“What’s Inside of You Now is Just Bones and Skin”: The Tension between Restorative Meaning-Making and Deliberate Detachment in Maternal Experiences of Stillbirth

Abstract

This article explores the ways in which bereaved mothers framed experiences of continuing bonds with their stillborn child and aims to enrich an understanding of maternal sense-making. Four interviews were carried out with bereaved mothers and approached using Interpretative Phenomenological Analysis, so as to offer deeper insight into their individual experiences. Themes which arose from the analysis include: “Continuing bonds and the female body;” “Conflicted bonding with the shape-shifting baby;” and “Experiencing connection in the life beyond loss.” These findings point to a tension between restorative meaning-making and detachment in maternal sense-making following stillbirth and have implications for clinicians working with bereaved mothers.

The traumatic experience of stillbirth reverberates through the life of every woman who encounters this profound bereavement (Golan & Leichtentritt, 2016). The bonds between mother and child begin to form in the first knowledge of pregnancy, when experiences of foetal movements, as well as physical changes to the mother’s body, nurture a relationship grown in utero. The death of the baby shatters this conjoined experience and can leave bereaved mothers with a lifelong sense of loss and yearning (King et al., 2019).

Brierley-Jones et al. (2014-2015) further suggest that the creation of a social identity, which develops through pregnancy, is abruptly disintegrated by stillbirth and that this sudden deconstruction of newly fledged parts of self causes feelings of disconnection. The distress of mothers is often compounded by an experience of taboo regarding the social response to their loss (Cacciatore et al., 2009). Traditional mourning patterns, designed to enhance the potential for feelings of emotional resolution, are often profoundly lacking around stillbirth. In the absence of a genuine acknowledgement of the personhood of their baby, bereaved mothers face an amplification of grief (Crawley et al., 2013; Doka, 1989; DeFrain, 1986; Lewis & Page, 1978).

Stillbirth is estimated to occur in approximately one in 200 UK births (Gardosi et al., 2013), and legally refers to a child who is born from its mother after the 24^th week of pregnancy and did not at any time breathe or show any other sign of life (RCOB, 2005). Prior to 1978, common hospital practice involved the stillborn baby’s removal from the room on delivery and the subsequent incineration of the baby’s body routinely took place on hospital premises, without either parent being present (Lovell, 1983). However, this practice was eventually discouraged when it became apparent that a lack of post-delivery contact led to feelings of disorientation and regret for many bereaved mothers (Lewis & Page, 1978; RCOG, 1985). In 2002, a controversial study suggesting that promoting contact with the stillborn baby was associated with worse psychological outcomes for the mother resulted in new practice guidelines for postnatal health stipulating that mothers should not be encouraged to hold their stillborn babies (Hughes et al., 2002; NICE, 2007). Following a successful campaign by voluntary organisations including SANDS UK, guidance for psychological care following stillbirth was revised once again and today recommends offering parents the choice of whether or not to hold, dress and wash their child (NICE, 2010; RCOG, 2010). But research into parental experiences around these practices remains limited.

In that respect, current constructivist theory, which comprehends mourning in an increasingly nuanced manner as a process of meaning-creation connected to the development of continuing bonds, may hold particular relevance (Klass & Steffen, 2018). Neimeyer et al.’s, 2014 monograph on grief outlines experiences of loss as intricately social and involving narrative processes via which meanings are identified. Klass and Steffen (2018) further suggest that integrating the memory of the dead into the ongoing life of the bereaved provides experiences of resolution. This integration might involve facilitating the opportunity to create and narrate bonds; encouraging the bereaved to explore the parts of the self which are actualized within the bond; and enabling the sharing of characteristics of the deceased.

