Death Before Birth: The use of metaphor to understand and communicate about pregnancy loss

June is Sands (the Stillbirth and Neonatal Death Society) awareness month and the University is currently undertaking vital research into descriptions of Death Before Birth and Lived Experiences of Miscarriage in order to better understand and improve the experiences of those affected by miscarriage.

Pregnancy loss is an important and large-scale social issue: it is estimated that approximately 1 in 5 known pregnancies end in miscarriage, 1 in every 160 babies are stillborn, and 2,000 terminations for reasons of foetal anomaly are performed in the UK each year. Yet many of those affected face uncertainty, ambiguity and silence in the face of pregnancy loss. Often unexpected and unexplained, pregnancy loss engenders complex emotions that are difficult to articulate, even to those in nominally supportive roles.

Our Death Before Birth project, based in the English Language department, involves Professor Jeannette Littlemore, Dr Karolina Kuberska, Dr Sarah Turner and Meera Burgess at the University of Birmingham, Dr Sheelagh McGuinness at Bristol University, and Dr Danielle Fuller at the University of Alberta, Edmonton.

Our recent work with bereaved parents identifies the use of metaphor as a tool to understand, communicate and make sense of such difficult feelings. Studying the metaphors that the bereaved parents use when talking about this emotionally-complex, potentially isolating experience and the decision-making processes that accompanied it has provided a powerful way of gaining insights into their thinking and of opening up additional lines of communication with support agencies.
Through an analysis of interviews conducted with bereaved families and support agencies, we have found that:

• Using metaphor enables people to express feelings that might otherwise be inexpressible.
• The experience of pregnancy loss appears to shape the ways in which people view the world through metaphor. 
• Some of the ways in which it does this resemble responses that people have to bereavement more generally, but in other cases, the metaphorical thinking that takes place appears to be unique to this experience.
• Metaphors that appear to be distinctive to pregnancy loss are as follows:

1. They think about the baby’s body almost in terms of a living being: “Didn’t want him to be on his own when he went [to autopsy]”
2. They need to continue to look after the baby and do this by finding other outlets, such as charity work: “It was the only way we could find to parent him”
3. The metaphorical passing of time can be distilled and compressed: “he wanted a can of beer with his son and sadly his son was stillborn, so we let him have some beer in the family room with his baby”
4. For some, the metaphor of the ‘divided self’ becomes more marked and the body is given agency which allows for it to be blamed for what has happened: “There is a whole range of emotions from feeling really angry with my body and myself not knowing that it was happening and for my body for letting me down.” 

• These metaphors demonstrate a fundamental change in the way these people are experiencing their lives in the physical world: “It is literally a different world”

The implication of these findings is that it is important for those who care for people who have experienced pregnancy loss (including healthcare professionals, support workers, family and friends) to be sensitive to, and tolerant of, metaphorical responses to the situation which at first sight may seem ‘irrational’ but which are in fact powerful ways of dealing with and coming to terms with the situation. They should listen to the language that is being used and respond to this language in non-judgemental ways, taking the lead from the bereaved.

Working with our partner organisations – the Miscarriage Association, Sands, Antenatal Results and Choices (ARC) – we are identifying the best ways of using our research to inform training for supporters, to provide an evidence base for formal guidance produced by the Royal Colleges, and to contribute to public awareness about and sensitivity to those who experience loss.

Our commitment to answer the questions asked by those who experience pregnancy loss and to inform clinical recommendations for care is ongoing. For example, we are now exploring male experiences of miscarriage, through a package of work within our National Centre for Miscarriage Research supported by Tommy’s charity and hosted by our College of Medical and Dental Sciences.

There is evidence to suggest that gender stereotypes obstruct opportunities for men to acknowledge, articulate or seek support for difficult feelings during and after pregnancy loss. We hope to inform future healthcare policy and practice to more effectively meet the support requirements of all parents irrespective of gender.