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Journal of Family Studies
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/rjfs20
The loss of a grandchild during pregnancy:
an exploration of long-term outcomes for
grandparents and their families
Jane Lockton, Melissa Oxlad & Clemence Due
To cite this article: Jane Lockton, Melissa Oxlad & Clemence Due (2022): The loss of a grandchild
during pregnancy: an exploration of long-term outcomes for grandparents and their families, Journal
of Family Studies, DOI: 10.1080/13229400.2022.2101504
To link to this article: https://doi.org/10.1080/13229400.2022.2101504
Published online: 16 Jul 2022.
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The loss of a grandchild during pregnancy: an exploration of
long-term outcomes for grandparents and their families
Jane Lockton , Melissa Oxlad and Clemence Due
School of Psychology, Faculty of Health and Medical Science, University of Adelaide, Adelaide, Australia
ABSTRACT
Inquiry focussing on grandparents’experiences following a child’s
pregnancy loss has concentrated on shorter-term grief and
support outcomes. We aimed to understand longer-term
wellbeing impacts exploring outcomes 10–20 years after the loss
of a grandchild/ren during pregnancy. Our study addressed the
questions: what are the longer-term outcomes for grandparents
experiencing the loss of a grandchild in pregnancy?; what factors
contribute to reduced grandparent/family coping or increased
family distress?; what supports could be of benefitto
grandparent wellbeing and family coping? We used thematic
analysis to analyse interviews with 12 grandparents from Australia
and the United States of America. Four themes resulted: The grief
is ongoing, the support continues; Subsequent pregnancies:
joyful anticipation has changed to anticipatory fear; Adjustment:
Our lives, our family, and our wellbeing changed,and; Reflecting
on these changes, how did our family cope? These findings
confirm those of shorter-term studies but indicate that
grandparents’grief and the support they provide to their children
are ongoing and, therefore, grandparents may require
information and support for many years following loss. In
addition, grandparent coping is influenced by parent coping.
Therefore, interventions that focus on family adaptation to loss
may also benefit families experiencing multiple losses or
continued relationship disruption.
ARTICLE HISTORY
Received 16 February 2022
Accepted 10 July 2022
KEYWORDS
Grandparents; pregnancy
loss; grief; support; family
systems
Introduction
Most currently available evidence about the significant and often devastating psychoso-
cial impacts of pregnancy loss has focussed on parents’experiences. More recently,
however, research is emerging concerning the impact of a child’s pregnancy loss upon
their parents (i.e. the baby’s grandparents) (Bennett & Chichester, 2015; Lockton, Due,
et al., 2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021;O’Leary et al., 2011). To
date, much of this emerging research has considered shorter-term psychological
impacts (Lockton, Due, et al., 2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021)
rather than longer-lasting effects on grandparents’wellbeing. As such, to develop a
more nuanced understanding of the impact of pregnancy loss on grandparents and
© 2022 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Jane Lockton jane.lockton@adelaide.edu.au University of Adelaide, North Tce, Adelaide, South Aus-
tralia, 5005, Australia @JaneLockton1
JOURNAL OF FAMILY STUDIES
https://doi.org/10.1080/13229400.2022.2101504
complex family grief, we aimed to explore grandparents’experiences 10–20 years follow-
ing the loss of their grandchild/ren.
For many people, the role of grandparents is unique and imbued with meaning, as
illustrated in the anticipation and construction of the role before the –particularly
first –grandchild is born (Bennett, 2000; Hayslip & Fruhauf, 2018). Bennett (2000) pro-
posed that for some, the transition to grandparenthood is a milestone that may represent
continuity, renewal and a meeting of the past, present and future. Therefore, grandpar-
enting can be an integral part of an individual’s identity, with attachment developing
before birth (Bennett, 2000; Callister, 2006; Hayslip & Fruhauf, 2018). Furthermore,
grandparents are frequently seen as family figureheads, with family members often
relying on grandparents for guidance and direction in times of crisis (Hayslip &
Fruhauf, 2018).
Past research with grandparents who experienced the loss of a grandchild due to mis-
carriage, stillbirth or medically indicated termination of pregnancy (hereafter ‘pregnancy
loss’), six months to five years previously, identified that grandparents experience signifi-
cant distress (Lockton, Due, et al., 2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021).
Specifically, these studies found that pregnancy loss is an ambiguous, compounded, dis-
enfranchized loss, characteristics that in other research on grief have been associated with
difficulties adjusting to loss (Cacciatore et al., 2008; Doka, 1999; Obst & Due, 2019).
Additionally, grandparents reported feeling isolated and struggled with changes to
family relationships that occurred due to the loss (Lockton, Due, et al., 2020; Lockton,
Oxlad, et al., 2020; Lockton et al., 2021;O’Leary et al., 2011). Grandparents also
formed a central component of the support system for their child, the baby’s parent
(Lockton, Due, et al., 2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021;O’Leary
et al., 2011). These studies found that while grandparents prioritized their child’s
needs and often provided extensive support to their child when pregnancy loss occurred,
they lacked knowledge about how best to help. Furthermore, while grandparents had the
two-fold task of grieving and caring for their child, the support available to grandparents
was limited and primarily informal. While exploring grandparents’experiences in pre-
vious studies, it became apparent that some families experienced ongoing challenges
due to the loss of a grandchild, including ongoing grief and distress and disruption to
family relationships. However, research has not explored the longer-term impacts on
grandparents’wellbeing.
