Bereavement is a concern that extends beyond the boundaries of clinical interest; it affects at some point every family and raises logistical and policy issues for the health and social service agencies of every community (2). PB is characterized by a complex emotional response, most manifested as grief in both the mother and father, but often expressed differently between them, both in intensity and duration. The grief response of PB is influenced by situational, internal and external factors.

Often, PB is interchangeably used with terms like grief and mourning. Distinguishing between bereavement, grief and mourning, Stroebe and Hansson ( (2) emphasized that where bereavement is the objective situation of having lost someone significant; grief is referred to the emotional response to one’s loss. On the other hand, the actions and manner of expressing grief is known as mourning which often reflect the remembrance practices of one’s culture. Grief, which has been measured to know the bereavement, is a symptom of bereavement (2, 7). However, it is not the only response to bereavement (17). It is the emotional reaction that follows the loss of a valued other, or a normal response characterized by intense and deep sorrow that may be manifested in psychological, physical, behavioral or social ways. Similarly, mourning has been noted as a time-limited and dynamic expression of bereavement, varying from person to person and across time. It is further described as the manifestation of culturally patterned behaviors during bereavement that incorporate the experience of the loss into the outward expression as life is lived (18).

PB as a concept emerged in the 1970s; until then, the death of a baby, whether by miscarriage, stillbirth, or neonatal death, was not recognized by the medical community as a meaningful loss (19). With growing demand for reproductive rights, advances in abortion-related medicine, and increased clinical deliveries, reporting of fetal, perinatal, and neonatal deaths rose globally. Consequently, perinatal loss and its associated bereavement became a focus of interdisciplinary study.

The seminal work of Kennell et al. (19) provided the first empirical evidence that women experience significant mourning following infant death. This recognition spurred extensive research on PB through the 1980s (18, 19). Since this period, several self-report tools were designed to measure grief symptoms (2, 19–25). The development of these measurement scales was grounded in broader theoretical frameworks that sought to explain how individuals experience and cope with loss. Stroebe and Hansson ( (2) outlined three key theoretical approaches to bereavement: psychoanalytic, attachment, and stress theories. Drawing on Freud (26), the psychoanalytic view sees grief as a cognitive process of “grief work,” where the bereaved gradually detach emotional energy from the deceased (25, 26). Bowlby’s (1969) attachment theory interprets grief as a biological response aimed at restoring closeness to the lost attachment figure, while cognitive stress theory frames bereavement as a stressful life event whose impact on health can be moderated by coping resources such as social support (2, 27). While these scales have informed understandings of loss, less attention has been given to how parents experience and make sense of perinatal bereavement within their socio-cultural contexts. This study addresses this gap through an interpretative phenomenological examination of mothers’ and fathers’ lived experiences.

This study employed a dual-phase qualitative analysis design to understand the lived experiences of parents who had experienced either stillbirth or the death of newborn within 24 hours of birth. The Phase I utilized Braun & Clarke’s six-step method to identify broad patterns, while Phase II (IPA) explored the idiosyncratic, lived experience of loss. The IPA was chosen because it enables in-depth exploration of how individuals experience, interpret, and give meaning to their loss (28). The final interpretation was guided by an integrated theoretical framework: the Dual Process Model (DPM) was used to categorize themes into ‘Loss-Oriented’ and ‘Restoration-Oriented’ stressors, while Continuing Bond Theory provided the lens for understanding how participants maintained connections with their infants (29). The study followed the consolidated criteria for reporting qualitative research (COREQ) checklist (30) to systematically enhance clarity, transparency, and rigor in qualitative research reporting, which has been provided as Supplementary Table 3.

The study was conducted in Palwal district of Haryana, a state in north India, as part of the SHRiSTI Project, an initiative supported by the Indian Council of Medical Research (ICMR). The broader SHRiSTI project is a multi-site IR program operating across six states of India (Karnataka, Maharashtra, Rajasthan, Meghalaya, Uttar Pradesh, and Haryana) to generate context-specific evidence for stillbirth prevention (31). The present study, however, aims to deepen understanding of how parents experiencing perinatal loss make sense of their bereavement and cope with loss within a specific socio-cultural context.”