While the majority of existing literature in the field of stillbirth does not approach stillbirth loss via these more progressive bereavement theories (Neimeyer, 2016), the importance of continuing bonds in stillbirth bereavement is borne out by the literature. Findings signpost maternal experiences of the continued psychological presence of the baby, the profound impact of stillbirth on experiences of the self and others, and the identification of maternal routes to constructing and deconstructing a post-death relationship with the baby (King et al., 2019; Leichtentritt & Mahat-Shamir, 2017; Ustundag-Budak et al., 2015). Due to the uniquely small window for memory creation, ritual and memorial take on vital importance in the validation of the existence of the stillborn child and the scaffolding of maternal identity. By participating in post-death rituals, which may include naming, holding and dressing the baby, taking footprints or photographs, allowing other family members to view the baby or taking the baby home, the bereaved mother is able to care for her child in a manner which may contribute to the salving of emotional pain (Tseng et al., 2018). Participation in these rituals further assist in amplifying a sense of motherhood and community acknowledgement of critical import since mothers of stillborn babies commonly experience feelings of disenfranchisement, guilt, and shame, which are linked to a lack of community legitimizing (Burden et al., 2016; Brierley-Jones et al., 2014-2015).

Existing findings already point to the need for those involved in the grieving process to pay closer attention to social and individual sense-making around the memory of the stillborn child and the mother-baby relationship. An exploration of the way bereaved mothers make sense of their continuing bonds with their lost baby is missing from the literature. The present study therefore addresses the following research question: How do bereaved mothers make sense of their experience of continuing bonds with their stillborn child?

Method

The study used a qualitative, phenomenological approach to engage with the texture and quality of bereaved mothers’ experience (Willig, 2013). Taking a contextual constructionist epistemological standpoint, and using Interpretative Phenomenological Analysis, the intention was to provide insights into the experience of participants (Smith et al., 2009). The findings presented in this paper are part of a larger, pluralistic study (Hunt, 2020) which also included approaching the text via Gee‘s (1991) Structural Narrative Analysis.

Recruitment and Sample

The four women who agreed to take part in the study had experienced the stillbirth of their first child in an NHS hospital no less than 3 years and no more than 10 years previously. They were married and their ages ranged from mid-thirties to late forties. All four participants were white, with two referring to themselves as British, another born in Australia and a fourth describing herself as Eastern European. Three participants reported being educated to degree level. Two of the women identified with the Christian faith, one with the Jewish faith and one as atheist.

Materials and Procedures

Semi-structured interviews were carried out by the first researcher and lasted between 60-120 minutes. Two of the participants chose to be interviewed on university premises and two were interviewed in their own homes. The questions were deliberately open and were designed to encourage the participant to share her experience. Participants were further invited to bring a meaningful object to the interview in order to facilitate natural reflections on their lived experience (Willig, 2017). For example, three of the participants chose to bring images of their sonograms at 12 or 20-weeks’ gestation.

The verbatim transcripts were approached in stages as outlined by Smith et al. (2009). An initial phase of reading took place and general notes were made in the margin of the transcript. The transcript was then analysed using line-by-line inductive coding of themes. These codes were then examined for meaningful patterns, organised into labelled clusters, and the clusters organised into higher-order categories. Engagement with the material was reflexive and involved a fluid interaction with the entirety of the transcripts. The identity of all participants and other named parties has been protected by the use of pseudonyms.

Ethics

This study aligns with the BPS ethical guidelines regarding research projects and participant care (BPS, 2014). Following the receipt of ethical approval from the Research Ethics Committee of the Department of Psychology at City, [University of London], participants were recruited via snowball sampling, using the personal contacts of the first researcher.

Findings

The findings presented here comprise three superordinate themes. In the first one, “Continuing bonds and the female body,” experiences of pregnancy and birth construct birth as a connecting experience, but also as an horrific event prompting the wish to deconstruct bonds; in the second, “Conflicted bonding with the shape-shifting baby,” fluid perceptions of the baby construct opposing interpretations of the baby as foetus, corpse, child, or angel; in the third theme, “Experiencing connection in the life beyond loss,” the post-loss world is experienced in different ways, with a desire to retain connectedness as well as a longing to forget and to move beyond loss. Taken together, these findings suggest differing interpretations of the stillborn baby and frame relational tensions between restorative experiences of continuing bonds on the one hand, and more disjointed and painful experiences of continuing bonds on the other, which may lead to the deliberate deconstruction of relationship.