While few studies relating to grandparent grief in any context, let alone the loss of a
grandchild in pregnancy, exist, studies exploring the multigenerational impact of child
loss identify factors that contribute to increased distress. In general, the death of a
child has been found to be more intense than any other type of loss and affects
parents’whole being as well as their intergenerational relationships (Hunt & Greeff,
2011;O’Leary et al., 2011; Pinkeney, 2020). The same is true for grandparents, with
the death of a grandchild being psychologically devastating while also challenging
boundaries, subsystems and alignments within the broader family unit (Youngblut &
Brooten, 2018). Studies that explored the death of older grandchildren have also ident-
ified traumatic and unexpected deaths as particularly challenging, with individual,
family and cultural factors influencing the expression of grief (Nehari et al., 2007; Rosen-
blatt, 2017; Tourjeman et al., 2015). Furthermore, lack of control in the circumstances
surrounding the death, compounded losses and witnessing the emotional pain of
2J. LOCKTON ET AL.
others all contribute to increased distress and decreased overall wellbeing for parents and
grandparents (Hunt & Greeff,2011; Tatterton & Walshe, 2019).
Family Systems Theory (Bowen, 1978; Kerr & Bowen, 1988) provides a useful frame-
work for considering the complex interactions that may result from pregnancy loss
within families. Specifically, Family Systems Theory asserts that families are an emotional
unit where all members are connected. All members are influenced by their relationships
and roles within the family, including those within one’s immediate family as well as the
wider family unit (Bowen, 1978; Kerr & Bowen, 1988; Masterson et al., 2013; Wirick &
Teufel-Prida, 2019). In the context of grief following the death of a child or grandchild,
research has found that the loss situation, family belief systems (i.e. meaning-making and
spirituality), and family organization factors (i.e. the flexibility of the family system) all
interact to affect grief and wellbeing (Bowen, 1978; Catherall, 2013; Wirick & Teufel-
Prida, 2019). Moreover, disruptions to usual emotional relationships following the
death of a child or grandchild can be particularly challenging, where, in addition to indi-
vidual differences in grieving styles, family systems influence grief behaviours and
support. Therefore, after pregnancy loss, it follows that grandparents are likely grieving
and adapting to their loss alongside the parents, while also negotiating complex inter-
actions and changes in relationships.
Given the lack of research on grandparents’experiences of pregnancy loss and the
resulting impacts on their relationships, and studies indicating that the impacts of preg-
nancy loss for parents are long-standing and can result in changes in psychological well-
being and family relationships (Burden et al., 2016; Grauerholz et al., 2021), it is
imperative to explore long-term grief experiences among grandparents following preg-
nancy loss. Therefore, the overarching aim of this study was to understand longer-
term impacts of pregnancy loss for grandparents, including in relation to grief and well-
being, and relationships with other family members. Specifically, the study was guided by
the following questions: (1) what are the longer-term outcomes for grandparents experi-
encing the loss of a grandchild in pregnancy?; (2) what factors contribute to reduced
grandparent/family coping or increased family distress?; (3) what supports could be of
benefit to grandparent wellbeing and family coping? Answering these questions may
provide insight into ways to protect and benefit grandparents’wellbeing after losing a
grandchild during pregnancy.
Materials and methods
Participants
Participants were 12 grandparents (nine grandmothers and three grandfathers, including
three couples), aged 64–83 years (M= 71.9, SD = 5.5), fluent in English, from Australia
(N =10)and the United States of America (USA) (N =2)whose child had experienced
a pregnancy loss between 10 and 20 years ago. Four grandparents had also experienced
additional losses in the previous five years. In terms of loss type, two grandparents experi-
enced the miscarriage of one or more of their grandchildren, and 11 experienced one or
more stillbirths of their grandchildren. Three experienced the loss of a grandchild in the
neonatal period, three hours (two participants) and three days post-delivery (one partici-
pant), due to complications during delivery or pre-term birth. The gestational age of all
JOURNAL OF FAMILY STUDIES 3
miscarriages could not be determined. Therefore, the statistical data presented represent
the losses over 20 weeks’gestation only. Gestational age ranged from 22 weeks to 40
weeks (M= 30.6, SD = 7.5) and time since loss ranged between 11 and 20 years (M=
15.1,SD= 2.9).
Ethical considerations
The Human Research Ethics Committee of the University of Adelaide approved the
research. All participants received information sheets and consent forms and provided
informed consent prior to interview. As part of a distress protocol, to ensure that partici-
pants retained control over what information they chose to share and could manage
possible distress, participants were told that they could pause or end the interview at
any time or decline to answer any question if they wished; one participant chose not
to disclose some specific family-related information. Furthermore, as a duty of care, fol-
lowing each interview, participants were given a list of support organizations that could
be contacted if desired and offered additional formal support; no participants requested
additional support.
Procedure
Recruitment
To recruit grandparents, information sheets and flyers were submitted to organizations
where Australian families experiencing pregnancy loss might seek information and
support, such as Stillbirth and Neonatal Death Support (SANDS), the Stillbirth Foun-
dation, Still Aware, and Pillars of Strength. Community groups and Men’s Sheds were
also asked to share flyers, and passive snowball sampling occurred. Recruitment infor-
mation was also shared with international organizations in an attempt to capture a
broader range of experiences, including Star Legacy USA, SANDS United Kingdom,
Tommy’s United Kingdom, and SANDS New Zealand. These countries were chosen as
their population diversity, health infrastructure, management of pregnancy loss, and
support organizations are similar, and therefore participant experiences can be more
readily compared. Only two grandparents were recruited from the USA and none
from the other countries. Recruitment may have been more successful if potential par-
ticipants had an opportunity to have in-country contact with the researchers. Potential
participants were invited to contact the researchers to express interest. A time frame
of 10–20 years was chosen because previous research (Lockton, Due, et al., 2020;
Lockton, Oxlad, et al., 2020; Lockton et al., 2021) exploring losses six months to five
years previously indicated that grief and, in some cases, family disruption, was
ongoing for these families. Therefore, to understand longer-term experiences, we
chose 10–20 years to give time for any potential long-term consequences of the loss to
become apparent, as pregnancy loss rates in Australia have remained stable over the
past 20 years (Australian Institute of Health and Welfare, 2020). Also, while even 20
years ago hospital and support practices were likely different following pregnancy loss,
longer timeframes may have led to more significant changes in grandparents’experiences
due to changes in hospital policies and procedures.
