Ambiguous Loss After Miscarriage, Stillbirth, or a Diagnosis

You're filling out a form at a new doctor's office, and you stop at the line that asks how many times you've been pregnant. Or a friendly stranger at the park asks if this is your first. You know the true answer. You also know it could change the whole conversation, and you have about two seconds to decide which version to give.

If that pause feels familiar, there's a name for part of what you're carrying. Here's what ambiguous loss is, why it shows up so often around pregnancy and birth, and what helps.

What is ambiguous loss?

Pauline Boss, a family therapist and professor emeritus at the University of Minnesota, has studied ambiguous loss since the 1970s. Her early research was with wives of pilots missing in action in Vietnam. Their husbands were gone, and no one could tell them for certain whether they were alive.

She describes two kinds:

• Physically gone, psychologically present. Someone is absent, but you still carry them with you. Boss's phrase is "bodily absent but psychologically present."
• Physically present, psychologically gone. Someone is here, but not in the way you knew or expected. Her phrase is "physically present but psychologically absent."

Boss calls ambiguous loss "the most stressful kind of loss." It "defies resolution": there's no clear ending, often no ritual, and little public recognition that anything was lost.

She's also skeptical of closure. In a 2022 interview with the American Psychological Association, she called closure "a harmful word in human relationships" and said, "we don't close the door, we live with loss and grief."

Why pregnancy and baby losses carry so much ambiguity

Boss's definition is about losses without certainty. With miscarriage and stillbirth, we know the outcome: the baby has died. But there's still so much about the experience that is ambiguous.

In a 2011 Canadian study, researchers interviewed 13 couples at three points in the year after their baby died during pregnancy or soon after birth. They described perinatal loss as "a type of ambiguous loss" and found ambiguity in four places:

• Whether the pregnancy was viable
• The physical process of the loss
• Making arrangements for the baby's remains
• Telling other people

The couples also ran into what the researchers called "society's minimization" of their grief. Grief researcher Kenneth Doka named this in 1989: disenfranchised grief, the grief of a loss that other people don't openly acknowledge or support. I've written more about disenfranchised grief after miscarriage.

When a loss is unclear and the people around you don't count it, grief has nowhere obvious to go.

Miscarriage

Many miscarriages happen before anyone else knew about the pregnancy. There may be no body to hold, no name yet, no funeral, and medical paperwork that says "products of conception" or "spontaneous abortion."

The physical process can be drawn out, too. You might bleed for days, wait for the pregnancy to pass, have a procedure, or need another scan to confirm it's over. Even the moment of the loss can be hard to pin down.

So the questions pile up. Was it a baby? Am I allowed to be this sad? Do I count it when someone asks? Your answers may change over time, and they may be different from your partner's.

Stillbirth

Stillbirth happens in about 1 in 175 births in the US, about 21,000 babies a year, according to the CDC.

You go through labor. Your body recovers from birth, and your milk may come in. You may have held your baby, named them, and taken photos. Then you leave the hospital without them.

Joanne Cacciatore, a stillbirth researcher at Arizona State University, applied Boss's work to stillbirth in 2008. She and her coauthors describe stillbirth as, in many ways, an invisible death. Your baby was fully real to you, and barely known to anyone else.

That's where much of the ambiguity lives. You are your baby's mom, and the world may not see you as one. Boss calls this boundary ambiguity: uncertainty about who is part of the family. It comes up in small moments, like a birthday you don't know how to mark, or the question of how to tell your future kids about their sibling.

For more on the first weeks after a stillbirth or miscarriage, see perinatal grief and loss.

When your baby has a diagnosis

This is Boss's second kind of loss. Your baby is here, or on the way, and you're grieving anyway. The grief is for the pregnancy, birth, baby, or future you had pictured, at the same time you're loving and caring for the baby you have.

With a prenatal diagnosis, the baby is there, but a loss may be coming and no one knows yet what it will be. That uncertainty is the ambiguity.

Grieving the future you expected says nothing about how much you love your child. Many parents in this spot feel both, often in the same afternoon: I love my daughter. I'm grieving her diagnosis.

