# **Birth and Death Studying Ritual, Embodied Practices and Spirituality at the Start and End of Life**

Edited by Joanna Wojtkowiak and Brenda Mathijssen Printed Edition of the Special Issue Published in *Religions*

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## **Birth and Death: Studying Ritual, Embodied Practices and Spirituality at the Start and End of Life**

## **Birth and Death: Studying Ritual, Embodied Practices and Spirituality at the Start and End of Life**

Editors

**Joanna Wojtkowiak Brenda Mathijssen**

MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tokyo • Cluj • Tianjin

*Editors* Joanna Wojtkowiak University of Humanistic Studies The Netherlands

Brenda Mathijssen University of Groningen The Netherlands

*Editorial Office* MDPI St. Alban-Anlage 66 4052 Basel, Switzerland

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## **Contents**


## **About the Editors**

#### **Joanna Wojtkowiak**

Joanna Wojtkowiak (MSc in cultural psychology, PhD in religious studies) works as an assistant professor at the University of Humanistic Studies, the Netherlands. Her research focuses on secular rituals, meaning making, spiritual care, humanist chaplaincy, and birth and death as existential transitions. She is a scientific coordinator of the one-year celebrant training program for new rituals at the University of Humanistic Studies.

#### **Brenda Mathijssen**

Brenda Mathijssen (PhD in religious studies) works as an assistant professor at the University of Groningen, the Netherlands. Her research focuses on death and bereavement rituals in Europe, the interdisciplinary study of religion and death, and rituals in spiritual care. She is the scientific director of the Centre for Religion Health and Wellbeing at the University of Groningen, and is an associated researcher at the Centre for Death and Life Studies at Durham University.

## *Editorial* **Birth and Death: Studying Ritual, Embodied Practices and Spirituality at the Start and End of Life**

**Joanna Wojtkowiak 1,\* and Brenda Mathijssen <sup>2</sup>**


Birth and death are fundamental human experiences. Both life transitions are not only meaningful and profound but can also lead to ambiguous feelings, negotiated in embodied, cultural, spiritual, and ritual practices (Hallam et al. 1999; Kaufman and Morgan 2005; Mathijssen 2018; Wojtkowiak 2020). The liminality and ambiguity of birth and death evoke the need for rituals. Across cultures, rituals accompany birth and death as major life transitions, for instance, by welcoming the child or mother-to-be/parent-to-be through name-giving ceremonies or symbolically transitioning the deceased into the world of the dead. In this edited volume in *Religions*, we explore new theoretical and empirical research on birth and death rituals from multidisciplinary perspectives, such as anthropology, psychology, and religious studies, in order to offer novel insights with respect to lived spirituality and religiosity.

The importance of studying birth and death from an embodied and ritualized perspective relates to several observations. First, all humans are related to their own birth and death and are often involved in the birth and death of others (Hennessey 2019; Schües 2008). But entering the world, as well as saying farewell to loved ones, is not a linear transition. Liminal and ambiguous meanings go hand-in-hand with pregnancy and birth as well as death and dying. Cultural, spiritual, and ritual practices accompany these transitions and also accommodate possible ambiguous states. Secondly, both life transitions are related to spiritual and existential questioning, revealing what matters to us (Wojtkowiak and Crowther 2018). Thirdly, rituals and embodied practices—varying from quotidian story telling, performances, meditation, and beautification practices to initiation rites and funerals—are grounded in the body, senses, and material culture. Gaining insights into embodiment, the physical and material dimensions of spirituality are therefore significant, but they have been underdeveloped in the literature (McGuire 2008). Fourthly, because of changing religious and cultural contexts, shaped by secularization, medicalization, migration, and globalization, the ways in which we frame and give meaning to birth and death are changing and leading to pluralistic and possibly conflicting meaning frames. Rituals at the start and end of life have also been changing (Grimes 2002). Rituals can not only be prescribed by cultural and religious traditions but can also emerge in new post-secular and interreligious contexts through ritualizing and re-inventing traditional rites.

What kind of challenges do we face in changing birth and death contexts? What can we learn about meaning making and spirituality by studying birth and death rituals? How is embodied spirituality negotiated in birth and death rituals? The main question of this edited volume is *what can we learn about notions of embodied spirituality by studying birth and death from a ritual perspective?*

In the consensus definition by Puchalski et al. (2014) spirituality is defined as *"the dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect*

**Citation:** Wojtkowiak, Joanna, and Brenda Mathijssen. 2022. Birth and Death: Studying Ritual, Embodied Practices and Spirituality at the Start and End of Life. *Religions* 13: 820. https://doi.org/10.3390/ rel13090820

Received: 26 August 2022 Accepted: 28 August 2022 Published: 4 September 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

*to the moment, to self, to others, to nature, to the significant, and/or the sacred" (p. 644).* Systematic approaches to the spiritual dimension of palliative care also reveal the focus on the connection or relation to the transcendent, purposeful, and ultimate meaning in life (Rego et al. 2018). While these approaches are helpful in making clear that spirituality is an important dimension of human existence and meaning, they, in our view, sometimes neglect the bodily, embodied, and material dimensions of spirituality. Therefore, this edited volume explicitly focuses on embodied practices in various cultural contexts to reveal how spirituality takes shape within and among bodies and embodied realties. Such an emphasis on birth and death as embodied transitions sheds new light on our commonsense understanding of spirituality that is somehow "out there" or "within our mind". Studying spirituality from the body always and often implicitly means that material and embodied experiences are shaped by cultural, religious, gendered, and ethnic experiences. Some bodies, such as pregnant, ill, or dying bodies, are treated differently from others. They need special attention and might even be stigmatized. An embodied spirituality implies that the political dimension of embodiment needs to be considered in research (Butler 2009).

#### **Embodied beginnings and endings**

Birth and death are both universal *and* unique human transitions. Every human that is born is a unique person and at the same time part of a larger community of previous and later generations (Arendt 1958; Schües 2008). Being a member of a group or society, one is also involved in the birth of others. This can occur directly by becoming a parent, grandparent, aunt, uncle, or any other relation with newborns and can also be understood in a more general sense, for instance, the idea of providing for future generations. Increased consciousness about our ecological footprint, which is increasing in many societies, is motivated by the idea that we have to provide for future generations. Moreover, many cultures celebrate birthdays and a birthdate is an important juridical fact.

Pregnancy, the state before birth and a necessary phase in order to exist, is surrounded by many cultural and religious beliefs and practices across the world. Pregnancy is an ambiguous state, where the future mother or parent is transitioning physically by creating life and birthing the new living being. Pregnancy and birth are very strongly intertwined to bodily and embodied transitions: We come from the body of another human being, which makes our beginning an absolute embodied reality. Looking at spirituality and meaning making from the perspective of birth, thus, not only teaches us about the meaning of the beginning of life but also about the meaning of embodiment. In pregnancy, the dualistic distinction between object and subject is challenged by an embodied relationality. The baby grows within the body of the mother or person who is carrying the pregnancy, revealing a two-in-one subjectivity and pre-subjectivity.

Like birth, death is an "ordinary and everyday as well as life-changing and defining experience" (Woodward and Woodward 2020, p. 1). The ritual engagement with death that is, with the process of dying and bereavement, and the relationship with the dead relates to sense making. Rituals and ritualizing equip people in framing their encounter with death and the dead (Utriainen 2020). On the one hand, they enable people to transcend the finitude of life in social and symbolic ways by creating *connections* "to the moment, to self, to others, to nature, to the significant, and/or the sacred" (Puchalski et al. 2014, p. 644). In rituals, people can (re)establish temporal and spatial relationalities and give expression to their sense of reality. On the other hand, rituals allow people to *set things apart*, such as their emotions, memories, bodily remains, material objects, or relationships with ancestors. By setting apart one's experience with death and the dead (as special or sacred), people can revisit their emotions at an aesthetic distance (Wojtkowiak 2018). Furthermore, rituals evoke a subjunctive mode of potentiality that creates space to affirm and play with what "could be" (Jongsma-Tieleman 2002; Kapferer 2006; Kreinath 2009).

The papers in this edited volume illustrate that embodiment and materiality play key roles in birth and death rituals in five particular ways. First, many authors show that the body is a vehicle for mediating and incorporating knowledge. In her study of death rituals in Assam, for example, Hagjer (2022) illustrates how mourners repeat the physical technique of *meser*. She argues that this technique is central to safeguarding the passage of the deceased to *damra*, to the social integration of individuals within the community, and to the integration of knowledge through the organization of people's dispositions. Hagjer thus shows that rituals can be understood as bodily techniques that improve the spiritual wellbeing of the ritual participants—both the living and the dead—and that support the integration and routinization of social and spiritual knowledge. Through the act of ritual, spiritual knowledge becomes inscribed in the body, and in that sense, spirituality is always embodied. In their paper on funeral and birth rituals in Russia, Mokhov and Novkunskaya (2021) draw our attention to the importance of transmitting knowledge about "ritual fractures". Ritual fractures can be defined as challenges that exist in the infrastructure of the organization of a funeral or birth, such as issues with existing rules, legislation, or transport. The authors illustrate that people perceive "ritual fractures" not as problems but as a special form of necessary tests. Ritual fractures carry a symbolic meaning: through processes of meaning-making, people make these fractures significant, meaningful, or even sacred.