4J. LOCKTON ET AL.
Data collection
The interviews followed a semi-structured approach, with questions based on relevant
theoretical concepts such as Family Systems Theory (Bowen, 1978; Kerr & Bowen,
1988) as well as previous studies concerning pregnancy loss for parents and grandparents
(Lockton, Due, et al., 2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021; Obst & Due,
2019;O’Leary et al., 2011). Example questions included: ‘Could you share your experi-
ences of your child’s pregnancy loss?’, and ‘Has your relationship with your child
changed following the loss of your grandchild?’.
Interview times ranged between 40 and 130 min, with an average length of 66 min.
Data saturation was used to ensure that sufficient interviews were conducted to try to
capture the potentially diverse experiences of this group. In this study, data saturation
was defined as the point at which no new information was obtained to develop the
codes and themes relevant to the research aims. Data saturation was achieved by the
eighth interview. However, following previous research practices when exploring grand-
parents’experiences of the loss of a grandchild during pregnancy (Lockton, Due, et al.,
2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021), interviewing continued until all
grandparents who had expressed interest were interviewed to allow grandparents an
opportunity to share their experiences. These additional interviews confirmed data
saturation.
Following best practice in largely inductive qualitative research (Braun & Clarke, 2021),
reflection occurred following each interview to ensure the appropriateness and clarity of
the interview schedule and to respond to any interesting or novel issues raised by partici-
pants in previous interviews. Specifically, additional questions or prompts for discussion
were considered and added to the interview schedule if relevant to the research aims.
This reflection led to the refinement of interview questions across the first four interviews,
with no additional questions added after the fifth interview. Due to participants’geographi-
cal location and COVID-19 restrictions, most interviews were via telephone; only two were
face-to-face. Given the study’s aims and the methodological approach to addressing the
study questions, data saturation was deemed to be an appropriate way to determine
sample size (Braun & Clarke, 2021; Guest et al., 2020; Morse, 2015).
Interviews were transcribed verbatim, and Tracy’s(2010)‘Big-Tent’criteria for excel-
lence in qualitative research were followed to enhance methodological rigour. All partici-
pants were allocated a pseudonym, and identifying details were removed from
transcripts. An audit trail was kept to reflect on the quality of the interview process,
enable decisions regarding interview schedule modifications, and facilitate data analysis.
Finally, self-reflexivity while conducting qualitative research is important to identify
and minimize the effect of researcher bias (Braun & Clarke, 2013; Tracy, 2010). The
first author, who conducted the interviews, is a middle-aged female with three children
and experience of pregnancy loss. Questions asked by participants about the interviewer’s
personal experiences were deferred until after each interview; however, most participants
were aware that the interviewer had conducted previous research on this topic. This
awareness may have facilitated more open conversation across some question areas or
led to assumptions that the interviewer understood certain experiences and therefore
they did not require further explanation. The second author has two children but has
not experienced pregnancy loss, and the third author has three children and experience
of pregnancy loss.
JOURNAL OF FAMILY STUDIES 5
Data analysis
From a realist ontological position, data analysis was completed manually following
Braun and Clarke’s(2013) six-step approach to thematic analysis; we undertook an
exploratory inductive thematic analysis. The first step involved data immersion and fam-
iliarization via interview transcription and multiple readings of the transcripts. The
second step entailed the generation of initial codes relating to the research questions.
Next, we reviewed the initial codes and grouped them into possible themes. In the
fourth step, we reviewed possible themes to ensure they appropriately reflected the
data. Step five entailed finalizing and naming the themes, and finally, step 6 involved
identifying the most appropriate extracts to illustrate the themes. All authors discussed
the analysis to ensure trustworthiness and refined and agreed on the final themes.
Results
Themes
Participants reflected on the challenges and changes that pregnancy loss 10–20 years ago
had brought to their families. Four themes were generated: The grief is ongoing, the
support continues; Subsequent pregnancies: joyful anticipation has changed to anticipat-
ory fear; Adjustment: Our lives, our family, and our wellbeing changed,and Reflecting on
these changes, how did our family cope?
Theme 1: the grief is ongoing, the support continues
Theme 1 comprises two subthemes, Grief is ongoing, reflecting the long-term persistence
of grandparents’grief, and The support continues,reflecting on the support grandparents
continue to provide to their families.
Subtheme 1: grief is ongoing
Most grandparents explained that the grief for their grandchild/ren was ongoing. While it
became easier for most to cope with their grief, the loss permanently changed their lives
and remained a part of their life narrative. Paula, whose family had experienced multiple
miscarriages and stillbirth expressed:
Grief is a long process, every person is different. It doesn’t matter, you get through it in your
own time, some take years, some never get over it …. Time doesn’t really heal, it’s a part of
you.
Val, whose child had experienced a stillbirth, also described how the grief remains some-
thing her family carries as a whole unit:
Everyone has these things, these losses, and this one is ours. The family carries a burden of
grief.
All participants acknowledged the importance of individuals being able to grieve in their
own way, and that differences in grief behaviours, ranging from more instrumental (i.e.
cognitive, problem-solving approach to grief) to more intuitive approaches (i.e. outward
emotional expression of grief), meant that each grandparent brought their strengths to
the family dynamic, with grieving styles in part a reflection of those strengths.