The objective of this study is to examine parents’ lived experiences and responses following perinatal loss, and to explore the factors shaping their grief and coping strategies. In the present study, PB refers to the loss experienced by parents due to perinatal death, encompassing both stillbirths and early END. For this research, perinatal loss is operationally defined as the death of a baby either before or within 24 hours after birth. Stillbirth is defined as intrauterine death (IUD) occurring at or beyond 28 weeks of gestation, where the fetus shows no signs of life at birth. END, in this context, refers specifically to the death of a live-born infant within the first 24 hours of life. This definition is adopted to maintain consistency in case selection and to focus on the most acute period of perinatal loss that has significant emotional and psychological impact on the parents.

The study participants were identified through a multi-step process. First, the details (name of the parent, date of delivery, contact number) of cases with stillbirth and END were extracted from the delivery registers at the District Hospital (DH), Community Health Centers (CHCs), and Primary Health Centers (PHCs). Along with this, the cases of Home delivery or private delivery were collected from the Accredited Social Health Activist (ASHA) workers by two research team members. A combined linelist which included detailed list of cases of stillbirth and END was prepared from the collected information by the research team member with a degree of B.Sc. Nursing. Later, this list were handed over to the project coordinators with master’s in public health, who compiled the lists and were responsible for confirmation of the cases for reported pregnancy outcomes via telephonic interviews with bereaved parents (mostly fathers they received the calls in most cases. Afterwards, another research team member with B.Sc. Nursing was responsible for conducting a Verbal Autopsy and Social Autopsy (VASA) interview with all the mothers with stillbirth and END cases using the World Health Organization (WHO)-VASA Tool which confirmed the case’s stillbirth or END status (34). The final list was then prepared by the project coordinator and followed via telephonic interview by three other team members with graduate degree. The identified and confirmed cases with different outcomes of perinatal loss were contacted one week before the day when the in-depth interviews (IDIs) were conducted.

Given the idiographic orientation of phenomenological analysis, purposive and relatively homogenous sampling was prioritized. Homogeneity in qualitative research does not imply uniformity but rather ensures that participants share key characteristics related to the phenomenon of interest, which facilitates in-depth exploration and comparison across cases (32, 33). Inclusion criteria were bereaved parents (both mothers and fathers) aged 18 years or older who had experienced a stillbirth or END within the preceding six months from the date of interview. Participants were required to be permanent residents of the study area, able to provide informed consent, and available for an IDI at the time of data collection. Exclusion criteria included parents who had permanently relocated outside Palwal district, could not be contacted after repeated attempts, or declined to participate in the study. The restriction by timeframe of loss, geographic location, and socio-economic context ensured relative homogeneity of the study population.

IDIs were conducted between January and August 2025 with bereaved mothers and fathers. To ensure cultural appropriateness and participant comfort, mothers were interviewed by a female social scientist and fathers by a male qualitative researcher, both holding and pursuing PhDs in Anthropology respectively. A male and a female team member with graduate degree accompanied the interviewers. They were responsible for note-taking, documenting the interview context, and recording non-verbal cues, which were later used to supplement the transcripts. Each interview was scheduled in advance at a time convenient for the participant and was conducted at their home, workplace, or another private location of their choice. In the case of working mothers and fathers, interviews were often arranged early in the morning before 10:00 AM or on Sundays to accommodate their work schedules. A total of 30 IDIs (15 mothers and 15 fathers) were conducted across different blocks of the district. Each interview lasted between 45 and 75 minutes, was audio-recorded with the participant’s consent, and supplemented with detailed field notes. The process of data collection continued until ideographic completeness was achieved, defined as the point at which no new themes emerged from the narratives. The timeline of data collection has been provided as Figure 1.

Separate IDIs were conducted with bereaved mothers and fathers using pre-structured interview guides developed individually for each group. The guides were prepared after reviewing existing literature, international guidelines, and national documents on maternal health and bereavement support, and through consultations with subject experts in community medicine, obstetrics and gynecology. Additional inputs were incorporated from experiences narrated during social autopsy and positive deviance interviews undertaken in the larger project (35). The guides explored the bereavement experience of the parents, their pregnancy journey, the circumstances surrounding the loss, interactions with the health system, communication by healthcare providers, and the emotional reactions and support received from family and health workers. They also covered the struggles and challenges faced by the participants in physical, psychological, social, cultural, and financial domains, the coping mechanisms adopted individually and collectively within the family and community, the factors that amplified their grief, and their perceptions regarding the availability, gaps, and need for bereavement care and support.

