JOURNAL OF WOMEN’S HEALTH
Volume 17, Number 3, 2008
© Mary Ann Liebert, Inc.
Grief Following Miscarriage: A Comprehensive
Review of the Literature
NORMAN BRIER, Ph.D.
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 elucidate
the nature, incidence, intensity, and duration of grief at this time and to identify potential
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 standardized
measure 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 match
descriptions 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 types
of major losses and is significantly less intense by about 6 months. Few conclusions can be
drawn in regard to potential moderators of grief following a miscarriage.
Conclusions: Although additional research is clearly needed, guidelines for coping with
grief 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 and
symbolic loss, practitioners need to encourage patients to articulate the specific nature of their
loss and assist in helping them concretize the experience.
the loss of other family members, the grieving in-
dividual has had few direct life experiences or
actual times with the deceased to review, remem-
ber, and cherish. There is no publicly acknowl-
edged person to bury or established rituals to
structure mourning and gain support, and, often,
relatively few opportunities are present to ex-
MISCARRIAGE, OR SPONTANEOUS ABORTION, is a
psychologically challenging event. Unlike
press thoughts and feelings about the loss due to
the secrecy that often accompanies the early
stages of pregnancy. When others do know about
the loss, they often fail to appreciate its impact or
minimize it, making comments such as, “It was
not meant to be” or “It is for the best.”1–7
Although there is increasing acceptance that a
miscarriage represents a significant loss experi-
ence,4the empirical literature relating grief to
miscarriage 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’s
Evaluation and Rehabilitation Center, Bronx, New York.
be poorly and inconsistently defined.8,9The
scales 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 central
construct underlying measures of perinatal grief
tend either not to be specified or to vary across
scales.10,11In addition, the assessment intervals
used in studies have ranged widely. As the in-
tensity of grief is significantly affected by the pas-
sage of time,12,13the use of varying assessment
points confounds results. In addition, some stud-
ies have measured grief while symptoms are be-
ing directly experienced, whereas other studies
measure grief retrospectively so that descriptions
of grief are primarily based on recall. Finally,
pregnancy loss in studies of grief is sometimes
viewed as a unitary category in which distinc-
tions between early and late miscarriages, ectopic
pregnancies, stillbirths, and neonatal deaths are
Consequently, this review comprehensively
surveys the literature on grief following miscar-
riage. It emphasizes studies that have focused on
grief in regard to early miscarriage, specified the
assessment intervals used so that the time since
loss can be considered, and used a reliable and
valid measure to assess prenatal grief. Qualitative
studies are included when the results can be em-
ployed to develop hypotheses. The purpose of
this review is threefold: to elucidate the nature of
grief following an early miscarriage; to determine
the incidence, intensity, and duration of grief at
this time; and to identify the variables that po-
tentially moderate its intensity and duration. As
a result of this analysis, clinicians will be better
able to understand the nature and course of their
patients’ grief following miscarriage and thereby
better help patients cope. Patients, in turn, will be
more likely to feel that the import of their loss is
recognized and understood and be able to acquire
clearer expectations as to what they are likely to
feel and for how long.
First, the terms grief and miscarriage are de-
fined. Next, the nature, duration, and intensity of
grief following miscarriage are discussed, in-
cluding differences in grief associated with gen-
der. Key moderators are then noted. In the final
section, the research and clinical implications of
the review are described.
MATERIALS AND METHODS
An electronic search of the Medline and Psych
Info 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 searches
were then carried out using references cited in the
identified papers. Searches were not circum-
scribed by date or by language if an English ab-
stract was available. Studies were subsequently
included in the review if the majority of women
in a study sample (i.e., at least 51%) experienced
an early miscarriage (i.e., before the 20th week of
gestation), a standardized measure of perinatal
grief was used, and assessment intervals were
clearly specified. Qualitative studies, as noted,
were included when helpful in formulating hy-
Grief refers to the affective, physiological, and
psychological reactions to the loss of an emo-
tionally important figure14,15and typically in-
cludes severe and prolonged distress.16There is
a lack of consensus as to what constitutes normal
grief.18For example, the American Psychiatric
Association’s Diagnostic and Statistical Manual
(DSM-IV)19does not note what a typical grief re-
action is. Instead, the DSM-IV describes a set of
symptoms that are not characteristic of a normal
grief reaction, such as excessive guilt, suicidal
ideation, and feelings of worthlessness.
Various authors have attempted to delineate
what constitutes normal grief by describing the
signs and symptoms that are typically present in
the bereavement period.20–23Prigerson et al.,9,22
for example, described a holistic set of character-
istics of grief as part of their effort to distinguish
complicated and normal grief. Organizing the de-
scriptors into affective, behavioral, cognitive, and
physiological categories, they noted that, affec-
tively, people are depressed, despairing, dejected,
angry, and hostile. Behaviorally, they tend to act
agitated and fatigued, cry spontaneously, and are
socially 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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Address reprint requests to:
Norman Brier, Ph.D.
Clinical Professor of Psychiatry and Pediatrics
Albert Einstein College of Medicine of
Children’s Evaluation and Rehabilitation Center
1410 Pelham Parkway South
Bronx, NY 10461