6J. LOCKTON ET AL.
Grandmothers, in particular, conveyed the depth, difficulty and distinctiveness of this
type of loss. For example, Rosa, whose family experienced several losses, including still-
birth, neonatal death and infant death, said:
Do I know what it’s like to lose a child –no I don’t, but I know what it’s like to lose a grand-
child …the death of those children has changed our lives.
Uma, whose family experienced multiple miscarriages, multiple stillbirths, and infant
death, shared how unique the experience of pregnancy loss of a grandchild is, different
also from that of the parents. She stated her belief that a person would only fully under-
stand if they had also experienced it:
To this day I don’t think any of the kids really understand what it has meant to me. And we
are close. People don’t understand unless they have been through it. I don’t know what it’s
like to lose a baby, but I do know what it’s like to lose a grandchild.
As Zac, whose grandchild was stillborn, explained, hopes and expectations before the
loss influenced the grief journey for his family, highlighting how individual differences
in circumstances may impact outcomes following the loss. Zac noted that his wife
struggled with some aspects more than he did, but that they were both impacted
strongly:
It was a time we will never forget, it was a very difficult time. I think it was harder for [my
wife] because she had so many expectations and hopes. It turned our world upside down.
Grandparents’different approaches to managing grief also indicated the need for a range
of available support options. Participants also described how each individual within the
family experienced and managed their grief in their own way. Many commented on the
differences between how men and women grieve, with grandparents generally describing
men as less open in expressing their emotions and focussed on supporting their families.
This view was expressed as applying to sons, sons-in-law, and grandfathers –with Will,
whose family experienced stillbirth, saying:
I dealt with it as it came along and tried not to get too involved in the emotion. I tried to
handle everything that might get in the way of everyone else being able to express their
emotions …. I feel like I’m the one that gives support, not the one that needs it.
In some cases, differences in grieving styles resulted in tension amongst family members
and relationship challenges following the death of the baby. For example, Zac explained
that grieving differences created barriers to communication and that differences in per-
spectives made decisions more difficult to make for his daughter and son-in-law:
[Son-in-law] is the quiet type. Some men may not be as responsive. He didn’t always see
decisions the same way, they had different perspectives. It caused tension between [my
daughter] and [my son-in-law], but they got through.
However, participants did not always view gender as determining grieving style; some
grandmothers also described a more instrumental style of grief often associated with
men, suggesting that grandparents may orient to this grief style in the case of the preg-
nancy loss of a grandchild. For example, Uma described how she managed the expression
of her grief to help her family. As a grandparent, Uma responded in ways that she felt
were important to support her family, despite the cost to herself. While the losses she
JOURNAL OF FAMILY STUDIES 7
experienced ranged from five to 15 years ago, her grief remains compartmentalized to
ensure she can cope:
I held it together because everyone else was falling apart. I was the rock. But that came at a
cost …I know how to compartmentalise my feelings, I bury it. It helps me not to let it out. If
I start crying I’ll never stop.
Subtheme 2: the support continues
Grandparents stated that they received little if any support at the time of loss of their
grandchild/ren. Those grandparents who had experienced the loss of a grandchild/ren
more than 10 years ago and a more recent loss described no difference in the support
received between the earlier and later loss. Comparable to participants in studies of
more recent losses, grandparents’primary concern was for their child experiencing
such a loss and the ongoing support they could provide for their child, as shown by Val:
There’s no right or wrong way. We’ve always been close, they don’t know if they would have
gotten through it as well without us and their sisters …Refrain from giving advice, be
careful with your advice. Just support them.
While grandparents continued to support their child, in most cases, the nature of this
support changed from that provided in the early months and years following the loss.
As time passed, less practical day-to-day support was required. However, grandparents
continued to provide understanding and emotional support and to honour their grand-
child/ren and engage in memorial activities as needed. In particular, grandparents, as
noted by Zac, continued to mark their grandchild/ren’s death by ensuring contact
with their child on anniversaries and other significant days:
We go [to the burial site] several times a year, he is still very much a part of our lives and part
of the family.
In this way, grandparents participated in activities that strengthen and drew their family
together. Some described how the memorial activities changed over time but stressed the
importance of continuing bonds with their grandchild. Val expressed:
We brought flowers for 4 or 5 years, but we didn’t know if we should keep doing that.
[Daughter’s name] said that even just a text or phone call was enough to know that
people hadn’t forgotten. Now we wear rose on the day, we still do, and we include her in
our number of grandchildren. We make sure they know we haven’t forgotten.
Overall, the results demonstrate that the grief associated with the loss of a grandchild/ren
is long-standing and that the support provided by grandparents to their families may
change form, but is ongoing.
Theme 2: subsequent pregnancies: joyful anticipation has changed to anticipatory
fear
A key challenge identified by grandparents was their child’s subsequent pregnancies and
the pregnancies of other family members. As a result, many were unable to enjoy the
anticipation of a new grandchild and were fearful until the baby was born. For some,
this fear extended to anyone they knew, due to increased awareness of the potential of
pregnancy loss. Uma stated:
8J. LOCKTON ET AL.
You don’t stop worrying. Now when I hear of anyone being pregnant I just feel scared about
what will happen and will I be able to cope.
Furthermore, some found these fears made it more difficult for them to bond with a new
grandchild. For example, some grandparents explained how they felt previous loss/es had
affected their connection with subsequent grandchildren, including in the long term. For
example, Yvonne, whose first grandchild was stillborn, said:
I poured a lifetime of love into [Grandson’s name], and I’m being a good grandmother, but
it has affected my relationship with my other grandchildren. When I held [Grandson’s
name] all of my love as a grandmother went to him, and in a sense has remained with
him. I feel it has changed my relationship with my other grandchildren. It’s terrible, it’sa
terrible burden.
