he loss of a child is recognized as a very difficult
life experience, which can often cause complicated grief
(CG) reactions that risk negatively affecting psycholog-
ical and physical well-being.1,2In a population-based
sample, bereaved individuals who had lost a child
showed the highest prevalence of CG.3Perinatal loss is
a relatively common occurrence which, in this article,
refers to the death of an infant due to miscarriage, still-
birth, and neonatal death. In 2007 in the United States
the infant mortality rate was 6.9 deaths per 1000 live
births.4Miscarriage, generally defined as an unintended
termination of the pregnancy prior to 20 weeks of ges-
tation, is the most common type of pregnancy loss. The
overall prevalence is 15% to 27% for women aged
between 25 and 29, increasing to 75% in women older
than 45 years,5with elevated risk for women who have
lost a previous pregnancy.6The death of a fetus after 20
weeks’ gestation with a birth weight of over 500 g is
referred to as a stillbirth. In these cases, the fetus has
either died before or during labour, often unexpectedly
or after an uncomplicated pregnancy. A relatively new
issue that has emerged in the field of perinatal loss is
that continuing development of prenatal diagnostics has
increased diagnosis of fetal abnormalities, with relatively
high corresponding termination rates. A European sur-
vey found average termination rates of 88% for Down’s
syndrome as well as in cases of neural tube defects.7
Although parents have not built up a relationship with
their infant, grief after pregnancy loss does not differ sig-
nificantly in intensity from other loss scenarios. As has
C l i n i c a l r e s e a r c h
Copyright © 2012 LLS SAS. All rights reservedwww.dialogues-cns.org
Complicated grief after perinatal loss
Anette Kersting, MD; Birgit Wagner, PhD
Keywords: miscarriage; stillbirth; termination of pregnancy; loss of pregnancy;
complicated grief; bereavement; depression; prenatal loss; neonatal loss; perinatal
Author affiliations: Department of Psychosomatic Medicine, University of
Address for correspondence: Birgit Wagner, PhD, Department of Psychosomatic
Medicine, University of Leipzig, Semmelweisstr. 10, D-04103 Leipzig, Germany
The loss of an infant through stillbirth, miscarriage, or
neonatal death is recognized as a traumatic life event.
Predictors of development of complicated grief after pre-
natal loss include lack of social support, pre-existing rela-
tionship difficulties, or absence of surviving children, as
well as ambivalent attitudes or heightened perception of
the reality of the pregnancy. Risk of complicated grief was
found to be especially high after termination of a preg-
nancy due to fetal abnormality. Studies have revealed that
men and women show different patterns of grief, poten-
tially exacerbating decline in a relationship. Although it is
clear that prenatal loss has a large psychological impact,
it is concluded that there is a substantial lack of random-
ized controlled studies in this field of research.
© 2012, LLS SASDialogues Clin Neurosci. 2012;14:187-194.
been found in bereavement involving first-degree rela-
tives, grief symptoms usually decrease in intensity over
the first 12 months.8,9Longitudinal studies have demon-
strated that in a normal grieving process, grief declines
over a period of 2 years after the pregnancy loss.8,10
Perinatal losses have also been shown to have a sub-
stantial psychological impact on parents and families,
and are associated with post-traumatic stress, depression,
anxiety, and sleeping disorders.11,12Overall, high levels of
CG are generally associated with a poorer state of men-
This article reviews literature on CG reactions to peri-
natal loss. Typical grief reactions and unique aspects of
bereavement after perinatal loss are described, before a
summary of the risk factors which influence grief out-
come. The specific issue of termination of pregnancy due
to abnormality is outlined and gender differences
between fathers and mothers after prenatal loss are then
addressed. Finally, clinical implications for parents after
pregnancy loss are discussed.
