COMMENTARY

The Silent Birth: A Feminist Perspective
foanne Cacciatore

We grieve all that cannot be spoken, that for
which there is no name (GrifFin, 1978).

T

he social work profession embraces the
idea that social action is necessary as a
part of the field's responsibility to society.
This includes political and social action that seeks
to improve the lives of others, particularly the
underrepresented and the vulnerable populations
(Reamer, 1998).The feminist perspective, a theoretical paradigm often used to examine women's
issues and one embraced by many social workers,
"rests on the concept of the personal is political"

(Collins, 1986, p. 215).There is, perhaps, no more
deeply personal and profound experience for many
women than losing a baby to stillbirth (Cacciatore
&Bushfield, 2008).
Stillbirth, or sudden intrauterine death, occurs 10
times more frequently than Sudden Infant Death
Syndrome, yet it has failed to be acknowledged as
a public health problem ("Racial/Ethnic Trends,"
2004) .This translates to about one in 110 pregnancies
that will end in stillbirth. Despite improvements in
prenatal care and advanced medical testing, stillbirth
rates over the past 10 years have declinedbnly slightly
in the United States (Ananth,Liu,Kinzler,& Kramer,
2005; Goldenberg, Kirby, & Culhave, 2004; Silver,
2007). Many sudden intrauterine deaths occur at
or near full-term to otherwise apparently healthy
infants. Upon postmortem examination, one-fourth
to one-half of stillborn infants die as a result of causes
that are indiscernible (Froen et al., 2001). Mothers,
and often fathers, are left searching for answers, for
any explanation to the questions surrounding the
child's death, often left in the turmoil of irrational
self-blame (DeFrain, 1986). Although etiological aspects of stillbirth are cloaked in obscurities,
the psychosocial dimensions of grief responses to
stillbirth, as well as child death in general, are often
even more elusive (Froen et al., 2001; Goldenberg
et al., 2004).
The birthing process is often a traumatic physiological event (Silver,2007;Slade,2006;Soet,Brack,

CCC Code: 0037.8046/09 $3.00 62009 National Association of Social Workers

& Dilorio, 2003; Smith Armstrong, 2002; Hendrick,
Altshuler, & Suri, 1998). Researchers in England
discovered that "20% of mothers who have a stillbirth experience prolonged depression," and at least
one in five suffer from posttraumatic stress disorder
(Walling, 2002). Approximately 20 percent to 30
percent of women who have experienced stillbirth
exhibit "appreciable psychiatric long term morbidity" (Radestad, Steineck, Nordin, & Sjogren, 1996).
As a result, it is not unusual to observe significant
Stressors in families after such a tragedy. These
disruptions can result in prolonged dysfunction
leading to an erosion of familial relationships and,
sometimes, even severances. The emotional effects
of giving birth and death simultaneously are often
misunderstood (Fletcher, 2002; Malacrida, 1997;
Michon, Balkou, Hivon, & Cyr, 2003) and rarely
examined beyond the cursory rhetoric of perinatal
death (Cacciatore, 2007). Women who give birth
to a dead baby may feel disenfranchised from social
groups in which babies and children are integral,
while their mourning experience is generally decried by so<;iety in general (personal communication with R. E. Kubier, Scottsdale, Arizona, 2004;
DeFrain, 1986; Fahey-McCarthy, 2003; Fletcher
2002; Saddler, 1987;Worth, 1997).
Fathers, i:oo, are often faced with tumult after
stillbirth. Both bereaved mothers and fathers demonstrated significantly higher levels of depression
from a control group, those effects being longer
lasting in mothers up to 30 months after the death
(Boyle, Vance, Najman, & Thearle, 1996; Vance &
Najman, 1995). "Fathers are in a difficult position
after a stillbirth for a number of reasons: They are
expected to take care of the wife emotionally; they
are expected to continue to work and pay the bills;
and they need to grieve for their lost baby themselves" (DeFrain, Martens, Stork, & Stork, 1990,
p. 97). Layne (2003) noted that "most men are
socialized not to discuss their feelings and to avoid
emotionally charged situations" (p. 131). One father
said, "I had to be strong...I was told not to show
any emotion because it would upset her. It's funny:

91

I was hurting too, but I was not expected to show
it (Peppers & Knapp, 1980, p. 53).
POLICY ISSUES RELATED TO SUDDEN
INTRAUTERINE DEATH

