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When a Baby Dies: Ambiguity and
Stillbirth

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Joanne Cacciatore
John DeFrain
Kara L. C. Jones

ABSTRACT. Stillbirth, or sudden intrauterine death, is in many
ways an invisible death. A stillborn infant is one mature enough developmentally to have lived outside the womb but for some reason, or
perhaps multiple reasons, was born dead. Stillborn infants are often

Joanne Cacciatore, PhD, LMSW, FT, is Assistant Professor in the
School of Social Work at Arizona State University.
John DeFrain, PhD, is an extension professor of family and community
development in the Department of Family and Consumer Sciences,
College of Education and Human Sciences, at the University of Nebraska,
Lincoln.
Kara L. C. Jones cofounded KotaPress, an expressive arts outreach
specialist for bereaved parents and those who care for them (Website:
http://www.KotaPress.com).
Address correspondence to Joanne Cacciatore, Arizona State University,
Dept. of Social Work, 4701 W. Thunderbird, Glendale, AZ 85306. E-mail:
joanne.cacciatore@asu.edu
Sincere thanks to participants at the 2004 MISS Foundation Conference
who discussed the questions they deal with in regard to the loss of their children; thanks also to KotaPress Online Discussion Group Members and
MISS Forum Board Members for their e-mail responses to our questions
and to Genc Janaqi, MS, a doctoral student in the Department of Family
and Consumer Sciences, College of Education and Human Sciences, University of Nebraska-Lincoln, for his considerable efforts searching the literature
for relevant sources on ambiguous loss and stillbirth.
Marriage & Family Review, Vol. 44(4) 2008
# 2008 by The Haworth Press. All rights reserved.
doi: 10.1080/01494920802454017

439

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demarcated from other types of child death and are rarely legitimized
as a real loss. When a baby is stillborn, mothers, fathers, surviving
siblings, and grandparents may struggle for years to find answers to
a series of complex and inherently unanswerable questions. The family
members’ profound feelings of grief and ambiguity loss are borne in a
social environment that denies this reality because the child’s death
was invisible to most of the world. Boss’s framework for understanding ambiguous loss proves quite helpful in thinking about stillbirth.
KEYWORDS. Ambiguous loss, bereavement, boundary ambiguity,
infant death, stillbirth

INTRODUCTION
When a baby dies in a family, the surviving family members begin
a journey toward healing that continues, realistically speaking,
through the rest of their lives. They struggle together and as individuals to find answers to countless critical questions that, in many
profound ways, probably defy answers. In our own experience working with bereaved families who have lost a baby and as researchers,
we found ambiguity to be a dominant theme. The pioneering work
of Pauline Boss (1977, 1987, 1988, 1999, 2001, 2002) on ambiguous
loss, boundary ambiguity, and subsequent stress in families can be
used to better understand the nature of this tragedy.
Yet, literature searches in two prominent computerized databases
yield no studies linking infant death, in general, or sudden intrauterine infant death, in particular, and ambiguous loss. The American
Psychological Association’s PsycINFO catalogues more than
2,000,000 research-based and clinically based sources with none
making the connection. Similarly, Family and Society Studies Worldwide database, a joint project of the National Information Services
Corporation and the National Council on Family Relations (2004),
lists more than 600,000 sources: however, none recognizes the utility
of Boss’s ambiguous loss framework for understanding the emotional
crisis in the wake of the death of an infant.
Boss identified ambiguous loss as an element of the process and
underscored the difficulty of the challenges we face in life. The subtitle, Learning to Live with Unresolved Grief, to her book, Ambiguous
Loss (1999), illuminates this challenge. She is telling us in no

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uncertain terms that we can learn to live with the tragedies life brings
us, but resolution is less likely to be attained (Boss, 1999, p. 140):

