Pregnancy Loss Memorialization & Practical Considerations

Whether you can take bereavement leave for a miscarriage depends on your employer’s policy.  Some companies proactively include miscarriage and pregnancy loss in the eligibility criteria for their bereavement leave policies, whereas others may have separate policies defined specifically for miscarriage. When a miscarriage is included in an existing bereavement leave policy, you can generally expect to have a few days of paid time off from work. However, if miscarriage is not included in the policy, it may mean that you have to take unpaid time off or use vacation time to cover your absence.

As an alternative to bereavement leave, women who have experienced a miscarriage are entitled to take time off under the Family Medical Leave Act (FMLA). Miscarriage is considered a serious health condition related to pregnancy, and most women are entitled to up to 12 weeks of unpaid, job-protected leave through FMLA. This extended leave may be helpful if you need additional time to process your loss. However, if your employer has a bereavement policy that allows you to take a certain number of days off with pay, this may be more helpful if you need your income to support yourself and your family. 

In an effort to address gaps and lack of consistency regarding leave coverage for miscarriage, many states have started amending legislation to require that companies acknowledge pregnancy loss in their bereavement leave policies so that employees can take time to grieve and process their loss. Further advocacy will likely be needed to maintain momentum in the efforts to have pregnancy loss widely recognized and included in bereavement leave policies throughout the nation. Until then, advocating for yourself and being transparent about the need for time off after experiencing a miscarriage is a crucial component in caring for your well-being and prioritizing your health.

Sources

“You Can Take Time Off After a Miscarriage. Here’s How to Do It.” InHerSight. https://www.inhersight.com/blog/pregnancy/miscarriage-leave-from-work 

“Emerging trend: Bereavement leave covers reproductive losses”. HR Morning. https://www.hrmorning.com/news/bereavement-leave-pregnancy/ 

Since every state has guidelines for reporting fetal death and stillbirths, the provision of a certificate and the type issued can vary. These state guidelines determine whether an individual is required to file for a death certificate or an alternative certificate after a stillbirth or miscarriage has occurred. Types of certificates that may be issued based on state requirements can include the following:

• Fetal death certificate 
• Certificate of spontaneous termination of pregnancy (miscarriage)
• Certificate of stillbirth

If the fetus has reached a gestational age of 20 weeks or beyond, some states will issue a fetal death certificate. This certificate may also be issued if the fetus weighs 350 grams (12 ounces). Although the gestation requirement of 20 weeks is relatively consistent across states, the weight requirement can vary. In states where a certificate of spontaneous termination of pregnancy (miscarriage) is available, such as New York, the certificate is typically issued for fetuses that are 20 weeks of gestation or less. 

Fetal death certificates must be filed within a specific period after delivery according to each state’s reporting requirements. For example, Alaska requires the filing of fetal death certificates within three days after delivery. States can also choose to adhere to a five-day reporting period per the recommendations in the Model State Vital Statistics Act and Regulations of 1992.

When fetal death certificates are not issued, alternative forms of documentation, such as the certificate of stillbirth or the certificate of spontaneous termination of pregnancy (miscarriage), are used instead. These certificates may serve some administrative or legal purpose. However, their primary purpose is to acknowledge the loss that the individual has experienced. 

In states that have specific weight or gestation requirements, a fetal death certificate may not be required if the fetus doesn’t meet those requirements. If a state bases its fetal death certificate requirement solely on gestational age, but the gestational age cannot be determined, the parents are generally allowed to decide whether they want to file the fetal death certificate or not. 

Sources

“Stillbirth or Miscarriage Certificate”. NYC 311. https://portal.311.nyc.gov/article/?kanumber=KA-03562 

“State Definitions and Reporting Requirements”. NCHS. https://www.cdc.gov/nchs/data/misc/itop97.pdf 

“Model State Vital Statistics Act and Regulations”. NCHS. https://www.cdc.gov/nchs/data/misc/mvsact92b.pdf 

The term “rainbow baby” or “double-rainbow baby” refers to a child born following the loss of a previous pregnancy or infant. This loss may be due to miscarriage, stillbirth, or other types of infant loss. A “rainbow baby” follows one loss, while a “double-rainbow baby” follows two. The rainbow terminology is intended by many as a symbol of hope and joy after a difficult period, much like a rainbow appears after a storm. It is important to note that while this term is beautiful and meaningful to a large community, not all parents are comfortable with this metaphor, as experiences of loss are deeply personal.

Parents in a subsequent pregnancy or with a new baby after a loss navigate unique emotional challenges, celebrating the arrival of a child while mourning the loss of another. While these parents may feel joyful and excited about their new baby, they also tend to feel anxious and sometimes fearful for the future since they have already experienced loss. Sometimes feelings of guilt emerge as some parents may feel that they don’t have the right to be happy about the arrival of a new baby since they are still grieving the loss of their previous child or children. This complex range of emotions often means that parents navigating pregnancy after a loss are also facing the unique challenge of experiencing how grief and joy coexist throughout their journey into parenthood.

