., 2014), as they contribute to a better acceptance of the loss (Holland & Neimeyer, 2010).

The integrative model postulates that the death of a loved one may be inconsistent with the structures of meaning before the loss, forcing the individual to recognize those meanings as no longer true or useful, reviewing and reconstructing structures of meaning in a complex and continuous process. This construction of meaning occurs at an individual and intrapsychic level and at an interpersonal and family level since the structures of meaning constitute social constructions (Gilles & Neimeyer, 2006). This view of the meaning-making as a family process is articulated with the systemic assumptions of family resilience (Walsh, 2016). In a complementary way, the integrative model operationalizes the concept of finding meaning in adversity, one of the key processes of family resilience.

Gilles et al. (2014), based on this model, proposed a classification system composed of 30 categories, which encompass the three dimensions of meaning construction and seek to assist in the qualitative survey of this process. The categorization showed excellent reliability, including both positive and negative themes related to the process of finding meaning. The meaning-making process in PL is challenging due to specificities of this type of loss (Lang et al., 2011).

In Brazil, few studies on grief have been carried out from the perspective of meaning construction (Consonni & Petean, 2013; Franqueira et al., 2015; Hispagnol, 2011; Luna & Moré, 2017; Mazorra, 2009), and none has used the Gilles et al. (2014) classification. Consonni and Petean (2013) carried out a study with ten women from São Paulo, Brazil, who experienced pregnancy termination due to fetal malformation, identified references to religious beliefs and self-blame, revealing the need for these women to remain connected to their lost child. In the study by Franqueira et al. (2015), with five mothers from Rio de Janeiro, Brazil, who lost adult children, only one participant found no benefit in the experience of loss. All the others mentioned improvement in their levels of empathy and the adoption of a positive perspective on life. Social support was mentioned as essential to cope with grief.

However, in addition to individual constructions, the loss of a child poses the challenge of constructing meaning within the marital subsystem. Multiple factors can be involved in the meaning-making process of bereaved parents, such as the type of death (Keesee, Currier, & Neimeyer, 2008). In this sense, parents bereaved by PL have been underrepresented in grief studies (see Lichtenthal, Currier, Neimeyer, & Keesee, 2010 and Gilles et al., 2014). As a result, studies to investigate the unique characteristics of different grief situations are needed (Gilles et al., 2014). Thus, this study aimed to investigate the process of meaning construction in adult Brazilian couples bereaved by PL.

Methods

Subjects and procedures

This is a cross-sectional, qualitative, exploratory-descriptive study (Creswell, 2010), drawn from broader research on family resilience in PL situations (Vescovi & Levandowski, 2017). The study was composed of eleven heterosexual couples (28 to 47 years old) from different Brazilian cities who experienced PL. The sample was intentional and non-probabilistic, and the research invitation was disseminated through social media. The inclusion criteria were cohabitation, any duration and type of relationship, minimum of 18 years old, and experience of at least one PL in the last five years. Couples in the process of marital separation/divorce were excluded. Having experienced other types of loss (such as neonatal or loss of family members) was not a reason for exclusion, except if the most recent loss was not PL.

The characterization of participants is shown in Table 1. The couples were predominantly from the Southeast and South regions of Brazil. It should be noted that all households had electric light, running water, and were located on a paved street. The age of men ranged from 29 to 47 and women from 28 to 40 years old. The duration of the relationship (marriage or stable union) ranged from 3 to 15 years. The parental situation varied between couples without living children (n = 8) and couples who had children before (n = 2) or after PL (n = 1). Two participants were pregnant at the time of data collection. The time between the most recent PL and data collection ranged from five years to one month. Six couples had at least one PL with more than 20 weeks of gestation.