Grief reactions after pregnancy loss
Grief is a deeply personal process which nevertheless
follows a fairly predictable course. Reactions to the loss
of a significant person often include temporary impair-
ment of day-to-day function, retreat from social activi-
ties, intrusive thoughts, and feelings of yearning and
numbness which can continue for varying periods of
time. Although grief is a natural, nonpathological phe-
nomenon, it can lead to CG, where symptoms are more
disruptive, pervasive, or long-lasting than in a normal
grief response. This is especially likely if the death has
occurred in a sudden, violent, or traumatic way. CG
(alternatively “prolonged grief disorder”), a descriptive
diagnosis developed from two previously proposed diag-
nostic criteria,14,15is still not in the DSM-IV or ICD-10. It
is, however, proposed that CG may be given official
recognition in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders.16
Adjustment after bereavement has been empirically
shown to occur through a sequence of stages in a longi-
tudinal study of bereaved individuals.17This study
revealed that in normal grieving, negative grief indica-
tors such as disbelief, yearning, anger, and depression
peak within approximately 6 months of loss. Lin and
Lasker found a similar grief process in a study that
looked specifically at bereaved parents after pregnancy
loss.18In this study, grief scores were initially relatively
high and declined most steeply over the first year. In a
2-year follow-up their evaluation of the grief process
showed an interesting result: whilst 41% of participants
showed a normal decline of grief scores, the remaining
59% showed different patterns of pervasive presence or
delayed resolution of grief.
CG reactions after perinatal loss can be generally spec-
ified within the existing diagnostic criteria, but they dif-
fer from grief after other significant losses in a number
of key aspects. A consistent feeling of guilt is commonly
experienced after pregnancy loss and is associated with
CG reactions.8,19,20Self-blame may prolong the normal
grieving process, especially if there was a feeling of
ambivalence towards the pregnancy21or if the subject
perceives having done something wrong (eg, smoking or
jogging during pregnancy). Another unique aspect of
pregnancy loss is that women feel that their bodies have
failed, and that their femininity has been undermined.20
Women who have already suffered a miscarriage show
higher levels of psychological distress than women who
have not experienced perinatal loss.22Sometimes “child
envy”—the feeling of being envious of other people’s
children—can be an issue for those who have been
through perinatal loss. These women often struggle to
make contact with friends or family members who have
children or who are at the same stage of pregnancy as
that at which the loss was suffered. Difficulty coping with
these feelings and continuous avoidance often leads to
isolation of these mothers.
As pregnancy losses are typically sudden and unex-
pected, parents usually have no time to anticipate grief
or prepare themselves for the change in situation. Unlike
the death of other close family members, parents
bereaved by a perinatal loss have few or no direct life
experiences with the infant. The introduction of imaging
techniques such as ultrasound and 3D presentations
mean that the fetus is now more likely perceived as a
baby than as a fetus,23,24but studies evaluating the psy-
chological effect of having viewed ultrasounds have
reported discordant results. Whilst some studies report
higher levels of grief in those who have seen the ultra-
sound image of the unborn child, especially in men,25
others found no relationship.26
An additional aggravating factor is that if the loss takes
place at an early stage of pregnancy there will usually be
no funeral or other rituals of mourning, and the loss may
remain unacknowledged by the family and friends.
C l i n i c a l r e s e a r c h
Generally, the possibility of saying goodbye after the loss
of a significant person is assumed to have a positive
impact on the bereaved person.27,28These issues may com-
plicate the grieving process and increase a sense of iso-
lation for the parents. De Wijngaards and colleagues
found in a study of bereaved parents that presenting the
body for viewing at home and the feeling of having said
goodbye to the child were associated with lower levels of
grief.29Previously it was common practice to remove a
baby quickly after stillbirth, but this policy has been
updated in recent years, with the general assumption that
seeing and even holding the infant helps the mourning
process. Often parents are nowadays encouraged to hold
and see their stillborn infant’s dead body. There is, how-
ever, controversy over this practice and the concept has
recently been challenged by recent studies. It has been
found that women who hold their deceased infant have
significantly higher rates of post-traumatic stress disorder
(PTSD), anxiety, and depression even 7 years after the
event.30,31It has been reported in these publications that
women who hold their dead infant have significantly
higher rates of depression than those who only looked at
them, and the least impact on depression was found in the
mothers who did not have any contact with the fetus.31
Risk factors of grief reactions
A number of variables predict CG reactions following a
perinatal loss; for example it is widely documented that
social support plays a large role in adjustment after
bereavement. Based on stress theory, social support is
thought to have a buffering effect, and poor social sup-
port from family and friends is associated with CG reac-
tions.8,10,13,32High levels of perceived emotional support
from society is consistently associated with lower scores
of perinatal grief in all studies examining it.13
Furthermore, religious communities have been found to
be beneficial as another source of social support, as
greater religious participation has been related to
increased perception of social support contributing to
less grief-related distress for parents.33Following this
argument, lack of support from a partner and poor mar-
ital relations have both been described as other strong
components associated with more intense grief.10,32
Projections of guilt and blame as well as angry feelings
towards a partner and loss of the vision of a future as a
family may put considerable stress on the relationship.
