HMN 2026: How After early pregnancy loss, ‘what if’ thinking affects 72% within first week

When a person goes through a traumatic experience, they often find themselves thinking that what happened could have been different or even avoided. This process, known as counterfactual thinking, is an automatic psychological response to adverse events. Now, a study published in the journal Scientific Reports explores how this type of thinking affects women who have suffered an early pregnancy loss.

The study’s findings show that counterfactual thinking is highly prevalent in these cases, and that it may initially serve an adaptive function: It may help individuals to process their loss and redefine future goals, such as the possibility of a new pregnancy.

The study is led by the experts Antoni Borrell, a professor at the Faculty of Medicine and Health Sciences at the University of Barcelona and a member of BCNatal Fetal Medicine Research Center at Hospital Clínic de Barcelona, and Aida Mallorquí, a clinical psychologist in the Clinical Health Psychology Section at Hospital Clínic. The study was conducted in collaboration with Antoni Rodríguez-Fornells, from the UB’s Faculty of Psychology and the Institute of Neurosciences (UBneuro) and the Bellvitge Institute for Biomedical Research (IDIBELL).

Imagining alternative ways of living better

The nature of the cognitive processes resulting from perinatal loss remains poorly understood. This new study examines the prevalence and time progression of counterfactual thinking in a cohort of 119 women immediately following an early pregnancy loss. Using an online psychological assessment, the researchers analyzed the traumatic impact, rumination and the frequency of this type of thinking.

“This longitudinal study is the first to immediately follow a large sample of women from the immediate aftermath to study a phenomenon that can affect mental health after pregnancy loss,” notes specialist Aida Mallorquí, the article’s lead author.

“Interestingly, until now, most studies on trauma and counterfactual thinking have been based on people assessed years after the traumatic event, which limits our understanding of this type of psychological response.”

According to the study, counterfactual thinking was present in the majority of women (72%) during the week following the loss. In fact, 99% of the participants imagined scenarios in which the loss could have been prevented.

In 91.6% of cases, these thoughts were self-referential; in other words, they related to the participants’ behavior, thoughts or emotional state. This was associated with a strong sense of personal responsibility and possible feelings of guilt linked to the loss—”if only I had not exercised so much,” “if only I had not been so worried or stressed.”

Negative emotions were also often perceived as potentially harmful to the fetus, as were an unhealthy diet or other behaviors considered harmful. However, most early losses are caused by fetal chromosomal abnormalities, a factor unrelated to the woman’s behavior.

“The belief that the mother’s psychological state can affect the fetus, as well as the fear of developing perinatal depression with consequences for the child, is widespread and commonly observed in perinatal psychology consultations,” note the experts.

The study also shows that, although this type of thinking was present in most women, its persistence and frequency over the first four months indicated that the loss had been experienced as traumatic. Furthermore, the researchers identified an association with rumination traits, that is, the tendency of some people to dwell repeatedly on negative emotions and worries without reaching an effective resolution.

More psychological resources to help cope with pregnancy loss

The findings suggest that the initial activation of counterfactual thinking may act as an adaptive cognitive mechanism, providing psychological resources to cope with negative experiences. “This type of thinking may help women process their experience, prompting them to reflect on their behavior in relation to the circumstances and the final outcome, and possibly to prepare for a future pregnancy, given that epidemiological data suggest that 85% of women will achieve a pregnancy following an early pregnancy loss,” the research team notes.

“Nevertheless, our study suggests that when this pattern of thinking persists over time, it may indicate that the loss has been experienced as traumatic. This can affect a woman’s mental health and may influence future reproductive decisions. If health care professionals provide information on the psychological impact of a pregnancy loss from the very beginning, this could facilitate emotional adaptation and adjustment. A pregnancy loss is not just a biological event, but also an experience with a profound emotional impact that requires comprehensive care.”

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