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The dilemma for all of us is to bring clarity to an ambiguous
situation. Failing that, and we will in most cases, the critical
question is how to live with ambiguous loss. For each of us,
the answer will be different. But the answers are less critical than
the questions.
Her definition of family coping complements her thinking on
ambiguous loss (Boss, 2002, p. 79):
I therefore define family coping as the process of managing a
stressful event or situation by the family as a unit with no detrimental effects on any individual in that family. Family coping is
a cognitive, affective, and behavioral process by which individuals and their family system as a whole manage, rather than
eradicate, stressful events or situations.
In sum, the bereaved live with loss and manage loss, but loss remains
a part of grieving parents forever—for both better and for worse.
Loss, particularly death in a sense, can change people. And specifically, the death of a child changes the makeup of any family to
some degree.
Boss explains that when there is ambiguity regarding a family
member’s presence or absence in the family, the situation can be
called ambiguous loss. The family’s interpretation or perception of
the situation of ambiguous loss can be called boundary ambiguity
and as such is a risk factor or barrier to the family’s management
of stress, increasing feelings of disenfranchisement (Boss, 2001,
pp. 94–95). The relationship between boundary ambiguity and family
stress is relatively easy to grasp by looking at Figure 1.
Boss (2001) argues that low levels of boundary ambiguity (congruence between physical and psychological presence or absence) are
related to low levels of stress. As an illustration, in the long expected
death of an elderly parent, the middle-aged children and grandchildren of the deceased loved one are likely to grieve and then move
on with their lives. Or, in the case of an amicable divorce, the marriage over the years has lost its vitality, the spark is gone, and the
individuals are relatively free to begin new lives because of the

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Figure 1. Boundary Ambiguity and Family Stress. (From Boss, P. (2001).
Family stress management (2nd ed.). Thousand Oaks, CA: Sage.
Copyright # 2001 by Sage Publications. Reprinted by permission of Sage
Publications.)

congruence between physical absence and psychological absence. The
most debilitating aspects of grief are likely to end and the level of stress
for both ex-partners is low. Similarly, in situations in which there is
both physical and psychological presence there is also low stress. A
happy marriage is a good example of an intact family in which the partners are physically and psychologically together inside the system.
On the other hand, high-ambiguity situations, in which there is
physical absence and psychological presence or physical presence
and psychological absence, tend to be highly stressful. Physical presence coupled with psychological absence can be illustrated by families
with a member with Alzheimer’s disease or alcoholism.
Physical absence and psychological presence are critical elements of
families whose baby has died. Using Boss’s framework, we would argue
that the death of a baby is a highly ambiguous event and thus highly
stressful for family members: Although the baby is physically absent
after death, for many bereaved parents the baby’s psychological presence
continues for the rest of the family members’ lives in a multitude of ways.

STILLBIRTH, OR SUDDEN INTRAUTERINE DEATH
Stillbirth, or sudden intrauterine death, is in many ways an invisible death. A stillborn baby is one mature enough developmentally

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to have lived outside the womb but for some reason was born dead.
Gestational age distinguishes a stillborn baby from a miscarriage. A
miscarriage is defined as the spontaneous termination of a pregnancy
resulting from natural causes before the fetus is viable outside the
mother, generally before 20 weeks’ gestation. A stillbirth is defined
as the death of an unborn baby weighing more than 500 grams after
at least 20 completed weeks of gestation but before birth (DeFrain,
Millspaugh, & Xie, 1996; Institute of Medicine, 2002).
The number of deaths reported from stillbirth is equal to that of all
infant deaths combined (Ananth, Shiliang, Kinzler, & Kramer, 2005;
MacDorman, Hoyert, Martin, Munson, & Hamilton, 2007; National
Institutes of Health, 2003; Silver, 2007). Each year, more than 26,000
American women experience a stillbirth, compared with 2,500 infant
deaths each year attributed to sudden infant death syndrome
(National Institute of Child Health and Human Development,
2005; National Institutes of Health, 2003). Many stillbirths occur at
or near full term. Upon postmortem examination, between onefourth and one-half of stillborn infants are found to have died from
indeterminable causes (Faye-Peterson, Guinn, & Wenstrom, 1999;
Frøen, Gardosi, Thurmann, Francis, & Stray-Pedersen, 2004; Saller,
Lesser, Harrel, Rogers, & Oyer, 1995; Silver, 2007). In essence, a perfectly formed baby is born . . . dead.
Medical examiners and perinatal pathologists are unable to isolate
and identify the biological mechanisms for the death. Mothers are left
searching for answers, for any explanation to the questions surrounding the child’s death, and often in the turmoil of irrational self-blame
(DeFrain, Martens, Stork, & Stork, 1986, 1990). Although the clinical aspects of stillbirth are cloaked in obscurities, the psychosocial
dimensions of grief responses to stillbirth, as well as child death in
general, are even more elusive and sometimes disregarded by
researchers (Cacciatore, 2007).
For the woman, a baby’s death may incite an existential crisis.
Particularly in the case of stillbirth, a baby’s death is often demarcated from other types of child death and is rarely legitimized as a
real loss. Thus it may be difficult for a mother to reconcile her profound feelings of grief and loss. This pervasive sense of invisibility
after a baby’s death may exacerbate the boundary ambiguity related
stress, heightening the emotional tumult and social isolation.
And for both parents in the case of stillbirth, their status as ‘‘parents’’ becomes complicated because there are no tangible signs of