In 1998, nursing researchers at East Carolina University described something they called chronic sorrow: "the periodic recurrence of permanent, pervasive sadness or other grief related feelings associated with a significant loss." They describe it as a normal response to an ongoing gap between what is and what you'd hoped for. It tends to come back at trigger points, like an appointment, a milestone, or another family's birth announcement. If the grief returns after you thought you'd moved through it, that fits the pattern.

If you've been told your baby may not live long after birth, ask your care team about perinatal palliative care. These teams help families plan for the time they'll have with their baby.

The NICU

A NICU stay can bring both kinds of ambiguity at once. Your baby is alive and right in front of you, but you may not be able to hold them when you want to. The nurses may know your baby's routines better than you do. You go home every night without your baby, and for days or weeks, you have no definitive timeline for when you'll get to bring them home.

A 2003 study of parents of premature babies found what the researchers called a "joy-grief contradiction." Parents were glad their baby was alive and mourned "the loss of a full-term pregnancy" while fearing for their baby's life and health.

It doesn't always end at discharge. In a 2018 New Zealand study, nine moms whose children were born at 28 weeks or earlier still described grief years later, when their kids were 4 to 7. They also celebrated their children's successes and noticed their own resilience. Both were true.

Other losses that can feel this way

Ambiguity shows up in many other perinatal losses. A few that moms often don't realize they're allowed to grieve:

• Very early loss or chemical pregnancy. A positive test, then a period. You may wonder whether it counts.
• Missed miscarriage or blighted ovum. The pregnancy has ended or never developed an embryo, but your body hasn't caught up. Sometimes there's a long wait between the news and the loss itself.
• Ectopic or molar pregnancy. These are often handled only as medical emergencies, and the grief gets skipped. A molar pregnancy can also mean weeks or months of blood tests before you can try again.
• Losing one twin. Whether early or later in pregnancy, you're grieving one baby while caring for the other, and people tend to see only the baby who's here.
• Ending a wanted pregnancy after a diagnosis. Sometimes called TFMR, this carries all of the above plus a decision you never wanted to make. Because many families keep it private, the grief can be especially lonely.
• Pregnancy after loss. You may hold back from attaching "until we're safe," and live scan to scan. If the worry takes over, prenatal anxiety is worth reading about.
• Failed IVF transfers or leftover embryos. A negative test after a transfer, or deciding what to do with embryos you won't use, rarely comes with any ritual at all.
• Placing a baby for adoption. This is a clear case of Boss's first kind of loss: the child is alive and absent. A 2000 study of 163 birth moms found the child stayed psychologically present in their lives.
• Your partner's grief. Partners often grieve quietly and are asked about least.

Getting support for grief

Grief after these losses can be intense and can last a long time, and you don't have to wait until it feels unmanageable to get support. Therapy can help with grief at any intensity. It's helpful to process a loss like this with a trained provider, even when you're getting through most days.

Some signs mean it's especially important to reach out soon:

• Weeks or months later, you're struggling to get through the day
• You keep replaying the birth, the hospital, or the moment you got the news, or you're avoiding anything that reminds you. These can be signs of trauma, and birth trauma recovery covers what helps.
• You're pregnant again and the fear is taking over
• You feel numb or hopeless, or like you don't want to be here

If you're having thoughts of not wanting to be alive, or of hurting yourself, call or text 988, or the National Maternal Mental Health Hotline at 1-833-852-6262 (free, 24/7). If you're in immediate danger, call 911.

The Postpartum Support International HelpLine, 1-800-944-4773, isn't a crisis line, but it can connect you with support. PSI also runs free online support groups, including groups for pregnancy and infant loss.

What helps: ideas from Pauline Boss

Underneath all of Boss's work is what she calls both/and thinking. In the APA interview, talking about hoping for an answer while also moving forward, she said: "It has to be both. It can't be one or the other." With perinatal loss, that might sound like:

• I'm grateful for my rainbow baby, and I still miss the baby before him.
• My son is home and doing well, and I'm still grieving the birth we didn't get.
• I love my daughter, and I'm grieving her diagnosis.

