“I Want to Bury It, Will You Join Me?”: The Use of Ritual in Prenatal Loss among Women in Catalonia, Spain in the Early 21st Century

: Prenatal loss, such as miscarriage and stillbirth, may be understood as the conﬂuence of birth and death. The most signiﬁcant of life’s transitions, these events are rarely if ever expected to coincide. Although human cultures have long recognized death through ritual, it has not typically been used in cases of pregnancy loss. Interest in prenatal losses in the ﬁelds of medicine and the social sciences, as well as among the general public, has grown signiﬁcantly in recent years in many countries, including Spain, as evidenced by increasing numbers of clinical protocols, academic books and articles, public events and popular media coverage. Even with this growing attention, there are still no ofﬁcially sanctioned or generally accepted ways of using ritual to respond to prenatal losses in Spain. However, despite a lack of public recognition or acceptance of the use of ritual, we found that women in the autonomous community of Catalonia, in Spain, are employing ritual in various fashions, both with and without the support and acceptance of their family, friends or community, to process their losses and integrate them into their lives.


Introduction
For her third childbirth, Alicia had decided to labor at her home in a small city in Catalonia. As a two-time veteran, she felt comfortable with the process, and she also wanted to be in charge of how things went after delivery. The first time Alicia delivered a baby, it was her 32-week stillborn son. She and her family were devastated by the loss, and it took her and her husband a few years to try for another. Their second child, a healthy girl, was three years old when Alicia got pregnant for a third time with another, much-wanted baby. Unfortunately, at her first prenatal ultrasound she learned that the embryo no longer had a heartbeat. In lieu of having a surgical procedure or waiting it out in the hospital, Alicia went to her parents' home, where she labored upstairs in her mother's company while her husband took care of their daughter. Eventually, Alicia caught her 8-week embryo in a sanitary napkin, just as she had hoped and planned. She held out her hands to show her mother, and together they carefully looked at what was on the pad. Although it was vanishingly small, Alicia said you could still discern some human qualities to it. What struck her even more than that was the amniotic sac, perfectly intact and shining amongst the blood and other tissue. After admiring it for a while, she turned to her mother and said, "I want to bury it. Will you join me?".
Alicia's experience is not at all common in 21st century Catalonia, one of 17 autonomous communities in Spain. Most miscarriages take place in a clinical setting, and even if they do happen at home, the focus is usually on the physiological process. For the most part, healthcare professionals there do not advise women about the emotional or spiritual aspects of the experience. They do not inquire about their patient's sense of

Ritual and Ambiguity
There is no single, agreed-upon definition of ritual in the social sciences (Lan 2018;Roth 1995;Stephenson 2015), with Leach (1968, p. 526) going so far as to say, "there is the widest possible disagreement as to how the word ritual should be used and how the performance of ritual should be understood". According to the most recent edition of Britannica (Penner n.d.), ritual is "the performance of ceremonial acts prescribed by tradition or by sacerdotal decree. Ritual is a specific, observable mode of behavior exhibited by all known societies". Beyond the more generic definitions of ritual, social scientists have long theorized that ritual and related embodied practices exist to resolve conflict between two states of being: Durkheim's ([1912] 1968, p. 37) "sacred and profane", Turner's (1979, p. 234) "betwixt and between", and Douglas' (1966) "purity and danger" (see also van Gennep [1909van Gennep [ ] 1988. The conflict lies in the ambiguity of liminal states, and Durkheim devised the concept of "collective effervescence" to describe the way in which ritual helps resolve this ambiguity by inducing a shared emotional state in all its participants. These shared emotional states are found in many rituals that still exist today, from the joy experienced during a wedding that resolves the liminal state of being betrothed, to the collective fear followed by shared relief of fraternity initiands, who are no longer liminal "pledges", but have now become fully and permanently "brothers". In the second half of the 20th century, ritual scholarship moved beyond watershed life events and began to focus on the presence of rituals in everyday life (Bell 1992;Collins 2004;Goffman 1959). Rituals are now apprehended in events as diverse as the cigarette break (Collins 2004) and media coverage of Michael Jackson's death (Sumiala 2013). Despite these sometimes competing and always evolving definitions, what has remained consistent from van Gennep's ([1909] 1988) Les Rites de Passage to Grimes' Deeply into the Bone (Grimes 2000), is the acknowledgment that life events such as birth, puberty/adulthood, marriage, and death seem to warrant, if not demand, recognition through ritual. The present study is focused on the use of ritual in prenatal loss, events that are characterized by the confluence of birth and death. In addition to being the most significant of all of life's transitions (Wojtkowiak and Crowther 2018), birth and death are, with few exceptions, never expected to coincide. And while liminality of any type is generally considered dangerous and undesirable (Douglas 1966;Thomassen 2012;Turner 1969), embryos and fetuses that die before they are even born must certainly be among the most liminal beings of all (Rapp 2018;Reiheld 2015).
For this study, we developed the following definition of prenatal loss ritual, based on a comprehensive review of the literature (Bell and Kreinath 2021;Durkheim [1912Durkheim [ ] 1968Leach 1968;Rappaport 1999;Roth 1995;Stephenson 2015;Turner 1969;van Gennep [1909] 1988), combined with our own experience in both clinical and applied anthropology settings, and the analysis of the ethnographic data presented here: A prenatal loss ritual is a one-time or repeated action, enacted either in solitude or in the presence of others, that takes as its focus the lost embryo or fetus and is designed to engender a specific emotional experience in participants through acknowledgment the existence of that which has been lost.

