From Outcomes to Mechanisms: Evaluating Early-Stage Psychosocial Support and the Role of Grief Rituals In Perinatal Bereavement In Hong Kong

Background and Purpose

Pregnancy loss can precipitate acute psychological distress and complex grief, highlighting the need for timely psychosocial support. Early-stage interventions may stabilise emotional responses, yet their mechanisms remain underexplored. Grief rituals may facilitate meaning-making, emotional expression, and continuing bonds. This study evaluates the effectiveness of an Acute Psychological Support Service (APSS) and examines how ritual elements contribute to bereavement outcomes.

Methods

Two complementary datasets were analysed in Hong Kong. First, a pre–post evaluation was conducted, over a three-year period, among 93 bereaved parents who accessed APSS. The intervention included individual or couple counselling, memorial practices, and art-based activities. Participants completed the Depression, Anxiety, and Stress Scale (DASS-21) and the Chinese Short Version of the Perinatal Grief Scale (PGS) at two time points.

Second, cross-sectional data from 115 bereaved parents were collected using an adapted Bereavement Activities Questionnaire assessing perceived helpfulness across 22 ritual components, 22 activities, and 27 grief-related outcomes. Ratings of 4 or above on a 5-point scale were categorised as highly helpful. Descriptive and inferential analyses were conducted.

Results

Findings from the outcome evaluation indicated that engagement with APSS was associated with statistically significant reductions across all domains of psychological distress. Depression scores decreased from M = 14.11 (SD = 5.50) to M = 12.26 (SD = 4.65), t(92) = 3.80, p < .001, d = 0.39; anxiety from M = 12.39 (SD = 10.31) to M = 9.44 (SD = 8.73), t(92) = 3.41, p < .001, d = 0.35; and stress from M = 17.91 (SD = 10.99) to M = 14.37 (SD = 9.60), t(92) = 3.51, p < .001, d = 0.36. Perinatal grief also showed meaningful improvement, with moderate reductions observed in domains related to pain recollection (d = 0.52) and sense of worthlessness (d = 0.46), suggesting improvements not only in emotional distress but also in core grief processes.

Findings from the ritual evaluation provided further insight into potential mechanisms underlying these improvements. Symbolic and aesthetic components, such as receiving an angel cloth (94.1%), a memorial box (93.4%), and a birth identity certificate (93.3%), were most frequently rated as highly helpful. Relational and expressive activities, including creating memorial objects (93.1%) and preparing funeral-related materials (88.1%), were also highly rated. In terms of perceived outcomes, participants most frequently reported benefits related to containment and meaning-making, including feeling that the child was remembered (89.5%), being able to express gratitude (86.0%), and honouring the child’s memory (85.1%).

Female participants also reported significantly greater perceived helpfulness of expressive and art-based components compared to males (M = 4.51 vs. 3.94, p = .005), suggesting potential gender differences in preferred modes of grief processing.

Conclusions and Implications

Findings suggest that early-stage psychosocial support is associated with meaningful reductions in distress and grief. Ritual elements characterised by symbolic meaning, emotional expression, and structured engagement may represent key mechanisms underlying these effects. Integrating multi-dimensional grief rituals into early bereavement care may enhance emotional processing and support culturally sensitive adjustment following pregnancy loss.