Superordinate Theme 1: Continuing Bonds and the Female Body

Experiences of pregnancy and birth - which revealed individual life worlds - constructed maternal bonds from this unique period of contact between mother and baby. This period of time inevitably feeds into powerful memories which promoted feelings of connectedness following the death of the baby. Some of the participants experienced the birth itself as a connecting experience, which allowed them to forge corporeal memories of their own body’s interaction with their child. However, for other participants, the experience of childbirth appeared to be rendered meaningless by their lifeless baby and was encountered as a painful shattering of bonds.

Subordinate Theme 1: Forged in the Body

The participants in this study chose to share memories of pregnancy as a route to reinforcing feelings of relationship with their lost baby. For the mother of a stillborn child, to reflect on the experience of pregnancy was to relive the limited window of time which existed for the creation of bonds. Reflecting on the pregnancy promoted a sense of maternal relationship, as connection was noted via the changes which occurred within the female body, feeling the baby moving in the womb and viewing the baby during monitoring scans.

Caroline characterised her “tummy” as a place of safety and described her own body as her baby’s “home.” As she recalled her womb providing shelter for her baby, she acknowledged the live connection between her own body and that of her child: “That’s where the baby’s home is. That’s where he’s safe. In your tummy.” (Caroline.) The fact of pregnancy built a relational connection with the personhood of the baby and this shared experience of life bound mother and child in unique ways: “It’s like an actual person inside of me.” (Rachel.) The female body became the sole vessel of the child’s life, as continuing bonds came to represent something embodied and lived: “That was his life, inside of me.” (Caroline.)

The bolstering of feelings of relationship and continuing bonds could not be more concrete than when encountered via the growth scan. Three of the participants chose to share images taken during scans at their participant interviews. These pictures of grainy, foetal shapes provided vital links to the baby and were transformed into connecting objects of meaning following stillbirth. These moments of visual representation also allowed for thematic characterisations of the baby. Rachel described her experience of observing her daughter’s movements on the hospital monitor. She nicknamed her baby “Little Fish” because of her constant “flipping around.” In the excerpt below, Rachel used the pronoun “we” to denote the shared experience of viewing her child. The scan provided a point of connection which allowed Rachel and her husband to assign characteristics to their daughter. In this rare moment of shared sense-making, “Little Fish” was “hilarious” and “chilled” – a baby who flipped and yawned inside her mother’s belly, as the maternal body became the site of family memory creation: “We just called her ‘Little Fish’… She was always flipping around. She was the most hilarious baby. We were always scanning her and she’d be like yawning and totally chilled...” (Rachel).

A maternal wish to identify the moment in which the baby passed from life into death recurred in participant narratives. The noting of final movements or a sense of ominous stillness marked the cessation of life and may have served as a means of marking the importance of all that had been lost. As with the experience of mourning itself, the baby was both present and absent, still encased within the mother’s body. Aurelia described her experience of noting the cessation of movement in the excerpt below. She shared an eerie experience of stillness and “anxiety” as she became aware that something was wrong. Discomfiting “thoughts” hover darkly over the lines and the repetition of “the baby does not move” adds a hollow refrain.

I am saying: “The baby does not move today.” … And then, the evening was approaching, and I am having thoughts and a kind of anxiety. I am thinking that I am feeling weird. And the baby does not move. And that was it... Just a lack of feeling. (Aurelia.)

Subordinate Theme 2: Birth as a Route to the Construction or Deconstruction of Bonds

The birth may offer the potential for a vital bonding experience. Conversely, it may also represent a raw and devastating deconstruction of bonds. Laura described an instinctive desire to experience the physical pain of childbirth, which she interpreted as rooted in her knowledge that she was “not going to have a baby.” The excerpt below revealed her innate desire to physically “feel” the birth. She intentionally heightened her own physical experience of the delivery in order to provide herself with “memories” upon which she could draw. The experience spoke to the intentional crafting of continuing bonds in the moment of birth, as the mother elected to curate her own experiences of her child in such a way as to strengthen feelings of connectedness.

They [medical staff] asked if I wanted an epidural but I couldn’t. In my head, I just knew that I needed to be able to feel this happen… because I’m not going to have a baby… I still have very strong memories of giving birth… (Laura.)

