Analyzing Professional and Social Discourse on Pregnancy Loss

Despite the high prevalence rates of nearly 20 to 50% of North American pregnancies, miscarriage and pregnancy loss are consistently underrepresented in literature and poorly supported in both clinical environments and social networks (Romney et al., 2021). In literature and policy, the language around pregnancy loss ranges includes terms such as reproductive loss, miscarriage, and fetal demise, which carry ambiguity around bereavement related to a loss, while simultaneously not acknowledging the death of a person (Andipatin, Naidoo, & Roomaney, 2019). Additionally, in Canada, there is no national system for monitoring and recording pregnancy losses, meaning data is insufficient, care delivery for miscarriages is disconnected and variable in different regions (Tuyl, 2024). In a similarly complicated and disjointed vein, the grief experience for miscarrying mothers and fathers is misunderstood and often invalidated, since fetal personhood is classified by the delivery of the baby as a form of distinguishing “the ‘being’ from the ‘non-being’”, with the implication that a miscarried fetus or stillborn is a ‘non-being’ (Andipatin, Naidoo, & Roomaney, 2019, p. e553). In the clinical environment, pregnancy loss is often treated from a biomedical approach, dealing mainly with the physical component of care that has become routine due to the frequency with which these cases occur in clinics and emergency departments (Andipatin, Naidoo, & Roomaney, 2019). However, the experience of pregnancy loss for the grieving mother and father is anything but routine; in fact, these experiences are embedded in social discourse and structured by both the language around them, as well as the silence and lack of acknowledgement (Andipatin et al, , Naidoo, & Roomaney, 2019). This silence around pregnancy loss, among several other discourse themes, will be explored in this paper analyzing how this discourse perpetuates power dynamics, and address the various cultural issues embedded within the linguistic construction of pregnancy loss.

Approach to the Literature Search

            In order to analyze the literature on pregnancy loss, the literature search was focused on the Athabasca University library, primarily due to access and time constraints of being able to locate full papers that could be read online. Into the Scholarly Article Search text box, the searched phrase was “discourse on pregnancy loss”, which initially yielded 252 results. In order to narrow down results to recent papers, which would help with ensuring the discourse analysis is relevant and up-to-date, the search criteria was modified to papers within the last 10 years, as well as to only show peer-reviewed papers to ensure reliability of data. As mentioned as well, only papers that were fully available online were included in the search. With these criteria combined, there were 45 results. Of these papers, nine were selected, mostly due to time limitations and criteria for this assignment. The selection process was aimed at ensuring the papers represented a relatively broad view of the discourse and covered different perspectives or approaches. For instance, one paper was selected because it focused on the perspective of the father experiencing pregnancy loss, which is a rarely addressed perspective in the literature (Gershfeld-Litvin, Ressler, & Yosef, 2024). Another paper was selected due to its focus on government policy and regulations around pregnancy loss, which would address discourse shaping power dynamics (Middlemiss, 2021). Besides these strategic selections of papers, the rest of the chosen papers were randomized for data collection.

Paradigms

            For the purposes of this paper, three major paradigms were considered in the discourse analysis: empirical/positivist, constructivist, and critical theory. The majority of the articles in this review were written from constructivist approaches, while some were critical theory based; however, many articles did mention elements of empiricism/positivism in the context of asserting that empirical approaches are insufficient for understanding and responding to pregnancy loss.

Empirical paradigms, also known as positivism, center on the biophysical processes, which in the context of pregnancy loss, is described by one author as lacking empathy through regarding pregnancy loss as a “purely physical experience” and even metaphorizing it to a mechanical breakdown of a car (Andipatin, Naidoo, & Roomaney, 2019, p. e556). The paper on government policy and procedure regarding pregnancy loss discusses that, in England for example, policy is developed through a biomedical perspective that equates fetal matter with placental matter in the disposal process, treating the fetal matter as clinical waste, which was notably disturbing for the grieving mothers (Middlemiss, 2021). Throughout the papers analyzed in this review, evidence of the invalidation of grieving parents following pregnancy loss is consistent. But even when it is validated, their grief is viewed empirically according to conventional grief psychology, which aims for “moving on or forgetting” based on the “biological reality of life and death” (Kristensen & Hedtke, 2018, p. 25-27). For many of these mothers, however, the grieving process is much more complex and does not truly follow the process of typical loss of a person; thus, while the biomedical discourse remains dominant in medical service delivery for pregnancy loss, the literature consistently reports its insufficiency to address the complex, context-dependent factors associated with the experience.

