Grief in women with previous miscarriage or stillbirth: a systematic review of cross-sectional and longitudinal prospective studies

Figures & data

Figure 1. The PRISMA flow chart.

Table 1. Basic characteristics and risk of bias for the included studies.

First author	Title	Journal	Number of groups	Specific feature of the study	Risk of bias
					Representativeness of the sample	Sample size	Comparability of respondents and nonrespondents	Ascertainment of grief	Thoroughness of reports regarding descriptive statistics	Sum score
(Black et al., 2021)	Dreaming of the deceased after miscarriage: A pilot study	Dreaming	2 (both birth mothers and their partners)	Focus on couples	1	1	1	0	1	4
(Burgoine et al., 2005)*	Comparison of perinatal grief after dilation and evacuation or labour induction in second trimester terminations for foetal anomalies	American Journal of Obstetrics and Gynaecology	2 (method for termination of pregnancy)	–	0	0	0	1	1	2
(Conway & Russell, 2000)*	Couples’ grief and experience of support in the after-math of miscarriage	The British Journal of Medical Psychology	1	Focus on couples	0	0	0	1	0	1
(Das et al., 2021)	Grief reaction and psycho-social impacts of child death and stillbirth on bereaved North Indian parents: A qualitative study	PLoS One	4 (parents who had stillbirths or child death, their family members and community representatives)	Focus on parents who had stillbirths or child death and their family members	0	1	0	1	1	3
(De Montigny et al., 2017)	Women’s persistent depressive and perinatal grief symptoms following a miscarriage: The role of childlessness and satisfaction with healthcare services	Archives of Women’s Mental Health	4 (time since pregnancy loss)	–	1	1	0	1	1	4
(Gozuyesil et al., 2022)*	Grief and ruminative thought after perinatal loss among Turkish women: one-year cohort study	Sao Paulo Medical Journal	1	-	0	0	0	1	1	2
(Güçlü et al., 2021)*	Perinatal grief and related factors after termination of pregnancy for foetal anomaly: One-year follow-up study	Archives of Neuropsychiatry	1	-	0	0	0	1	1	2
(Hanschmidt et al., 2018)	Stigma in the context of pregnancy termination after diagnosis of fetal anomaly: associations with grief, trauma, and depression	Archives of Women’s Mental Health	1	-	0	1	0	1	1	3
(Johnson & Johnston, 2021)*	The psychological implications of a subsequent pregnancy outcome in couples with a history of miscarriage	Journal of Reproductive and Infant Psychology	2 (couples: two consecutive miscarriages versus live birth following a miscarriage)	Focus on couples	1	1	1	1	1	5
(Keefe-Cooperman, 2005)	A comparison of grief as related to miscarriage and termination for foetal abnormality	Omega	2 (variant of loss)	–	1	0	0	1	1	3
(Kersting et al., 2005)	Trauma and grief two to seven years after termination of pregnancy because of foetal anomalies – a pilot study	Journal of Psycho-somatic Obstetrics and Gynaecology	3 (time since loss and control group)	-	0	0	0	0	1	1
(Köneş & Yildiz, 2021)*	The level of grief in women with pregnancy loss: a prospective evaluation of the first three months of perinatal loss	Journal of Psycho-somatic Obstetrics and Gynaecology	1	-	0	1	0	1	1	3
(Krosch & Shakespeare-Finch, 2017)	Grief, traumatic stress, and posttraumatic growth in women who have experienced pregnancy loss	Psychological Trauma: Theory, Research, Practice and Policy	1	Online survey	1	1	0	1	1	4
(Kulathilaka et al., 2016)	Depressive disorder and grief following spontaneous abortion	BMC Psychiatry	2 (presence of a control group)	-	0	1	0	1	1	3
(Lafarge et al., 2017)	Posttraumatic growth following pregnancy termination for foetal abnormality: The predictive role of coping strategies and perinatal grief	Anxiety, Stress & Coping: An International Journal	1	-	1	1	0	1	1	4
(Nazaré et al., 2012)	Grief following termination of pregnancy for foetal abnormality: Does marital intimacy foster short-term couple congruence?	Journal of Reproductive and Infant Psychology	1	Focus on couples	0	0	0	1	1	2
(Rich 2000)	The impact of post-pregnancy loss services on grief outcome: Integrating research and practice in the design of perinatal bereavement programmes	Illness, Crisis, & Loss	1	Focus on couples	1	1	0	1	0	3
(Scheidt et al., 2012)*	Are individual differences of attachment predicting bereavement outcome after perinatal loss? A prospective cohort study	Journal of Psycho-somatic Research	1	-	0	0	0	0	1	1
(Séjourné et al., 2016)	Internet forums following a miscarriage: A place for women in particular pain?	Journal of Reproductive and Infant Psychology	1	Online survey	1	1	0	0	1	3
(Serrano & Lima, 2006)	Recurrent miscarriage: Psychological and relational consequences for couples	Psychology and Psychotherapy	1	Focus on couples	0	0	0	1	1	2
(Volgsten et al., 2018)*	Longitudinal study of emotional experiences, grief and depressive symptoms in women and men after miscarriage	Midwifery	2 (presence of a control group)	Focus on couples	0	0	0	1	0	1