A sense of the importance of the birth experience as a route to maternal identity seemed to arise in the analysis. Though the use of the transitive verb “forced” in the excerpt below suggests an experience of tension and perhaps coercion, Aurelia also seemed to retrospectively share feelings of gratitude and to acknowledge that the experience of birth had helped to actualise her maternal identity: “I was very grateful that they forced me to give natural birth because then I felt like I was the mother and I had given birth… As much as I didn’t want to, I was so grateful.” (Aurelia.)

Conversely, themes also appeared which related to the deconstruction of bonds. In the segment below, the birth was rendered pointless, as the pain of labour failed to bring the usual reward, and Rachel’s language was dismissive, as she repeated the refrain: “I can’t be bothered.” She juxtaposed the “ridiculous” with the “painful,” as her jarringly defeated tone clashed with an agonising physical experience.

“I was in agony. And a lot of it was like: ‘I can’t be bothered to do this anymore. This is the most ridiculous thing I’ve ever done in my life.’… I think that was the most pointless activity. It was so painful!” (Rachel.)

Elsewhere in her account, the birthing female body seemed to become the site of torture and gore, with the negated baby being perhaps interpreted as a painful void: “You’re going to be bleeding and bleeding and bleeding away because you’ve got a hole in your body.” (Rachel.)

Themes of the birth providing a potential route to the severing of bonds further highlighted a wish to excise the baby from the mind and body of the mother. Aurelia expressed a profound will to dismantle bonds and to erase the emotional pain of the loss, as well as the physical presence of the baby: “I wanted to have a C-section because I wanted to, kind of like, cut it out from my mind, my body.” (Aurelia.) While in the excerpt below, Rachel rejected the construction of meaning in her birth experience and “Little Fish” became an “it” without a name who must be “gone”: “The whole thing was just … pointless… I could have just had a Caesarean and just had it gone. I didn’t need to have this whole experience that’s meant to be so liberating and empowering.” (Rachel.)

Subordinate Theme 3: Birthing the “Dead Baby Inside” and its Impact on Continuing Bonds

Here themes of horror and fear recurred. The baby became abject, and an experience of repulsion prevented maternal connection via feelings of intimacy: “I am pushing out a dead baby.” (Rachel.) Grief itself appeared fragmented by an experience of horror which seemed to erode the personhood of the baby. Aurelia deliberately refused to experience her child: “I gave birth but I couldn’t look at the baby.” (Aurelia.) In the segment below, she shared a sense of disbelief at the impossibility of tolerating the knowledge of the “dead baby inside”: “They said: ‘Do you want to go home and wait for the birth?’ And I was like: ‘What are you talking about? You want to send me away with a dead baby inside?’” (Aurelia.)

Themes of rejection seemed to arise from this close proximity to death. In the quotation below, Rachel discounted feelings of connection with her daughter, as she refused to experience her as a person.

What’s inside of you now is just bones and skin. Totally dead! And I was like: ‘I want this out now, now, now, now!’ … The whole thing just totally grossed me out… I was like: ‘I’ve just got this whole mound… dead!’... It’s suddenly a corpse. (Rachel.)

Rachel’s language transformed “Little Fish” from beloved baby to composite human remains, as she relayed her horror at the fact that her swollen belly had suddenly become a burial “mound”. Her use of colloquial language denied the traditional vocabulary of mourning and conveyed her rejection of this “corpse” within. Language which polarised “inside” and “out” amplified the impossible relationship of intimacy and distance in this moment of maternal distress.

Superordinate Theme 2: Conflicted Bonding with the Shape-Shifting Baby

Fluid perceptions of the baby lay at the core of this superordinate theme which maintained a focus on the different ways in which each mother made sense of her experience of connectedness with her baby. The continuing bond was influenced by seemingly mercurial experiences of bereavement, with differing constructions of what was lost as being foetus, corpse, child, or angelic being.

Subordinate Theme 1: The Beloved Baby

Continuing bonds can be interpreted as an experience by the bereaved of what it is that the loss of their loved one triggers within them, in terms of shifts in personal identity and experiences of grief and remembrance. A maternal drive to nurture and protect the stillborn was vividly present in this subordinate theme which engaged with configurations of the baby as beloved.