Second, a number of papers illustrate how material forms enable the bereaved to give expression to subjunctive futures. Subjunctive futures—futures that could have been become embodied within rituals and are, thus, made present in the here and now. In their paper on embodied grief and perinatal loss in Australia, Norwood and Boulton (2021) illustrate that not only the personhood of the baby is lost but also a sense of motherhood and sense of self. They argue that through the "thoughtful re-presentation of medical insight into pregnancy and fetal development", the body of the mother can become part of the distributed personhood of the baby. The body of the mother is, thus, reframed to make the lost baby materially present. A similar observation is made by Vaerland et al. (2021), who showed that perinatal death is often disenfranchised and, therefore, difficult to acknowledge openly. Their study in Norway indicates that "materially grounded metaphors", which are objects such as scrapbooks and boxes that highlight bonds with the deceased and mark important memories, can help overcome this difficulty, as they enable people to capture the personhood of the deceased and the parenthood of self. The significance of materiality also becomes visible in the article by Manfredi (2022), who analyses tattoos in relation to death and birth as "intimate and self-centred acts" (p. 11) in Italy. Manfredi's interlocutors understand their tattoos as the embodiment of relationships. Tattooing both freezes time, allowing the person to capture a sense of the relationship with the subject-person, and projects a self in the future. By tattooing, specific forms of self and self in relation to the deceased are produced. Such productivities cannot only be understood as memory making but also as forms of meaningful relating. Tattoos physically touch the existential dimension of self, and thus can be understood as embodied forms of spirituality.

Third, several authors show that rituals of perinatal loss create room for a social recognition of the life that has been carried. In their study on perinatal loss in Catalonia, Spain, McIntyre et al. (2022) emphasized that ritualizing allows women to express *both* the life that has been *and* the life that could have been. Rituals surrounding perinatal loss thus not only resemble death rites but also initiation rites. This emphasis on initiation is particularly important in relation to perinatal lives, since these lives are not always fully recognized. In the context of Spain, for example, there are no common rituals for perinatal loss due to the "ambiguity of the Catholic Church's stance on the stance of unbaptized babies"(McIntyre et al. 2022, p. 5). By ritualizing, for instance, by creating personal shrines, marking birthdays, or the beautification of the body, the authors show how women ritualize motherhood and their child's existence. They "make real the life that they have carried" (McIntyre et al. 2022, p. 13) and in doing so acknowledge that life. Biel et al. (2022) also examined subjunctive futures at the beginnings of life, but their study focuses on ritualizing abortion in the Netherlands. In abortion, the ambiguity of pregnancy is stressed: There is a beginning, but it does not lead to a newcomer. Ritualizing was found in symbolic expressions for the imagined child, writing poems or letters to the potential

child, memorializing specific dates in private, and in some cases, sharing these symbolic expressions in a digital community for recognition and community building. Ritualizing abortion negotioates meanings and marks the event as meaningful.

Fourth, some authors investigate ritual origins and the re-appreciation of traditional rituals, such as Hennessey (2021), Ohaja and Anyim (2021), and Janiak and Gierczyk (2021). Hennessey (2021) discusses the role of art and material culture in contemporary rituals of birth and studies the re-sacralization of material objects through art and birth practices in nonreligious contexts in the US. While birth has been much less visualized than death, the here studied material and visual representations of birth show how birth is related to other rites of passages. The new, re-invented objects have origins in indigenous or traditional cultures and Hennessey (2021) asks to what extent the re-appreciation of existing cultural tools and objects reaches cultural appropriation. Ohaja and Anyim (2021) reflect on the ritual culture surrounding pregnancy and birth in various African contexts, such as Cameroon, Ghana, Kenya, and Nigeria. The authors discuss how the uniqueness of the newcomer is incorporated into the community, going beyond embodied persons, and is closely linked to ancestors. The naming ceremony for newborns reveals the intertwinement of the meaning of the baby as a unique newcomer *and* as a member of society, illustrating Arendt's (1958) notion of the plurality of being at birth. The authors argue that ritual practices help women in spiritually connecting to a greater whole and community, giving meaning to this life transition. Janiak and Gierczyk (2021) focus on the absence of ritual knowledge and the need to re-appreciate the former expertise of catholic clergy on death and dying in Poland. Clergy were typically present at the death bed and, therefore, have hands-on experience with dying. Via these teachers, the authors suggest that people can refigure what it means to die well and can learn the art of dying, the ars moriendi, once again. By doing so, the authors argue that death and dying can be rehumanized in a post-Christian and secularized society.

Fifth, several studies in this volume offer critical notes to the sometimes simplistic use of the Van Gennepian tripartite distinction of rites of passage in the literature and the Turnerian emphasis on transition as a turning point (Van Gennep [1909] 1960; Turner 1969). Hennessey (2021), for example, draws attention to feminist thinkers who show that while pregnancy is a transition into a new state, birth is more of an intensification of the previous transition than a new transition of statuses. Akin to this, Ohaja and Anyim (2021) show that birth rites are not only expressions of collective joy for the newcomer but also a farewell for the mother. This becomes visible in the practice of burying the placenta and umbilical cord, which is performed with great care and attention for detail. These burial rituals following birth offer new insights into birth as a transition: The birth of a child is welcomed by joy *and* is a goodbye for the mother, the end of a 9-month pregnancy during which the baby has been living and growing within one's body. Furthermore, many papers show that ritualistic practices happen before, during, and/or after birth and death and do not necessarily occur during the "main" rite of passage and do not always follow a linear transition. The studies on perinatal loss from McIntyre et al. (2022), Norwood and Boulton (2021), and Vaerland et al. (2021), as well as Manfredi's (2022) work, on tattoos surrounding death and birth evidence that many people continue to ritualize the (re)integration of the deceased in their everyday lives not only after death has occurred but also long after human remains have reached their final destination (cf. Hertz [1907] 1960). These practices not only include the (im)material absence–presence of the baby as deceased but also of the baby as newborn.

In sum, this edited volume illustrates the importance of an inclusive and critical understanding of embodiment in the field of ritual and spirituality studies. We argue that, in addition to the dominant male narratives that emphasize "climax, conversion, reintegration, triumph, the liminality of reversal or elevation" (Bynum 1984, p. 108), it is imperative to involve the embodied perspectives of tangible other bodies in ritual studies theory, including women, mothers, parents, newborns, and the dying. This does justice to the ambiguity and multivocality of ritual, as well as to the ambiguity of life transitions. Doing so reveals that birth is not "just" a beginning and death is not "just" an

end. Both are closely connected to everything that comes before and after previous and future generations, as well as other rites of passage during one's life. The papers across this edited volume have confirmed that birth and death are fundamental human experiences, that are necessarily embodied and experienced through particular bodies. As Manfredi (2022) aptly describes: "Bodies work excellently to manifest cultural values, social status, or other messages readable by those who share a common cultural background and are aware of their meanings ... " (p. 2). The bodily transmission of shared cultural knowledge that many authors in this Special Issue have hinted at has implications for our definition of spirituality: We must *explicitly* include the body in our understanding of spirituality. Adding embodiment to the consensus definition of Puchalski et al. (2014) would mean to speak at least of the dynamic, *embodied* dimension "of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence," (p. 644).

**Author Contributions:** J.W. and B.M. co-authored this manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

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

#### **References**

Arendt, Hannah. 1958. *The Human Condition*. Chicago: University of Chicago Press.


Grimes, Ronald L. 2002. *Deeply into the Bone: Re-Inventing Rites of Passage*. Berkley: University of California Press.

Hagjer, Pamidi. 2022. Dimasa Rituals of Death and Mourning in Contemporary Assam. *Religions* 13: 82. [CrossRef]


Hertz, Robert. 1960. *Death and the Right Hand*. Aberdeen: Cohen & West. First published 1907.


McGuire, Meredith B. 2008. *Lived Religion: Faith and Practice in Everyday Life*. New York: Oxford University Press.


Schües, Christina. 2008. *Philisophie Des Geborenseins*. Freiburg and München: Verlag Karl Alber.


Woodward, Kath, and Sophie Woodward. 2020. *Birth and Death: Experience, Ethics, Politics*. Milton Park, Abingdon and Oxon: Routledge.

## *Article* **Dimasa Rituals of Death and Mourning in Contemporary Assam**

**Pamidi Hagjer**

Department of Sociology, Tezpur University, Napaam 784028, India; pamidi@tezu.ac.in

**Abstract:** Deaths provide an important setting for Dimasas in Assam to engage in collective ritual performance. These rituals not only allow the people to affirm their identities, but also provide a space to create strategies to adapt to the changing urban landscape. This paper is an attempt to understand the shift in Dimasa death ritual processes in contemporary Assam. The essay has traced how people mobilize resources as a community to ensure the smooth journey of the deceased from this world to the afterlife, within the constraints of an urban environment. A small but critical part of this process is engaging in bodily techniques that recreate the unique cultural practices of *meser-moso* and collective grieving, called *grasimang*. By using ethnographic methods, the paper highlights the perseverance of the people as a functioning collective, and the meanings and symbols that are shared to ensure a successful ritual.