Notes: The table contains the 21 studies which are included in the review. It also contains points (0 or 1) for the quality of the five criteria derived from a modified version of the Newcastle–Ottawa scale for the assessment of the risk of bias of studies included in a systematic review or a meta-analysis (Wells et al., 2021) as well as the corresponding sum scores as assessed by two independent reviewers. A total score of >2 points reflects a low risk of bias and a high methodological quality of the corresponding study. In contrast, a total score of ≤2 points reflects a high risk of bias and a low methodological quality of the corresponding study. *Prospective longitudinal studies. Studies without * are cross-sectional studies. Five of the 13 cross-sectional studies (38%) (Black et al., 2021; Das et al., 2021; Nazaré et al., 2012; Rich 2000; Serrano & Lima, 2006) and three of the eight prospective longitudinal studies (38%) (Conway & Russell, 2000; Johnson & Johnston, 2021; Volgsten et al., 2018) focussed on couples. However, the main findings were reported for men and women separately; thus, it was possible to include data for women separately in this review.

Table 2. Extracted variables and their frequencies

Variable	Cross-sectional studies (n = 13)		Prospective longitudinal studies (n = 8)
	Number	Frequency (%)	Number	Frequency (%)
Period of assessment	6	46	6	75
Sample size	13	100	8	100
Mean age	13	100	7	88
Country	11	85	8	100
Kind of pregnancy loss	13	100	8	100
Duration of pregnancy	8	62	5	63
Proportion of recurrent pregnancy losses	3	23	6	75
Proportion of women with living children	8	62	6	75
Uniform time of measurement	0	0	8	100
Mean sum score of the grief scale	11	85	6	75
Prevalence of severe grief scores	4	31	2	25
Comorbidity	3	23	1	13
Psychiatric pre-diagnosis	1	8	0	0

Table 3. Mean grief scores and frequencies for severe grief scores.