Instead, most of the chosen articles operate on constructivist approaches as a means of better understanding, exploring, and offering approaches for counseling and treating individuals experiencing pregnancy loss. The majority of articles in the search were qualitative studies utilizing semi-structured interviews with open-ended, reflective questions to elicit narratives that could be analyzed for emerging themes (Andipatin, Naidoo, & Roomaney, 2019; Gershfeld-Litvin, Ressler, & Yosef, 2024; McMorrow, 2024; Romney et al., 2021; Tuyl, 2024). Many of the articles highlight the importance of a constructivist approach: one article emphasizes that a transdisciplinary, patient-oriented approach brings together knowledge from different lived experiences in order to co-construct meaning of and improve access to support around pregnancy loss (Tuyl, 2024). Further to the concept of meaning, studies from a constructivist approach emphasize that meaning is a subjective determination rooted in lived experience and social context. In the context of pregnancy loss, one study discusses the ability of the pregnant woman in determining the value of her pregnancy, and her fetus, for herself (Stoyles, 2015). Pregnant women engage in “calling a fetus into personhood” by creating a social space for the fetus that they would eventually fill when they are born, thereby ascribing a meaning to the pregnancy and the unborn fetus that is not directly related to the physical birth (Stoyles, 2015, p. 94). This contrasts to the empirical approach mentioned earlier, whereby from a legal stance, a fetus is “the legal opposite of a person in the UK” (Middlemiss, 2021, p. 300); from a constructivist approach, however, that concept of personhood is vastly more complex, especially in the context of pregnancy loss where the woman often describes wanting to engage in continuing to remember her child even in their death (Andipatin, Naidoo, & Roomaney, 2019). Clearly, there are limitations of language in articulating the experience of pregnancy loss from both a legal perspective and empirical perspective.

Constructivist approaches, in contrast, offer ways to surpass those limitations, as demonstrated by a researcher that used an arts-based phenomenological approach in semi-structured interviews (McMorrow, 2024). This researcher used drawing during interviews with mothers who experienced pregnancy loss and was able to effectively capture their feelings and thoughts through imagery (McMorrow, 2024). The creation of these drawings, and subsequently sharing them with the participant who was the subject of the drawing, was therapeutic, “validating and potentially healing” for the participants (McMorrow, 2024, p. 184). Certainly, the main difference between empirical and constructivist approaches establishing discourse around pregnancy loss is the theme of validation of the lived experiences of mothers experiencing pregnancy loss, which cannot seem to be met by empirical perspectives, but for which constructive approaches allow space.

Some of the selected articles also had elements of critical theory paradigm, with many of them calling for more research and broader perspectives on grief: “how we as a society render bereaved parents isolated or pathologised in their efforts to remember their dead child” (Kristensen & Hedtke, 2018, p. 20). Other authors critically analyze the Canadian healthcare system, and Canadian society as whole, noting that even though Canada is a wealthy country and provisioning universal healthcare, there are still a multitude of barriers related to equitable access that many pregnant women face (Tuyl, 2024). This author also speaks of positive deviance, whereby couples experiencing pregnancy loss would overcome social norms of avoidance and silence discussing their pregnancy loss, and instead “sought ways to acknowledge their loss amid systems that commonly did not provide support” (Tuyl, 2024, p. 7). In another article, the authors speak about how men are ignored in both the literature and discourse of pregnancy loss. They emphasize the need for more research on the experiences of men following pregnancy loss, and highlight that men experience “narratives of self-blame, loss of identity, and a need to hide feelings of grief and anger” (Gershfeld-Litvin, Ressler, & Yosef, 2024, p. 135).