Ritual and Death
Most human cultures have employed ritual in some fashion to address what Bautista (2013, p. 24) refers to as the "absurdity of death"; that is, its mysteriousness, its finality, and its ultimate refusal to be fully known to living humans (Hockey et al. 2001). Death ritual has largely been based in some form of cosmology; for example, the need to protect survivors from the angry god of death who had struck down the deceased or the desire to aid the deceased's transition to their next life (Bakker and Paris 2013;Cano Garcés 2012;Lan 2018). Deathways varied significantly depending upon many factors such as era and belief system but, according to Metcalf and Huntington (1991), these rituals were "never random, always meaningful" (p. 1). In the 20th century, practical changes in death ritual took place in Europe and North America, including the gradual disappearance of mourning dress, the physical removal of death and attendant ritual from the home, and the so-called commodification of death. Paradoxically, death was simultaneously both "denied" (Ariès 1974) and turned into "big business" (Mitford 1963; see also Metcalf and Huntington 1991). Regardless of the context, death rituals have largely been created and enacted by, and in some cultures even uniquely conducted for, the males of the society (Ariès 1974;Cecil 1996a;Metcalf and Huntington 1991). It should therefore come as no surprise that there is very little in the way of recorded death ritual for prenatal loss (Han et al. 2018).
Death ritual is changing in multicultural societies such as that of Catalonia. Racial, ethnic, and linguistic diversity, environmental activism, and religious progressivism, including atheism, are all converging to result in new (or sometimes "new-old") death rituals. After 2000 years of prohibition, Catholics can now cremate their dead (Gallagher et al. 2016). Moreover, while some people are choosing environmentally friendly burials where their bodies are placed directly into the earth wrapped in a biodegradable cloth, others are opting to attend their own funerals while they are still alive (Golden 2019; Porter 2017). In his brief but comprehensive overview of funerary practices in Spain throughout history, Zambrano González (2016) echoes many of the changes that occurred worldwide. Death went from the home to the hospital, putting an end to the velatorio [candlelit death watch] and effectively cutting the dying person and his immediate family off from the community that had joined them in this ritual for centuries.
Contemporary Catalan deathways resemble those of many other societies with a cultural foundation in Catholicism. Most dead are buried, although the rate of cremation in Spain is rising with each passing year, and many deaths are still acknowledged with a funeral mass or other religious ceremony, even among non-practicing social groups (Gutiérrez 2016). Spaniards are also engaging in more so-called alternative death ritual with, for example, some cemeteries offering spaces for burial of biodegradable urns containing ashes (Gutiérrez 2016;Zambrano González 2016). Perhaps the most undeniably Spanish of all the new death rituals encountered for this study is the growing popularity of placing urns in specially designed areas located within the stadiums of professional football teams (Gutiérrez 2016).

The Ambiguity of Prenatal Loss
This study focuses on the use of ritual in prenatal loss, which we define as the subset of perinatal loss (DeBackere et al. 2008) that occurs during pregnancy or before a live birth. Prenatal loss includes miscarriage, defined by the Spanish Society of Obstetricians and Gynecologists [SEGO] most recently in 2010 as pregnancy loss before viability, currently estimated at 22 weeks' gestation; stillbirth, defined as loss between viability and live birth (Diago Almela et al. 2013); voluntary interruption of pregnancy, which is currently legal in Spain through 14 weeks' gestation (Casado 2014); termination for medical reasons and selective reduction in a pregnancy with multiple embryos. It is notably difficult to ascertain precise figures regarding the prevalence of prenatal loss, given varying definitions and imprecise or occasionally absent recordkeeping (Diago Almela et al. 2013;Serrano Diana et al. 2015). In Spain and other countries of similar levels of development, approximately 1/4 of all pregnancies end in loss (Schummers et al. 2021; see also World Health Organization 2007 for its most recent global figures) and it is estimated that first-trimester losses comprise approximately than 85% of the total (Tommy's 2021).
In its protocol entitled "Spontaneous abortion", SEGO (2010) defines "abortion" as the spontaneous expulsion or the surgical removal of an embryo or fetus up to 500 grams in weight. Notably, there is no equivalent in Spanish or Catalan to the commonly used English word "miscarriage", while the Spanish term "aborto" can refer to an involuntary loss or to the voluntary interruption of a pregnancy. Moreover, although pregnancies are typically discussed in terms of trimesters, the recognized point of viability in Spain is 22 weeks' gestation, which occurs in the middle of the second trimester (SEGO 2010). Research on prenatal loss demonstrates that a jurisdiction's definition of viability can have an enormous impact on a person's experience of such losses. Middlemiss (2021) described the case of a woman in England who experienced two second-trimester losses, one three days before the medically and legally defined point of viability, and one two days after. In the first case, her loss was considered a miscarriage, a fact that prevented recording the child as a member of the family. Since the second loss occurred a few days after viability, the woman's medical treatment varied dramatically and the family was able to include that child, only 5 days older than the first, in the official record of their family.
In Spain, prenatal losses are not recorded in the aggregate either demographically or medically, although individual hospitals or health systems may track them (Elisa Llurba, personal communication, 9 February 2021). Losses from 22 weeks' gestation through non-live birth are considered late fetal/intrauterine death ("muerte fetal tardía" or "muerte intrauterina") (Diago Almela et al. 2013). Such losses would be called "stillbirths" in the English-speaking world, but its equivalent does not exist in Spanish or Catalan. However, despite the use of the word "death", which implies the loss of a person possessing of life, these losses are not recorded demographically as persons, nor can they be included in the family book ("libro de familia"), an official document that lists all first-level kinship relationships in Spain (Umamanita n.d.).
Although research points to the significant and sometimes devastating effects of prenatal losses on those who experience them, including depression, anxiety, ruptured relationships, and decreased participation in work and society (Badenhorst and Hughes 2007;Gravensteen et al. 2013), they have not received the amount of attention one would expect from academia and/or medicine given their ubiquity (Herbert et al. 2022). This is likely due in part to their much higher incidence until the mid-20th century, as well as their ambiguity in the eyes of many people and cultures (Cecil 1996a;Halcrow et al. 2018;Han et al. 2018;Kilshaw and Borg 2020;Woods et al. 2006). This ambiguity is understood to result from the liminality of both the pregnant person-who is not quite a mother and not not a mother-and the embryo or fetus that they carry-who is not quite a person and yet not not a person.