Navigating Pregnancy After Loss: Finding Support

The anxiety and complex emotions of a pregnancy after loss are normal, and seeking support is a sign of strength. Practical strategies include:

• Seek Specialized Professional Support: Consider a therapist or counselor specializing in perinatal mental health or grief. They can provide tools to manage anxiety and process conflicting emotions in a safe space.
• Connect with a Supportive Community: Seek out in-person or online support groups specifically for pregnancy after loss. Sharing experiences with those who truly understand can reduce feelings of isolation. Your healthcare provider or local hospital may offer referrals.
• Communicate with Your Care Team: Be open with your obstetrician or midwife about your history and anxieties. They can offer more frequent check-ups, additional monitoring, or simply a listening ear to help you feel more secure.
• Develop a Coping Plan: Work with a partner, friend, or professional to identify what triggers anxiety and establish calming rituals, such as mindfulness, gentle movement, or journaling, to use when feelings become overwhelming.
• Honor Your Unique Journey: Allow yourself to feel all emotions without judgment. It’s okay to be cautious about bonding during pregnancy, to celebrate milestones on your own terms, and to find personal ways to remember your lost baby while embracing the new pregnancy.

Many parents also find connection and recognition on National Rainbow Baby Day, observed on August 22nd, although not all parents affected by pregnancy after loss choose to participate solely on this date. The intent in observing this day is to reflect, remember, and honor these losses that have been experienced. It also serves as a day of gratitude and celebration for babies who were eventually born after these losses occurred. 

Sources

“What is a Double-Rainbow Baby? A Pediatrician Explains”. Romper. https://www.romper.com/life/what-is-a-double-rainbow-baby 

“What to Know About Having a Rainbow Baby”. Parents. https://www.parents.com/baby/what-it-means-to-be-a-rainbow-baby-and-why-rainbow-babies-are-beautiful/ 

The cost of an infant or stillbirth funeral can vary, but it can cost a minimum of $3000 when embalming, a casket, and additional services are included. Similar to adult funeral expenses, fees for services such as body preparation and transportation can quickly increase the overall cost of the funeral. While many people are prepared for an adult funeral due to pre-planning, most individuals do not anticipate the death of an infant and frequently struggle to afford the costs of making final arrangements. 

There are often significant medical expenses associated with a stillbirth or the death of an infant. Although insurance can cover many of these expenses, it can be difficult to afford the additional expenses of a funeral after paying the out-of-pocket costs following a stillbirth or infant death. The costs of funerals, burials, and cremations often need to be handled more imminently and many individuals struggle to pay. Hospital social workers can help by connecting affected individuals with financial assistance programs and non-profit organizations that may be willing to help cover these costs. Additionally, some hospitals set aside funds for financial assistance if individuals can demonstrate need and an overall inability to pay for a funeral. 

There are many funeral homes that are willing to work collaboratively to plan a funeral that fits within the budget of families who have experienced a stillbirth or infant death. Options such as financing may be available, and some funeral homes will also significantly discount the cost of services to make a suitable funeral more affordable. Ultimately, maximizing the use of local resources and working closely with a funeral home can help bereaved families design a funeral that honors their infant or stillborn baby in a sensitive and dignified manner. 

Sources

“Tips for Getting Through Infant Funeral Planning”. Direct Cremate. https://www.directcremate.com/tips-for-getting-through-infant-funeral-planning/ 

“From diagnostics to autopsy to burial, stillbirths are alarmingly expensive in America”. Vox. https://www.vox.com/the-highlight/2019/7/23/20698480/stillborn-stillbirth-baby-costs-expensive 

The final arrangement options that are available for a stillborn infant can sometimes vary based on the gestational age and weight of the baby in accordance with state regulations for fetal deaths. For example, Texas state law requires that stillborn babies weighing over 350 grams (12 ounces) or older than 20 weeks gestation must be buried or cremated by a funeral home. But Pennsylvania state law has a similar requirement for stillborn babies who are 16 weeks gestation or older. Assuming that the registration for fetal death requirement is met, many states treat stillbirths the same as adult death and require a cremation or burial as a result.

A key distinction that varies among states is the alternative option of allowing the hospital to make final arrangements. There are some states that mandate the disposition of fetal remains and provide the option of allowing the hospital to handle the arrangements, while there are other states that only require that the death be registered and a certificate of stillbirth issued if necessary. When hospitals become responsible for the disposition of the remains, communal cremations or burials in a shared plot are the only options available. 

Ultimately, while the responsibility of making arrangements generally falls on the guardian or parent, state laws and mandates often greatly inform which arrangements can be made. Due to the complexities of state laws and ongoing legislation surrounding fetal death, individuals are advised to consult with local professionals to understand the requirements and respective options that are relevant to their state. Factors such as whether the stillbirth occurred at home or in the hospital can often affect how state laws are interpreted, and likewise, if there are specific criteria that must be met for a cremation or burial to occur. 