**Keywords:** Dimasa; death rituals; urban; ritual performance

#### **1. Introduction**

For the Dimasas, death at an old, ripe age, after bearing children and seeing those children grow up, is the ideal scenario;. With access to minimum health care, most can attain this goal today. Unless one dies of old age or serious illness, sudden deaths, however, are looked upon suspiciously. There are good deaths and there are bad ones. The implication of this is that the level of threat from bad deaths is much higher than good ones. Special care, therefore, must be taken to treat them differently. In the Dimasa society, however, death rituals are performed equally for everyone, i.e., it does not matter if the individual was morally bad or good, lazy, selfish, greedy, notorious, kind, etc., during their lifetime. As a society that maintains the stratification of age and gender, death becomes a reflection of how the deceased are treated in terms of this principle.

The present paper is primarily a study on death rituals and practitioners -the Dimasa community of Assam. The community as a context is important, because in a critical life event such as death, the response to an individual's death is, for the most part, determined by the nature of their social grouping. In the case of the Dimasas, this is their kinship network. The relationship between the local neighborhood/community and clanship, and the obligation towards one's ancestors, lies at the center of Dimasa death rituals and, like several other communities in the region, we also see the Dimasas slowly trying to fashion their cultural practices with forces of modernity and urbanization. It is in this context that the paper asks a broad question—what can rituals of death and mourning tell us about the lives of communities, particularly those that identify with clans and kinship network, in an urban setting? Urban spaces are heterogeneous spaces, that are multiethnic and multi-cultural. With diminishing physical space for the dead, there have been accompanying changes in ritual processes. In such situations, events that require some degree of adherence to a specific set of cultural norms have to be strategically reformulated to ensure a successful completion. As it is not in the nature of humans to be a passive recipient of culture, we do not simply receive it and reproduce it—we also transform it and create new forms. An urban setting creates structural constraints which demand these

**Citation:** Hagjer, Pamidi. 2022. Dimasa Rituals of Death and Mourning in Contemporary Assam. *Religions* 13: 82. https://doi.org/ 10.3390/rel13010082

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 23 November 2021 Accepted: 12 January 2022 Published: 17 January 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

rituals to be performed under unique conditions; yet, at the same time, it also creates opportunities for the performers to mold part of their rituals according to such conditions, thereby breaking away from norms without the imposition of impending sanctions (Borer 2006; Kong 2012; Pascaru 2019; Bergmann and Schaflechner 2020).

Dimasa death rituals, from the time of cremation till the purification, can last for months. This "ritual journey", i.e., the transition of the soul of the deceased to the afterlife, requires the constant engagement of the kins of the deceased, and a space to perform rituals of offering to the deceased every day. The Dimasa rituals of death take place, in equal part, both in the house of the deceased (a relatively private space) and in the communal cremation ground. For societies in transition, where geographical and social space is a space for contestations of multiple identities, rituals of death can be both disruptive to collective identity, and at the same time suggestive of new ways for identity affirmation. Relying mainly on ethnographic methods of participant observation and interviews, this study has been an attempt at understanding a core component of Dimasa culture in contemporary urban Assam, and the adjustments that have been made to ensure its continuity (Parry 1994; Maaker 2016; Lipset and Silverman 2016).

#### **2. A Brief Note on the Dimasa Community in Assam**

The Dimasa people, also known as the Dimasa Kachari, constitute an important tribal– ethnic community of Assam. They mainly inhabit the district of Dima Hasao, and are found in small numbers in parts of the Nagaon, KarbiAnglong and Cachar districts, and certain areas in the state of Nagaland (Bordoloi 1984; Barman 2014). The exact place from where they migrated to the valley of Assam is a matter of speculation. Barman (1992) speculates that the arrival of the much larger Kachari group was around 5000 years ago, leading to their settlement along the confluence of 'Di-Louhi' (Lohit) and 'Tsang-Di' (Tsang-Po). This knowledge, he claims, along with Kachari traditions through traditional narratives, has been passed down through generations by a clan, Zaun-thai<sup>1</sup> (Barman 1992, p. 15). Gaits (2013) mentioned that the meaning of Dimasa may be translated as children (-sa/basa) of the great river (Dima). It is thus widely believed that before the coming of the Ahoms, the Kacharis must have inhabited the banks of Brahmaputra and its various tributaries. Using etymological arguments, but basing the opinion on a more materialistic interpretation, Bathari (2017) added to this discussion on the history of the Dimasa dynasty, emphasizing the emergence of rice-cultivation, its links to the plains of Brahmaputra, archaeological evidence in Dimapur ruins and the technology used, thereby hinting at much older origins of the Dimasa kingdom. The architectural structures in Kasomari (Golaghat), Khaspur (Cachar), Dimapur (Nagaland), and Maibong (Dima Hasao), and the inscriptions and coins discovered there have, to a certain degree, helped in the reconstruction of this history. Lastly, it has also been argued that Dimasa is derived from the word Arikhidimasa, which translates to children of Arikhidima, who is believed to be one of the mythical creators of the Dimasa people.

Despite being a prominent dynasty in the Dhansiri valley, extending from the southern bank of Brahmaputra in Nagaon to upper Assam, the Dimasas have no written scripts, and the information on the history of migration (and the speculation around it) has been derived either from oral knowledge (folk songs, tales, etc.) for the most part, and from the Ahom chronicles of Buranjis. Folklores discuss the formation of the capital at Dimapur around 1086 C.E, until the defeat the hands of the Ahom in 1536 C.E. After the fall of Dimapur in 1536, the Dimasa king shifted his capital into the uninhabited hills on Dima Hasao, in Assam where, with time, a second Dimasa kingdom with its capital at Maibang, on the banks of the river Mahur, developed. Eventually, another attack on Maibang in 1706, by the Ahom king Rudra Singha and his allies, forced the Dimasa king Tamradhdvaj to shift his kingdom to the plains of the Barak Valley, now in the Cachar district of Assam, where the new capital was established in Khaspur near Silchar in 1750. After Govindachandra's death, the kingdom was annexed by the British in 1832, thus marking the end of the dynasty in Cachar. Post independence in 1947, the Dimasas were classified as a separate tribe in

the 1961 census, and the 1971 the North Cachar Hills (now the Dima Hasao Autonomous District Council) was made into a district. The Dimasas are now constitutionally recognized as Scheduled Tribes (Hills) in Assam.

Central to the Dimasa social organization is their double-descent system of lineage, where both the matrilineal and patrilineal clans are exogamous. The matriclan (julu/jadi) and patriclan (sengphong) are said to number forty-two and forty, respectively. The society is patriarchal in nature, and clan identity is fixed and non-interchangeable for all socio– religious–political purposes and, to this day, clan membership determines a person's social roles in critical life events, to a large extent. All patriclans are also grouped and tied to each other through their notion of sacred geography—an institution called the *daikho*. The entire Dimasa land was divided into several territories falling under the jurisdiction of a particular god (Ramirez 2006). Each of these territories is known as a daikho, twelve in number, which translates to an 'abode or sanctuary of god', and each are affiliated to a particular god who control/protect it, including the people who live there. The daikho is also a gendered space where women are not allowed, along with non-Dimasa.

In the course of the expansion of the Dimasa kingdom (and the subsequent migration of the people), the Dimasa kings began to gradually provide patronage to Brahmin priests and incorporated Hindu ideals into their way of life. This was solidified by the reign of Krishanchandra in 1773, who constructed several temples in Khaspur in the Cachar district of Assam. Thus, the impact of Brahmanical Hinduism cannot be underplayed. The initial phase of the coming of Hinduism strengthened the state formation. However, during its final hundred years, it is said that the royalty and aristocracy, having inducted themselves heavily into the Brahmanical order, grew distant and alienated from the masses, as well their traditional customs. Although the conversion to Hinduism brought about changes within the community, the Dimasas, by and large, have belief systems which are distinct and still very much prevalent. Today, a majority of the population follow a "mixture" of the traditional system and the Hindu religion. There is also a presence of Vaishnavism (for e.g., ISKCON), as well as Christianity among a small but growing segment, especially in Haflong. It is often argued that the Dimasas residing in Cachar have been Hinduised far more intensely than their counterparts elsewhere. This is reflected in their identity as 'Barman Kacharis'. However, what needs to be focused on are the traditional ideologies, beliefs and notions of cosmology that still retain an important position. The deities of the Dimasa pantheon are several in number, and with the incorporation of Hindu deities into the religious system, the functions of rituals (both indigenous and non-indigenous) and its observance have only increased.

#### **3. The Experience of Death**

The Dimasa cosmology is a two-part reality: the living world *habsao,* and the after world or land of the dead, *damra.* There is therefore no clear notion of heaven or hell, unlike the dominant religious systems, nor a 'centered' space or a single focal point, such as the Nordic 'Cosmic Tree'. There does exist is a sense of 'sacred' geography, as seen from the discussion of *daikhos*, which connects the after world, earth, the gods, the spirits and society. This idea of *damra* is very important, as it plays a prominent role in death rituals. Of course, significant appropriation of Hindu practices has taken place, and the contemporary Dimasa practices have clearly incorporated some of these ideas and rituals.