Liminality and Disputed Personhood in Pregnancy and Early Childhood
Ritual has long been employed both to protect an embryo, fetus, or newborn through to achievement of personhood and also to confer personhood, thereby resolving the conflict of liminality (Cecil 1996a;Davis-Floyd and Cheyney 2022;Han et al. 2018;Lancy 2008). Less commonly, rituals have sometimes been withheld, seemingly in order to deny personhood to a baby unlikely to survive (Cecil 1996a;Scheper-Hughes 1991). According to van Gennep ([1909] 1988), pregnancy and the early postpartum period were one continuous "transitional period" that necessitated not only the separation of the dyad from the community, but also a ritual action to reincorporate the woman and her (now) baby back into society.
Victor Turner (1969) elaborated on the concept of liminality, likening it to "death, to being in the womb, to invisibility, to darkness, to bisexuality, to the wilderness, and to an eclipse of the sun or moon" (p. 95). Similarly to van Gennep, Turner understood ritual as the means to carry someone from separation through transformation and reincorporation, while Douglas (1966) viewed such enactments as a way to keep the liminal being safe from danger during a transition. Douglas specifically referred to unborn children and their pregnant mothers when she said "these are people who are somehow left out in the patterning of society, who are placeless. They may be doing nothing wrong, but their status is indefinable" (p. 96). These earlier anthropological understandings of the goal of ritual seem to conflict with the reality of prenatal loss. The woman cannot cross van Gennep's threshold or make Turner's transition to motherhood, nor can the fetus cross to full personhood. According to Douglas, the ritual has either failed or is no longer needed: the baby is dead, and the woman-who-would-be-mother must instead go back to her state of simply being a woman.
More recently, social scientists have devoted increasing attention to pregnancy and infant loss (Grout and Romanoff 2000;Kaufman and Morgan 2005;Keane 2009;Layne 2003;Malacrida 1999;McCreight 2004;Morgan and Michaels 1999;van der Sijpt 2017). However, there remains only a small body of literature on the use of ritual in prenatal losses. Those conducted in areas where rates of loss are high indicate that ritual remains uncommon or even verboten (Cecil 1996a;Han et al. 2018;Kilshaw 2020;Njikam Savage 1996;van der Sijpt 2020). In many such places, pregnant people and their families are struggling to have such losses acknowledged at all, let alone through ritual. In countries such as Spain where prenatal loss rates have decreased significantly in the past halfcentury and where voluntary pregnancy interruption has been legal for at least several decades, there appears to be a movement toward both individual and collective ritualization of these losses (Han et al. 2018;Kuberska 2020;Layne 2000;Luehrmann 2018;Walsh 2017). Regardless of their culture of origin, embryos, fetuses, and other "products of conception" (Hooker et al. 2016) throughout the world continue to exist primarily in liminal space, without personal boundaries of their own and subject to the current beliefs and understandings, from spiritual to scientific, of the society in which they were conceived.

Ritual for Prenatal Loss in Spain and Catalonia
In Spain, there is no accepted ritual for prenatal loss. The ambiguity of the Catholic Church's stance on the status of unbaptized babies effectively barred burial on consecrated grounds until the early 21st century (Bydlowski 2000;Cecil 1996b;Pullella 2007). The landscape of prenatal loss in Spain began to change in the early 21st century, in part due to the establishment of advocacy groups and the recognition of International Pregnancy and Infant Loss Remembrance Month in October of each year (F. Bentué, personal communication, 11 February 2019). In addition to providing direct support and resources to loss families, these groups advocate for improved care that encompasses emotional and spiritual dimensions, leave from work after losses regardless of gestational age, inclusion of embryos and fetuses in the libro de familia and, most germane to the present study, for the establishment of dedicated, public spaces where prenatal losses are acknowledged and where parents and others can manifest their relationship to their loss (Altimira 2021;Franco 2021;Matas 2018;Rila 2021; for examples in other countries, see Kilshaw and Borg 2020).
Despite such progress, loss parents in Catalonia still report a significant lack of support and understanding, not only from professionals but also from friends, family members and others in society. Many feel left to their own devices to figure out how to recognize and integrate their loss into their own life story, and the lack of any cultural script to follow adds to their stress and dislocation. Moreover, some who experience loss report not just indifference or a lack of empathy, but active resistance to their attempts to incorporate their losses, and the potential people they represent, into their families and larger communities.