Although policies help shape public opinion about
the worthiness of a woman's grief experience after a
baby is stillborn, they also contribute to misconceptions about the defmitions and parameters of sudden
intrauterine death and the women who suffer such
tremendous loss (Cacciatore,2007). À country's rate
of infant mortality is commonly used as a marker
to measure societal well-being. Yet, stillbirths, even
at full-term, are not counted in infant mortality
data, thus, affecting pubUc perception, funding, and
research. Critics assert that this is a public health
problem that has been largely overlooked and even
ignored. Devaluation and the political status of the
unborn (Layne, 2003) and the absence of accurate
data have also led to relative inaction by policymakers
(Cacciatore & Bushfield, 2008).
One policy related to stillbirth that has recently
come under fire has to do with vital records and
data keeping. All 50 states required the issuance of
a death certificate and mandated final disposition,
through cremation or burial, of stillborn babies.Yet,
women wanting a stillbirth certificate for their babies
were categoricaDy denied the option to obtain such
a document (Cacciatore & Bushfield, 2008). As one
mother described:
I called the vital records office after my baby
died. I wanted her birth certificate. They told
me I couldn't have one and that I didn't have
a real baby. But she was real to me. She was
almost ten pounds and the autopsy could not
find a cause of death. She was and will always be
my child...I've never been so offended. (MISS
Foundation, 2005b)
The grassroots efforts of some mothers from an
Arizona support group led to the passage of the first
law of its kind. Enacted August 9,2001, House Bill
2416 altered the way in which stillbirths are handled
and recorded in the state of Arizona:
ARS 36-329.01 Certificate of Birth Resulting
in Stillbirth
A. In addition to the requirements of section
36-329, the state registrar of vital statistics
shall establish a certificate of birth resulting

92

in stillbirth on a form approved by the state
registrar for each fetal death occurring in
this state after a gestational period of at least
twenty completed weeks. This certificate
shall be offered to the parent or parents of
a stillborn child.
Since Arizona's passage ofthis legislation, 20 other
states have passed similar laws, including California.
New York is currently considering this legislation,
along with seven other states with pending bills.
Supporters contend that there are tangible psychological and geneological benefits to the issuance of
the new certificate recognizing the birth (Lewin,
2007). Throughout childhood and adolescence,
individuals acquire material items in day-to-day life;
objects that abet memories, and those memories
are attached to family narrations.Yet, there are few
tangible mementos for mothers and fathers whose
babies are stillborn. These "emotional artifacts,"
(Layne, 2003) such as a birth certificate, help women
actualize their losses and may help them to cope with
their losses. And women whose babies die as a result
of stiUbirtb must still give birth. This recognition is
crucial to many women and has captured the attention of the mainstream media, including the NewYork
Times, Boston Globe, Stateline, and CNN (Gardner,
2007; Lewin, 2007; "Richardson Must Apologize,"
2007;Vestal, 2007). Yet, this piece of legitimacy for
grieving mothers has faced substantial opposition
in some states, including California where it was
finally signed into law in October 2007 and in
New Mexico where it was vetoed (Lewin, 2007;
"Richardson Must Apologize," 2007).
Other significant legislative changes have also
occurred since the late 1990s. For example, in
Arizona in 2002 the MISS Foundation successfully
passed SB2001, the inception of the Unexplained
Infant Death Advisory Council, an interdisciplinary committee charged with investigating data on
infant deaths, from stillbirth to age three, for which
there is no obvious cause. Under Arizona Revised
Statutes section 36-2291, although the ultimate goal
of a death scene investigation is to accurately assign
a cause of death, equally important goals are the
identification of health threats posed by consumer
products; identification of risk factors associated
with unexplained infant deaths; and the referring
of families to grief counseling and support groups
(Arizona Department of Health Services, 2007) .The
committee would be charged with collecting data