An instinctive will to bond appeared, as the mother experienced feelings of love and connection. Following delivery, Laura described her overwhelming instinct to physically bond: “I wanted to hold him straight away.” (Laura.) In the extract below, she shared her experience of powerful maternal affection, which was represented by the importance of visiting her stillborn baby. She articulated “the next day,” “every day,” and “for as long as we could,” in a manner which showed her desire for ongoing connection. Laura wished to stay with Hal, but he was moved into “a cold place,” which conjured the presence of death and separation.

We stayed with him for as long as possible but then they had to take the baby away and put him in a cold place. So, then we went home and came back the next day and, in fact, every day and for as long as we could … Having that time was so very important to me… I just wanted to keep holding him. (Laura.)

Themes which related to experiences of a continuing maternal love which remains consistent beyond death were present. The memory of Baby Hal endured for Laura as a beloved “son” whom she wished to protect and remember. In the segment below, Laura constructed the personhood of her child so that others could recognise and relate to her loss. Language was the vehicle which allowed Hal to become real, and Laura used the phrase “all the time” and also the negative-time adverb “never” to convey a sense of permanency.

As his mother, it’s very important for me to keep his name there and talk about him all the time and for him to be part of our family because I want to protect his memory, because he was a person. You know, because he was a person, a little boy, a little baby, that should have had a life, and sadly didn’t, and it’s really important how we never forget him. (Laura.)

Themes of ongoing connection appeared, as participants shared a sense of a continuing bond which remained undiminished by the passing of time. In the excerpt below, Rachel characterised her daughter as a permanent connecting force between herself and her husband. She immortalised her child as a beloved “daughter”, who remained forever in position as “eldest” child and was automatically absorbed into the family narrative: “She’s our daughter! She’s our child! If we have future children, she’s still going to be our eldest… It’s very straightforward… She’s part of our lives.” (Rachel.)

Subordinate Theme 2: The Rejected Baby

Experiences of deconstructing maternal bonds displayed the way in which the bereaved mother struggled with responses to her child. The following segment articulates an instinct to reject. Rachel’s use of the depersonalised pronoun “it” underscored her deliberate distancing. She denied the personhood of her baby, and, in this moment of disorientation, the baby became something undeserving of maternal contact: “They [medical staff] were like: ‘Do you want to hold her?’ And we were like: ‘No! We want nothing to do with it!’” (Rachel.)

In these moments of detachment the participant’s language altered, and the child was veiled by the impersonal. Aurelia’s use of language seemed to distance her from her child. She explained that she could not speak her son’s name and chose to refer to him as “the baby.” She used the impersonal pronoun “it” to distance herself from the personhood of her son: “Every time … I am calling it ‘the baby.’ I never call it by the name.” (Aurelia.) She also described the way in which she did not wish to “look at” her child or to “hear” about him.

I didn’t want to have anything to do with it... I couldn’t look at the baby. I asked them [medical staff]: ‘I don’t want to look at the baby.’ Then one of the doctors, I heard: ‘Your baby is perfect.’ And, I was like: ‘I don’t want to hear it! (Aurelia)

Subordinate Theme 3: The “Empty-handed” Mother

The simultaneous presence and absence of the baby seemed to be a recurrent theme in the analysis. In the aftermath of her delivery, Rachel articulated a sense that the physical presence of her daughter alleviated frozen feelings of detachment. In the segment below, she shared feelings of disorientation, which abated with physical contact with her child. In this moment, it seemed that the child held the mother, as the baby’s physical body helped to contain the mother’s experience of disorientation: “I was just numb – just numb. When I held her [the baby], I was in-touch and I could cry... But, the rest of the time, I was just confused and dazed.” (Rachel.)

Themes which related to experiences of a lack of recognition of the personhood of the baby by family and medical staff were present. Experiences of continuing bonds were seemingly challenged by attempts by others at erasing the existence of the lost baby. In the segment below, the anonymous “they” of the medical staff proved obstructive in Rachel’s meaningful constructions of her daughter.