Yvonne’s comment emphasises the extent of the compounded losses that grandparents
may experience following the loss of their grandchild/ren during pregnancy, including
the risk of complicated grief. Furthermore, her experiences underscore how such
impacts may affect family relationships and the importance of appropriate support for
grandparents.
Where grandparents experienced more than one loss, they often described being
better prepared the second and subsequent times to help their child. However, as
Matt, whose family had experienced stillbirth and neonatal death, explained, grandpar-
ents valued further information even after a subsequent pregnancy loss, so they could
build on their existing knowledge about how to help and support their child:
It was easier to talk about it the second time, we were more ready, we had done it before. But
I still wanted to know how to help more.
Significantly, notwithstanding his previous experiences, Matt also desired support fol-
lowing this second loss. In particular, Matt suggested a supervised peer support group:
I would have liked a counselling group that brought people together. I felt alone and like a
stranger. I would have liked something that would provide comfort and knowledge. The
worst experience was being remotely placed.
Importantly, Matt noted that living a long way from his daughter contributed to
additional communication difficulties. Thus, grandparents may need access to support
over a long period and potentially for multiple losses, as past experiences may not be pro-
tective and may compound grandparent grief even further. Additionally, support strat-
egies to manage geographical distance could help reduce the distress associated with
providing support from a distance.
Some grandparents experienced a further consequence; their child and child’s partner
were very protective of their subsequent children, with resulting impacts for grandpar-
ents’own relationships with their grandchildren. For example, participants said that
this protective behaviour affected the time they could share with their grandchildren,
which was often a source of further distress for some This was the case for Olivia,
whose family experienced stillbirth:
[Son-in-law’s name] became very possessive, and was pushing us away. It was because he
was trying to keep them close, so we stayed away …In hindsight we could see that snowball
starting, and had we been more aware of those signs we could have got him some help.
JOURNAL OF FAMILY STUDIES 9
Overall, anticipatory fear became dominant during subsequent pregnancies for grand-
parents. Such feelings often had unanticipated impacts and demonstrated that ongoing
support may benefit grandparents.
Theme 3: adjustment: our lives, our wellbeing, and our family changed
In many cases, participants noted that the loss of their grandchild/ren brought ongoing
change to their lives. All of the grandparents who experienced multiple losses found the
effects compounded and described the need for support in some form, whether pro-
fessional, community or peer-based.
Many grandparents noted that their psychological health was affected by the preg-
nancy loss/es, such as Trish, whose family experienced stillbirth and neonatal death:
I had a nervous breakdown 2 years after [second Grandson’s name] birth. We had no
support, and no acknowledgement as grandparents.
Trish went on to speak of the lack of support and acknowledgement that occurred on
more than one occasion:
I could accept it the first time, but not the second time. We were disregarded the second time
as well as the first.
Grandparents who experienced more than one loss described similar support experiences
between the first and subsequent losses and relied on their past experience to know how
to cope with the subsequent loss/es. The lack of early support appeared to increase the
risk of physical and psychological health issues for families. Additional losses com-
pounded this further, suggesting a need to support grandparents and identify those at
increased risk of sequelae and requiring additional support.
Importantly, most grandparents expressed that they may not be aware of available
supports at the time of the loss. For example, Nina, whose grandchild died at birth,
had also experienced a pregnancy loss herself and yet did not find that her personal
experience of pregnancy loss as a parent helped her address the numerous impacts her
family faced:
It would have been helpful to know that counselling was available, and that it was ok for me
to have it …My own experience didn’t help me, I didn’t know what to do with all this.
All grandparents noticed long term changes in at least some family relationships. For
some, their grandchild/ren’slossbroughtfamilymembersclosertogether,withthe
shared grief strengthening and growing existing family relationships. However, for
some families, these losses led to strained family relationships. For example, Olivia
described how she felt an enduring emotional distance between herself and her
daughter following pregnancy loss, in contrast to the closer relationship they once
enjoyed:
[Daughter’s name] wears a coat of armour now. She’s very strong but she doesn’t allow that
softness of grief to come through. Our relationship is different.
Furthermore, as previously described, differences in grieving styles may lead relation-
ships to become strained, misunderstandings to arise, and communication breakdowns
to occur. In some cases, family members acted in ways that others found hurtful, with
10 J. LOCKTON ET AL.
long term impacts. For example, Rosa described how her family were once close but that
this changed after the loss:
We were very close knit; we were a perfect family. But now [daughter’sname]hasno
contact with her sister. It’sveryawful,andhard.Wegrieveforthechildrenwho
passed away, and grieve for our daughter who is suffering, and we grieve for the break
in communication. So it’ssortoflikearollercoaster…Lots of things have fallen to
bits because of it.
Other participants described how they continue to recognize and remind their families,
many years later, that individuals grieve differently, suggesting that the adjustments
required following pregnancy loss are an ongoing consideration to families. As
Yvonne noted:
I continue to reassure her that men and women grieve differently. It was a damn good thing
that the marriage survived, it’s a credit to them. But I did have to talk her through a number
of times.
Some grandparents found that their child’s intimate relationship broke down following
the loss. In these cases, grandparents thought that lack of support, particularly for fathers,
contributed to this breakdown. Matt explained
I think [son-in-law’s name] really suffered due to a lack of support. He lived in an isolated
town and workplace, and his family were on the other side of the world. It was too much for
their relationship.
The strained or lost family relationships described by participants are a significant source
of grief for grandparents that may impact their wellbeing. Appropriate support, particu-
larly where multiple losses, geographical distance or limited social support exist, may
reduce adverse outcomes.