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parenthood to affirm their roles. Even if they have older living children, the full scope of their parenthood is ambiguous because most
people will not acknowledge the child who died at birth as a member
of the family.
Collectively, the family—mothers, fathers, surviving siblings,
grandmothers, and grandfathers—struggles through the years to find
answers to a series of complex and inherently unanswerable questions
(DeFrain, 1991; DeFrain, Jakub, & Mendoza, 1992; DeFrain et al.,
1986, 1990):
Why did our baby die?
Did I contribute to the death of our baby?
How can I love my spouse when my baby is dead?
Have I killed my sister?
Am I still a brother=sister?
What can others say that would make things better?
What can I do to help myself and others?
Should we have another baby? Will this happen again? Could I
endure it?
. Who will continue to be my friend now that my child is dead?
. Can good be found in the midst of such tragedy?
.
.
.
.
.
.
.
.

We do not answer these questions definitively in this article,
because they are essentially among the most elusive and complicated
aspects of infant death. But we use examples from our research, clinical work, commentary from support groups with whom we work, and
personal experiences to show how both individuals and family members struggle with the ambiguities of the loss of their baby and how
some are able to embrace the discordant and find peace even through
the uncertainty and unpredictability of ambiguous loss.

METHODS
This was a retrospective analysis of anonymous data collected by
two nonprofit organizations that provide care and support to grieving families after child death: MISS Foundation and KotaPress.
MISS Foundation is an international organization based in Arizona
that offers aid to families experiencing the death of a child at any age
and from any cause. They hold an annual international conference

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for bereaved families and professionals and have 27 online support
groups with thousands of members. KotaPress is a local group near
Seattle, Washington that mentors grieving families through the arts.
Quotations from bereaved family members cited in response to the
questions presented below in the Results section were compiled with
permission from 74 people, including grieving mothers, fathers, sisters, brothers, grandmothers, grandfathers, and an aunt. The questions were targeted to families who had experienced stillbirth only.
Locations of data collection included a discussion group with 55 participants at a bereavement conference in Phoenix, Arizona and an
online discussion group with 19 participants. The questions posed
by the nonprofit organizations were informed by empiric research
led by John DeFrain on infant death over the past 30 years
across nine distinct studies and involving more than one thousand
participants.

RESULTS
Why Did Our Baby Die?
There may or may not be a clinical answer as to why a baby died,
but the larger question of why is often more elusive. Many individuals
pose this question after the death of a baby, and some endure a genuine crisis of faith after the death of their child. These parents not only
end up searching for ways to endure the death, they may also lose
faith or seriously question their belief system. Some of them eventually find resolution, whereas others do not. For many, the death of
their baby precipitates its own type of ambiguous relationship with
their faith:
I thought God was testing me like he tested Job in the Bible
. . . but . . . there is no answer to WHY.
Does [G]od really care that my baby died? Maybe if I would
have been more faithful . . . [G]od wouldn’t have had to take
my daughter to teach me things . . ..
It sounds selfish, but why did ours have to die? Were we picked
for a reason?