Along with the qualitative guides, a short socio-demographic tool with pre-structured closed-ended questions was administered before each interview. This tool captured background information, including the age and education of both parents, family structure, monthly income, adverse pregnancy history, previous stillbirths, gender of the child, gestational age at the time of loss, mode of delivery, and place of delivery. The interview guides were pilot tested with a two bereaved parents outside the study area to ensure clarity, sensitivity, and cultural appropriateness. Feedback from these pilot interviews were used solely to refine the phrasing, sequencing, and framing of questions, resulting in the final version of the interview guides, which are provided in Supplementary Annexures 1, 2.

The researchers were aware that their own positions could influence both the process of interviews and the interpretation of narratives. The two primary interviewers were trained anthropologists with doctoral-level expertise, one specializing in maternal and child health and the other in ethnographic research. The male researcher’s ethnographic training focused interviews on cultural practices and contextual meaning, while the female researcher’s maternal mental health expertise guided exploration of emotional experiences and psychological impacts. While they did not share the personal experience of perinatal loss, they were sensitized and well equipped to issues of grief, gender, and family dynamics through their disciplinary training. Both interviewers were relative outsiders to the local community, which helped participants speak without fear of local judgment, but it also required building rapport and trust at the start of each interaction. Research team members, drawn from similar cultural backgrounds as the participants, further bridged this gap by providing contextual understanding and helping the team remain grounded in the lived realities of the community. To promote comfort and openness, the interviews were conducted in locations chosen by participants, most commonly their homes, although in some cases, particularly for fathers, interviews were conducted at their workplaces. Privacy was prioritized by requesting family members not to be present during the interviews, and flexible arrangements, such as rescheduling or shifting to quieter locations, were made when privacy could not be ensured.

Given the sensitive nature of pregnancy loss, a previously developed response guide was used by the interviewers for addressing emotional distress during the IDIs (34). This document titled as Solace Protocol, designed to guide researchers on how to respond/react during data collection for distress management, was carefully followed, which has been provided in Supplementary Annexure 3. If a participant showed signs of emotional distress during the discussion, the interviewer paused the interview, provided reassurance, and resumed only with the participant’s consent. To maintain rigor and reflexivity, the research team held debriefing meetings every two days to review field notes, discuss emerging themes, and refine the interview guide as needed. Aware that our backgrounds could shape how we engaged with bereaved parents and interpreted their experiences, interviewers maintained personal notes after each interaction, reflecting on emotions, assumptions, and challenges. These reflections were discussed in team meetings to remain self-aware and minimize bias. While the interview guide offered structure, conversations flowed naturally, allowing participants to speak freely and at their own pace. Non-verbal cues and contextual details were carefully noted to preserve meaning of the narratives. By combining careful listening, respectful probing, and ongoing team discussions, we sought to ensure that the accounts presented in this study remained close to what parents wanted to share.

All interviews were audio-recorded with participants’ consent, transcribed verbatim in the Hindi language, and subsequently translated into English by the same researchers who conducted the IDIs. This process ensured fidelity of meaning and preservation of cultural nuances. The interview guide was organized around the study’s objectives, with broad sections addressing responses to loss, coping strategies, and support needs. However, interviews were conducted in a flexible and participant-led manner, allowing respondents to elaborate freely on issues they considered important, and enabling the conversation to move beyond the pre-defined themes as new insights emerged. This ensured coherence between the thematic and IPA. We conducted this dual analysis of data set by applying thematic analysis to transcripts from the full sample and IPA to sub-sample for identifying the individual perspectives. This combined approach allowed both an exploration of emergent themes and an in-depth understanding of participants’ lived experiences.