The belief in the presence of the *beseh* (soul), which resides within all living individuals, could be the starting point of this account. When a person dies, the role of those alive is the transportation of the *beseh* to the *damra* (afterworld) as swiftly and smoothly as possible; all succeeding rituals have this one singular purpose, and despite there being several people performing several roles, they are all united by this end goal. Unlike childbirth, death has a strong influence to suspend mundane and daily activities. Therefore, it is only common that death rituals are more elaborate, performed with greater care, and with more utilized resources. As in most cultures, Dimasas also believe that failure to perform death rituals in an appropriate manner can bring shame on the people.

There is a widely accepted ritual model, but Dimasa death rituals are known to have small variations, similar to most cultures. There are, however, patterns to be found. For instance, upon death, the announcement is made by the family members to the rest of community, through whichever means possible. The first step, after the event of death, is to let people of the *raji*, and the neighboring rajis know about the death, so that people may come and participate in the activities. Raji, is a term used for village/neighborhood, and remains an essential representation of the community in the Dimasa society. Every *raji* has a village head called *khunang*, and the raji functions similarly to a neighborhood association, making decision on behalf of its members; in any 'life-crisis' events, the *raji* will either support (or at times oppose) the family, etc. Rajis are thus called upon for almost any activity, and can be used for mobilizing resources, if and when required. Haflong town has 14 (fourteen) rajis in total; Guwahati has 1 (one).

#### **4. Confronting Death in the Community**

The core arguments of this paper come from research performed in Guwahati and Haflong between 2013 and 2016, with two death rituals observed in Guwahati and two in Haflong. Both the towns are located in the state of Assam, in the northeast region of India. Guwahati is the center of administrative and business activities in North-East India, and Haflong is the headquarters of the hill district of Dima Hasao, located in the southern part of Assam. The first Dimasa family to set up residence in Guwahati happened in the 1950s, followed by the settling of few others over the next few decades. Today, as a migrant community, they number to approximately 700–1000 in the city, which include a mobile group such as students and young working individuals, and around 80–100 families. The Dimasa community in Guwahati comprises people who have come from various areas: Nagaon, Karbi Anglong, Cachar, Dima Hasao, and Nagaland. The Greater Guwahati Dimasa Association, headed by a *khunang* (politico-cultural head), constituted by the members of the community, functions as a formal body representing the interest of its members. What this has led to is the creation of a more diverse Dimasa identity, based on cultural components from the above region. The Haflong town became a part of the old Dimasa kingdom when the capital moved to Maibang in 1536. The Dimasa people constitute a dominant majority (demographically and in terms of visibility of culture) in Dima Hasao. Historically, one can trace and locate the assertion of their tribal identity (in post-independent India) here as well. This is significant to the study as it highlights the distinction between the two areas of study. Haflong and Dima Hasao, due their status as politico-administrative centers of a majority of the Dimasa population, hold an important place in the imagination of the community; Guwahati's importance lies in its ability to provide economic opportunities and independence.

In the case of Guwahati, both the deceased were kins (mother and daughter); thus, the setting for the rituals was the same household. The mother was a non-Dimasa who married into the community and, following the customs, converted to 'Dimasa' by accepting a new matriclan and her husband's patriclan. Her children (her daughter included) were thus considered to be Dimasas with membership into both matriclan and patriclan kin groups. It would be naïve to not point out that being born with a certain (respectable) status, and being married into a family with a similar reputation, can make the process of assimilation and acceptance on one end much easier. The Dimasa community, as mentioned, is highly endogamous in nature. Inter-community unions are not prescribed, and they come with sanctions that can range from mild gossip to long-term disassociation from the life of the community itself, depending on the 'other' community concerned. The daughter herself never married; her patriclan when she died was thus the one she was born into. In Haflong, both the deceased were elderly men who died after dealing with long-term health conditions. Although one of them had been ailing for a long time from terminal illness, the other's death was gradual and was partly because of old age.

Typically, Dimasa deaths occur at home, with relatives already present, and thus the encounters and confrontation with death is direct. The experience of death itself therefore remains central to members of the community. Especially in Dimasa villages, children grow up seeing deaths, unless in case of accidents. However, this has altered in the case of urban households where a significant number of deaths occur outside the residences, such as in hospitals, etc. In the four cases followed and observed, all the deceased were going through different stages of illness, some more prolonged than the others; hospital deaths were therefore the common premise.

One of the informants in Guwahati informed me that the reason why death rituals are large affairs is because one does not need an invitation to be a part of it. It is a moment where people show solidarity without being asked. Death rituals and mortuary practices have always been viewed as prototypical rites of passage. The dilemma of dealing with the unpredictability of death requires a symbolization of some degree of continuity, i.e., engaging in imaginative forms of ways to transcend 'death'. In the Dimasa community, this is resolved through the concept previously mentioned—the existence of *damra*, the afterlife, and *beseh* (the soul) which reside with all living individuals and could be the starting point of this account. When a person dies, the role of those alive is the transportation of *beseh* to *damra* as swiftly and smoothly as possible; all succeeding rituals have that one singular purpose, and despite there being several people performing several roles, they are all united by this end goal.

In this section, I present a narrative of funeral practices, beginning with the preparation for death and the treatment of the deceased, followed by the cremation and the main feast at the end of pollution period. The description is not of a single case, rather a generalization of death rituals in urban Assam among the Dimasa community, with the aim of providing a coherent picture. Of course, in reality, there are variations depending on the geography and type of death, but the processes mentioned are mostly similar. The significance of the variations is also noted to show the similarity and difference between the rituals as performed in Guwahati, versus that in Haflong. The completion of Dimasa death rituals can take anytime between one to six months. There are rituals specific to events (such as the preparation of the body for cremation, final purification rituals, etc.), and there are daily routine rituals of offering food to the deceased until the end. The death and funerary rituals can be broadly classified into three parts: firstly, the preparation and performance of cremation rites; secondly, the preparation and performance of *jumangsho*; lastly, the *maimutharba.* There are several rites being performed simultaneously, and sometimes more than once, with each one being given a unique function and role. The reason, therefore, for the classification, is that over the entire duration: (a) these three events hold a special significance, demanding a collective effort that goes beyond just the involvement of the kins of the deceased; and (b) they are performed only once, and the dates for which are pre-fixed (aside from cremation). The classification therefore does not completely correspond to van Gennep's<sup>2</sup> classic three parts of the rites of separation, transition and incorporation, although all the stages are present in their own distinct forms within Dimasa death rites. In the succeeding rituals that follow the death of an individual, all members of the *raji*, including the kins of the dead, come together and perform various duties and roles. The most prominent role is that of the headman of the *raji, khunang* who distributes the work among other adults. As in most tribal societies, the *khunang* is not only a prominent ritual head, but also has an important role to play in matters of most social events, such as marriage and birth. However, there are other adults (unmarried, married and/or widowed) who assist in the performance of the entire ritual process.

The Dimasas cremate their dead. The male relatives of the deceased make arrangements for cremation, whereas the female relatives start the preparation for what the Dimasas term as *makhamgarba, i.e offering of the food*. Since the *mangkhlongling*, the cremation ground, is a communal property, there is a process of 'buying' the ground called *mangkhlongrebma*, for the purpose of the cremating the dead, and occupying space for the construction of the repository, *thaire*, and the associated funerary rituals. The community members should

have a partial ownership, so the process may complete without any interruption. *Jom raja*, as a deity who brings death, is invoked, so that the petition (to buy) can be made. It is the *khunang* and the *hojai*, who offer *khaodi* (cowrie or small shells) as a mode of payment to *Jom raja* (god of the death) and *Sibarai* (a prominent male deity believed to be the ancestor) for safe passage to *damra* and from the earth, respectively. In Haflong, the Dimasas have a fixed location near the Kalibari Temple, located near Main Town for cremation purposes. All cremations are performed there, and the place is collectively maintained by the members of the community. Although there is no water source in the area, most of the arrangements are made beforehand, such as the gathering of firewood, etc., and symbolic purchase of the spot for cremation is still performed. Guwahati presents a different situation, since the community has no ground as such to call their own. Therefore, the cremations in the instance of the two cases were performed in a crematorium in the city located in the foothills of the Navagraha Hills in the Silpukhuri area. The entire ritual process of buying and chanting prior to cremation were forgone for practical purposes; as such, things were already taken care of in the towns, where the cremation grounds already had the pyre ready. The management of disposing of the bodies of the deceased, whether through cremation or burial, is no longer the responsibility of the families; authorities have mechanisms to deal with such situations which take into consideration the pressures of demographic changes. As a migrant community in Guwahati, this is certainly true for Dimasas, where services of GLP and Marwari Yuva Manch are used to carry the body of the deceased to the cremation ground. Instead of symbolic payment, the community now must make actual monetary payment for the use of space and its resources; the means (money) and the roles (the management of the cremation ground) which are secular in nature become crucial to attain (pre-dominantly) non-secular goals.