So they [medical staff] ended up taking her out of our room and putting her in a storage cupboard. … My husband had to go look for her. And then he was like: “I found her in the storage cupboard!”. And I was just like: “Just keep her. Just keep her with us!” (Rachel.)

Superordinate Theme 3: Experiencing Connection in the Life beyond Loss

Individual participants appeared to experience the post-loss world in different ways. Whilst some encountered a drive to retain connectedness with their baby, others longed to move beyond the grief and loss into a place of forgetting.

Subordinate Theme 1: An Altered World: “I Was That Person”

The world may appear irrevocably altered by the stillbirth experience, and perceived changes to close relationships and altered sense-making relating to existential purpose may be experienced by the bereaved mother. Aurelia shared the way in which she was affected by unfeeling social responses to her bereavement. Sharing meaningful memories of the baby, which might reinforce continuing bonds, became risky for the mother, as she became increasingly aware that others may fail to appropriately respond to the loss: “You are angry because somebody said something … insensitive... They try and be supportive but, even now, if I would talk to somebody, I could be upset... It’s a fragile subject.” (Aurelia.)

There appeared a sense that memories of the baby must be sanitised in order to be safely shared with others. A lack of recognition of meaningful anniversaries further served to promote feelings of isolation. Rachel’s language in the excerpt below reinforces an experience of disenfranchised loss, as the lines reverberate with the lonely repetition of “no one”: “The anniversary of her death was 2 weeks ago. No one remembered. Zero remembered. I called my parents. I called my siblings. No one remembered!” (Rachel.)

Laura described a desire to safeguard baby Hal’s position in the wider family. Here, the use of a more socially acceptable “birthday” cake-baking event appeared better received than Rachel’s “anniversary of death.” The repetition of “birthday,” “know,” and “everyone” underscored Laura’s desire for the outside word to acknowledge Hal’s personhood. There was a sense that Laura must advocate for Hal in order to keep his memory alive.

He is very much a part of my whole family… they know when his birthday is and it’s marked… The first year, we did a massive cake-baking... And I do push it a lot... It’s so important to me that people are acknowledging him. (Laura.)

But themes of a desire to deny memorial also arose in the analysis. In this regard, Aurelia shared a profound wish to forget anniversaries. In the excerpt below she described her strong dislike of the seasonal reminders which painfully triggered the unbidden pain of remembrance: “Sometimes, I hate the spring because, you know, I remember having a stillbirth and I remember the smell of the spring.” (Aurelia.)

Subordinate Theme 2: Holding On, Letting Go

The positive impact of bereavement support groups allowed some participants to encounter a community of loss which validated and fostered their experiences of continuing bonds. In the following excerpt, Laura described locating a sense of fellowship, which allowed her to experience her perceptions of a continuing bond with her lost child as being understood by others: “We [members of the support group] try and see each other, especially when we know it’s each other’s anniversaries [of stillbirth]. Just having that kind of unified relationship – just somebody that gets it …” (Laura.)

With the passing of time, the bereaved mother may gradually feel better able to personally encounter and publicly share her memories with others: “Time definitely does help… And you can talk about it easier to strangers.” (Caroline.) For some, it seemed more possible to treasure precious memories of the lost child and to simultaneously background feelings of regret: “I’m not sorry that it happened… I’m so grateful for the time that I had.” (Caroline.) It seemed that the passage of time may somewhat lighten the grief in a manner which allowed for more contained experiences of loss: “I think I’ve come a long way. It doesn’t feel as dark. I can sit and cry for a bit but then I can get up and do something else. It’s painful but it has eased...” (Laura.)

In time, the bereaved mother may become more able to remain connected to the positive aspects of continuing bonds and less inclined to pursue detachment: “Most of the time, you don’t have the painful loss but you remember the nice things.” (Caroline.)

Subordinate Theme 3: Ways of Relating to the Stillborn Baby via Subsequent Children

At point of interview, two of the participants had gone on to have children following their stillbirth and themes of subsequent children providing routes both towards and away from continuing bonds with the lost baby could be identified in the analysis. Subsequent children may offer a pathway to hope and continued sense-making for the bereaved mother: “It [having a subsequent child] helped give me life.” (Laura.)