Another important predictor of grief intensity is the
presence of living children. Childless women who suffer
a miscarriage have significantly higher levels of grief
than women who already have children,34,35and a num-
ber of studies revealed that grief intensity decreases sub-
stantially after a subsequent successful pregnancy.18,36 In
the longitudinal study completed by Lin and Lasker,
however, grief symptoms in the group of “normal griev-
ers” had still not completely disappeared during the 2-
year study period,18suggesting that even though pre-
existing children or subsequent pregnancies might help
to assuage grief, continuing low levels of grief will still be
found in most subjects.
Personality has been found to be another significant pre-
dictor, with women shown to have a relatively high
degree of neurotic personality characteristics before loss
being more likely to develop intense grief reactions after
the infant’s death.8These findings are consistent with the
study by Toedter and colleagues who evaluated pre-loss
mental health13and found that pre-event status predicted
the likelihood of a persistent intense grief reaction at 2
years of follow-up. Another study, this time examining
the reactions to miscarriage of women with a history of
major depression, found that 54% of subjects experi-
enced a relapse in their psychiatric symptoms.34
As mentioned above, ambivalent attitudes toward the
pregnancy were found to be associated with more
intense grief reactions, and loss of an unplanned preg-
nancy was often reacted to in the same way.37,38It is
thought that these findings might be explained by guilt
or blame which these women felt after pregnancy loss.
Mothers who had more invested in their pregnancy, for
example those who had thought of a name or bought
things for the baby, also showed a higher level of grief-
related yearning for the loss of the infant,39and this was
matched by greater grief in women who had experi-
enced the fetus moving inside of them. It is thought,
therefore, that the more the mother has experienced or
comprehended the reality of the baby the higher the
level of grief.23Contrary to these findings, however, are
a number of studies have evaluated the association
between length of gestation and level of distress after
perinatal loss, and could not find an increase in psycho-
logical distress with higher gestational age.23,34Therefore,
mothers who have lost their infant at an early stage of
pregnancy may be seen to develop similar grief symp-
toms to mothers in a later stage of pregnancy.
A number of further predictors have been generally
associated with psychological morbidity after prenatal
CG after perinatal loss - Kersting and WagnerDialogues in Clinical Neuroscience - Vol 14 .No. 2 .2012
loss, but no specific relationships could be found
between grief and maternal age, marital status, or occu-
In contrast to other perinatal losses, the termination of
a pregnancy is not an unexpected event. Once a diagno-
sis of fetal abnormality has been made, parents are con-
fronted with the decision as to whether to continue or to
terminate the pregnancy. Factors which contribute to a
decision to end the pregnancy are the child’s prognosis
and future well-being, as well as consideration of the
consequences for the family and marriage.6There is
often little time between diagnosis and termination,
which is then completed by either dilation and evacua-
tion or induction of labour. No significant difference in
grief intensity at 12 months’ follow-up has been found
between methods.40As with a stillbirth, women who have
undergone induced labour must decide if they wish to
view or hold the infant. Viewing the fetus, which may
have visible evidence of deformity, may be a very trau-
matic experience, but on the other hand it may provide
the couple with the welcome confirmation that they
have made the right decision in terminating the preg-
nancy.6After termination, a number of important issues
need to be considered before communicating the event
to family and friends. As some people may experience
condemnation by sections of society that do not approve
of the decision to terminate, a number of families decide
to pretend that the loss was due to miscarriage.6
A number of recent studies have revealed that the loss
of an unborn child after discovery during pregnancy of
fetal malformation or severe chromosomal disorders can
be considered as a traumatic life event with high psy-
chological impact. This is especially relevant if the ter-
mination of pregnancy takes place in the 2nd or 3rd
trimester of pregnancy.41-43PTSD and CG reactions have
been documented in parents years after a termination
on the grounds of abnormality. In their longitudinal
study, Kersting and colleagues found that 14 months
post-loss, 14% of women fulfilled full criteria of CG and
17% had been diagnosed with a psychiatric disorder.42
These findings were confirmed by Korenromp and col-
leagues, who documented that 20% of the women suffer
up to 1 year of CG and psychological consequences after
such a procedure.44Several predictors of negative long-
term outcome after pregnancy termination, including
high level of distress immediately after the procedure,
low self-efficacy, lack of support from the partner, and
high levels of doubt whilst making the decision.42,44In
spite of changes in mental state following termination,
however, only 2.7% of the participants regretted their
decision. Interestingly, firmer religious faith, as assessed
14 days after the loss, predicted lower levels of CG 14
Loss of an infant during pregnancy can clearly deeply
distress a woman and put strain on her relationship
with the father, but it may also have a distinct psycho-