Study	Validated instrument for the assessment of grief	Subgroup	Measurement time	Mean grief score ± standard deviation	Frequency of grief scores above the corresponding cut-off score
Cross-sectional studies
(Black et al., 2021)	ITG (modified)	2 (pregnancy trimester 1 and 2 in which the miscarriage occurred)	Up to one year	2.58 ± 0.81 (total sample) Birth mothers: Trimester 1: 2.51 ± 0.83 Trimester 2: 2.85 ± 0.82	–
(Das et al., 2021)	PGS-33	3 (mothers): with a deceased child (n = 13), with a deceased neonate (n = 12), with a stillbirth (n = 15)	Six to nine months	Mothers with stillbirths (median) (inter-quartile range): 107** (97–117) AG: 41** (32–42) DC: 32** (25–33) D: 35** (27–43)	80%
(De Montigny et al., 2017)	PGS-33	–	Up to six years	78.5 ± 26.6 (1–6 months) 68.9 ± 30.2 (7–12 months) 73.5 ± 31.9 (1–2 years) 65.0 ± 26.5 (>2 years)	–
(Hanschmidt et al., 2018)	ICG	–	On average 3.6 years*	15.2 ± 12.6	17.6%
(Keefe-Cooperman, 2005)	PGS-33	Two (variant of loss)	Up to two years	101.7** (miscarriage) 103.4** (TOPFA)	–
(Kersting et al., 2005)	MTS	According to measurement time (2-7 years and 14 days)	2–7 years and 14 days	2.7 ± 0.6 (2–7 years) 2.9 ± 0.6 (14 days)	–
(Krosch & Shakespeare-Finch, 2017)	PGS-33	–	On average four years	95.2** ± 24.9 AG 37.4** ± 8.3 DC 31.0** ± 9.6 D 26.9** ± 9.2	–
(Kulathilaka et al., 2016)	PGS-33	–	6–10 weeks	–	54.7%
(Lafarge et al., 2017)	PGS-33	–	29.2%: up to 6 months 19.3%: 7–12 months 14.9%: 1–2 years 36.7%: >2 years	95.1** ± 27.7 AG 37.7** ± 9.5 DC 29.3** ± 10.5 D 28.1** ± 9.3	–
(Nazaré et al., 2012)	PGS-33	–	1–6 months, on average 2.4 months	–	32.6%
(Rich 2000)	PGS-33	–	2–60 months, on average 16.5 months	92.5** ± 25.2	–
(Séjourné et al., 2016)	TGI	–	Up to 18 months	63.4 ± 11.6	–
(Serrano & Lima, 2006)	PGS-33	–	At least three months	89.9 ± 21.7 AG 38.9** ± 8.6 DC 24.7 ± 9.3 D 25.9 ± 6.9	–
Prospective longitudinal studies
(Burgoine et al., 2005)	PGS-33	Two (D&E and IOL)	D&E: 4 months	74.1 ± 16.2 AG 23.2 ± 7.4 DC 27.1 ± 5.3 D 23.8 ± 5.5	13% AG 13% DC 40% D 47%
		–	D&E: 12 months	73.3 ± 17.1 AG 22.1 ± 7.2 DC 26.1 ± 5.0 D 25.1 ± 6.2	27% AG 13% DC 20% D 40%
		–	IOL: 4 months	90.2 ± 22.8 AG 29.5 ± 9.8 DC 31.9** ± 7.4 D 28.8** ±  7.2	46% AG 38% DC 69% D 69%
		–	IOL: 12 months	86.4 ± 19.8 AG 25.8 ± 7.2 DC 29.8** ± 7.6 D 28.9** ± 7.6	38% AG 15% DC 46% D 62%
(Conway & Russell, 2000)	PGS-33	–	As fast as possible (up to three weeks)	88.7 ± 46.9 AG 24.1 ± 11 DC 38.5** ± 10.1 D 42.8** ± 9	–
		–	Two to four months	125.7** ± 24.6 AG 37.3** ± 11.2 DC 42.1** ± 7.8 D 46.3** ± 7.5	–
(Gozuyesil et al., 2022)	PGS-33	10 (age: 20–29, 30–39, 40–49 years; child-lessness (yes/no); number of pregnancy losses (0,2,3+); miscarriages, stillbirths)	Miscarriages: T0: ≤ 48 h T1: month 3 T2: month 6 T3: month 12 after discharge Stillbirths: T0: ≤ 48 h T1: month 3 T2: month 6 T3: month 12 after discharge	Median (range) 94.5** (50–143) 73.5 (42–117) 57 (36–90) 48 (36–90) Median (range) 92** (43–130) 75 (47–130) 55 (37–120) 45 (38–125)	Total sample: T0: 55.7% T1: 21.1% T2: 3.5% T3: 3.5%
(Güçlü et al., 2021)	PGS-33	–	T1: week 6 T2: month 6 T3: month 12	75.4 ± 20.5 AG 28.9 ± 10.1 DC 24.3 ± 5.6 D 22.1 ± 7.8 67.5 ± 20.3 AG 25.6 ± 10.3 DC 22.6 ± 5.5 D 19.2 ± 6.9 63.8 ± 21.6 AG 22.2 ± 9.9 DC 22.3 ± 6.1 D 19.1 ± 7.5	–
(Johnson & Johnston, 2021)	PGS-33	4 (men versus women; miscarriage/miscarriage versus miscarriage/live birth)	T1: week 6 following the first pregnancy outcome T2: week 6 following the second pregnancy outcome T3: month 6 following the second pregnancy outcome T4: month 12 following the second pregnancy outcome	Only women: Miscarriage/Miscarriage group: 86.66 ± 11.85 AG 32.19 ± 9.60 DC 25.44 ± 7.07 D 29.06** ± 11.55 Miscarriage/Live Birth group: 86.48 ± 12.02 AG 30.02 ± 7.11 DC 26.05 ± 6.05 D 28.19** ± 10.31 Miscarriage/Miscarriage group: 84.59 ± 10.16 AG 35.16** ± 4.96 DC 21.33 ± 3.80 D 28.11** ± 8.28 Miscarriage/Live Birth group: 85.75 ± 13.47 AG 33.41** ± 5.64 DC 24.09 ± 2.43 D 28.25** ± 6.02 Miscarriage/Miscarriage group: 99.23** ± 7.10 AG 36.97** ± 5.27 DC 30.66** ± 7.30 D 31.61** ± 8.58 Miscarriage/Live Birth group: 63.89 ± 8.63 AG 26.55 ± 5.05 DC 18.59 ± 6.61 D 18.75 ± 3.84 Miscarriage/Miscarriage group: 93.45** ± 7.70 AG 34.06** ± 6.06 DC 29.89** ± 5.92 D 29.50** ± 6.92 Miscarriage/Live Birth group: 61.19 ± 10.99 AG 24.70 ± 5.53 DC 17.53 ± 6.22 D 18.95 ± 4.40	–
(Köneş & Yildiz, 2021)	PGS-33	45***	T1: first 48 h T2: one week T3: one month T4: three months after the perinatal loss	Only for women with time of perinatal loss in utero (T2 and T3 data were not available): T1 (first 48 h): 107.3** ± 26.9 AG 45.4** ± 9.9 DC 30.8** ± 9.3 D 31.0** ± 9.8 T4 (three months after the pregnancy loss): 107.7** ± 30.3 AG 44.7** ± 11.3 DC 31.4** ± 10.3 D 31.5** ± 10.8	–
(Scheidt et al., 2012)	MTS	–	One month	3.3 ± 0.7	–
		–	Six months	3.1 ± 0.7	–
		–	Nine months	3.0 ± 0.7	–
(Volgsten et al., 2018)	PGS-33	–	One week	– AG Median 29.5 (range 11–53) DC Median 19 (range 11–54) D Median 15.5 (range 10–42)	–
		–	Four months	– AG Median 22 (range 11–54) DC Median 17 (range 11–54) D Median 15 (range 11–46)	–