Materials and Methods
Given the evolution of both public and private approaches to prenatal loss over the past few decades, we hypothesized that some women in Catalonia are creating and engaging in rituals and embodied practices around their losses, and that in doing so, they are not simply reflecting their culture or society, nor are they just performing. Instead, they are actively creating the society in which they want to live and raise their families, and their rituals are transforming themselves into mothers, and their lost embryos, fetuses and newborns into beloved and forever-remembered children. With this in mind, we turn our attention to the present investigation exploring the use of ritual among women who experienced prenatal loss in Catalonia.
This study relied on the production and analysis of qualitative data. Descriptive statistics were also captured so that the reader may have a clearer picture of the final unit of analysis see Table 1. Focus groups, semi-structured interviews, and direct observation were all employed to generate data. Given that informant's losses had taken place prior to data collection, participant observation of death ritual was not possible. However, direct observation was conducted via review of informants' mementos, keepsakes, and other materials from the time of loss, including photographs, memory boxes, items of baby clothing, and jewelry. Observation was made of both the types of items as well as how they are used, displayed, and/or interacted with by the informants and others. All focus groups, interviews and observations were conducted by the same investigator. Given the high specificity of the investigation and the potential difficulty of recruiting informants given the sensitive subject matter, the criteria for inclusion were kept purposefully broad to allow for the greatest number of informants possible. Informants were limited to the gestational carrier of the loss being studied. They could be of any nationality, provided that they lived in Catalonia at the time of the loss, and of any educational level, and socioeconomic, religious, and/or marital status. Informants had to be either English, Spanish or Catalan speaking. Regarding specific loss criteria, informants had to have experienced their loss after medical confirmation of pregnancy, and they could participate regardless of parity.
Informants were recruited using a snowball sampling approach. A flyer was produced in Spanish, with instructions that interested parties could communicate with investigators in English, Spanish, or Catalan. The flyer was disseminated via email, text message and social media to the investigators' personal and professional contacts and printed and distributed at various professional events. Information about the study reached an estimated 500 people based on the number of individual contacts and the impact of the social media postings. Except for one informant, who was connected to the investigators by a mutual friend, the remaining informants contacted the investigators themselves to be included in the study. All individual interviews were conducted in the informant's homes, and focus groups were held at professional offices. Interviews and focus groups were audio recorded and automatically transcribed, followed by manual review and correction, and data originating in Spanish and Catalan was translated into English by the same investigator.
Working from the existing literature on the topic as well as exploratory interviews, the study took a deductive approach to data analysis, allowing the investigators to "use [their] research questions as a guide for grouping and analyzing [their] data" (Achievability n.d.), appropriate when a researcher has well-founded hypotheses based on secondary research or experience. A phenomenological approach guided all aspects of the investigation, from data production through analysis, synthesis, and writing. Phenomenology was selected over other approaches because it allows the investigator to "immerse [herself] in data, engaging with [it] reflectively, and generating a rich description that will enlighten a reader as to the deeper essential structures underlying a particular human experience" (Thorne 2000, para. 11). A combination of in-vivo coding and pattern coding were used for organizing the data for analysis, based on the study's aim and objectives.

Overview
A total of 10 women participated in the study see Table 1. Two focus groups were conducted, each involving three women. Four other women participated in one individual interview each, while one woman granted two separate interviews. Finally, one participant did both a focus group and an individual follow-up interview. The interviews ranged in length from 35 to 79 min, while the focus groups averaged 1 hour and 40 min in length. One focus group was conducted in Spanish and the other in Catalan. Three individual interviews were in English, two in Spanish and two in Catalan. Interviews took place in various locations in Catalonia between February and May 2019.
The average age of the women at the time of their participation was 36 years. All were married or partnered at the time of the first loss except for one; some marital statuses had changed since the loss(es). They were a relatively well-educated group: seven of the ten held university degrees, two had taken university-level classes, and one holds post-secondary professional training. Half of the women identified as either Christian or Catholic, although with varying degrees of adherence. One of the Christians strongly identified with Buddhist and yogic traditions as well. The other half identified as either atheist (4) or agnostic (1), with one atheist also endorsing Buddhist influence. To obtain a sense of the participants' cultural background and influences, they were asked three separate questions: where they were born; where they grew up; and the origins of their cultural influences. Seven of the ten women claimed Europe as their unique cultural influence, from birth through adulthood. Of those remaining, one participant was born and raised in Latin America and also claimed influence from European culture; one European participant identified strong cultural influence from the United States; and one participant's cultural influence was entirely based in Oceania.
Given the limited number of participants, their loss experiences were more varied. Six of the women experienced one loss, while two participants experienced two losses, and two had three. The number of years from the first loss ranged from less than one to eight. The gestational age of the losses ranged from 6 to 34 weeks, with only one second-trimester loss at 25 weeks, just one week shy of the third trimester. The other nine losses took place either in the first or third trimester. One of the informants had no living children at the time of the interview; among the remaining, three women have two living children and six have one child. All names used below are pseudonyms.
All of the women who participated in this study engaged in some type of ritual or embodied practice, which is especially notable because none of the recruitment materials or pre-interview interactions mentioned "ritual", "ceremony" or other related words. Activities that met our definition of ritual varied from traditional funerals and cremations to more inventive activities such as writing letters, creating shrines, and infusing everyday objects with significance as mementos. Participants also engaged in private and public ceremonies, including annual outings on a death or delivery anniversary and attendance at public ceremonies during International Pregnancy and Infant Loss Awareness Month. Although all of our informants engaged in some form of commemoration, not all of them were joined to the same extent by people in their immediate or wider social circles. For those who did engage, even if their activities were invented or non-traditional, they clearly served the more traditionally understood purposes of mourning the loss and remembering that which has been lost. Moreover, many of our informants' activities, whether they were single occurrences or repeated actions, contributed in some way to healing the emotional and spiritual wounds inflicted by the loss.
6.2. How Did They Decide? 6.2.1. Spontaneity The clinical literature demonstrates that the intensity of women's emotional reactions to pregnancy loss is not associated with the duration of the pregnancy (Badenhorst and Hughes 2007;Kilshaw and Borg 2020;Markin and Zilcha-Mano 2018). Similarly, in our study there was no connection between either gestational age or the reason the pregnancy ended, and use of ritual or embodied practices. Mariana, who had one of the earliest losses at 10 weeks, knew right away that she would enact some type of ritual to say goodbye to her lost child. After being informed there was no heartbeat and asked by the doctor, "When should we schedule the procedure?", she and her husband left without making any medical plans. As Mariana described, "We were in shock. I was looking at my husband, and it was obvious that we had to get out of there as soon as possible. We didn't understand what was happening, but we knew we needed to do something to say goodbye". Juliet, who experienced a miscarriage at six weeks, was the only informant who did not actively decide to engage in ritual. However, one was enacted for her at a prenatal yoga teacher training she was attending at the time. All of the pregnant trainees were given gifts related to their impending motherhood. To Juliet's surprise, her colleagues also presented her with a gift and verbally acknowledged her motherhood even though she had lost her pregnancy and had no other living children. It was during her interview for this study that Juliet realized how important this public enactment was for her, saying "[the miscarriage] was a big deal, and I had to be reminded of that". Sandra experienced the latest loss which, at 34 weeks' gestation, occurred approximately three months after viability. Despite the baby's level of development and the fact that Sandra and her partner are Catholic, they did not hold a funeral. According to Sandra, they avoided the ceremony because "it would have meant even more pain for us". Serena and her partner did have a funeral for their 28-week fetus, after terminating for medical conditions incompatible with life. Serena described the decision to engage in a traditional death ritual as one that required almost no discussion for the couple, and she emphasized the importance of having friends present to bear witness. However, five years later, she puts little stock in the role the funeral played in her recovery process, then or now: "Until the other day when I talked to you and we were thinking about ritual things,. . . I had not at all been thinking about it or have not thought ever again about the funeral. It's not that I forgot that we had it, but. . . . I don't know, in my story, it's something completely irrelevant for me. Or maybe it is relevant, but I don't know how. . . " Below, we will see how other types of embodied practices play a much more important role in Serena's processing the loss of her child. Other informant's experiences tracked those detailed above, with the earlier losses just as meaningful, and in some cases devastating, as those that occurred in later stages of pregnancy.