logical impact on the grieving father. Although it may
seem predictable that fathers are also affected by the
loss, there has only been a limited amount of research
in this field. A number of quantitative studies com-
pared the grief responses of fathers and mothers after
perinatal loss and found lower levels of grief intensity
in the fathers.45-50Beutel and colleagues found that men
tend to grieve less intensively and for shorter periods
than their partners. Symptoms of grieving in men were
found to be similar to those of women, except that
men report less crying and feel less need to talk about
their loss. Similar findings were reported by Stinsons
and colleagues, who reported that women already had
significantly more intense grief responses at 2 months,
and that this trend was still relevant after 2 years of
follow-up.45The men in this study were also found to
internalize and deny their grief, or attempt to distract
themselves rather than speaking about their loss.47
Johnsson and Puddifoot51had slightly different find-
ings: they evaluated an all-male cohort and showed
that grief responses were at a similar level to those of
women after miscarriage. In general, these findings
support the idea that fathers also experience grief after
perinatal loss, but it is assumed that reactions are gen-
erally less intense. Coping mechanisms differ from
those of women, it is thought that these differences in
grieving may often contribute to misunderstanding
and conflicts in the relationship. It would certainly
seem that one of the greatest challenges in these situ-
ations would be to provide support for a partner whilst
trying to cope with grief. In summary, it has been
shown that the greatest risk to a relationship is pre-
sented by unequal or noncongruent grieving processes
C l i n i c a l r e s e a r c h
Clinical implications after
Although it is widely recognized that perinatal loss can
lead to psychiatric disorders and CG, only a small num-
ber of the women who have experienced miscarriage
receive routine follow-up psychological support.54As
interventions typically aim to alleviate depressive symp-
toms, there seems to be little on offer for the prevention
of development of CG.55If intervention is offered, it gen-
erally begins early, often immediately after the loss when
the patient is still under hospital observation. Normally,
psychological aftercare will involve programs of coun-
seling, whilst manualized interventions are rare and are
seldom based on evaluated intervention programs. The
current literature highlights a number of methodical
challenges to this system. Reviews and meta-analyses of
general bereavement interventions have shown that
although effectiveness of bereavement interventions is
often assumed, empirical evidence yields inconclusive
results. It has even been claimed by some reviewers that
there is no strong evidence that these interventions are
at all effective.56,57Although bereavement interventions
appear to be effective if aimed high-risk groups or at
those whose grieving process has already complicated,57-59
interventions aimed solely at preventing grief seem to
have inconsistent support.60
Only a few randomized controlled studies have been
carried out for women after prenatal loss, and most of
these have been limited by being aimed at outcomes of
depression and psychiatric disorder rather than grief
itself.61-63One exception to this was an intervention to
prevent grief after perinatal loss specifically aimed at
women following a stillbirth. This program began before
hospital discharge and continued over a period of 4 to 6
months. However, no statistical differences were found
in overall grief scores between the treatment and con-
trol groups (who received routine hospital care).64
Lilford and colleagues also compared prenatal bereave-
ment counseling with treatment as usual in a random-
ized controlled trial but again found no differences
between counseling and control groups with respect to
grief, anxiety, or depression.65Swanson and colleagues
evaluated a couple-focused intervention in a random-
ized controlled trial and found a beneficial impact on
grief resolution.66In a meta-analysis of 14 studies of
intervention in CG, Wittouck and colleagues60found that
only four studies reported positive results in terms of
decreased CG measures. Interestingly, all four of the suc-
cessful trials were based on cognitive-behavioral tech-
A further recent study examining the efficacy of an
Internet-based cognitive behavioral therapy for moth-
ers after pregnancy loss67showed positive treatment
effects, with the intervention group showing significantly
reduced symptoms of grief, PTSD, and depression after
treatment relative to the waiting-list group, and this
symptom reduction was maintained at 3-month follow-
up.68,69The treatment program involved self-confronta-
tion with the most painful memories relating to the loss,
social sharing as well as cognitive restructuring with
regard to feelings of guilt and blame.70
Overall, methodological flaws, the lack of randomized
control groups, and the absence of proven efficacy of
grief interventions after prenatal loss make it difficult to
suggest guidelines outlining which form of intervention
may be most beneficial. It may be concluded, however,
from meta-analysis of general bereavement interven-
tions that the best treatment outcomes seem to be
reached by interventions aimed at a high-risk group or
those that include some element of cognitive-behavioral
The results of this review emphasize that perinatal loss
of an infant has the potential to have a large impact on
mothers, fathers, and the relationship of a couple.
