At Hospital Clínic de Barcelona, researchers led by Antoni Borrell and Aida Mallorquí have documented something many who've experienced early pregnancy loss know intimately: the mind's relentless "what if" conversations that begin almost immediately after loss. A landmark study of 119 women reveals that 72% of those who miscarry engage in counterfactual thinking—imagining alternative scenarios where the loss could have been prevented—within the first week alone. The findings, published in Scientific Reports, represent the first large-scale longitudinal study to examine this psychological response in real time, capturing women's experiences from the immediate aftermath rather than years later.
Counterfactual thinking is an automatic cognitive response to trauma, where the mind rewinds events and reimagines different outcomes. What makes this research significant is its timing and specificity. Most prior studies on trauma and psychological response have tracked people years after their loss, creating a gap in understanding how these thought patterns actually unfold. By assessing women online immediately following early pregnancy loss, Mallorquí and her team have opened a window into the acute phase of grief that was previously invisible.
The nature of these "what if" thoughts reveals something deeply human about how we process loss. Nearly all participants—99%—imagined scenarios where the loss could have been prevented. But the burden lies in where blame lands. In 91.6% of cases, counterfactual thinking was self-referential, meaning women traced responsibility back to their own behavior, thoughts, or emotional states. "If only I had not exercised so much." "If only I had not been so worried or stressed." These internal attributions often carried a crushing weight of guilt, rooted in a widespread belief that a mother's psychological state can harm her fetus. Women worried that negative emotions, poor diet, or stress had caused the loss.
The irony, and tragedy, is that the majority of early pregnancy losses stem from fetal chromosomal abnormalities—factors entirely beyond a woman's control. Yet the research shows that fear of these psychological connections persists in how women interpret their loss, something Borrell and Mallorquí note is commonly seen in perinatal psychology consultations. This disconnect between perceived cause and actual cause speaks to a gap in how pregnancy loss is understood and discussed.
The researchers also identified a crucial distinction: while counterfactual thinking appeared in most women initially, its persistence and frequency over four months correlated strongly with experiencing the loss as traumatic. Those prone to rumination—the tendency to dwell repeatedly on negative thoughts without resolution—were more vulnerable to prolonged counterfactual patterns. Yet here lies an unexpected finding: initially, this type of thinking may serve an adaptive function. Rather than pure suffering, counterfactual thinking may help women process their experience, reflect on their circumstances, and prepare psychologically for a future pregnancy. Epidemiological data shows that 85% of women who experience early loss go on to have subsequent pregnancies, a fact that suggests the mind's "what if" conversations may be preparing ground for hope.
The study underscores a need for better psychological support around pregnancy loss—one that acknowledges both the reality of grief and the way women's minds automatically search for meaning in trauma. Understanding counterfactual thinking not as a pathology but as a normal cognitive response may help guide more compassionate care.