Back in the households of the deceased, preparations are undertaken to build the *dolai*, with bier made from bamboo to transport the body. This bier has to be constructed by men belonging to the patriclan of the deceased, who are brought in from their native villages or towns. While this is being done, the body of the deceased, the *mangathik*, is bathed, cleansed and clothed with fresh new clothes, according to the sex of the deceased, and laid upon the mat, covered, in the main hall/entrance room of the house with the feet facing the entrance, in the main room of the house, on the floor. This room is somewhat more public, and serves the purpose of letting the residents know what is happening outside as well. In all the cases observed, these rooms had direct access to the front yard. Drawing on Singh's (2016, pp. 29–30) arguments on death rites in Varanasi, the architectural significance of this main hall/entrance room as a public space can be highlighted as opposed to the "cooking, dining and retiring", which is a private part of the house. Elderly and adult women sit around it, while men usually sit or remain outside. It is important that one of the women should fan the dead constantly with the mulberry plant, while the others start engaging in *grasimang*, which will be further explained in detail. This is the first of the several emotional and embodied moments which is shared by those involved in the process. Depending on the time of the death, the Dimasas also engage in the activity of 'watching/guarding' the body of the deceased. This is known as *horkhamba* (hor = night, khamba = to sit), a way of keeping vigil in the olden days when wild animals were plenty in the vicinity, if the death were to occur at night and the body needed protection. The community does not believe in keeping the body overnight, but if it has to then a collective activity of protecting the body is performed.3 As death is considered polluting, visitors who make trip to the household before cremation generally undergo purification (spraying oneself with *tulsi* water) once they go home, to be free of all contamination of "dirt".

All the acts, such as the construction of the bier and the dressing and covering of the body of the deceased, follow a specific method wherein all the cutting, chopping, laying of the materials, dressing and covering is performed in what the Dimasas term as *meser*. *Meser* indicates an act of completing something in reverse, opposite, or turned upside down (Jahari 2010). The explanation for this lies in the traditional understanding of the *damra.* The *beseh*, in order to find peace and have no disruption in its existence, must be able to

travel from the physical, natural world of the living and move on to *damra*, where it will continue to live as it did in the natural, living world. The disjunction caused by death, wherein the *beseh* momentarily transforms into *simang*4, a state of being spirit or ghost-like, is dangerous and should be kept as short as possible. The belief is that, in the afterworld, *damra*, everything is *meser-moso*, i.e., it is in a state of topsy-turvy, and reversed. In order to ensure that the *beseh-simang* journeys to the unknown lands and finds a comfortable life, the preparations have to be made from the world of living, and have to be completed in a manner that reflects the topsy-turvy nature of *damra*. Anything in contrary to this will only result in the possibility of the spirit of the deceased in an eternal state of confusion and limbo. This must be avoided at all costs, for a confused and lost spirit can also be potentially malevolent. This *meser* technique emerges repeatedly until the last of rituals are performed (such as offering of the food with the left hand), and it can be safely be said that the notion of *damra* has a tremendous influence on the ways and techniques of the rituals, and can be considered as that one singular belief that binds and provides a sense of cohesion to the entire process. This physical technique that accompanies all rituals shows how bodily aspects are central to the integration of the members and their belief systems (Mellor and Shilling 2010). They organize people's dispositions such that it produces similar knowledge as well as goals.

Crucial to this process of transportation of the dead is the preparation, and the offering of the sacrificial food. Food is central to all cultures; therefore, it is only natural that food becomes a medium for rituals, and food rituals, a marker for taboos, and a sacred symbol (Fox 2014). There are three categories of *garba* that are performed here. First is *makhamgarba,* second is *simanggarba*, and third is *midogarba*. *Garba*/*gerba* denotes a form of ritual where the community worship together. *Makham* (cooked food) *garba* is the act of offering cooked food specifically to the deceased. *Simanggarba* is the food offered to the ancestors, whereas *mido* (cooked meat) *garba* is the offering of meat and rice beer to the gods and deities, usually at the altar of Sibarai. The women make preparations for both *makhamgarba* and *simanggarba*, i.e., they are exclusively prepared, and the feeding is performed by women, while the men make preparations for *midogarba*, i.e., feeding the gods. The food is also consumed by those who prepare them, i.e., women consume the food prepared for *simanggarba* and men consume that of *midogarba*. Eating is, thus, an important theme linking women's activities in death to those in ordinary life. Women, essentially, bear the responsibility of caring for the dead, just as they do for the living. The *makhamgarba* begins immediately before the cremation until the day of *maimutharba*, but *simanggarba* and *midogarba* is performed only on the day of *maimutharba*. Both in Guwahati as well as Haflong, the first *makhamgarba* before the cremation took place in the cremation ground itself, while the rest (which had to continue until the final event of maimutharba) were performed at the home of the deceased. The daily routine of offering food to the deceased in the vicinity of one's private space in Guwahati was done, as the access to cremation ground was no longer possible after the deed was complete. In Haflong, however, women from the raji would continue to go to the Kalibari for the daily offering.

As any death event, the moment of cremation is an emotional one for the family members, and before the burning of the body, the bereaved family mourn. However, it is also a ritual prescribed by customs, where members of the clan also engage in what is known as *grasimang*(gra = cry/weep; simang = spirit of the deceased/ancestors). *Grasimang* is not only an important ritual, but it is also the most explicit response to grief and death. One could equate it to a type of mourning where people weep, and lament in groups or individually. This 'performance' of mourning takes place before cremation, and then during *makhamgarba*. What should be added here is that *grasimang* is not just a simple weeping, but a kind of conversation that the weeper has directly with the deceased, unlike a eulogy. *Grasimang* typically takes the form of a mourning ballad, where the ancestors are invoked upon to help the deceased pass on to *damra* safely. Part of the ballad also has reference to the deeds of the deceased (Thaosen and Thaosen 2017, p. 48). The more formal aspects of it consist of laments, many of which are conversations with the dead. For instance:

Ningla Dambra thangka Lairidi himka, (You have departed for the other world, where the goddess has walked) Dambra thangkabo Lairidi himkabo (And even though have departed) Thikabo, ninikuribada dong kuribubi dong (Your family, brothers, sisters still live) Thikabo ning wainsoh maiya buji maiya (Yet you are not to remember them, worry about them) Ning githini githijing gathang nigathang. (You are no longer a part of this world, Let the dead be dead, and let the living live)

Here the speaker engages directly with the deceased, expressing their regrets, sadness and even gratitude. These are women, who are not professional mourners, but because of their experience have the ability both to control and to let go of their emotions and thus are engaged by the family members to mourn during *simang garba*. Most of these women are clan members or married to the clan members of the deceased, and are therefore kins by default. The fact that their emotions can be both "theatrical" and "natural", is an indication that grief and sorrow can be stylized, and performed as the situation demands (Grimes 2007, p. 245). Most of the time, the *grasimang* is not as eloquent. In fact, the louder voices are usually simple, personal, and raw where all that is said is " ... . Amai .... amai ... amai ... . (oh mother ... mother ... mother ... )" or " ... . abai(father) ..." or " ... adai(grandmother) .." or " ... . aaju (grandfather)" repeatedly or some phrases that demand answers (e.g., why have you left us?). This lack of complex verses, replaced by free-flowing speech, creates an impassioned environment. The *grasimang*, thus, as a crucial component of the rituals, accompany all the major moments of the rituals. One can easily see how the participants become aware of their emotive practice; the dramatic practice is communicated and learned by the members in the form of bodily knowledge. Embodied ritualistic experience is the context for collective identity for the Dimasas, and to communicate to the dead and those alive.

After the fire is extinguished with water and ashes, the other remains are collected and thrown away in the river or stream by the family in a suitable time. In the case of Haflong, the Diyung river is where the remains are thrown. In Guwahati, the lack of communal space means that only the ashes are collected and disposed off as wished by the family members. Whatever is left of the charred bone from the *manggreng* and the charcoal remaining after cremation is collected. *Manggreng* is a combination of two words *mangathik* (dead body) and *begreng* (bones). Thus, *manggreng* would signify the bones of the deceased post-cremation. This bone is the remains of the forehead, which is kept in a *phontho*, a container made out of bamboo and buried in the *jaara*, a small symbolic house which is tied to the tree near the *thaire* (Danda 1978). The construction and the use of the jaara is considered as an important aspect of the transition period of the spirit of the deceased. However, this aspect was missing in Guwahati, the reason being the difficulty in construction of the jaara and the skills required to do so, i.e., the lack of people to build it. Instead, the remains were put inside a container made on bamboo pole and buried in the mangkhlong. Usually, the area where the body was burned is transformed into an enclosure, and the men built a fencing around it. This enclosure is temporary and dismantled after the final *makhamgarba*, and it is here that the *jaara* and *mangkhlong* are placed. They are sacred spaces and represent the temporary resting place for the deceased before their final journey to the *damra*. In Guwahati, the *mangkhlong*, fashioned in the likeness of the actual site was constructed within the yard of the house, and it was there that the *manggreng*, which is the remains of the deceased, was buried. The *mangkhlong* is a conical-shaped structure, about two–three feet tall, which is constructed within the fencing. The skeleton of the structure is bamboo poles, covered by bamboo mat paneling and finished on top with cloth similar to *risa* (traditional Dimasa clothing). This is the temporary shelter for the spirit of the deceased until it is ready to move on to the other-side

(Jahari 2010, pp. 108, 149). It also acts as repository of sorts, where some of the 'items' such as clothes, combs, brushes, etc., used by the deceased when they were alive, are kept. These items, however, are made non-functional—they are twisted, broken and torn—before being offered, thus observing the meser-mosoh principle. The *garba* is performed here twice a day, morning and evening, for the next few days post-cremation, and once a day until the final rites. It becomes the responsibility of the family (and the community) to ensure that the deceased is sent off with sufficient belongings, thus ensuring a comfortable and content life in *damra*.