Theme 4: reflecting on these changes, how did our family cope?
Some grandparents reflected on the ways in which the loss of their grandchild/ren led to
changes in their perspective on life and family relationships. For example, grandparents
found that in adjusting to their loss, some beliefs and world views also adjusted, particu-
larly concerning what was important to them, as shown by Uma:
It’s made us all realise how precious children are. You don’t take anything for granted, you
make the most of every day with them.
Rosa’s family encountered relationship and physical and psychological health issues that
she attributed to the strain on their family after multiple losses. She said that focussing on
the positive things in her life helped her to cope with the compounded losses that she
faced:
You have to look for the blessings in your life, they may be small, but they are there.
When asked what protected her family relationships and kept them intact, Moira, who
had experienced the stillbirth of her grandchild, suggested:
Wanting to help each other, to be there for each other. That’s probably it. Talking to them,
letting them know you care. You’re there.
JOURNAL OF FAMILY STUDIES 11
Overall, participants indicated that being there to support each other and talking about
their feelings and experience helped to process and integrate the loss. However, many
grandparents identified difficulties and changes in family communication associated
with family system changes and grieving styles as areas of concern. Some participants
recommended alleviating the impact on family relationships by addressing communi-
cation difficulties as they arise. Zac suggested:
Carefully observe how relationships are changing, and use good communication and
compassion.
Grandparents who were geographically distanced from their child/children confirmed
previous findings regarding the difficulties presented by geographical distance
(Lockton, Due, et al., 2020). As shown by Nina, distance presented challenges associated
with communication and practical assistance that were difficult to overcome and made
supporting their child and knowing how to help even more difficult:
I had no idea how to help, and the distance from [my child] was a problem. That was the
biggest challenge apart from not knowing what to do.
Several participants eventually found themselves living closer to their child/children, and
even if several years later, found that geographical proximity alleviated some concerns.
For example, while not always possible, Uma, who endeavoured to support her family
through several losses while working overseas, found that once she resided in Australia,
the geographical proximity helped her family cope:
Physical closeness has helped. Being there is definitely better than long distance, if you can
be there, be there.
All grandparents commented on the importance of self-care, which particularly involved
allowing themselves the space to grieve in their own way and in their own time. Moira,
aware of grandparents’desire to protect their child from further pain, encouraged other
grandparents to share their feelings, as this helped her family adjust:
Don’t be afraid to show your emotions. And don’t be ashamed if you still have emotions
years later.
Possessing a strong faith was also a source of solace and strength for some grandparents
and allowed them to focus on ‘blessings’(Rosa) and ‘hope’(Val). For Paula, whose family
had experienced many losses, this was particularly important to her wellbeing:
My faith is my hope, you need that when you go through hard times. It helps me to see the
bigger picture. I wouldn’t be here without it.
Participants’comments suggest that faith can be protective and a source of comfort
for some grandparents, but that allowing space while also maintaining family close-
ness helped grandparents cope in general. In reflecting on their experiences, grand-
parents described a range of behaviours that helped their families to cope with their
loss.
Grandparents accounts clearly demonstrated the ongoing impact of grief on them-
selves and their families and the ways in which they continue to support their families
many years after the loss of the grandchild/ren. They noted how subsequent pregnancies
12 J. LOCKTON ET AL.
brought fear instead of joy, and although families adjusted, they were changed and grand-
parents questioned how their families coped.
Discussion
This study aimed to explore longer-term outcomes for grandparents following their
child’s pregnancy loss, and to identify the factors that contributed to grandparent/
family coping or distress, as well as the supports required. Our analysis confirmed the
findings of previous research that examined the shorter-term impacts of pregnancy
loss for grandparents (Lockton, Due, et al., 2020; Lockton, Oxlad, et al., 2020; Lockton
et al., 2021). Specifically, contextual factors, including the ambiguous and compound
nature of the loss and the disenfranchisement of grief, impacted grandparents’grief
experiences. Individual factors identified included grieving style, mourning rituals, and
belief systems. In addition, we identified further factors contributing to long-term out-
comes, including multiple pregnancy losses and family relationship changes. Our
findings also highlighted that grandparents often provide extensive support to their
families following the loss of a baby/ies and require support options themselves.
Finally, we identified coping mechanisms that may benefit families more generally.
Our findings indicated that grief is ongoing for grandparents, with participants who
had experienced their loss/es up to 20 years prior continuing to grieve, describing
their losses as a continuing part of their life narrative. While many participants had
learned to carry their grief, it nevertheless continued to impact themselves and their
families. A range of factors influenced participants’grieving styles and family coping,
including individual differences in grieving style (ranging from more affective intuitive
styles to more physical or cognitive instrumental styles), gender, and family factors
such as communication style, role within the family, and belief systems (Bonnette &
Broom, 2011; Doka & Martin, 2010; Obst et al., 2021; Wirick & Teufel-Prida, 2019).
Societal expectations also placed limitations upon the ability to express grief and the
length of grieving.
Participants in our study endorsed previous research findings regarding the com-
pounded nature of grief (Lockton, Due, et al., 2020; Lockton, Oxlad, et al., 2020;
Lockton et al., 2021). Specifically, several grandparents who experienced multiple
losses found that each loss brought additional grief and family change. This finding is
consistent with research regarding older persons and other types of compound or cumu-
lative loss, as well as research with parents experiencing multiple pregnancy losses
(Gilrane-McGarry & O’Grady, 2012; Nehari et al., 2007; Voss et al., 2020).