It is not only men that are ignored in the discourse on pregnancy loss, as another author discusses that the literature is also lacking in how to support and treat other non-pregnant partners:, the treatment of couples as a whole unit, and members of the LGBTQ community, the last of which is even more complicated as means of conception can vary considerably (Romney et al., 2021). Finally, one of the authors uses a feminist critical theory approach, calling on clinicians to work collaboratively with clients to “deconstruct dominant discourses that may overtly or covertly silence clients’ perspectives and experiences” (Hiefner, 2020, p. 68). From the critical theory perspective, a common theme emerges from these articles, which is that of the authority to establish discourse and those experiencing pregnancy loss having to overcome the established norms for their experiences to be voiced and validated.

Power Relations

            Participants throughout the selected papers, specifically individuals who experienced pregnancy loss, consistently noted themes of silence, disenfranchisement of experience, and the normalization of their pregnancy loss, all of which were associated with the power imbalance inherent to the discourse around pregnancy loss. “Strategic silences” involved not only the social taboo of speaking about pregnancy loss, but also within the clinical environment wherein patients who experienced pregnancy loss were not given any answers as to why they experienced loss in the first trimester (Andipatin, Naidoo, & Roomaney, 2019, p. e555). In fact, within the biomedical discourse, pregnancy loss is considered so normal and routine that policy does not require investigating pregnancy loss until a woman experiences three consecutive miscarriages; a practice which many women stated makes them feel “ignored and unimportant” (p. e555). This discourse is perpetuated by the power inherent to empirical approaches in North American medicine, as well as the language that healthcare practitioners use in discussing pregnancy loss.

Healthcare providers are often the first point of contact when people experience pregnancy loss, but there is a power imbalance and related discourse of silence that makes women feel uncomfortable in asking questions and in seeking support (Hiefner, 2020). In one of the selected papers, the authors discuss common terminology in Canada, in addition to terms mentioned earlier in this paper, such as “spontaneous abortion, missed abortion, products of conception, and to “confirm” one’s miscarriage” (Tuyl, 2024, p. 6). Participants of the study voiced how this terminology made them feel invalidated by not reflecting any of their emotional and lived experience of the pregnancy loss. Even the defining of personhood and determination of fetal dates of viability are arbitrary matters that add to the discourse of pregnancy loss, often furthering stigma around grief and expressions of loss (Middlemiss, 2021). As the gatekeepers of care, healthcare providers and public health institutions have an inherent power dynamic in creating the social discourse; in this case, stigmatizing the self-expression of those experiencing pregnancy loss (Tuyl, 2024).

The hierarchical care provided to women experiencing pregnancy loss in the first trimester, as compared to delivery of a stillborn, furthers the invalidation of lived experiences of pregnancy loss. In fact, delivery of a stillborn constitutes delivery of a dead person, whereas early pregnancy loss is referred to as products of conception, and by terms mentioned earlier; this invalidates the patient’s experience of grief and loss experience (Middlemiss, 2021; Tuyl, 2024). Consequently, mothers who experience early pregnancy loss do not receive the same kind of mental health care and other supports as mothers who deliver a stillborn, even though they are at risk of similar mental health complications (Tuyl, 2024[MS5] ). 

Fathers experiencing pregnancy loss are also affected by this power imbalance in the sense that they are systematically neglected and experience “disenfranchised grief” as their feelings are overlooked in the process (Gershfeld-Litvin, Ressler, & Yosef, 2024, p. 135). The inequity for men surrounding pregnancy loss emerges from the social perception that women are experiencing the loss and need support,  while men should be providing that support. There is a widespread lack of social recognition that men need the support as well (Gershfeld-Litvin, Ressler, & Yosef, 2024). LGBTQ individuals are also highly misunderstood and neglected within the discourse of pregnancy loss: this is a crucial oversight, especially considering the multitude of ways modern conception can occur[MS6] , with pregnancy having even more complex meanings for non-pregnant and pregnant partners alike (Romney et al., 2021).