However, themes of a deep longing for “another baby” who might eclipse the stillborn child also arose. Aurelia shared her experience of a powerful desire for another child to hold in her arms. This imagined replacement child served both to soothe her longing and also suggested a wish to efface the painful knowledge of the existence of the stillborn boy.

The most important thing was to have another baby. I didn’t want to tread on the past because I knew it will not bring the baby back ... The most important thing, for me, was I want to have a baby … I need to hold a baby in my arms. (Aurelia.)

Ways of relating to subsequent children which might also serve to erase the stillborn child appear in the segment below. Aurelia shared the way in which she constructed the gender of her second child, a daughter, in relation to the gender of her stillborn son. Her language was permeated with concepts of rewriting or deleting the past and framed her living daughter via the metaphor of a “new chapter.” She seemed – in this moment – to wish for a blank page upon which to rewrite her maternal experience in such a way as to deny the existence of her stillborn baby.

I was little bit sad that we had a girl … We thought, if we would have a boy, then it was kind of like it [the stillbirth] never happened. If a boy to come, then we start from beginning. But then, thinking, maybe having a girl is better? Because it is not just replacing one with another. It is different – a new chapter… (Aurelia.)

A desire for the stillborn baby to be hidden or segregated from subsequent living children could also be identified:

I don’t have time, or I don’t have energy, to lose on grieving because I need to live for the kids. They don’t know yet about the stillbirth. I have said to my husband that they are too young. I do not want to put any burden on them. I don’t want to make them guilty or in any way confused. (Aurelia.)

Conversely, in the excerpt below, Laura explained the way in which she valued the familial conduit between her stillborn baby and her two subsequent children and suggested that her subsequent children were able to “give” her “something” of Baby Hal. Here, the subsequent children seemed to re-animate the stillborn Hal, as they were translated into a lived embodiment of what could have been.

We didn’t know if he [subsequent child] was going to be a boy or a girl… If he looked like Hal when he was born, does that mean there’s a similarity to what Hal could have looked like? It’s important – that blood connection between the boys. And it gives me something of what Hal might have looked like… It helps. (Laura.)

Elsewhere, Laura shared the way in which she talked to her living sons about their stillborn brother. She and her children appeared to create a shared narrative relating to Hal. The existence of a continuing bond, passed from mother to child, seemed evident. The family unit constructed Hal as a beloved family member, who remained permanently present, though irrevocably distant: “My sons talk about Hal a lot. We talk about him being in the stars. I heard one of them saying to a friend the other week: ‘I’ve got a brother, another brother, he’s up in the stars.’” (Laura.)

Discussion

The findings suggest multi-faceted maternal responses to the experience of continuing bonds. As each bereaved mother explored ways to represent her child to herself and to those around her, the stillborn baby seemed to shift shape, triggering a complex navigation of bonds which highlights the deeply personal nature of responses to maternal loss. Sense-making relating to continuing bonds is powerfully present in the findings, with moments that are uniquely shared between mother and child amplifying the relational aspects of pregnancy. The bereaved mother may locate her experiencing of the personhood of her baby within the physical changes of pregnancy. This valuing of pregnancy, as a means of building maternal relationship, mirrors findings by Ustundag-Budak et al. (2015). Recalling the embodied experiences of pregnancy and birth may also facilitate an amplification of maternal identity (see also Leichtentritt & Mahat-Shamir, 2017). This has implications for the clinical care of the bereaved mother and points to the need for vital psychological support throughout induction and delivery and also in the postnatal period. In offering the mother an opportunity to see, hold, wash and dress her baby, health professionals may enable the bereaved to substantiate her sense of motherhood and also to say goodbye (Kelley & Trinidad, 2012). In relation to the period which follows delivery, it also seems important that the bereaved mother is offered psychological support in order to assist her in processing the bereavement, to check-in on feelings of isolation and emotional difficulty, as well as to acknowledge the profundity of the loss.