Although not all participants in the presented studies
suffer long-term CG, there are still a significant number
of women found to be grieving years after loss. This is
especially likely if they fulfil criteria for any of the risk
factors described above. Pathological grief was found to
be particularly high in women after termination of an
abnormal pregnancy. The presented studies have also
documented the differences in coping styles of women
and men, and have highlighted how these can lead to a
decline in the quality of a relationship. It is therefore
suggested that future intervention approaches should
involve male partners, including them in psychotherapy
and ensuring an ongoing dialogue between the grieving
While there is a large body of literature on the subject
of risk factors and patterns of grieving, very little
research exists documenting the efficacy of different
interventions. What is clear, however, is that the current
CG after perinatal loss - Kersting and WagnerDialogues in Clinical Neuroscience - Vol 14 .No. 2 .2012
findings indicate the importance of psychotherapeutic
monitoring and support. Randomized controlled trials
have shown a mixture of results, but this is in line with
the findings of meta-analysis of general bereavement
intervention. Further research is deemed necessary, and
it is recommended that future studies focus on random-
ized controlled trials, especially in the areas of general
prevention of CG development, tackling of high-risk
subgroups and possible courses of action to help parents
already suffering from CG. ❏
C l i n i c a l r e s e a r c h
Duelo complicado después de una pérdida
La pérdida de un bebé por muerte fetal, aborto o
muerte neonatal se reconoce como un aconteci-
miento vital traumático. Entre los predictores del
desarrollo de un duelo complicado después de la
pérdida prenatal están la falta de soporte social, las
dificultades en las relaciones pre-existentes o la
ausencia de niños vivos, como también las actitudes
ambivalentes o la percepción exagerada de la rea-
lidad del embarazo. Se ha encontrado que el riesgo
de un duelo complicado es especialmente elevado
después del término de un embarazo debido a una
anormalidad fetal. Los estudios han mostrado que
hombres y mujeres muestran patrones distintos de
duelo, los que potencialmente aumentan el dete-
rioro de la relación de pareja. Aunque es claro que
la pérdida prenatal tiene un gran impacto psicoló-
gico, se concluye que existe una ausencia impor-
tante de estudios controlados randomizados en
este campo de investigación.
Deuil compliqué après un décès périnatal
La perte d’un enfant mort-né ou par avortement
spontané ou mort néonatale est un événement de
vie traumatisant. Les facteurs prédictifs d’un deuil
compliqué après une telle perte sont l’absence de
support social, des antécédents de difficultés rela-
tionnelles, l’absence d’enfant vivant ainsi que des
attitudes ambivalentes ou une perception aiguë de
la réalité de la grossesse. Le risque de deuil compli-
qué est particulièrement élevé après l’interruption
d’une grossesse pour anomalie du fœtus. Des
études ont montré différents schémas de réaction
psychologique de deuil pour les hommes et les
femmes, ce qui peut aggraver une dégradation de
leur relation. L’impact psychologique d’une perte
prénatale est important, pourtant des études ran-
domisées contrôlées manquent considérablement
dans ce domaine de recherche.
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