Personhood & Motherhood
All informants except Juliet acknowledged in some way the liminality of their own motherhood and their child's personhood. However, the presence or absence of a perception of themselves as mothers to erstwhile children did not impact their decision to use ritual to process the loss. Nuria refers to her experience as "losing a pregnancy" and does not consider herself their mother, but she does think of the thing she lost as "my little girl" (she is the mother of two living sons). Alicia had 2 losses, the first a 32-week stillbirth and the second an 8-week miscarriage, with a live daughter born in between. Although Alicia buried the miscarried embryo, she neither considers herself their mother, nor does she count them among her children, while she does count her stillborn son. Ona was deeply affected by all three of her miscarriages between ten and twelve weeks and engaged in various embodied practices to process them. However, when she is asked how many children she has, she says "I've had four pregnancies, and I have one child." Irene, on the other hand, ascribes personhood to both of her first trimester losses, one through miscarriage and one through voluntary interruption. Of the two, she is mother only to her miscarried child, precisely because she had to labor to deliver the embryo. However, she enacted rituals for both, whom she describes this way: "I thought of them as my children. I visualized both of them. I saw them being born, I saw them growing up, I have dreamed about them. . . and they are people." Our informants' experiences indicate that it's not just "mothers" of lost "children" who are drawn to engaging in ritual or embodied practice to confront a prenatal loss.

Religiosity
The use of ritual did not correspond to the informant's religion or their degree of religiosity, although specific rituals were informed by their identified cultural influences. Mariana, a South American woman married to a Catalan man, participated in an extended ritual of Mexican origin that was performed by Spanish psychologist. Although Mariana has no direct connection to Mexican culture, she said that as soon as she learned about the process of cleansing one's reproductive organs using obsidian eggs, she knew it was exactly what she needed to do to complete the mourning of her ten-week embryo and prepare herself for another pregnancy. Sandra, who identified as the most religious of the informants and the most influenced by Catholic culture, decided with her husband not to have a funeral for their 34-week stillborn daughter. Although they were married in the Catholic church and planned to attend a mass on the anniversary of their daughter's death, a public funeral did not feel appropriate to the couple: "It's our loss, so. . . to have a funeral, it doesn't make sense because no one knew her, you know?. . . It's true that it can help to validate the loss, but we finally decided that it wasn't the right thing for us, because we really felt it was something we had to do [alone]." Other informants such as Serena held religious ceremonies despite identifying as atheist, largely because it appeared to be the default thing that was expected of them. According to Serena, in the days after her termination for medical reasons (TFMR), her attitude was "Just tell me where to go and what to do, and I'll do it." And, although Juliet did not initiate the public ceremony in which she participated at a yoga training, the entire experience was very much aligned with her community's Buddhist values and cultural influences. Several informants cited beliefs and practices of other cultures that they found particularly comforting and appealing in light of their loss, including the Buddhist belief in reincarnation and the Islamic understanding that deceased children ease their parent's way into heaven (Shaw 2014). In a multicultural society such as Catalonia in the 21st century, it appears that women with prenatal losses are increasingly drawing on various cultural influences to engage in ritual or embodied practices around their loss.