The second phase of funerary rituals is that of *jumangshao khainba*. This is held after a week, i.e., on the seventh day of the cremation. This event is for the *raji*; this is first time where the family formally invites the members of the community to discuss further plans of the funeral. The ceremony of *jumangshao* (ju = *alcohol*, mang = dead (body) and (shao = cremate), *khainba* (offering of some form of liquid for consumption) takes place; as the name suggests, there is offering of the rice beer to the men who assisted in cremating the body. However, the key component of the ceremony is the fixing of the date for the final rites. In Haflong, women (of the patri-clan and/or raji) accompanied by a few male members go to the *mangkhlong* on the day and perform *makhamgarba*. After the completion of the *garba*, the members of the *raji*, the family and relatives, come and sit together to discuss the appropriate date for the final event. This is done keeping in mind, first, the time needed by the family to gather resources for *maimutharba*, and second, to make sure that the date coincides with a waning moon, and is again on the same day as the death of the deceased. Earlier, such a decision was determined by people's ability to remember the seasons and the weather conditions, whereas today, the calendar is the main tool to determine the waning- waxing phases of the moon. While all elders give their input, it is the *khunang* who makes the final decision regarding the matter. *Jumangshao* is a fairly low-key affair. Haflong managed to gather a decent number of people, but in Guwahati, there were only about five to six men who had participated in these discussions. Not surprisingly, it was the men who decided on these matters, although it is not prescribed as mandatory according to the customs.

*Maimutharba*, (mai-paddy; tharba-purification) is the final event, and it is ideally held within two–three months from the day of the death. Although there are no rigid rules as to when the day should be observed, the constraint on the family of remaining polluted, i.e., *gushu*, until the purification is a crucial factor as to why people prefer to hold the ceremony at the earliest possibility. As death is so polluting, these rituals are mechanisms to refine the dead, thereby allowing the transformation of the soul into that of an ancestoral spirit, who can be worshipped and invoked in the future. The morning of *maimutharba* begins with a condolence meet to pay respect to the deceased. The formality of this activity stands out in stark comparison to all other activities which are all marked by a distinct sense of mild chaos. Both in Guwahati and Haflong, the ritual was conducted in the front yard where the men mostly gathered in groups and sat. While this was completed, guests were fed, and this was called *mel* (meeting/function) *khamba* (to sit). Death by itself was bad, but Dimasa funerals were not completely devoid of good times as well. There were always people conversing with great energy, drinking, and joking, and casual conversations became an opportunity for people to catch up with each others' lives. The abundance of food and alcohol meant, at some point, someone would be more than simply mourning. The people of the neighborhood, kins and the village have to be entertained with a grand feast of food and drinks, and it is usually believed that the entertainment of a larger number of the people at the death ceremony ensures the spirit of the deceased a more happy and prosperous life in the next birth.

Once the guests are fed and all preparations are complete, there is one final visit made to the *mangkhlong*, to pay the final respects to the deceased. Transportation, if needed, is arranged to take the family members and kins to the cremation ground. Those who have not been able to do so earlier, such as relatives who live far away, usually make a point to attend this. It is plain to see that this time *grasimang*, the mourning, is longer and louder. During mourning (whether in the cremation ground or the front yard of the house), the living mourners and the deceased make up a special group, situated between the world of the living and the world of the dead, and how soon living individuals leave that group depends on the closeness of their relationship with the dead person.

After the completion of *garba*, the process of dismantling the *mangkhlong* begins; this is completed by the men who take the *mangkhlong* apart and burn it down. Few remain behind, while most of the visitors return to the resident of the deceased after someone from the raji sprinkles the visitors with *dither/dither* or holy water (di = water, thar = purified), 'purifying' the community and the family (Thaosen 1995, p. 258). Once people have returned home, preparations are made for *songikhoba* (songi = sickle and khoba = release), a social ritual where the family and the men who carry the bier and cremate the body negotiate the payment, due to the latter. Much of the conversation between the *hojai* (who speaks on behalf of the rest) and members of the household is symbolic. There are no expectations from these men for actual payment on the day. It is believed that carrying the body is a sacred job that demands gratitude and some token of appreciation. The *hojai* and few men involved in the process sit down with a family member and engage in a series of back-and-forth discussions, where the former express their gratitude for the services. The family member conveys their inability to repay the debt in the form of gold and silver and instead request the *hojai*, and the men to accept rice-beer as payment. The payment through *judima* is the standard mode of payment which is accepted by all. It is believed that carrying the body is a sacred job that demands gratitude and some token of appreciation. It is clear from the conversation that the *hojai* and the men represent the larger community: '*raji*'. It is the *raji* who provide labour, support and pitch in the management of the entire event. In Guwahati, for instance, young boys and girls who are in the city for their studies are also engaged by the students' association to assist with serving, and other work. *Songikhoba*, where any form of indebtedness is resolved, is a representation of the importance of community in a life-changing event.

The unavailability of clan members, especially experienced ones, can delay the start of the process. In Guwahati, situations like these are handled by relying on larger kinship networks across districts. Thus, the family members from Haflong arranged for patriclan members to be driven to Guwahati to construct the thaire, the bier and the *mangkhlong* at the shortest of notice. By the time the final event (maimutharba) arrives, more specialists, who also include clan members and hojai(s) are also brought in. Due to the presence of a large number of visitors and guests, and the number of multiple rituals and the feast that has to be completed in a single day, *maimutharba* truly becomes a space to observe communal cooperation. It needs to be mentioned that one can observe minor ritual variations especially in form of incorporation of events which are not indigenous to Dimasa oral traditions across the duration of mourning. Following the rules of (patri)clanship relations, meser-mosoh principles, and the purity–pollution demarcations are very important. However, the same mourning processes have also included an evening of singing *kirtans* (devotional songs typically about Lord Krisna) in the name of the deceased and even organizing a *sraadh* (a Hindu ceremony performed in honor of the deceased family member). The reason for this small variation is the inclusion of mainstream Hindu beliefs and practices into Dimasa practices. Dimasas, as a community, have been able to blend Hinduism with their own (borrowing deities and rituals into daily religious practices), thus allowing the community to construct a certain socio-cultural model that allows them to connect with the wider society, yet maintain continuity with the oral traditions. This has allowed for minor adjustments in rules of mortuary rituals, as long as they fall within the larger framework of accepted arrangements.

#### **5. Management of Dead and the Living**

As mentioned at the beginning of the paper, at the center of all Dimasa death rituals is the relationship between the community/neighborhood (raji), and the larger kinship network tied together with ancestral worship. While conflicts may arise in the private space of the family, the rituals are performed as a family, and there is a strong need to maintain a unified public image in order to protect the reputation of the deceased. The ritualized crying of *grasimang* is a clear depiction of social unity of the community, raji and kinship. Furthermore, the elaborate offering of food to ancestors on the final day of funerary rituals, and the daily routine of food to the deceased depict the important status of those long past. There is, therefore, a close interrelation between the dead and the living where the comfort of both are interdependent. Part of navigating this relationship requires an understanding of how the contemporary urban space is utilized by members of the community for the successful completion of the rituals. In the light of the demographic transition, the pressure on land-use for communal purpose, by a community that is a relative minority in terms of population, is clear. In Guwahati, there is acceptance of a public ground cremation ground which is not a 'Dimasa' communal ground as a space for such acts. The permanence of the cremation ground in Haflong is clearly missing in Guwahati, where the community members have to negotiate with an external party, i.e., non-Dimasa individuals in matters of disposal of the deceased. In Haflong, along with the family members, the raji (khunang, hojai and few other adult male members) play a dominant role in the matter of cremation. In contrast to Guwahati, all decision-making authority lies with them, procuring the necessary materials (wood, etc.) to construction all takes place within the community itself. There are distinct cultural shifts in the ritual journeys of the Dimasa people in Guwahati and their belief systems. However, at the same time, these same collective ritual performances also demarcate between those who can or cannot participate, displaying the persistence of their collective identity. It is in these moments that the members make a 'place' for themselves.