In the first stage, a deductive approach was followed for conducting thematic analysis using Braun and Clarke’s six-step method (36). All the transcripts were first uploaded into NVivo software version 15. In the first step, the two qualitative researchers (SM and KKY) read the transcripts independently to become familiar with the data. In the second step, they generated initial codes by tagging meaningful segments of text related to experiences of pregnancy, immediate and extended responses to the perinatal loss, coping mechanism, and perceptions on the need for bereavement care and support. This iterative process was followed by a joint review in the third step, where codes were grouped into potential themes and sub-themes, using NVivo’s coding dashboard. In the fourth step, generated themes and sub-themes were refined and cross-checked against coded verbatim extracts. In the fifth step, these themes were clearly defined with operational descriptions, and finally, in the sixth step, the results were tabulated with supporting verbatim and interpretations. However, during this process some cases showed the in-depth, pragmatic and existential experiences. These cases were subsequently re-examined using an IPA approach. This approach helped in engaging deeply with the idiographic accounts of parents. The process involved reading and re-reading individuals’ verbatim, developing exploratory comments, identifying emergent themes within each case, and then examining patterns of convergence and divergence across cases. This idiographic focus allowed the research team to remain grounded in the unique experiences of each parent, while also drawing out shared meanings among the bereaved parents. The IPA was followed using the Dual Process Model of Coping with Bereavement and the Continuing Bonds theory (37). This helped to interpret emergent themes in relation to existing theoretical understandings. This process generated two new themes which were ‘Amplifiers of grief’ and ‘need for closure.’ Cases were selected for IPA based on narrative richness and depth rather than representativeness, consistent with the idiographic commitment of phenomenological inquiry. The IPA was not used to validate themes generated through thematic analysis, but to deepen understanding of meaning-making processes.

By combining thematic analysis and IPA, the study sought to balance breadth with depth: capturing common patterns while preserving the individuality and emotional richness of bereaved parents’ experiences. The findings were organized around two broad types of stressors, as conceptualized in the Dual Process Model of bereavement: loss-oriented and restoration-oriented stressors. Loss-oriented stressors referred to experiences that drew parents’ attention directly to perinatal loss and its emotional and traumatic consequences. Restoration-oriented stressors, in contrast, reflected parents’ efforts to adapt to life after the loss, including attempts to cope, reorient daily life, and make sense of the absence. Within this analytic framing, four interrelated themes were identified. Loss-oriented stressors were captured through the themes of Response to Grief and Amplifiers of Grief, while restoration-oriented stressors were reflected in the themes of Coping Mechanisms and Search for Closure (38). The complete process of data analysis has been provided in Figure 2.

The socio-demographic and health characteristics of the participants provide essential context for understanding the experiences of families who recently faced stillbirth or END. Most mothers were young, with 60% falling in the 18–25 years age group (mean age: 25.74 ± 4.58 years), while the mean age of fathers was 30.86 years [Standard Deviation (SD) ± 6.36], with most (73.3%) between 26–35 years. In contrast to mothers (33.33%), the majority of fathers (73.33%) were literate, underscoring a gender gap in educational opportunities. Most mother were homemakers and lived in joint family households (80%). Nearly half of the families reported a monthly income of ≤10,000 INR, indicating low socio-economic status. Regarding obstetric history, 60% of mother were multigravida and 20% were primiparous. One-third (33%) of babies were delivered before 37 weeks of gestation. The majority of deliveries (80%) occurred through normal vaginal delivery, and 60% of births took place in private hospitals (Table 1).

The thematic analysis of all interviews followed by a more detailed IPA of selected in-depth interviews, highlighted how multiple social, relational, and experiential factors come together to shape the bereavement process within the study community. Four major themes emerged from our thematic and IPA analysis which included parents’ response following their loss and coping mechanism (Table 2) and amplifiers of grief, and the search for closure (Table 3) respectively. Parents’ response to their loss meant their immediate and long term emotional, psychological and physical reactions after the loss of their child. Amplifiers of grief meant the internal and external factors that intensified the experience of grief and prolonged the process of healing. Coping mechanism was the strategies parents used to manage their grief, including emotional expression, seeking support, and finding meaning in their loss. The last theme which was search for closure refers to the parents’ ongoing emotional struggle to find understanding, resolution, and acceptance after their loss. The theme wise narratives have been given in the Supplementary Table 1. Following sections discuss these themes in detail.