Table 1
Participants’ characterization

Identification, age (years)	Loss(es) description and time since the event(s)	Religion and state of residency when loss(es) occurred	Relationship duration and parental status	Monthly income in minimum wages / Number of residents
Couple 1	3 PL	W: Spiritism	6 years;	12 to 15 MW / 5
W: 40	18wp, 5 years and 11 months ago; 6wp, 4 years and 10 months ago; 24wp, 4 years and 4 months ago	M: None	One child after third PL
M: 42		MG
Couple 2	2 PL	W and M: Christian (Protestantism)	10 years; None living children in common. M: child from a previous relationship	1 to 3 MW / 2
W: 38	35wp, 2 years ago; 6wp, 4 months ago	MG
M: 36
Couple 3	1 PL	W: Spiritism	12 years;	9 to 12 MW / 2
W: 31	6wp, 9 months ago	M: None	None living children
M: 36		RJ
Couple 4	1 PL	W and M: None	3 years; None living children in common. W: child from a previous relationship	6 to 9 MW / 4
W: 37	29wp, 1 year and 5 months ago	PI
M: 29
Couple 5	2 PL	W: None	13 years;	3 to 6 MW / 2
W: 36	7wp, 2 years ago;	M: Attend to a Spiritism center	None living children
M: 47	11wp, 3 months ago	PR
Couple 6	1 loss (3 months old child) and 1 PL 10wp, 1 year ago	W and M: Christian (Latter Day Saints movement)	15 years; 2 children before PL. W: now pregnant	3 to 6 MW / 4
W: 34		RS
M: 39
Couple 7	2 PL	W and M: Christian (Roman Catholic)	10 years; None living children. W: now pregnant	More than 15 MW / 2
W: 36	8wp, 2 years and 3 months ago;	SP
M: 36	12wp, 1 year and 9 months ago
Couple 8	1 PL	W and M: Christian (Roman Catholic)	3 years;	3 to 6 MW / 3
W: 26	13wp, 1 year ago	RS	None living children
M: 31
Couple 9	3 PL	W: Christian (Protestantism)	5 years;	1 to 3 MW / 2
W: 30	15wp, 4 years ago; 2wp, 3 years and 6 months ago; 21wp, 1 month ago	M: Christian (Roman Catholic)	None living children
M: 33		MG
Couple 10	1 PL	W and M: Spiritism	6 years; One child before PL, none living children after. M: child from a previous relationship	3 to 6 MW / 4
W: 28	during child-birth, 35wp, 4 months ago	MG
M: 41
Couple 11	1 PL	W and M: Christian (Roman Catholic)	10 years; None living children	9 to 12 MW / 2
W: 37	25wp, 1 year and 8 months ago	RS
M: 37

• Note: M= man; W= woman; PL= pregnancy loss; wp= week of pregnancy; MW= minimum wages in Brazilian Real (at data collection, one minimum wage represented around 900,00 reais)

Data Collection Procedures, Instruments, and Ethical Considerations

The couples expressed their interest in participating via social media. The inclusion/exclusion criteria were then verified through a questionnaire of sociodemographic and clinical information. A day and time were scheduled for a joint semi-structured interview, in-person (n = 03) or using Skype (n = 08). The interview script was built based on the key processes of family resilience (Walsh, 2016). Questions regarding the meaning of PL, the perspective the couple adopted to deal with loss (including values, practices, and spirituality), and life changes caused by PL, among other topics, were addressed to the couples. All interviews were audio-recorded and transcribed with Inqscribe software by previously trained members of the research team. The study was approved by the Ethics Committee of Universidade Federal de Ciências da Saúde de Porto Alegre (Register number 2.341.006) and followed all recommendations for studies with human beings (Resolutions 510/2016 and 466/12 of the National Health Council).

The interview transcriptions were submitted to deductive Thematic Analysis (Braun, Clarke, Hayfield & Terry, 2019), using the categorization proposed by Gilles et al. (2014). The Kappa index (Cohen, 1960) was calculated to verify the agreement of the categorizations carried out between two researchers in the first six interviews, resulting in an index considered excellent (Fleiss, Levin, & Paik, 2003; k = 0.75). This analysis was continued in the other interviews. Subsequently, an inductive Thematic Analysis was carried out considering all the interviews (Braun et al., 2019) to raise specific aspects of the PL that the previous categorization might not have covered.

The analyses were then integrated to build a unique and different theme structure from that proposed by Gilles et al. (2014). Some categories were eliminated because they did not apply to PL (e.g., Release from Suffering), others were adapted (Time together was renamed Short time together), and new categories were created from the data (e.g., Parenting as a life project and Search for peers). Afterward, the categories were grouped into the three dimensions of the integrative model, something not proposed by Gilles et al. (2014). An additional dimension (Meaning-making process) was created and included both new categories and those from the structure of Gilles et al. (2014). Questions were discussed among the authors to reach a consensus. All analyses were carried out with NVivo 12 software, which allowed for complementary analyses (cross-reference tables).