Death, in its most basic form, can be observed in the responses of the mourners or the bereaved to the death of their loved ones. In earlier years, people usually died at home and death was witnessed by the family; however, today, the hospitals have taken over5. From the observation of the mourning, it can be concluded that death leaves a rupture. Thus, there is a need to respond to it or confront it through questions, and through inquiries (Lipset and Silverman 2016, p. 235). It is very difficult to pinpoint when the mourning period ends, emotionally, to a person. Typically, integration back into the society and resuming normalcy is effective once *maimutharba* is completed. However, refraining from social events is, ultimately, a personal choice. Then, what about "working through" grief? Are the Dimasas expected to get over the grief within a certain period of time? The problem of managing the relationship between ritual form and that of feelings is persistent, but the relationship between death, emotion, and ritual is not straightforward. After all, grief cannot be ignored or denied; grieving is one way of acknowledging the notion that the dead are not forgotten and, more than that, the realization that those who mourn themselves are alive. However, when one engages in funerary rites, it does allow and facilitate a sense of grief in a manner which seems to be both personal as well as shared.

Contrary to Grimes' (2007) argument, protection of survivors is an important part of Dimasa death rituals. The realities of the Dimasas depict a commitment to urban ways of life, along with the need to accommodate how the members of the community deal with the distinction between sacred and profane. The urban setting is a reflection of the tension in a worldview that is in the process of transformation.

#### **6. Conclusions**

There is no single way to deal with death in private life, but as a community, such multiplicities are kept to a minimum, and the reason behind this, especially in Guwahati, is the presence of the same factors. Several factors are directly responsible for this: the fact that both the deaths occurred in the same household implies that the same family members and kin members influenced the process. This also meant that the decision making was largely a matter of the members of the community who had been present or close to the family for a significant period of time. They constitute the dominant voices in such rituals. These voices were gendered in both Haflong and Guwahati. This can be seen not just

through the management of the rituals, but in other social functions as well. Of course, to assume that women are passive would be highly inaccurate, as they play an important role in creating a safe passage to *damra* for the deceased. With no choice but to accommodate the demands of the urban environment, small changes are made in terms of the cremating process, etc. These changes, which are part of the community adapting to a city where they are a minority, are not of much hindrance to the larger sentiments of the people themselves. The preparation of death rituals is communal, interlinked with the values and meanings to the people. Death rituals in urban spaces have so far tried to hang on to the traditional method of performing. Funeral arrangements tend to be both a personal and communal affair, although the responsibility of ensuring that all the ritual specialists are available on time for the rituals falls mainly with the family and immediate kins, and there are several other roles that the larger community take care of at the request of the family. The concerns for transmitting cultural values to the coming generations, and displaying themselves as having an indigenous religious identity, appears as a motivation behind the collective ritual performance. Oral traditions have a flexibility that allows the members of the community to bend certain rules and act creatively. Whether people truly believe with certainty that these rituals influence the fate of the deceased is uncertain, but it is a chance nobody wants to take. Sharing these values, and displaying shared group behavior appropriate for a Dimasa mourning, definitely aids in grappling with the situation.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The author declares no conflict of interest.

#### **Notes**


#### **References**

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van Gennep, Arnold. 1960. *The Rites of Passage*. Chicago: University of Chicago Press.

## *Article* **Infrastructural Breaks on the Road from Birth to Death in Contemporary Russia**

**Sergei Mokhov 1,\* and Anastasia Andreevna Novkunskaya 2,\***


**Abstract:** This paper addresses the problem of infrastructural breaks in two systems—the funeral market and maternity care. The authors analytically problematize how dysfunctions in the operation of these infrastructures shape the experiences of funeral and childbirth in contemporary Russia. The authors propose the conceptual model of the 'rite of passage', supplemented with the sociology of repair joint with the anthropology of infrastructures. Based on the ethnographic studies of the funeral market and maternity care (2015–2019), the authors uncover multiple infrastructural gaps and challenges that Russian families face while preparing for childbirth and funeral, especially in remote areas of the country. Empirical data of participant observations, in-depth and expert interviews demonstrated that continuous infrastructural failures can be considered to be an integral part of these life-cycle rituals, as both burial and maternity care arrangements never happen smoothly and unproblematically. In conclusion, the authors argue that necessity of "repairing" or patching the infrastructural gaps obtains self-sufficient symbolic meanings that possess ontological features.

**Keywords:** infrastructural breaks; sociology of repair; life-cycle rituals; funeral market; maternity care

In 2015–2019, the authors of this article were independently working on their field research projects. They were separately devoted to the maternity care system and the funeral market in contemporary Russia. At a research workshop, the discussion revealed considerable similarities between research projects: our informants often mentioned their experience of interacting with an infrastructure that often malfunctioned, broke down, and produced uncertainty. For example, cemeteries were regularly flooded with water, refrigerators in morgues did not work, equipment in hospitals was out of order, and ambulance cars did not meet sanitary requirements. Moreover, our ethnographical observations confirmed what the informants said. The entire process of preparing for a funeral or childbirth requires the resolution of multiple infrastructural problems.

The symbolic significance of these events, which frame the entire cycle of human life, and their similarities (in that both deal with bodies and, inevitably, materiality) provoked us to jointly reflect on the following questions. What kind of impacts did persistent infrastructure dysfunctions have on the funeral/birth processes? How do persistent infrastructure breakdowns relate to the cultural understanding of coping? In this paper, we argue that permanent breakdowns and their elimination have symbolic meaning and have become part of the life-cycle rituals in contemporary Russia.

#### **1. Theoretical Framework: Infrastructure, Repair and Ritual**

We used several theoretical frameworks that complement each other and allowed us to explain how the repair of technical infrastructure can have symbolic meaning and be a part of a ritual.

Firstly, we refer to the classical conceptualizations of pregnancy, childbirth, and funerals in different forms and different societies as the 'rites of passages' (Van Gennep 1960, p. 11).

**Citation:** Mokhov, Sergei, and Anastasia Andreevna Novkunskaya. 2021. Infrastructural Breaks on the Road from Birth to Death in Contemporary Russia. *Religions* 12: 1115. https://doi.org/10.3390/ rel12121115

Academic Editors: Martin Hoondert, Joanna Wojtkowiak and Brenda Mathijssen

Received: 9 September 2021 Accepted: 17 December 2021 Published: 20 December 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

The key characteristic of these rituals, as Belgian anthropologist Arnold Van Gennep defined them, is their threefoldness: they start with the rites of separation, continue with the "transition" or liminal period itself, and end with the celebration of successful completion. Thus, rites of passage, in general, are conceptualized as 'rites which accompany every change of place, state, social position, and age' (Turner 1977, p. 36). Moreover, scholars have shown that the structure and function of these remain even in non-religious societies (ibid), and that 'liminality' concerns multiple and various cases of change and transition, both related to human lives and entire societies (Szakolczai 2009; Thomassen 2016). Our argument is that the arrangement and execution of the infrastructures of childbirth and death in modern Russia are such that they presuppose a prolonged state of transition, feeling of in-between, uncertainty, limitation of some social norms, and other properties of liminality. Thus, we aim to show that even without religious and sacred components, the organization and materiality of these processes turn them into the modern rites of passage.

Secondly are the theoretical developments in the anthropology of infrastructure. Infrastructure as an object of study was discovered by anthropologists more than twenty years ago, and it has since become a serious area of research (Larkin 2013), as evidenced by a large number of publications, as well as a separate issue of the journal Cultural Anthropology in 2015. Anthropologists have successfully shown how the construction of automobile roads can change the life of an entire city (Harvey and Knox 2015), the development of power lines played a key role in the creation of western states (Hughes 1993), and the emergence of the metro and railways led to the birth of a new type of urban dweller—the passenger (Hohne 2015). The infrastructural approach has been used in a number of works, e.g., to study the relationship between biopolitics and the pipeline in India (Anand 2012) and the role of the road in market relations in post-socialist countries (Harvey and Knox 2015). All works argue that infrastructure affects social life (Edwards 2002).

We can assume that infrastructure can influence not only everyday social practices but also more structural practices such as rituals, especially if we agree that in the modern world, previously sacralised (religious) rituals have ceased to be such and have become part of a more formal process. Researchers have already tried to show that rituals are associated with not only religious beliefs but also formal restrictions, including materiality. For example, Tony Walter described how different regulations of infrastructure ownership produce not only distinct institutional models of the funeral market but also different types of relationships between clients and representatives of the funeral industry, as well as construct the ritual practices themselves (Walter 2005, 2012). A similar approach can be found in the field of maternity care studies. For example, in several studies of pregnancy, maternity care, and midwifery in North America and Europe, Raymond De Vries and colleagues (2002) showed how care at birth has been shaped by state intervention, the organization of professions, and attitudes about and uses of technology (De Vries et al. 2002). The researchers argued that the 'design' of childbirth, on the one hand, is deeply rooted in existing political systems and cultural beliefs—hence conveying the core values of a society to birthing women (Davis-Floyd 2004, p. 2)—and, on the other hand, considerably determines the experiences of birth and comprises the set of material culture (Hennessey 2021), regular actions and ritualized practices on its own (Davis-Floyd 2004).

However, theoretical developments in the field of anthropology of infrastructure have demonstrated a number of compliance limitations that make the study of infrastructure dysfunctions complicated and that are not applicable in our cases. Thus, the anthropology of infrastructure assumes that objects exist in two conditions: 'working' and 'broken'. Accordingly, the functional state is perceived as a kind of 'normal' state, while the dysfunctional one is not. It is taken for granted that socio-technical structures strive for ideal working conditions and the elimination of breakdowns. In our case, dysfunctions and failures are not only constant but also defining characteristics of the infrastructures. Informants considered failures as some kind of inevitable state of the infrastructure for which they were preparing.