A deep valuing of experiences of connection can be identified in the findings which highlight feelings of love and ongoing affection for the stillborn baby. But the findings also identify emotional tensions, with sense-making suggesting disorientation. At points, participant language conveys an experience of emptiness and conflicting responses, as anger melds with denial as well as loving recognition. The distress and disorientation identified here align with the findings which relate to the rejection of the stillborn baby. They also support those of Ustundag-Budak et al. (2015), which suggest that bereaved mothers struggle with the contradictory process of accepting the existence of the stillborn baby whilst acknowledging the baby’s non-existence. This highlighting of experiences of distress, disorientation, and withdrawal points to the need for ongoing, careful assessment of the emotional capacity of the bereaved mother when providing clinical support. The safeguarding of the mother’s emotional wellbeing should also be rigorously held in mind, with frequent postnatal checks on maternal emotional health (Stewart & Vigod, 2016).

Golan and Leichtentritt (2016) identify fluid maternal interpretations of the stillborn baby which find echo within the current study, suggesting that the continuing bond may be alternately fortified and denied by the mother. The analysis identifies meaning-making related to shifting maternal perceptions of the baby, which may be mediated by the different ways in which the child is imagined. The baby may be characterised as beloved and cradled in a web of familial relationships. Conversely, the baby may also be rejected as an abject and depersonalised other and denied a place within the family narrative. In situating this finding in the context of long-term psychological support of the mother, it seems important that a dual process of meaning-making should be acknowledged by support services. This would allow for an exploration of the idea that the bereaved mother may simultaneously wish to remain connected to her lost child and also to find a way of moving beyond her loss (Stroebe & Schut, 2010). This duality prompts clinical suggestions which might involve acknowledging this dual process within short-term and long-term postnatal support for the bereaved mother. The findings also show starkly different responses to the baby among the participants. While further research into the psychosocial correlates of maternal approaches to continuing bonds seems warranted, there is an argument for the practitioner to maintain a highly attuned approach to the mother’s attachment style when planning appropriate support and to draw upon attachment-informed grief therapy (Kosminsky & Jordan, 2016; Uren & Wastell, 2002).

The findings suggest that the stillborn baby exists as an ongoing psychological presence for the mother and this experience may not diminish with time (Golan & Leichtentritt, 2016). Bereavement care models which encourage all support services to respond with amplified compassion and to prioritise an awareness of the potential long-term psychological impact of stillbirth should therefore be of benefit (Cacciatore & Flint, 2012). In the case of subsequent pregnancies, it also seems key to offer the mother an outlet which allows her to share her ongoing grief regarding her stillborn baby, despite the potential arrival of subsequent living children.

Limitations and Further Research

While the fact that the findings are not generalizable to a wider population because of the small number of participants can be seen as a limitation, it was the intention of this study to offer a rich ideographic exploration of this under-researched and multifaceted phenomenon, and in so doing to contribute to the growing bank of research into maternal stillbirth experience. The use of a phenomenological methodology seemed uniquely well suited to this purpose, ensuring that the voices of bereaved mothers be given sensitive attention throughout the research. Nevertheless, all four participants identified as white and heterosexual and were in a marital relationship. A larger and more diverse participant sample, including participants of differing race, ethnicity, socio-economic status and sexual orientation, would offer a fuller understanding of the phenomenon. Given the complex responses evidenced by the participants in this study, further research could also focus in more details on shifts in maternal experiences of continuing bonds over time, and explore the psychosocial factors associated with women’s differing wish and ability to nurture such bonds so that health professionals can better tailor the support offered during the grieving process.

Conclusion

The tension between restorative meaning-making and deliberate detachment which this exploration of maternal sense-making conjures suggests that this particular bereavement may run along two simultaneous paths. Continuing bonds may be deliberately sought or intentionally rejected and sometimes those bonds come unbidden to the mother, providing a source of connection and also pain. The findings suggest that beyond the bereaved mother’s encounter with her stillborn baby’s body, lies her ongoing encounter with what it is that she has lost and how she may formulate a life beyond this loss. When viewed through the lens of continuing bonds, the bereaved mother and her stillborn baby seem to remain in an ongoing dance of connection, sometimes moving close and sometimes travelling far apart, as processes of maternal reflection enable the bereaved mother to more fully view her child.