Results

Results are presented in Table 2. Categories and subcategories are organized according to the integrative model dimension they belong to, along with a description and the frequency of responses. The frequency was classified as General (if they occurred in all or almost all cases), Typical (if they represented more than half of the cases), and Variant (if they occurred in less than half of the cases), as proposed by Wright et al. (2017).

Table 2
Coding categories and frequency of responses

Categories, subcategories, and description	Frequency of responses
Dimension: Sense-making of death
Lack of understanding: One is trying to make sense or meaning but has not found it or has given up on searching for it. Confusion and questioning about why the loss occurred.	General
Purpose or mission: Vision that the child had a mission that was accomplished, so then the loss had a greater purpose for which the couple was destined.	Typical
Not the right moment: References to the moment in time when the loss occurred (e.g. it was not the right moment, things happen in God’s time).	Typical
Losing is part of life: Viewing the loss as a natural life process, as a random event.	Typical
Blame: Identifying a specific agent that caused the loss (e.g. medical error, woman’s fault, self-blame).	Typical
Lack of control: Loss as an event out of control, that cannot be controlled.	Variant
Medical explanations: Explanations based on mother’s or baby’s diagnoses or medical conditions.	Variant
Dimension: Benefit finding in the loss experience
Strengthened bonds: Reference to the couple being closer and united due to the loss.	General
Helping others: Desire to help and concrete help to others (e.g. donations).	Typical
Connecting with family/friends: Closer contact with family members (except spouse) and friends because of the loss.	Typical
Greater empathy: Greater empathy and a sense of respect for human suffering, especially for others who have gone through a pregnancy loss.	Typical
Positive perspective on life: Perceiving and valuing positive aspects in life despite the loss, having hope for the future.	Typical
Dimension: Identity change
Parenting as a life project: Maintaining or increasing the desire for parenting, the importance of being a mother/father in the life project.	General
Lost innocence: Loss of innocence, ingenuity, and trustiness in humanity.	Typical
Personal growth: Internal improvement that resulted in strength, changes in priorities, maturity, etc.	Typical
Mother and father identity: Consider oneself as a mother or father, mentioning my/our son/daughter.	Typical
Identity as a bereaved person: Mourning as a mark on life or personality, new identities assumed related to mourning (e.g. angel’s mother).	Typical
Lost identity: Loss of roles, functions, self, or faith in the future (e.g. loss of pregnant status).	Typical
Non-specific identity change: References to changes without specification of its nature (e.g. something has changed).	Variant
Additional dimension: Meaning-making process
Lack of social recognition: Lack of support and recognition about the loss and the grieving process from the social environment.	General
Gender differences: Differences between men and women in reacting and dealing with the loss.	General
Emotion intensity
• Emotionality: Reports of positive or neutral emotional states concerning loss and bereavement.	General
• Negative affection: Reports of negative emotional states concerning loss and bereavement.	General
• Affirmation of the baby as a real person	Typical
• Memories: Descriptions of the baby’s physical characteristics and collection of objects that represent the baby (e.g. clothes).
• Continuity of the bond: Mentions about the baby being someone present and real in the couple’s life, which will never be forgotten.	Typical
• Missing the child: Reference to missing the child and aspects that will not be lived due to death.	Variant
• Short time together: Mention of little time with the baby after birth.	Variant
• Coping strategies	General
• Spirituality: Searching for spirituality/religiosity as a source of support and comfort.
• Moving forward: Mentions to go on with life, continue, let the time pass, not to be beaten.	General
• Search for peers: Search for similar stories as a means of identification and support.	General
• Psychotherapy or psychiatric treatment: Psychotherapy or use of prescribed psychiatric drugs to deal with the loss.	Typical
• Externalizing: References to talk or write about the loss.	Typical
• Addictions, excesses, and isolation: Reports of addictive and excessive behaviors (alcohol, overwork, and food) and social isolation.	Typical
• Positive lifestyle changes: Performing physical exercises, retaking hobbies, connecting with nature and others (e.g. acupuncture).	Variant
• Acceptance: Generic mentions regarding accept what happened.	Variant
• Staying busy: Staying busy to deal with grief.	Variant
• Reading and searching for information: Research on possible medical causes for the loss and information on the grieving process.	Variant

• Note: General: 10-11 cases; Typical: 6-9 cases; Variant: 2-5 cases.