Community
Overall, 8 out of the 10 informants came to ritual on their own, while just 2-Serena with a 28-week TFMR and Alicia for her 32-week stillbirth-had the idea of ceremony suggested to them by healthcare personnel. Among the others, most either used the word "instinct" or a phrase that alluded to it ("I just knew", "it came from inside me") to describe how they arrived at the idea. Once the idea occurred to them, they primarily used the internet to obtain ideas and information. Almost all the women agreed with their partner about whether to engage in ritual and more specifically, what to do. The two exceptions differed greatly in significance to the women themselves. Nuria described showing her husband the necklace she bought to remind her of her loss through miscarriage: "He didn't really understand it. It was just like, 'What is that for? Why would you wear it?'" Nuria attributed his reaction to a lack of attachment given that it was early in her pregnancy, and she reported no ill feelings toward him, while she herself was content to have found something to remind her of her "little girl". Contrast Nuria's experience with that of Ona, who described her experience catching her 10-week fetus after she miscarried at home in the presence of her mother, while her partner took care of their young daughter: "This miscarriage was a childbirth experience for me. I caught it [in my hands]. I was going to hold onto it, to show [him], to say 'Look!' You know? 'Look!' Because he was acting like it was just a period. And I wanted to say, 'Look! It's not a period. It's not a period'. Everyone is focused on the physical experience of it, and not on the emotional loss. Even the partner, in this case. That's why I wanted to say to him 'Look! See? There is a head, there is a body'. Because at three months, it's all there. And the thing that I regret infinitely, infinitely, is that my mother said, 'Throw it in the toilet!'. . . . I had been in labor [for hours], trying to get it out, and when I heard my mother-you know I look at this as my only experience with childbirth-and I threw it in the toilet, and flushed, I pulled the chain. [Makes flushing sound and gestures with her arm as if pulling a chain down]. And afterward, I was like 'What did you do??!' You know? Because I was saying 'No, mom, we have to keep it, I'm keeping it'. And she was like, 'What are you stupid? Go! Go! Go! Go!'" Given the reactions of Ona's partner and mother, it is not surprising that she emphasized her solitude for all the various rituals and embodied practices she engaged in to process her losses. Experiences of loneliness and resistance to ritualization were endorsed by other informants as well. Linda's parents and in-laws would not speak to her about her 25-week fetus' death, but instead incessantly offered material support in the form of cooking and running errands. Mariana related how, after initial attentiveness from her mother and sister immediately following her loss, they began insisting that it no longer be discussed. And, Serena, who specifically invited friends to her son's funeral so they could bear witness to his existence, was told by other friends a few months after the loss that they could no longer spend time with her because she was "too toxic" because of her loss. In addition to devising ideas for ritualization largely on their own, these women were also facing sometimes significant resistance in making those rituals happen.
6.3. What Did They Do? 6.3.1. Institutionalized Rituals Our sample reflects the fact that funerals are not commonplace for prenatal losses in Spain, as only two of the informants held funerals. As mentioned above, Serena's experience organizing and attending her 28-week fetus' funeral could be described as "disembodied". She remembers the idea of a service being suggested after her TFMR, but not by whom, and she recalls assenting to the idea without much thought. She described "going through the motions" at the time, and she does not have many clear memories of the experience, nor does it hold much meaning for her today. One thing that does stay with her is the image of the tiny, white coffin that held her son's cremated remains, and which bore a plaque that said, "Fetus of Serena Doe". In fact, Serena's son had a name and, as she recounted with painful laughter during her interview, "In that moment [when I saw the coffin with that plaque], I don't know,. . . it could have been a little better if they'd asked us what his actual name was." Alicia's experience with the funeral for her 32-week stillbirth was dramatically different. After delivery, Alicia and her husband spent time with their son in the company of their parents and some of their siblings. Her family participated in the process of bathing and dressing the tiny body and preparing it for burial, an activity that clearly echoes the preparation of corpses for viewing that used to be enacted by family members and is now almost exclusively the purview of mortuary professionals (Ariès 1974;Mitford 1963).

Words and Fire
Many more participants wrote notes or letters to their lost children while Sandra, with the most recent loss among the group, continues to keep a journal where she talks with her stillborn daughter. Apart from the journal, all the other writings were disposed of in symbolic ways, usually through burning. Moreover, all informants arrived at the idea of writing and then disposing of what was written on their own. Irene wrote to both of her lost embryos. For her voluntary interruption, which was her first pregnancy, she devised an embodied practice that was directly influenced by her culture of origin: "I'm from the coast, so when. . . I was at my mother's house, and at the beach where I've always gone since I was a child, I did the ritual there. I wrote a letter, and attached a little flower to it, and I gave it to the sea." Years later, when she lost a second pregnancy to early miscarriage, she and her partner each wrote a letter to their child and burned them together. Irene considers those embryos as a boy and a girl, and this is how she described what the practice meant to her: "The fact that I talked to her, even if it was via a letter, and to him, for me it was really important, to be able to say those things. It was the letter that made it possible, to express myself, to talk to them and tell them how much I-even though they were never born-how much I loved them, and how present they were in my life. The letter is what gave me the chance to say that. And the fire too, it's so symbolic, the letters burn, and the wind comes, and takes them where they need to go." Fire played other roles in the women's embodied practices as well. Mariana's ritual included hours in a tent-like structure where a group of women sat in the presence of a fire that heated the obsidian eggs that would be used to cleanse their reproductive organs. The candles in Sandra's and Linda's homes that they light regularly for their stillborn daughters call to mind the rows of candles in Catholic churches that are meant to be lighted in remembrance of a deceased relative or saint. And, in the various forms of writing that informants engaged in, we see echoes of the continued role that fully social persons play even after death in many cultures (Mathijssen 2018). Likewise, the women's use of and experiences with fire served similar purposes of destruction, cleansing and remembrance that have long been documented in the literature (Durkheim [1912(Durkheim [ ] 1968Douglas 1966;Stephenson 2015).

