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July 21, 2018

Holding space for pregnancy loss: 3 components for doulas to consider

Women's Health Maternity
07182018_pregnant_woman_unsplash Photo by Unsplash


This article was originally published in the International Doula Volume 25, Issue 4 and is addressed to birth and postpartum doulas.

•  •  •

Most of us enter birth and postpartum doula work fully focused on supporting families as they experience the joy, and adjust to the challenge, of welcoming new life. After all, doulas are known for offering skilled presence, proven comfort measures, and loving support as a mother opens her arms and heart to her newborn child. We are known for this – and more and more women seek out our support. Most of us have been deeply drawn to the doula path. We love this work.

But what happens when a newborn dies? How equipped are we to hold space for such a profoundly devastating loss? And what about the many women we work with who have known the pain of pregnancy loss prior to a healthy birth? Whether through previous miscarriages or stillbirth, a good number of mothers carry shadows of sorrow in their reproductive histories. Subsequent pregnancies and births can trigger wounds that have yet to be integrated or understood. How prepared are we to be present for this process?

Certainly, it is possible for birth and postpartum doulas to become better equipped to support families through the devastation of pregnancy and/or infant loss. In fact, I believe all doulas have a moral obligation to do so.


Even if we collectively reach the goal proposed by the World Health Assembly and bring the global rate of stillbirth down to 10 per 1,000 births by 2035, stillbirth still exists. (As of 2016, the global rate of stillbirth is 18 per 1,000). In the United States today, it is estimated that stillbirth occurs in 1 out of every 160 births. The rates of miscarriage, calculated in this country as loss prior to the 20th week of gestation, are even higher with an estimated 1 out of 4 pregnancies ending in miscarriage.

Anyone who has been touched by death knows there is no returning to a previous life. We are irrevocably changed due to the loss of loved ones, particularly the death of our children. The companioning approach to understanding, and being with, grief acknowledges this reality. 

The longer one walks the doula path, the odds of encountering “unexpected outcomes” increase. Given this, one would think that speaking openly about birth entails an open approach to speaking about death. Yet pregnancy loss remains a taboo subject for many and is still, at times, regarded as an optional continuing education subject of study even in the birth world.

For example, upon teaching at a well-respected midwifery college last year, I came to realize that, prior to my training, there had been no formal integration of pregnancy loss into the curriculum. In a personal essay on miscarriage, freelance author Angela Garbes aptly observes: “People are uncomfortable talking about pregnancy loss, so they don't. It's no wonder—any meaningful discussion of it requires acknowledging death, sadness, blood, tears, and items being expelled from the vagina.”

As birth workers, let us not shy away from these meaningful discussions. The vagina doesn’t scare us; neither should tears, blood, or sadness. And if they do, we can wisely hold space for our own fears and move through them with courage.

Over the last two years, I’ve learned a great deal from deeply personal dialogues with more than 300 midwives, doulas, lactation consultants, prenatal yoga teachers, mental health professionals, funeral home directors, and bereaved parents on pregnancy and infant loss. These discussions occurred in person, via email, or through phone consultations and conversations. As part of a training I developed entitled "Holding Space for Pregnancy Loss," I’ve opened my heart and mind to these stories and emerged transformed. Certainly, birth workers from all backgrounds best serve birthing mothers when we are more fully equipped to support families through death and bereavement. Ideally, this isn’t an optional study.

In particular, three practices bring healing medicine:


There are many approaches to grief work. Some view grief as an illness that needs treatment. Within this “treatment” model, the goal is to return the bereaved to “normalcy,” to their prior function pre-loss, to their “regular life.”

“Companioning is about discovering the gifts of sacred silence; it is not about filling every painful moment with words.” – Alan Wolfelt, keynote speech at the Association of Death Education and Counseling

But anyone who has been touched by death knows there is no returning to a previous life. We are irrevocably changed due to the loss of loved ones, particularly the death of our children. The companioning approach to understanding, and being with, grief acknowledges this reality. 

Alan Wolfelt, the founder and director of the Center for Loss and Life Transition, describes it best. He writes: “Companioning is being present to another person's pain; it is not about taking away the pain.”

As birth and postpartum doulas, we hold space as women open to labor and life with a newborn. We recognize the power of compassionate presence. We don’t try to fill the sacred spaces of birth and early infant care with an onslaught of well-intentioned words. There’s much to be said for being present in loving silence and listening to a new mother process her own journey through the wilderness. We companion as doulas. Hence, applying the companioning model of “being with” to both birth and death is key.


Even in our globalized world where social media too often replaces the presence of real-time community, we can do much to strengthen the support networks that surround bereaved families. Consider the following example.

Imagine a rock dropping into still water. Imagine the ripple effect of this act. From the epicenter, all concentric and encompassing rings emerge. Now imagine death. A little one dies. The mother is at the epicenter of this devastation. Surrounding her are those nearest and dearest ~ her partner/husband, older siblings, her closest friends and family. As doulas we are also included in her circles of care and concern.

Clinical psychologist Susan Silk draws upon this image of concentric circles in her “ring theory.” As described in an LA Times op-ed entitled “How not to say the wrong thing,” Silk highlights that these circles of care are strengthened when people “dump out” and “comfort in.” In other words, we turn to those who surround and support us to process our grief – we dump out. And we bring forward our best care practices, including companioning, as we care for those closest to the epicenter of sorrow – we comfort in.


Rituals are central to the health of human societies, both preliterate and literate. Marking passageways such as birth, puberty, marriage, and death, rituals bring communities together and link generations across time. Religious or cultural traditions surrounding key life events often carry great meaning.

"We cannot step inside their shoes and feel what they are feeling, but we can become curious, enter into their story and honor their need to grieve as they choose.” – Jane Heustis, R.N. and Marcia Jenkins, R.N, authors of “Companioning at a Time of Perinatal Loss”

Yet, not everyone draws upon traditional rituals of marking death in searching for meaning or healing following the loss of little ones. In fact, some traditional rituals regarding pregnancy loss can feel, and have been, exclusionary. If a child dies before attaining the status of “personhood” within a given community, there may be no formal funeral or burial. Nonetheless, a grieving family is left in the wake.

Given this, some of the families we serve will want to craft their own rituals of acknowledging pregnancy and/or infant loss. And we serve families when we are knowledgeable about the laws in our communities regarding home funerals, home burials, and the cremation or embalmment of little ones. We can offer a list of rituals that have served others similarly bereaved.

Most importantly, we can listen as grieving parents express what matters most and plan various public or private events commemorating their child’s life. So often, parents don’t know they have a range of options wherein they can craft rituals of deep meaning. In this sense, we both companion and guide.


The pregnancy loss movement continues to work diligently to dismantle the silencing taboos that surround discussions of miscarriage, stillbirth, and/or infant loss. As birth and postpartum doulas, we are wise to support this movement and draw upon best care practices, like the three practices outlined above. Let us remember that just as we are skilled in holding space for the beauty and pain of birth and the early postpartum period, we can be similarly capable of companioning those we serve through death.

Let us acknowledge that birth and death are forever twinned and to hold space for one means that we would be wise to learn how to hold space for the other.

To learn more about hiring a doula, contact one of these organizations.

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