Discussion

Sense-making of death

In the process of attributing meaning to death, the lack of understanding about PL was common among the participants. This was characterized by the search for meaning, which was manifested by persistent questioning, as well as the inference of meaninglessness to death, causing anguish and unease:

“Guys, why me? Why just my baby won’t cry, you know? Why just my baby’s heart won’t beat?” (W11) ²

The absence of meaning and the lack of understanding of the loss is a common theme among bereaved individuals (Hispagnol, 2011; Mazorra, 2009; Lichtenthal et al., 2010). In our study, other processes of attributing meaning to death were also identified, although less frequently. Several couples reported that the baby’s death would be linked to a larger purpose or mission that they were destined to live (to teach a lesson, reunite the couple, save the mother from illness, for example). The interpretation for the PL considered plausible depends on the social and relational situation in which the woman and the couple are at the moment the loss occurs (Sijpt, 2010). For the author, this event is lived in an individual, family, social, and situational way. In this sense, the category Not the right moment included the understanding that the loss occurred to signal that moment was not suitable for the occurrence of a pregnancy:

“Maybe the Lord [God] will send another baby to us at another time, at the right time? Now we weren’t supposed to have it.” (W6)

These two categories had spirituality as a backdrop: God or other spiritual causes (energies, for example) were common explanations to why the loss occurred or why it was not the right time for a pregnancy. Brazilian studies, such as Morelli and Scorsolini-Comin, (2016), have already demonstrated the importance of spirituality for understanding death, strengthening the social support system, and promoting meaning to this experience. Consonni and Petean (2013) describe that, given the lack of objective medical answers to explain the loss, women seek to construct explanations predominantly based on religiousness.

Most of the couples in our study did not receive a diagnosis to justify PL. This is possibly related to the variant frequency observed in the Medical explanations category and has led couples to seek meaning based on spirituality. Religious and spiritual beliefs play a central role in the lives of many individuals, acting as coping strategies after a PL (Kalu, 2019). The participants described the experience of faith and the religious understanding of death as sources of relief and comfort (e.g., the idea of a reunion with the child), and religious institutions were described as places of emotional support.

The category Losing is part of life of typical frequency indicated responses that highlight losses as intrinsic to life, as frequent and random events, indicating resignation and understanding death as a natural and predictable process, a common perception among bereaved individuals (Gillies & Neimeyer, 2006):

“Death is a natural thing in life. That was going to happen eventually, with a family member perhaps, but unfortunately it happened to us.” (M4)

Similarly, the category Lack of control of variant frequency included perceptions of loss as an uncontrollable event, leading these participants to question the lack of control over life. Similar results have been identified in bereaved parents (Lichtenthal et al., 2010), such as the shortness of life, the inevitability of death, and the action of fate. Finally, the category Blame brought together responses related to the blaming of a specific agent, both external (medical error) and internal to the couple (one man indirectly blaming the woman or self-blame, presented by a man and three women). Self-blaming responses have been commonly found in studies that evaluated women after a PL (Consonni & Petean, 2013; Gold, Sen & Leon, 2018); on the other hand, blaming medical teams was uncommon in the present study.

Other investigations have identified that mourners with higher scores on psychiatric symptomatology assessments tended to construct self-referring meanings of ineffectiveness/guilt (Gold et al., 2018; Sebastião, 2017). In the present study, seven women claimed to undergo psychotherapy or psychiatric follow-up to deal with PL. The elaboration provided by the treatment may justify the low frequency of self-blame among the interviewees (n = 3). The difficulty in accessing psychological or psychiatric treatment did not seem to be an obstacle for the participants, unlike that identified by Morelli and Scorsolini-Comin (2016), possibly due to the couples’ medium and high socioeconomic status in our study.

Benefit finding in the loss experience

Among the benefits perceived in the PL experience, the strengthening of the couple’s bond was unanimous. The couples stressed how much this experience contributed to making them feel more united than before:

“It helped us to strengthen our relationship as a couple. On that side, it was good, you know.” (M7)

Conjugality is a resource for coping with grief (Morelli & Scorsolini-Comin, 2016). However, Morelli and Scorsolini-Comin (2016) have not identified unanimity in strengthening the bond between couples after the loss, as occurred in our study. Studies on quantitative methodology have already identified PL as a risk factor for the dissolution of the marital relationship (Gold, Sen & Hayward, 2010). The present study included only couples, implying that they remained together after PL, which may have biased our result. Nonetheless, the participants considered grief as a couple’s process, which suggests that their strengthened bonds (along with the previously mentioned low frequency of blame within the couple) may be related to why they remained together.