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Some mothers told us that God was punishing them because they
had not wanted the baby and had considered an abortion. Consistent
with past research, others said they were being punished for an
extramarital affair (DeFrain et al., 1986, 1990).

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Did I Contribute To the Death of Our Baby?
Both mothers and fathers seem to grapple with issues of selfconfidence after the child dies. Some focus on the failure of their
bodies to bring forth life. Others question their work ethic before
the death. This can result, for mothers in particular, in an ambiguous
relationship with their own bodies. Again, some resolve this for
themselves and some do not:
I felt quite guilty about the stress-level I endured=ignored that
was generated by my job throughout my pregnancy.
What did I do wrong? . . . I’ve reverted back to ‘‘family of
blamers’’ tendency.
I was her connection to life and my body failed, therefore I am
at fault.
I will always think I did something. . . I got sick with the flu. I
tried really hard to take care of myself but I still got sick.
. . .It was my fault that he died—I carry the gene that killed my
son.

How Can I Love My Spouse When My Baby Is Dead?
Boss’s ambiguous loss model asserts that high levels of boundary
ambiguity (incongruence between physical and psychological presence or absence) are also related to high stress. Tension in the couple
relationship is common, but couples may also be drawn closer
together by the death. An earlier study of stillbirth among 304
mothers and fathers (80% mothers, 20% fathers) asked about divorce:
‘‘Have you ever seriously considered divorce because of the stillbirth?’’ Only 9% of the mothers and 7% of the fathers said yes. Some
couples find comfort from each other, and the immediacy of grief

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447

seems to bond partners together. It is clear that partnerships are
being recreated, redefined on many levels:
We entered a new place as a couple as a result of this tragedy . . .
there is a sense of invincibility there now that was not there
before.

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Sometimes I get mad. . . because he doesn’t seem to show emotions . . . but . . . he is grieving in a different way.
I feel so far from him at times, and so close at others. I have to
love him because he is the only other person in the world who
lost as much as I did . . ..
Profound grief has the ability to make people cling together for
dear life, forcing them to become closer than ever before. It also
has the ability to tear deeply caring and close people apart . . ..
The fact is that, no matter what else happens, only he knows
what I’ve been through . . . [but] our love from one another has
been forever changed . . ..

Am I Still a Brother/Sister?
The handful of siblings who responded to the questions seemed very
confident in their role as a brother or a sister. All respondents were
older siblings, born before the baby’s death. It is difficult to say what
ambiguities would exist for a subsequently born sibling wherein the
family is predominantly silent about the loss, and this warrants further
study. In many of the responses by siblings, the theme of a psychological presence=physical absence is palpable, as they continue to recognize
their brother or sister as part of their family system:
Yes, I am still a sister, a big sister . . . I am happy to be a big sister. I can be her big sister by visiting her at the grave, putting
pictures in her cabinet, drawing pictures of her in our family,
and when I grow up I am going to write books for her.
Yes I am because [she] is still in my heart and she always will be.
When people say she is not my sister and she is dead . . . it makes

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me feel angry and I say that she still is my sister, whether she is
on earth or not . . .. When someone dies, it doesn’t mean they are
not a part of our family anymore . . ..
I feel that I am still [his] brother despite the fact that I have never
heard his voice . . .. I find myself thinking about him often. Most
people tend to not think of [him] as my brother. My sister recognizes him as our sibling, but she tends to be the only one who
brings this subject up . . .. My parents never shy away from letting
people know that they love [him] and wear his memory proudly
for all to see. Because of this fact, I have never felt uncomfortable
or unsure about where I stand with them either . . .. I feel that I
have a stronger bond with my parents . . . while I shared my
strength with my family, they were simultaneously sharing their
strength with me. It is a powerful feeling . . ..