In her 2006 book Loss, Trauma, and Resilience, Boss lays out six guidelines for living with ambiguous loss, built around meaning, mastery, identity, ambivalence, attachment, and hope. Here's how each can look after a perinatal loss.

Put the loss into words. Making meaning starts with naming what happened. Say "my baby died" or "our son has a heart condition" in your own words, to someone who can hear it. Meaning doesn't require a reason. You never have to accept "everything happens for a reason."

Ease up on finding out why. When a loss has no clear cause, many moms search for the thing they did wrong. Often there's no answer to find. Put that energy into what you can shape: who you tell, how you mark the day, what you need this week.

Decide who you are now. You are this baby's mom, whether or not anyone else sees it. You get to choose how you answer "How many kids do you have?" and the answer can change depending on who's asking. "Two, and one who died." "One here." "This is my first, and we lost a baby last year." All of those are honest.

Make room for mixed feelings. Relief and grief. Love and resentment. Being happy for a friend's pregnancy and not wanting to go to her shower. Mixed feelings are part of ambiguous loss, and having them says nothing bad about you as a mom.

Stay connected in a new way. You don't have to let go of your baby. Some families keep a connection through a name, a keepsake, an ultrasound photo, marking the due date or birthday, or joining others on October 15, Pregnancy and Infant Loss Remembrance Day. With a diagnosis, it can mean slowly loosening your hold on the child you pictured while you get to know the child you have.

Look for small, specific hope. That might be a good hour with your baby in the NICU, a friend who says your baby's name, a day that felt a little lighter, or a next step you feel ready to take.

Working with me

I'm Dr. Jana Rundle, a licensed clinical psychologist certified in perinatal mental health (PMH-C), which is the focus of my practice. Many of the moms I work with have been through a loss like the ones in this post.

If you'd like to talk it through, book a free 15-minute consultation. I see clients in person in Austin and online across Texas and PSYPACT states. You don't have to know what to call your loss first.

You don't have to resolve this loss to live with it. You can carry this baby as part of your family's story and still make room for whatever comes next.

Sources

• American Psychological Association. Ambiguous loss and the "myth of closure," with Pauline Boss, PhD. Speaking of Psychology, episode 181, 2022.
• Boss P. Ambiguous Loss: Learning to Live with Unresolved Grief. Harvard University Press, 1999.
• Boss P. Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss. W. W. Norton, 2006.
• Boss P. The Myth of Closure: Ambiguous Loss in a Time of Pandemic and Change. W. W. Norton, 2021.
• Boss P. Origins and history of ambiguous loss. AmbiguousLoss.com.
• Cacciatore J, DeFrain J, Jones KLC. When a baby dies: ambiguity and stillbirth. Marriage & Family Review, 2008.
• Centers for Disease Control and Prevention. Data and statistics on stillbirth.
• Doka KJ. Disenfranchised Grief: Recognizing Hidden Sorrow. Lexington Books, 1989.
• Eakes GG, Burke ML, Hainsworth MA. Middle-range theory of chronic sorrow. Image: The Journal of Nursing Scholarship, 1998.
• Fravel DL, McRoy RG, Grotevant HD. Birthmother perceptions of the psychologically present adopted child: adoption openness and boundary ambiguity. Family Relations, 2000.
• Golish TD, Powell KA. 'Ambiguous loss': managing the dialectics of grief associated with premature birth. Journal of Social and Personal Relationships, 2003.
• Joseph RA, Highton M. Ambiguous loss: implications for perinatal and neonatal nurses. Neonatal Network, 2025.
• Lang A, Fleiszer AR, Duhamel F, et al. Perinatal loss and parental grief: the challenge of ambiguity and disenfranchised grief. Omega, 2011.
• Wilson C, Cook C. Ambiguous loss and post-traumatic growth: experiences of mothers whose school-aged children were born extremely prematurely. Journal of Clinical Nursing, 2018.