Our findings illustrated that grandparents continue to support their families –
especially their child/ren who experienced the pregnancy loss/es –many years on. Impor-
tantly, the nature of this support changed over time, reflecting their child’s changing
needs. For many, this included listening, advice, and ensuring that their grandchild/
ren was remembered. Here, our findings offer a novel contribution as we were unable
to identify other research that has explored long-term outcomes or support provision
by grandparents after loss, including in relation to the death of an older child. Therefore,
it is impossible to determine whether this behaviour is typical of grandparents following
other loss experiences or whether this finding is unique to pregnancy loss; an important
area for future research.
JOURNAL OF FAMILY STUDIES 13
Our study also indicated that the loss of a baby/ies increased grandparent anxiety
regarding future pregnancies. For some grandparents, this was quite severe and applied
not only to the pregnancies of family members but also to friends when pregnant. Previous
research indicates that mothers who have experienced pregnancy loss may employ a
complex self-protective mechanism, known as emotional cushioning, to protect their
emotions and avoid prenatal bonding in future pregnancies (Côté-Arsenault & Donato,
2011; Côté-Arsenault & O’Leary, 2016). Emotional cushioning assists mothers in compart-
mentalizing the pregnancy and avoiding emotional attachment and investment in the new
baby for as long as possible. Participants in our study, particularly those who had experi-
enced multiple losses, employed emotional cushioning. Specifically, grandparents often
avoided attachment to an expected baby and lost anticipatory joy until the baby was
safely born. This finding has not been described in the literature to date and is an important
addition. While it is unclear what specific therapeutic interventions are best for parents
experiencing emotional cushioning, anxiety-reducing strategies, encouraging attachment
and sharing feelings for the deceased baby, and pregnancy loss support groups appear
helpful (Côté-Arsenault & Donato, 2011; Côté-Arsenault & O’Leary, 2016). Such
approaches may also benefit grandparents during their child’s subsequent pregnancies.
Finally, all grandparents found that their family relationships changed; in some cases,
relationships were strengthened, but they were permanently disrupted in others. As
noted in Family Systems Theory, some degree of interdependence between family
members always exists (e.g. Bowen, 1978; Kerr & Bowen, 1988); however, loss often
exacerbated this (Wirick & Teufel-Prida, 2019). Research shows that a death requires
individual and system grief work (Bowen, 1978; Kerr & Bowen, 1988; Masterson et al.,
2013), with effective family functioning through bereavement characterized by the
‘three C’s’: communication, cohesion and conflict (Masterson et al., 2013; Traylor
et al., 2003). Families that effectively process grief exhibit open communication and
expression of feelings, mutual support, remain cohesive without co-dependence and
manage conflict resolution. However, at a time when good communication is needed,
open communication following pregnancy loss is often minimized to protect family
members (Lockton, Due, et al., 2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021;
Tourjeman et al., 2015). Our findings suggest that family functioning requires careful
management and adaptation for all families, and even 20 years after the loss, grandpar-
ents feel responsible for mediating and managing these changes.
In terms of coping strategies following pregnancy loss, grandparents found self-care,
adjustment and acceptance, a willingness to help and support each other and –for some
–faith to be beneficial. Additionally, involvement in memory-making activities at birth
meant that families had memories to share and mementoes of the baby/ies that were still
valued 20 years later. Our findings showed that continuing bonds, a process of transforming
the relationship with the deceased and maintaining their legacy (Klass & Walter, 2001;N
ei-
meyer et al., 2006;Stroebeetal.,2010), appear beneficial in helping grandparents adjust to
their loss. Thus, talking about the child and including their memory can transform the
relationship from a physical to a psychological one. Furthermore, participation in memor-
ializing activities kept the child/ren present in the family and recognized them as loved
family members. Grandparents explained that this was an important task, highly valued
by their child and families, which often fell to them to maintain. These various strategies
were seen as helpful in maintaining family bonds and growth after pregnancy loss.
14 J. LOCKTON ET AL.
Implications
Our findings point to a range of implications. A key overarching finding is that grand-
parents must be recognized as grievers in their own right when a grandchild dies in preg-
nancy. It is also important to remember that grief changes across its course, and therefore
different interventions may be helpful at different times. As our research indicates, grief
can remain long term, and therapeutic interventions may be needed years after the loss.
While no evidence exists for effective interventions to assist grandparents following a
child’s pregnancy loss, participants in our study and previous research involving grand-
parents provide direction. Like grandparents in previous studies (Lockton, Due, et al.,
2020; Lockton, Oxlad, et al., 2020; Lockton et al., 2021), current participants suggested
that early access to information regarding how best to support their families to adjust
and cope with this type of loss would be beneficial and that providing this information
following delivery in hospital environments would be timely. This information provision
is important whether this is grandparents’first or subsequent experience of pregnancy
loss. Furthermore, our findings suggest that grandparent coping is integrally tied to
their child’s experiences and coping. Therefore, providing information and support
opportunities for grandparents will help them adjust to the loss and assist grandparents
in supporting their child and the family system.
The significance of our findings for grandparents and their families comes in provid-
ing evidence of the need for support opportunities to facilitate grieving. In our study,
grandparents described long term family disruption and poor health outcomes.
Finding a place where bereaved individuals can share stories of their loved ones is
highly beneficial in reducing complications of unresolved grief (Flesner, 2013; Neimeyer
et al., 2006; Shannon & Wilkinson, 2020). In societies where rituals surrounding death
have declined or are ambiguous, the trauma of grief may be eased through counselling
and support groups (Klass & Walter, 2001; Näppä & Björkman-Randström, 2020).
Hence it is unsurprising that grandparents valued these types of supports. Peer
support could be facilitated through pregnancy loss support organizations and, ideally,
would commence soon after the loss and be ongoing if needed. As our study illustrates,
grandparents still provide and require support many years following the loss of their
grandchild/ren.