Individual grief influences and is influenced by the marital relationship and the support received from the partner (Albuquerque, Ferreira, Narciso, & Pereira, 2018). Thus, providing support to the partner may be a way of relieving individual suffering by focusing on the need for care, which strengthens the couple’s bond (Albuquerque et al., 2018). In addition, the fact that parenting has remained a joint identity project for the couple (see section Identity change) may have acted as a protective factor for maintaining the relationship. Accordingly, the benefit of Greater empathy is linked to developing a sense of altruism and compassion, directed both towards the partner and other people. Participants described, for example, understanding and respecting the pain of individuals who also experienced losses.

Another benefit mentioned was feeling closer to family/friends after the loss, which includes a more positive perception of the existing support system. This closer relationship network is relevant, as the perception of social support is a well-known protective factor for complicated grief (Lobb et al., 2010). The category Helping others was characterized by the desire to help and by the actual help to others, such as donations and sharing of experience in support groups:

“I donated everything to her. Wow, she was very happy, you know ... In my pain, I was able to help someone else.” (M3)

Also, the participants described a more positive perspective on life due to the loss. The reports pointed to the appreciation of positive aspects, less commitment to minor daily problems, and higher hope for the future:

“We are trying to live life with that lightness. We cannot be terrified by everything, you know. This is something that I learned a lot.” (W6)

Similar categories are frequent in other studies with bereaved parents (Franqueira et al., 2015; Lichtenthal et al., 2010). In the Lichtenthal et al. (2010) study, although three-quarters of the surveyed sample reported at least one benefit due to the loss, the most frequent response was the absence of a benefit. In our study, all couples mentioned benefit, although this question was asked indirectly (question about changes identified due to the loss). This aspect may have facilitated the identification of benefits by couples since Lichtenthal et al. (2010) noted that many participants reacted negatively to the term benefit, which may explain the high frequency of negative responses, contrary to our findings.

Identity change

The construction of meaning also involves changes in the couple’s identity. The category Parenting as a life project, of general frequency, encompassed the maintenance or increase in the desire to have children, to continue seeking this life project:

“After this loss, we had no doubts that we wanted to get pregnant as soon as possible” (W3)

No other studies with parents bereaved by PL and similar findings were identified. This category may have been prevalent here because most couples do not have living children in common (n = 8), a factor associated with maternal anxiety (Kagami et al., 2012). In the same sense, the category Mother and father identity reflects the maintenance of a deceased child’s father/mother identity and the couples’ desire to continue considering him/her as a child. Maintaining the connection with the lost child is often mentioned by bereaved parents (Meert, Thurston & Briller, 2005), which was also noticed in the case of PL:

“I had a baby in my belly; I AM a mother.” (W8)

Another change in identity refers to Personal growth, linked to developing a new posture and new values. Participants reported having become stronger, more mature, and having changed life values​/goals due to the loss:

“I think that losing a child makes you extremely fragile and, at the same time, makes you stronger.” (W1)

In contrast and less frequently, more pessimistic or fearful interpretations about the future and life were identified, included in the category Lost innocence. These responses demonstrate non-conformity with the adverse outcome of pregnancy, interpreted as proof that it is necessary to be more cautious and have lower expectations regarding life plans. Also, the participants described the development of a new identity as a bereaved person, sometimes describing themselves as part of a special group of individuals who have lost a child. Some women, for example, identified themselves with the term angel mother, an expression used in different cultures to characterize mothers whose children have died, generally with associated pride (Sijpt, 2017):

“Angel Mother’s Day for mothers who don’t have children, right. It’s a Mother’s Day for us, who are without our children, you know” (W6)

Other aspects related to the meaning-making process

This dimension included factors that influenced the process of meaning construction, not included in the categories of the three previous dimensions: Gender differences, Coping strategies, Lack of social recognition, Emotion intensity, and Affirmation of the baby as a real person.

Gender differences in the grieving process have been extensively discussed (Breen & O’Connor, 2011; Carolan & Wright, 2016). It is common for women to feel the need to talk and express feelings about the loss more often than men do. The present study corroborates these findings (for example, the subcategory Externalizing had testimonies only from women), identifying a more passive mourning trend among men and more active among women. The female participants described varied and adaptive coping strategies (such as seeking psychotherapy, using medications, participating in online support groups and lectures, among others). Men more often referred to as waiting, keep going, and life goes on. Almost all men denied having engaged in any activity specifically to manage the grieving process (except for spirituality). The subcategories Positive changes in lifestyle and Reading and searching for information both with varying frequency also had more testimonials from women.