Personal Shrines
Several informants' embodied practices involved some type of shrine they have created in their home. Zulma has a framed photo of her 31-week stillborn daughter's feet on the wall with her name in colorful block letters. What could be considered a more significant "shrine" is the non-profit organization started by Zulma, whose name features an everyday Catalan word that contains the baby's first name, visible on a rainbow-colored sign on the street. Alicia's shrine would not be evident to anyone who hasn't been told about it, since she buried her miscarried embryo under a tree in her parent's backyard, next to the body of her childhood dog. Sandra and her husband have transformed their home into a shrine for their stillborn daughter Marta: framed photographs of her hang in their living room, an illustration of Marta as a young child with a friend (drawn by a friend of Sandra's who also had a stillborn daughter) can be seen in the erstwhile nursery next to a box that includes Marta's hand and footprints and a lock of her hair. Additionally, a large candle with the initial "M" attached is often lighted in the dining room, and the Sandra and her husband planted a lemon tree in their backyard to commemorate Marta's life. Linda's shrine, although much smaller in scope, is no less symbolic. Her stillborn daughter Laia was delivered a few days before the feast of Saint George, one of the most important holidays in Catalan culture that is commemorated with the gifting of roses, usually red for romantic love, often also yellow for the other color of the Catalan flag. Linda and her living daughter Carla collect white roses around the feast day, and on the date of Laia's delivery, they put the new roses in "her little corner" in the house, along with stones collected by Carla for her sister. They light the candle that they keep there, and they leave it burning "until it burns out". Mother and daughter keep the candle, roses, and stones in the same spot, attending to them and anticipating the next feast day, when they will engage in their shared ritual of remembrance. In all these cases, the shrines appear to serve a meditative purpose, where parents and other family members converse with their lost children or spend time in quiet reflection, much like someone who visits with a deceased loved one at a cemetery or continues the interaction in some other, less traditional way (Abramovitch 2015;Engelke 2019;Hockey et al. 2001;Mathijssen 2018;Metcalf and Huntington 1991).

Embodied Memorials
Beautification practices, both temporary and permanent, were common among this group of informants. Serena, Sandra and Nuria all wear necklaces that symbolize their lost children: Serena's features her son's name; Sandra's is a "tree of life" that mirrors the lemon tree in her backyard; and Nuria's is a feather in a bottle that, when she saw it, she knew was the "perfect" memento for her miscarried embryo. The permanent mementos are tattoos: Sandra's is a small, abstract figure, while Linda's is much larger and features the name of her living daughter alongside the first initial of her stillborn daughter, a rainbow, and a star. Both tattoos are in places that would commonly be visible to anyone in the women's presence. Linda's six-year-old daughter Carla recently suggested they incorporate another, temporary beautification to their suite of rituals: she wants them to get bracelets with Laia's name and wear them all the time, so that each time they look at the bracelet, they will think of her. These adornments recall the different ways that various cultures employ to mark the change in status of the living when someone important to them has died, including mourning dress, appliques, and bodily markings (Ariès 1974;Hockey et al. 2001;Metcalf and Huntington 1991). Although none of the informants specifically mentioned obtaining these mementos because of their role in traditional mortuary practice, it is possible that what they experienced as individual was in fact informed by the various examples of memorialization that they have witnessed throughout their lives.

Private Activities
In addition to the obsidian egg ritual that Mariana participated in, several other informants engaged in healing practices that meet our definition of ritual and which enabled them to continue their grieving process and more fully incorporate their loss into their life story. Linda visited a therapist who performs spiritual energy cleanses several years after the loss of Laia, and she described the experience with these words: "She was a bit weird, you know? And she said 'You have a soul attached to you, it won't leave. And it needs to leave. [. . . ] Do you know what it could be?' And I started crying so hard I couldn't explain it to her. When I finally did explain, I said, 'But I'm over it!' and she said 'No, you're not'. And she helped me with the whole process. I talked to Laia, and I thanked her for the time that she was with me, and I told her that she had to go. And after that I cried for three days straight, and from then on, well. . . it was different." Linda's experience is especially notable because, until then, she had been grieving almost entirely on her own. In addition to the reticence of her parents and in-laws, she had separated from her partner not long after Carla's birth. Her therapist's intervention not only helped elevate her mourning to another level, she said that it also allowed her to claim Laia more fully among her family and friends, which in turn led to additional healing.
Recurring private activities that mark birthdays and anniversaries were employed to ritualize all the stillbirths in group, although not for the miscarriages or the TFMR or voluntary interruption. As detailed above, Linda marks her stillborn daughter's delivery date each year by lighting a candle. Although Sandra had not yet arrived at the first anniversary of Marta's delivery, she was trying to work up the courage "to be brave enough" to scatter Marta's ashes on the lemon tree in her garden. Alicia, who is Christian, visits the family niche in the cemetery where her stillborn son is buried. Zulma, her partner and her two living sons leave the city every year on what she considers Cathy's birthday; they hike into the mountains and take a birthday cake with them, which they light with candles and sing the traditional birthday song to her. Although they may not adhere to the general definition quoted earlier (Penner n.d.), these activities align with our working definition of prenatal ritual, which seeks to encompass a broader range of expression and acknowledge the ways that families experiencing prenatal loss commemorate their children's existence.