While grief interventions are not necessarily effective for the bereaved generally, such
interventions can be beneficial and protective against further physical and psychological
health consequences for those at risk of prolonged or complicated grief. Research
suggests that carefully tailored interventions can be effective, particularly therapies
offering a range of options that address meaning-making and benefitfinding, such as nar-
rative therapies (Milman et al., 2019). As noted, grandparents who experience multiple
losses may have heightened anxiety during subsequent pregnancies. Voss et al. (2020)
recommend routine screening and psychological care for families experiencing multiple
losses. Our findings suggest that it would be prudent to include grandparents in early
screening and provide them with guidance about therapeutic interventions.
Our findings also suggest that support may be helpful for some family dyads or
groups. Participants in our study identified changed family relationships as a significant
outcome of the loss of their grandchild/ren. For some families, these changes were detri-
mental to the family, were long-lasting and had an enduring impact on health and
JOURNAL OF FAMILY STUDIES 15
wellbeing. For these families, therapy that addresses these issues may be of benefit.
Family-focussed grief therapy, where the guiding principles are that family members
work together to understand their group dynamics, improve communication and cohe-
siveness and reduce conflict, may be valuable (Catherall, 2013; Masterson et al., 2013;
Wirick & Teufel-Prida, 2019). However, it is also important to note that family
therapy may not be appropriate for some families. If the family system is closed and
inflexible or families are hostile, family therapies can be ineffective and potentially
harmful (Delalibera et al., 2015; Masterson et al., 2013; Traylor et al., 2003). Moreover,
when family members were geographically distant from each other, participants
explained that being very proactive in maintaining contact, such as frequently calling
and texting, using internet-based technology and visiting as often as possible, was impor-
tant. Encouraging families to engage in these behaviours may prove beneficial over the
long term.
Our study also points to a range of future research possibilities and directions. Specifi-
cally, further research that develops and investigates the impact and suitability of
resources and support services specifically designed for grandparents would be informa-
tive and would enable refinement to ensure the efficacy of such services. In addition,
analysis of the impact of early identification and support for families who may be at
higher risk of family disruption and associated sequelae may be informative for care plan-
ning. Finally, further research exploring grandparents’experiences following other types
of loss may prove useful in determining their long-term support needs more broadly.
Strengths and limitations
This study was the first of its kind to explore the long-term impact of pregnancy loss on
grandparents and provides novel insights regarding grandparent grief experiences. Our
findings begin to build an understanding of the ongoing impacts of this type of loss and
provide a basis for the inclusion of grandparents in support networks and care planning
for families. The qualitative methodology we employed provided rich data for addressing
the study aims. In particular, the inclusion of both grandmothers and grandfathers
enhanced the generalisability of the findings, and allowed for a greater breadth of
understanding.
However, it is prudent to be mindful of the limitations. Several of our participants
had particularly challenging experiences of multiple pregnancy losses and may have
self-selected for our study because they experienced ongoing distress. Therefore,
our participants may not be representative of all grandparents who lose a grand-
child/ren through pregnancy loss. However, our sample may represent those more
at risk of long-term impacts of this type of loss, and therefore helpful in determining
the individuals and families that support services and health care professionals may
best serve. Our study also recognizes the importance of support at all time points in
grief processing to prevent long term distress, poor health outcomes and family
disruption.
Additionally, our participants were largely homogenous, and, as such, care should be
taken in generalizing these findings derived from a participant group who were largely
Caucasian and residing in high-income countries to other cultural groups. The experi-
ence of loss is inherently culture-bound (Nehari et al., 2007; Rosenblatt, 2017; Tourjeman
16 J. LOCKTON ET AL.
et al., 2015), as cultural norms significantly impact rituals of death and societal expec-
tations of grief-related behaviours, and therefore grandparent experiences may differ
across cultures. Furthermore, given espoused benefits of spiritual and religious beliefs
and practices, samples including participants from diverse religious and cultural back-
grounds would enable support interventions to be more appropriately tailored. Such tai-
loring may be particularly relevant for pregnancy loss, where beliefs may impact the
recognition of the baby’s life. Further research across diverse cultural groups is
recommended.
Conclusion
The importance of our study lies in its ability to capture grandparents’views about the
long-term impact of pregnancy loss. The loss of a baby in pregnancy is typically unex-
pected, traumatic, and untimely, characterizing this as a particularly difficult loss to
process for grandparents. Significantly, grief continues to be felt many years following
the loss, and subsequent pregnancies may be stressful for grandparents. Recognition of
grandparents as grievers and strategies to facilitate grieving and offer support are key
to decreasing distress and reducing the risk of complicated grief, which, in turn, may
decrease the risk of adverse physical and psychological health outcomes. We recommend
that support service providers include grandparents in the care network, particularly
where a family has experienced distressing disruption and/or multiple losses. Grandpar-
ents desire early access to information and value peer support. Therapeutic interventions
such as family-based therapies may be helpful for individuals and families at higher risk
of long-term complications.
Acknowledgements
The authors would like to sincerely thank the grandparents who shared their experiences for the
purposes of this research. We would also like to thank SANDS Australia, the Stillbirth Foundation,
Still Aware, Pillars of Strength, Star Legacy USA, SANDS UK, Tommy’s UK, and local community
services that supported the work.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This research is supported by an Australian Government Research Training Program Stipend.
ORCID
Jane Lockton http://orcid.org/0000-0002-0637-5212
Melissa Oxlad http://orcid.org/0000-0001-9067-6706
Clemence Due http://orcid.org/0000-0001-6485-6076
JOURNAL OF FAMILY STUDIES 17
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