A systematic review (Due, Chiarolli & Riggs, 2017) on the impact of PL on men identified the tendency towards a less intense and shorter emotional distress than among women, but with engagement in compensatory behaviors. Accordingly, in the current study, men mentioned some maladaptive behaviors in dealing with the loss, such as alcohol use, overwork, and social isolation. However, women also mentioned excesses related to weight and food. This aspect draws attention since bereaved parents are considered a risk group, with higher rates of morbidity, mortality, and impairment of their general health impairment of their general health in the first months after the loss, compared to the general population (Dias, Brandon, Haase, & Tanabe, 2017). In our study, it was observed that men perceive themselves as supporters of their partners, often suppressing expressions of sadness due to the fear of overloading them; something also found in the literature (Due et al., 2017) that may be related to their compensatory behaviors.

The lack of social recognition of grief by PL was associated with the perception of invalidating situations about grief and the pressure to overcome the loss or not to share the pain:

“As it [the loss] happened at the beginning of pregnancy, it was like it were nothing, as if it were not a life, as if we did not feel pain for it. I was very indignant.” (W5)

The lack of recognition seemed to bring additional suffering to couples, making it challenging to construct meaning. Social narratives of pressure to overcome grief were also identified among the bereaved by other causes (Luna & Moré, 2017; Breen & O’Connor, 2011). However, those bereaved by PL go through a grieving process that is not socially regulated and intentionally not validated and characterized as illegitimate (Sawicka, 2017). On the one hand, the lack of social support for meaning construction is a predictor of adverse outcomes in the grieving process, and on the other, being validated has a relevant role in the posttraumatic growth processes (Bellet, Holland & Neimeyer, 2018).

The coping strategy Search for peers was mentioned by almost all couples, with the desire to seek similar stories as a way of identification and support. This strategy tends to facilitate the construction of meaning, which is why the interaction between peers has been the basis for grief interventions (Aoun et al., 2019). The main form of interaction between peers involved participation in groups of mothers via social media (in particular, Facebook and WhatsApp). The mothers reported their stories and exchanged advice (unanimous strategy among the women, but not adopted by any men). The practice of sharing experiences of grief online has been common and favors the expression of feelings and social interaction on taboo themes (Bousso, Ramos, Frizzo & Santos, 2012), such as PL.

The Emotion intensity category referred to how the process of experiencing grief and constructing meaning was emotionally intense, involving neutral or positive emotions (e.g., love for the child and pride in the Emotionality subcategory) and negative (Negative Affection subcategory). It is known that the grieving process after PL does not differ in intensity from other loss situations (Kersting & Wagner, 2012), and may even be intensified, as the experience is highly incongruous with parents’ expectations (Hutti & Limbo, 2019). This may explain why, in the present study, the two couples with three PLs reported the same number of references in the negative affection category as the six couples with only one loss, indicating that multiple PLs may be a risk factor for mental health (Price, 2008). Also, cross-reference analysis showed that couples who had at least one loss over 20 weeks of gestation had more references coded in the negative affection category (47 references for 6 cases) when compared to couples with losses before 20 weeks (18 references for 5 cases). In addition to the duration of pregnancy, however, parents’ perception of the lost baby as a child also explains attachment during pregnancy and predicts suffering after PL (Hutti, Armstrong, & Myers, 2013).

In this sense, the category Affirmation of the baby as a real person, composed of the subcategories Memories, Continuity of the bond, and Missing the child, includes descriptions of the child being perceived as a person and belonging to the family, even before he/she was born:

“How would she be, what would her one-year birthday party be like, what would it be like when she started dating…? We used to talk about her, we talk until today, she is present in our lives...” (W2)

The loss of the baby was a real loss for all participating couples. However, in PL, it is common to be unclear about everything that was lost, in addition to the loss of the actual baby (such as situations not lived and roles not played), making the meaning-making process quite challenging (Carolan & Wright, 2016). The couples in the present study indicated the need to take an extra step compared to other types of bereaved individuals, defending their baby as a real person and their role as parents.