What Can Others Say That Would Make Things Better?
Responses from the discussion and support group members varied,
but everyone seemed resolved to let it be known quite clearly that
clichés simply do not work. Most believed there was nothing that
really could be said, but there were ways to share something so the
newly bereaved do not feel so isolated in grief.
The most helpful things . . . people shared with me were their
own experiences . . .. I hope I’ve learned to never utter a cliché
again in my entire life.
You can be there for someone to hold their hand but you can
never make it better.
I can help others . . . by sharing my own [story] . . . it’s almost as if
I have the ability to lend normalcy to a very abnormal situation.
Sometimes, it’s enough just to know that you are not alone . . ..

What Can I Do To Help Myself and Others?
Those whose children died more recently seemed unable to identify
helping behaviors. Those who have had more time since the death

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449

seem to have found many ways to help themselves and others. Again,
the idea of a psychological presence=physical absence was observed
in their responses as they engage in immersive grieving styles that
help them remain connected to their child in meaningful ways:

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For me, I journal, write poetry and work on the memorial
website . . . [for others] send e-cards, snail-mail cards . . . let the
person know that someone cares . . . not forget them . . . knowing
knowing that the grief lasts a lifetime.
Simply speak the names of the dead to those who loved them.
You can first of all talk . . . the more I was able to talk . . . the less
alone I felt. I also found that I was able to help others over time
as my need to talk became less I was able to listen.
I find crafting to be very deeply therapeutic, so I put my sewing skills
to use by making quilts for families who have recently lost a child.

Should We Have Another Baby? Will This Happen Again? Could
I Endure It?
Stillbirth is not just about the child who died and the grief parents
endure. There is a certain ambiguity and uncertainty that follows the
death of a baby before birth. This experience also extends into future
pregnancies, redefines decisions about how many children people
have, and can bring new stresses as issues such as secondary infertility
come up and must be addressed:
What followed was . . . years of secondary infertility, diagnosed
with PCOS . . . finally . . . put on Metformin . . . I conceived . . ..
Sadly, that pregnancy ended at 7 weeks in miscarriage. So, it
DID happen again to us, and yes we endured . . ..
Part of what I lost was the innocence I previously had . . .. I will
never again be unabashedly excited over a pregnancy . . ..
My sub [subsequently born child] is absolutely the best thing I
can ever imagine . . . [but] that [subsequent] pregnancy was the

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scariest time of my life. Too scary and horrible to endure again
even for the huge payoff.

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This question hurts. I cannot have another baby . . . [we] are both
carriers of the genetic disorder that took our son, which would
also cause 50% of our children to die . . .. Even so much as I
loved—and continue still to love—our son, that is not a fate
I am willing to risk.

Who Will Continue To Be My Friend Now That My Child Is
Dead?
There is a saying among members of bereavement groups that ‘‘friends
become strangers and strangers become friends.’’ Each case is different,
but there is little doubt that death changes people. These changes can be
difficult on relationships, even family relationships, and can sometimes
become stressors that seem insurmountable. For some, the agony of
watching their friend suffer becomes too difficult and they try to offer
quick fixes that, instead, alienate the bereaved parent. Sometimes
bereaved parents themselves report a feeling of not fitting in with their
usual group of friends. Some friends move on in life to focus on their
own children and in the flow of their lives often forget special days in
the lives of the bereaved friend, such as the deceased child’s birth or death
day and Mother’s or Father’s Day. A bereaved parent loses much more
than their child in death. They often lose their sense of purpose, roles,
future orientation, and even their friends. All these unique features of
stillbirth can add to the ambiguity of their very intimate losses:
My little address book completely changed after my child
died . . . I have a whole new set of friends.

Can Good Be Found in the Midst of Such Tragedy?
If any question borders on cliché, it is this one. And the polarization
of answers to it reveals how vulnerable the bereaved parent can feel:
Yes, I believe so. So many people have come to me . . . with our
loss, they are finally freed to talk about [their losses], and that
talking is so healing.