Cultural Issues

            In North American culture, the preferred cultural script toward pregnancy loss has been identified as silence, much like the social discourse previously discussed (Andipatin, Naidoo, &  et al., Roomaney, 2019). The authors believe that this silence is based in the predominant biomedical discourse wherein cause of pregnancy loss in the first trimester is nearly always indeterminable; further, it is not investigated until it occurs three times in a row (Andipatin, Naidoo, & Roomaney, 2019). As a result, the social networks of people who experience pregnancy loss do not know how to support and respond to the bereaved and therefore may offer inappropriate or ineffective attempts at support; they may be uncomfortable discussing the matter, which serves to further reinforce stigma (Andipatin, Naidoo, & Roomaney, 2019). For men, this stigma is even more difficult to overcome; many men experience a complete lack of acknowledgement that they may be grieving or experiencing loss similar to what their previously-pregnant partner is experiencing, demonstrating that the stigma extends beyond the immediate patient (Tuyl, 2024). Some participants in a study reported that they sought cultural practices outside of North American culture in order to find ways to honor and grieve their loss, such as a First Nations candle lighting ceremony and placing a symbolic Buddhist statue inside the home (Tuyl, 2024). Evidently, North American culture is influenced by the biomedical discourse of silencing that is so predominant around pregnancy loss.

Conclusion

            While pregnancy loss remains a highly prevalent medical concern for so many individuals in North America, the discourse around it remains strikingly limited to the biomedical language and terminology that is alienating and invalidating of the individuals experiencing pregnancy loss. There remains a gap in the literature toward bridging the gap between the normalcy of pregnancy loss and the grieving experience of mothers experiencing it. There also remains a gap in addressing the non-pregnant partner’s experiences of grief, which are marginalized and sometimes erased by the dominant discourse of silence. However, the majority of recent research on pregnancy loss, as demonstrated by the sampling for this paper, is approaching the issue from constructivist and critical theory lenses, which allow space and validity to those experiencing pregnancy loss. Perhaps in giving a voice to these individuals and allowing them to co-construct the discourse on pregnancy loss, a change in social and professional discourse is possible.

References

Andipatin, M. G., Naidoo, A. D., & Roomaney, R. (2019). The hegemonic role of biomedical discourses in the construction of pregnancy loss. Women and Birth 32(2019): e552-e559. DOI: 10.1016/j.wombi.2019.03.006

Gershfeld-Litvin, A., Ressler, I., Yosef, Y. B. (2024). Experiences of pregnancy loss in Israeli first-time expecting fathers: A qualitative study. Psychology of Men & Masculinities 25(2): 134-141. DOI: 10.1037/men0000451

Hiefner, A. R. (2020). “A silent battle”: Using a feminist approach to support couples after miscarriage. Journal of Feminist Family Therapy 32(1-2): 57-75. DOI: 10.1080/08952833.2020.1793563

Kristensen, H. G., & Hedtke, L. Still alive : Counselling conversations with parents whose child has died during or soon after pregnancy. The International Journal of Narrative Therapy and Community Work 1: 22-30. DOI: N/A

McMorrow, D. J. (2024). Entering the womb house: Bringing visibility to women’s lived experience of pregnancy loss through an imaginal-hermeneutic method of research. American Psychological Association Qualitative Psychology 11(1): 165-190. DOI: 10.1037/qup0000278

Middlemiss, A. (2021). Pregnancy remains, infant remains, or the corpse of a child? The incoherent governance of the dead foetal body in England. Mortality 26(3): 299-315. DOI: 10.1080/13576275.2020.1787365

Romney, J., Fife, S. T., Sanders, D., & Beh, S. (2021). Treatment of couples experiencing pregnancy loss: Reauthoring loss from a narrative perspective. International Journal of Systemic Therapy 32(2): 134-152. DOI: 10.1080/2692398X.2020.1855621

Stoyles, B. J. (2015). The value of pregnancy and the meaning of pregnancy loss. Journal of Social Philosopjy 46(1): 91-105. DOI: 10.1111/josp.12088

Tuyl, R. V. (2024). Improving access, understanding, and dignity during miscarriage recovery in British Columbia, Canada: A patient-oriented research study. Women’s Health 20: 1-12. DOI: 10.1177/17455057231224180