The posttraumatic growth (PTG) process among bereaved parents for different causes is associated with the female gender, younger age of the lost child, higher levels of resilience, continued bond with the child, communication of the experience of stress, and the request for emotional and practical support from the partner (Albuquerque, Narciso & Pereira, 2018). The current study sheds light on some of these factors. For example, higher levels of PTG identified in women may be related to the higher use of adaptive coping strategies by women (more active grief). The fact that losing younger children is associated with higher levels of PTG in parents may not be related to shorter coexistence and more fragile bonds with the child but with the real possibility of getting pregnant again, maintaining parenthood as a couples’ life project as we found in the present study.

Continuing bonds with the lost child were frequently mentioned, even among couples with early PLs. This may indicate that identity changes happen in couples very early in pregnancy. Lack of social recognition seemed to operate contrary to continuing bonds, pressing couples to overcome loss or substitute the deceased baby, causing suffering exactly for not permitting the ongoing relationship with the lost child. Communication about the loss and support between partners may explain the strengthened bond among the couples.

Final considerations

This study aimed to investigate the process of meaning construction, based on the integrative model, in adult couples bereaved by PL. Similarities in this process were identified concerning bereaved parents for other causes, such as lack of sense-making for death, greater empathy, desire to help others, and spirituality as a coping strategy. This suggests the importance of validating the PL experience, which causes suffering and demands effort to adapt as other types of loss do.

The present study corroborates the literature on the social non-recognition of PL and gender differences in adapting to a loss. However, some relevant differences to the literature were found, such as maintaining parenting as a life project. Progress is made in the qualitative identification of some PTG processes after PL, such as strengthened bond within the couple through sharing the desire for parenting and greater empathy. Results also highlight the role of social media to overcome the lack of social recognition of the loss and to put into practice the desire to help others.

Further studies in the Brazilian context could use mixed methodologies to make associations between grief outcomes (complicated grief and PTG) and the meaning-making process. Additionally, the other key processes of family resilience could be investigated in their relationship with the construction of meaning (for example, the communication processes in the couple and the role of support systems). As limitations, the cross-sectional design adopted here prevented the understanding of meaning construction over time, which can be improved in future studies. Likewise, the wide variation in the time elapsed since the most recent PL and data collection can be considered a limitation since time is relevant for the meaning-making processes. Also, because this study derives from a broader project, the absence of questions in the interview directly related to meaning-making (particularly about the benefits in the experience of loss) may be a limiting factor. It is also necessary to consider the influence of participation in the study as an element that interferes in constructing meaning since it can act as a facilitator of this process (Mazorra, 2009; Franco, Tinoco & Mazorra, 2017).

On the other hand, when considering only couples bereaved by PL, this study investigated this phenomenon in greater depth. Unlike most studies on this topic, interviewing the couple and not just bereaved mothers has broadened the understanding of male suffering and marital processes. By combining deductive and inductive thematic analysis, this study accessed the data in a more complex way. In addition, it was the first study with a Brazilian sample to use the classification by Gilles et al. (2014) to understand the process of meaning-making in grief, which allows standardizing the qualitative and quantitative investigation of the themes.

Due to its systematization and accurate definition of each category, the classification system proved helpful to qualitative data analysis. However, as Gilles et al. (2014) mention, its broad feature may not include specific aspects of different subtypes of loss, such as PL. Thus, it is proposed that the categories elaborated here (Table 2) be used to contemplate the specificities of PL. Quantitative studies can use this categories system to verify its adequacy in a larger sample.

Finally, the findings of the present study promote relevant applications both in research and clinical practice. Concerning research, the provision of a specific category system for PL can assist quantitative and qualitative studies in the more accurate survey of needs and aspects of the grieving process of fathers and mothers who have gone through this experience. From the clinical perspective, the results can support interdisciplinary health teams that work with families in situations of PL, guiding their intervention practices in the grieving process.

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• 1
  The terminology pregnancy loss will be used in this study as a synonym for fetal death (World Health Organization, 2016) to refer to spontaneous losses that occurred during any stage of pregnancy and labor, excluding those that occurred after birth.
• 2
  The members of the couple are identified with the letters W (woman) and M (man), referring to the biological gender followed by the identification number of each couple.

Publication Dates

• Publication in this collection
  16 Dec 2022
• Date of issue
  Jul-Sep 2022

History

• Received
  04 Mar 2020
• Reviewed
  02 Oct 2020
• Accepted
  16 Mar 2021