Notes: The table contains the 21 studies which are included in the review. D&E: Dilation and Evacuation for second-trimester pregnancy termination. ICG = Inventory of Complicated Grief (Prigerson et al., 1995). IOL: Induction of Labour for second-trimester pregnancy termination. ITG = Inventory of Traumatic Grief (Prigerson & Jacobs, 2001). MTS = Münchner Trauerskala (in English: Munich Grief Scale) (Beutel et al., 1995). PGS-33 = Perinatal Grief Scale-33 (Potvin et al., 1989) with the subscales AG = Active Grief, DC = Difficulty Coping, D = Despair. TGI = Texas Grief Inventory (Nikcevic et al., 1999). TOPFA = Termination of Pregnancy for Foetal Anomaly.

Measurement times refer to the interval since pregnancy loss.

*Study without any pre-specified measurement time.

**The mean grief score was above the cut-off score of the corresponding scale (≥91) or the corresponding subscale (AC > 33, DC > 29, D > 26).

***The subgroups were as follows: Age groups (≤24 years, 25–35 years, ≥36 years) (3); educational status (literate, primary education, secondary education, high school, university) (5); employment status (employed, on maternity leave, unemployed) (3); family type (nuclear, extended) (2); marital status (married, single) (2); high-risk behaviours (none, smoking, alcohol, multiple) (4); type of current pregnancy loss (spontaneous, assisted) (2); pregnancy planning (planned, unplanned, indecisive, unwanted by herself, unwanted by husband) (5); regular antenatal follow-up (yes, no) (2); screening tests (none, double, triple, quad) (4); time of loss (in utero, postnatal) (2); gender of baby (unknown, girl, boy) (3); importance of gender (yes, no, indecisive) (3); gestational age at loss (early pregnancy loss (7–19 gestational week), late pregnancy loss (20–31 gestational week), advanced pregnancy loss (32–40 gestational week)) (3); previous pregnancy loss (yes, no) (2).

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Data availability statement

The data presented in this systematic review can be found in the included studies (Black et al., 2021; Burgoine et al., 2005; Conway & Russell, 2000; Das et al., 2021; De Montigny et al., 2017; Gozuyesil et al., 2022; Güçlü et al., 2021; Hanschmidt et al., 2018; Johnson & Johnston, 2021; Keefe-Cooperman, 2005; Kersting et al., 2005; Köneş & Yildiz, 2021; Krosch & Shakespeare-Finch, 2017; Kulathilaka et al., 2016; Lafarge et al., 2017; Nazaré et al., 2012; Rich 2000; Scheidt et al., 2012; Serrano & Lima, 2006; Séjourné et al., 2016; Volgsten et al., 2018).