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451

I think that in order to survive in this world, for me, the answer
to this has to be yes. I may not be able to articulate what it
is . . . but I believe it is there. I believe we can create it.

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No. I hate that phrase. Even though I have learned so much . . .
I would give it all back to have her back.
Boy, this is a tough one. I still have a hard time finding any good
that has come from our loss. But I guess . . . I have learned a lot
about myself . . . my family . . . how much we really do love each
other . . . how blind and selfish I was to the people who had lost a
child before us.
Certainly good can be found. My [surviving] children have
developed a sense of compassion and strength . . .. Of course I
would have rather them grow up innocent, but . . . [her]death
made me realize who I am . . . who my real friends are . . . what
is important and what is just the junk of life . . ..
[Can any good come from this?] No.

DISCUSSION
Boss’s ambiguous loss model is highly relevant for families experiencing stillbirth, and the experience of the baby’s physical absence and
psychological presence is apparent in these findings. Thus stillbirth
appears to be a highly ambiguous event, resulting in high stress for
family members. The stress arises on deeply personal levels. From
questioning their faith and their partner to questioning themselves,
some of these issues linger in ambiguity and are simply unanswerable.
For example, parents of children who have died often ask, Why
me? Why my child? Those questions can haunt parents despite the
age of the child or the cause of death. Sometimes, a seemingly simple
question can only be answered with ambiguity. For some couples,
physical closeness is an integral part of healing. For other couples
or individuals, even the thought of intimacy may be overwhelming,
and partners may not understand these feelings. Reasons for failing
relational intimacy after a child’s death may include exhaustion; lack

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of interest; physical recovery time; feelings of guilt, shame, or blame;
fear; and psychic distraction. Mothers, in particular, who participated in these discussions expressed a sense of shame—selfbetrayal—over their body’s failure to produce a living, healthy baby.
She may no longer trust her own body and may wonder if her partner
feels the same. This emotional burden may impede a woman’s desire
for intimate contact.
Siblings, too, are affected by the baby’s death. Often, their grief
can result in somatic distress and may include a parade of physical
symptoms ranging from insomnia or hypersomnia, lack of appetite
or over-eating, regression in development, anxiety, irritability, anger,
hostility, apathy, nervous tics, muscle tension, emotional outbursts,
rage-like episodes, and tearfulness. These may last for months or
years after the sibling’s death (Opie et al., 1992).
As demonstrated in the findings of this study, bereaved parents
have similarities during the process of mourning the death of a baby,
and they also have differences. Parents with a more recent loss
seemed to struggle more to find meaning in their losses. Still, for
all the respondents, there seems to be an interminability to grief.
Grief often does not keep to a schedule. It is a timeless, nonlinear
procession of emotions that rises and falls. The reality of the child’s
death includes the grief over the possibilities and potential loss, the
endless wondering over what it would be like if the baby were still
alive day-by-day: ‘‘What would she be doing right now? What would
he look like?’’ Each day represents a new loss. Each new loss brings
an awakened grief. It will surely always hurt, though parents often get
more skilled at managing the hurt and navigating the journey
through grief. Though the baby is physically absent after death, for
many bereaved parents their psychological presence continues for
the rest of the family members’ lives in a multitude of ways.

CONCLUSION
When we read Pauline Boss on ambiguous loss, we are drawn to
her words because they ring true with our experiences in trying to
understand the meaning of the loss of a child in the life of a family.
The beauty of Boss’s writings on ambiguous loss is that it is a theory
for grown-ups: It does not patronize us, it does not hold out false
hopes and pat answers.

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The death of a baby is a horrendous event that generates an endless
cascade of profound and essentially impossible questions, and Boss
makes it very clear that life will always pose questions for us that
we will not, in the final analysis, be able to answer. Rather than give
us a false sense of security by throwing out a 6-fold path to healing or
a 10-point program for overcoming the tragedy inherent in living, she
reminds us that our lives still can be worthwhile and meaningful even
if we really don’t have a solid understanding of the what, where, how,
or why.

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