Public Ceremonies
Public ceremonies were equally important to many of the women and their families and were typically centered around International Pregnant and Infant Loss Remembrance Day, which is observed in many countries around the world including Spain, as well as online, on the 15th of October. Zulma referred to it as a "sacred date" and said that her family has never missed the opportunity to participate since the ceremonies started a few years ago. A common feature of the ceremony is the releasing of biodegradable balloons into the air, symbolizing the "letting go" of the lost child. Although most of the women in our study attended these ceremonies in a largely anonymous way, for others there has been an element of performance that is often seen in other forms of embodied practice around the death of fully social human beings. Zulma's mother attended one such day of remembrance a few years after Cathy's death, and Zulma recalled the wonder and shock she felt when her mother stood up in front of the assembled crowd and publicly claimed her status as a grandmother: "And then my mother stood up and said, 'I'm Cathy's grandmother. And this is the first time that I have called myself that.' And I sat there thinking 'Oh my god, oh my god. I can't believe this is finally happening.'" These moments appear to be as important to loss parents as traditional new-baby initiation ceremonies such as Christian baptism and Jewish bris are to parents of living children. Through such events, people who have lost a pregnancy can manifest their parenthood to their community, a practice that had previously been denied to them if they didn't have other living children. In addition to participating in ceremonies and embodied practices organized by others, several informants have become activists themselves, working with their local governments and religious institutions to create public spaces for recognition of prenatal losses. However, none of the informants have advocated for official recognition of prenatal losses from the Catholic church, as has happened in places such as the U.S. and Northern Ireland (Hale 2015; see also Cecil 1996b). Moreover, a map of these public spaces of remembrance in Spain reveals a heavy concentration in Catalonia, one of the least Catholic of Spain's autonomous communities, with only a smattering throughout the rest of the country (Norma Grau, personal communication, 22 December 2021).

Conclusions
For the women in this study, the rituals and embodied practices in which they engaged "made real" the life that they had carried, enabling those beings to take what their parents saw as their rightful place in their family, community, and society. The practices described here supported transitions from liminal states such as pregnant woman, embryo, fetus, to statuses such as mother, daughter, and son, that hold recognized and permanent places in both individual and collective memory, much as we see with mortuary rites for fully social persons (Ariès 1974;Hockey et al. 2001;Metcalf and Huntington 1991). As such, they served the more traditional purposes of mourning and remembering that are common to death ritual in many cultures and across time, as well as what could be considered the more contemporary goal of emotional and spiritual healing from the effects of the loss. Many of our informants' practices also resembled rites of passage such as initiations, where the initiand is put through a severe trial in order to come out the other side as a different, and in many cases stronger person (Lan 2018;Stephenson 2015;Turner 1979). Grimes (2000) could have been describing these prenatal loss rituals when he wrote the following: "The primary work of a rite of passage is to ensure that we attend to [important life passages] fully, which is to say, spiritually, psychologically, and socially. Unattended, a major life passage can become a yawning abyss, draining off psychic energy, engendering social confusion, and twisting the course of the life that follows it". (p. 6) As Grimes so evocatively expressed, those who fail to move from liminality to (re)incorporation are understood to remain permanently in an ambiguous state (Douglas 1966;Turner 1969;van Gennep [1909van Gennep [ ] 1988. As ritual is understood to be the mechanism by which we transition from the liminal to the post-liminal state, the absence of socially supported or endorsed ritual in cases of prenatal loss seems all the more confounding. At the same time, our informants' enactment of ritual and embodied practice to resolve that liminality and claim their motherhood and their child's existence, even in the face of sometimes significant resistance, seems that much more resourceful and productive.
Professionals working in clinical and applied settings could learn from the practices of this study's informants, and others like them who are creating, borrowing, and enacting rituals and embodied practices of their own. More research is needed to understand what role such practices might play in preventing and/or mitigating the high rates of emotional suffering among people who experience prenatal losses. Ceremonies and enactments such as the obsidian egg therapy and energy healing described above remain on the margins of "best practices" when it comes to intervening in prenatal losses. However, the fact that women are seeking them out, sharing them with others, and apparently benefitting from them, behooves us to look more closely at these things that, at first glance, may seem to have very little to do with ritual as it is commonly understood.
Finally, it is important to note that for many of these women, although their losses occurred in the past, they are engaged in an ongoing process of mourning and incorporating their experience statuses into their life stories. As detailed above, some informants participate in private and public ceremonies every year, while a few have progressed from participant to organizer and activist, finding meaning in helping other parents who are at different stages of their own process. The evolving practices also reflect changing family dynamics, especially as living children grow up and take on more significant roles in the family. Recently, at the dedication of a new space of remembrance for prenatal losses at a cemetery in Catalonia in October 2021, a teenager performed a song she had written for her stillborn older sister, who died before the singer was even conceived. Taking in the scene was the girls' mother, who probably could never have imagined, almost 20 years ago, a situation in which her two daughters would interact in public before a gathering of dozens of people, all of whom readily acknowledged and accepted the existence and humanity of both of them, equally. Funding: Marre's participation was funded in part by the Spanish Ministry of Science and Innovation (PID2020-112692RB-C21/AEI/10.13039/501100011033) and Marre's ICREA Academy Award. Alvarez's participation was funded in part by the Spanish Ministry of Science and Innovation (PID2020-112692RB-C21/AEI/10.13039/501100011033).

Institutional Review Board Statement:
The Ethics Committee on Animal and Human Research of the Autonomous University of Barcelona confirms that the research conducted for this paper draws on secondary and anonymized sources of information and therefore it does not require ethics clearance from this research ethics committee (Comisión de Ética en la Éxperimentación Animal y Humana (CEEAH).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest:
The authors declare no conflict of interest.