SocialWork VOLUME 54, NUMBER I

JANUARY

1009

and issuing reports to the governor in an effort to
reduce the number of stillbirths and unexplained
child deaths in Arizona. Also, in May 2004 Arizona
Governor Janet Napolitano signed SB1003 into law,
an act that allows for a one-time tax deduction of
$2,300 for families experiencing stillbirth during the
same year in which the birth and death occurred
(MISS Foundation,2005a).This is intended to offset
the costs associated with the birth (hospital expenses,
childbirth preparation, ultrasounds, and other testing) and the death (final disposition expenses).
The National Institutes of Health (NIH) acknowledges that little is known about the etiology
of stillbirth (Alexander, 2003). Federally funded
research has followed the trend: For the first time,
the NIH, during 2003, earmarked funding for the
creation of the Stillbirth Research Collaborative
Network (SRCN)—five university-based research
centers around the country and an independent data
center—to collect and analyze statistics on stillbirth
(NIH, 2003).The research centers are collaborating
with NIH to determine the causes of stillbirth. The
five-year effort also seeks to develop standardized
research guidelines for reporting and investigating stillbirths. The five universities involved in the
SRCN are Brown University, Emory University,
University of Utah, University of Texas Medical
Branch, and University of Texas at San Antonio,
plus a data coordinating center at Research Triangle.
These research centers are currently working with
local hospitals to identify and track stillbirths. The
three specific aims ofthis five-year study are to
1. obtain a geographic population-based determination of the incidence of stillbirth,
defined as fetal death at 20 weeks gestation
or greater
2. determine the causes of stillbirth using a
standard stillbirth postmortem protocol that
includes a review of clinical history, protocols
for autopsies and pathologic examinations of
the fetus and placenta, and other postmortem
tests to illuminate genetic, maternal, and other
environmental influences
3. elucidate risk factors for stillbirth (National
Institute of Child Health and Human Development, 2007).
Interdisciplinary teams including obstetricians,
nurses, social workers, and grief counselors participating in the research initiative are also charged with

CACCIATORE / The Silent Birth: A Feminist Perspective

providing bereavement support for the mothers and
their families.
SOCIAL WORK'S ROLE

Social work requires an integrative worldview.
According to Bartlett (1970), this type of thinking
supports emotional and rational aspects of issues and
"requires a balance between our accountability and
our concern with things that cannot be quantified"
(Collins, 1986, p. 218). Although it may seem that
stillbirth is an emotion-based, social problem, there
are rational imperatives for social work's response.
Indeed, there is an obligation for a larger shift in the
macro culture; a shift that will likely sway attitudes,
beliefs, and values about women experiencing stillbirth. In particular, feminist-minded social workers
should be concerned with this uniquely woman's
issue.The shift needs to begin with subtle changes
to deconstruct the way that stillbirth is perceived
and to allow women who have undergone stillbirth
to construct their own realities about their losses.
Social workers, particularly in hospitals or as clinicians, have an opportunity to become involved in
helping women find their voices after the death of
a baby. This position is congruent with social work
values such as advocacy and social change, selfdetermination, and service. By adding stillbirth issues
to their agenda, social workers can break the silence
around stillt:>irth, acknowledging these women as
mothers and providing dignity and recognition
for their loved-and-longed-for babies (Cacciatore
& Bushfield, 2008). The landscape of stillbirth is
rapidly changing. Women, and even men, are no
longer finding themselves navigating "an unanticipated journey with outdated maps that no longer
accurately represent the sociocultural geography"
of their grief (Layne, 2003, p. 236). Improved standards of compassionate care in hospitals, supportive
nurturance from family and friends, and support
groups contribute to a lessening of posttraumatic
stress responses and chronic, debilitating grief (Cacciatore, 2007). These types of systemic changes and
grassroots efForts are giving women words—the
language—to speak about their losses, and when
individuals can find words to capture an experience,
society's responses to those experiences slowly evolve
in understanding. Legitimization for these grieving
mothers and fathers, through policy changes as well
as education, research, and advocacy, is a long overdue
change. And it is a change that can be supported by
academics, clinicians, and policymakers interested in

93

social justice. The time has come for these mothers
to ñnd their "power over mourning language" and
use their voices to influence relevant policies, even
when their pain is "pathologized, marginalized,
and otherwise restricted" (Kanter, 2002). It is an
opportunity for feminist social workers to respond
thoughtfully to a historically marginalized group of
grieving parents. And the hope is that as this social
movement gains momentum, women experiencing
stillbirth will no longer have to mourn their losses
in the same silence in which their dead children
were born. ECZl
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from http://www.stateline.org/live/details/
story?contentld=208701
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Joanne Cacciatore, PhD, MSW, is assistant professor. Department of Social Work, Arizona State University, P.O. Box
37100,
Plwenix,AZ85069-7100;e-mail:Joanne.cacdatore@
asu.edu.
Original manuscript received April 18, 2008
Final revision received June 19, 2008
Accepted July 11,2008

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