Sources

“Arrangements after a miscarriage or stillbirth”. Texas Children’s Hospital. https://www.texaschildrens.org/patients-families/patient-and-family-resources/death-child/arrangements-after-miscarriage-or 

“Navigating Immediate Decisions & Situations After Stillbirth”. Bodily. https://itsbodily.com/blogs/pregnancy-loss/stillbirth-support-what-you-need-to-know

An autopsy, also known as a post-mortem exam, is not mandatory when an infant dies of known causes, but may be recommended for further insight into the extent of those causes. However, the National Association of Medical Examiners (NAME) forensic autopsy performance standards indicate that a forensic autopsy should be performed if death is unexplained or unexpected in an infant or child. Some states have laws that require autopsies if the cause of death is Sudden Unexpected Infant Death (SUID). The state of Florida, for example, requires an autopsy within 24 hours or as soon as possible following the death of an infant under one year of age. 

If the physician is already aware of the cause of death of the infant, an autopsy may be requested so that the physician can understand the full extent of the condition or abnormality that caused the death, as well as any potential underlying conditions that were not previously known. These autopsies are typically voluntary, which means that they can only be performed with the consent of the parent, guardian, or other legally authorized representative. If the death is unexplained or unexpected and an investigation is mandated, then a coroner’s autopsy or forensic autopsy is conducted instead. These autopsies are required to resolve any investigative concerns surrounding a death of unnatural, suspicious, or unknown causes. 

Whether an autopsy is necessary following the death of an infant depends largely on the circumstances surrounding the death, as well as the professional discretion of legal authorities and medical providers in the area. Understandably, the idea of an autopsy can be a sensitive matter for those who are grieving the recent loss of a baby. However, autopsies can provide valuable insight into the cause of death, which can be a source of clarity and solace after a loss. In any regard, complying with a request for an autopsy is generally recommended, especially if there are any concerns surrounding the death.

Sources

“Autopsy Information for Parents and Relatives”. Manning Family Children’s Hospital. https://www.manningchildrens.org/services/hospital-services/autopsy-information-for-parents-and-relatives/ 

“The 2024 Florida Statutes (including 2025 Special Session C)”. The Florida Legislature. http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0300-0399/0383/Sections/0383.3362.html 

“Under What Circumstances Will an Autopsy be Performed?” Washoe, NV Regional Medical Examiner’s Office. https://www.washoecounty.gov/coroner/faq/when_is_autopsy_performed.php#:~:text=The%20National%20Association%20of%20Medical,in%20an%20infant%20or%20child. 

Some common memorial options for honoring your baby after a loss can include creating physical memorials, incorporating personalized jewelry or keepsakes, or establishing a legacy. Since losing a baby is often an intensely emotional experience, finding ways to honor and remember your baby can be an important part of facilitating the healing process. There is no ‘one-size-fits-all’ approach to memorialization, but finding a memorial option that feels right for honoring your child can aid in providing solace and comfort as you navigate through your grief.

Many people prefer physical memorials since they provide a more tangible sense of connection and create a space for reflection. Some popular choices for physical memorials include: 

• Planting a tree or shrub
• Creating a memorial garden 
• Making a dedicated space in your home for pictures and keepsakes
• Preserving your baby’s nursery 
• Creating artwork such as paintings or illustrations 
• Make a memory box, hope chest, or a collage 
• Have a memorial gathering 
• Start a website or a blog 
• Write poetry 

Another common memorial option that provides a similar level of tangibility is creating personalized jewelry or keepsakes. Many companies create personalized items such as keychains, necklaces, bracelets, rings, resin sculptures and more. These items can include your baby’s name and birthdate, but can also include a fingerprint or ashes if that is your preference. These are very popular options since jewelry and keepsakes can be kept close as you proceed with your daily routine. Additionally, you can also take a do-it-yourself approach to create something truly unique to carry with you. 

The decision to establish a legacy is a personal choice and can be a great way to honor your baby while having a positive impact on the lives of other people. There are a variety of ways to accomplish this. Some people opt to make a donation to a charity or foundation in memory of their baby, while others might prefer to start their own foundation or community initiative. Other possible activities include volunteering for charitable causes, helping out with community events, or even running a marathon. If the loss of the baby was due to a specific illness or disorder, some parents find it helpful to get involved with advocacy and other supportive efforts to increase awareness and fund research aimed at treating the disease.  

Sources

“11 Ways to Honor Your Baby Who Died on Their Loss Anniversary”. Pregnancy After Loss Support. https://pregnancyafterlosssupport.org/honor-baby-died-loss-anniversary/ 

“​​Ways to honor a baby who dies in pregnancy or infancy”. BabyCenter. https://www.babycenter.com/pregnancy/your-life/honoring-a-baby-who-dies-in-pregnancy-or-infancy_10339724