Third, we propose to supplement the frameworks presented below with theoretical developments from the sociology of repair (Dant 2010; Henke 2000; Graham and Thrift 2007; Jerome and Pontille 2019). They allow us to consider the very process of repair or maintenance of material objects, including infrastructures, as a social activity that involves communication and exchange. For example, participants in the repair process know exactly who is responsible for fixing a particular infrastructure object, as well as who and how quickly can fix the breakdown. In this sense, the ultimate goal of the repair is not necessarily achievable because the participants can pursue their own goals based on their personal ideas and tasks (Dant 2010). As a special kind of activity, the repair process involves the formation of a specific social space or, according to Jan Chipchase, 'repair culture' (Chipchase 2005). Tim Dant notes that manual repairs have an advantage over industrial (automatic) repairs because they bring more communication into the process. Repair becomes an end in itself when the actors are not interested in the working condition of the facility and its technical serviceability. The repair process not only allows actors to communicate with each other but also builds a special regime of relations between them. We can say that such practices blur the objectivity of a thing. The normative rationality of infrastructure facilities does not matter anymore. The social meaning of interactions that arise in the process of infrastructure maintenance/repair does, though. In Goffmanian's understanding of ritual, such practices can receive their symbolic explanation from culture and everyday interpretation but not through direct indication. Moreover, A. Van Gennep and R. Hertz described rites of passage, noting that they are always associated with difficulties that must be symbolically overcome (Hertz 1960).

As a result, we supplement the classical theory of 'rites of passage' with the analytical framework of the sociology of repair and the anthropology of infrastructure. Thus, using this conceptual framework, we look at the situation of maternity care and funeral services in contemporary Russia as social actions when participants actively interact with the infrastructure, trying to correct its condition and give it symbolic meaning.

#### **2. Materials and Methods**

We conducted our long-term ethnographic research in parallel. The study of the funeral industry took place in one of the central regions of Russia at a local funeral agency. It is a small private company, arranging no more than 40 funerals a month (a large company is considered to arrange more than 100 funerals a month). Within the framework of the fieldwork, this author was primarily interested in the influence of infrastructural factors on social interactions, expressed in the texts and actions of the key actors of funerals in relation to each other. Only actions that help carry out the burial of a deceased person were considered, including the problem of obtaining a body in a morgue and the need to comply with local traditional ideas about funerals. This is why employees of both the studied agency and other third-party actors, primarily competitors, local actors (workers of morgues, cemeteries, etc.), occasional participants in the funeral, and (of course) relatives of the deceased were recorded. This allowed the author to be included as a participant and observer to not only talk about the ethnography of a particular funeral agency but also describe and interpret the regional market for funeral services and its inherent funeral practices. Participant observation began in February 2016 and continued until March 2019. About a hundred different informal situations fell into the focus of research. All observations and many conversations were recorded in a field diary, but interviews were not recorded for ethical reasons and field restrictions. For this reason, the author of this article used entries from the diary.

The study of the maternity care system took place in two regions located in the central and north-western parts of the country in 2015–2019. The study was designed as a multiple-case study that considered a system comprising all medical institutions, providing assistance to pregnant women, women in labour, and new-borns within their areas as a case. The main method of data collection comprised in-depth, semi-structured interviews with medical professionals (midwives, obstetricians, neonatologists, and nurses) working

in such facilities (*n* = 25). One of the cases included observation carried out in a maternity ward (25 h), and the second one was carried out in another region in an antenatal clinic (60 h); also, the data were supplemented by observations of medical conferences, regional meetings of obstetricians–gynaecologists and neonatologists (29 h), expert interviews with representatives of different control and supervisory bodies, and patient and professional associations (*n* = 8). In addition, interviews with the families of young children (under 3 years old) living in remote settlements far from regional centres were conducted.

The interviews were recorded, transcribed verbatim, and underwent thematic coding and inductive analysis. Observations and interviews focused on the professional practices of doctors, nurses, and midwives caring for pregnant women, women in childbirth, and new-borns, as well as on the actions of healthcare managers aimed at maintaining the operation of the maternity care systems in remote districts. The fact is that obstetrics in Russia is extremely institutionalised and involves the mandatory medical supervision of pregnancy and hospitalisation at the stage of delivery, which is inevitably associated with the need to move between places of residence and medical centres. In some cases, the distance can be 100–300 km, and it involves frequent interaction with transport and hospital infrastructures.

Funerals and obstetrics are presented in separate paragraphs for the easier presentation of field material.

#### **3. Funeral in Contemporary Russia: When Infrastructure Gets Out of Control**

Contemporary Russian funerals usually take place in several stages. At the first stage, the relatives of the deceased choose a funeral company that will conduct the funeral. This stage also includes the purchase of necessary accessories, such as a coffin and included bed, a grave cross, wreaths, and their delivery to the place where the body is stored. The second stage includes the funeral itself, when the body must be taken from the morgue to the place of farewell (funeral service). Next, the relatives and the coffin with the body must be taken to the cemetery, where the coffin is eventually buried. The third and last stage consists of various memorial events. We have only described very general features of the infrastructure chain operation due to the limited size of the article.

A funeral and its preparation usually begin on the day of the death of a person and the last days until the body is buried. In addition to the selection of funeral accessories, the first and second stages address obvious infrastructure problems. For example, it is necessary to find a good place in a cemetery, make a decision regarding how the coffin with the body will be taken to the cemetery and carried to the grave, plan the route of the catafalque transport, and prepare the burial site. At this stage, one of the main tasks of the funeral company representative is to make sure that there are no unexpected overlaps in the procedure and nothing is out of order on the day of the funeral. The funeral procession must appear on time at all infrastructural points, i.e., in the morgue, at the place of farewell, and at the cemetery. At this stage, the first and most important feature of the Russian infrastructure environment—spatiality, or more precisely, the remoteness of all objects from each other in space—is manifested. A morgue, a cemetery, and a place of farewell can be located several tens of kilometres from each other. The path between the main points of the infrastructure takes most of the funeral time. The average time of a funeral (excluding the commemoration), according to the author's observations, is 3–3.5 h, of which the processes of the transportation and loading/unloading of the coffin and the body take at least two hours. The rest of the time is evenly distributed between waiting, a fairly quick funeral service/farewell, and burial in the ground. In addition to this spatial feature, it is necessary to note another specificity of the Russian funeral—time. The burial is performed within three days after death. In fact, the funeral agency should organise the entire chain of funeral logistics during such a short period of time. As a rule, there is not enough time to arrange any additional ceremonial actions, so the processes of preparing the burial site, solving infrastructure problems, and moving around replace the ritual itself.

*Only today I realised that one of the distinguishing features of a funeral is the desire of relatives to organise everything in three days. Any attempts to delay or postpone the funeral lead to serious misunderstandings. Relatives are convinced that it must take three days, period. At each funeral, I watched the undertakers rushing headlong all three days to arrange everything properly and in time—morgues, cemeteries, digging a grave, hearses. Of course, it usually doesn't come to a discussion of the farewell ceremony*. (Author's field diary, 12 June 2016; entry No. 99)

The first time and space reference, which the arrangement of the funeral begins with, is the exact time of the body release in the morgue. This issue is always negotiated in advance. The function of the funeral company is to ensure that the body will be released in the morgue on time (preferably at a convenient time) and without any cosmetic problems. However, most morgues do not have refrigerators or they are broken or full. This is one of the main services that relatives pay for, i.e., the body must be released without visible signs of decay. The funeral brigade provides the entrance of the hearse transport to the gate, where the body is handed over, and put in the coffin. The funeral company is a kind of intermediary between the morgue and relatives that ensures the "proper operation" of the morgue. A further schedule of the funeral is built around this time mark. The time of body delivery to the funeral service and farewell place, the route of the hearse transport, and the digging teamwork at the cemetery depend on when the body is handed over (and whether it is done on time). Any time shifts lead to serious costs.

*We attended a funeral today. They started at 10 a.m., but in fact, ended at almost 3 p.m.—at this time the coffin was eventually lowered and buried. We waited an hour, if not longer, at the morgue, because Mr. N. did not want to pay money to the morgue for the release of the body. They had a conflict there again. As a result, the orderlies used the standard time-wasting practice—they say that the body is not ready yet. If you want it to be ready and released on time, you have to pay. Relatives went angry, because they spent an hour at the morgue, but in the end, everything was delayed. Eventually, they gave up, paid, and got the body, though. At the cemetery, they also had to pay again so that they could say goodbye to the body, rather than quickly bury it, as the diggers wanted. Everyone is in a hurry to do everything as quickly as possible*. (Author's field diary, 18 September 2016; entry No. 135)

Contemporary Russian funerals imply that movement between infrastructure facilities (which is burdened by technical difficulties arising in the course of interaction) is necessary. The practices of transportation, choosing a route, and arranging funeral procession are associated with hearse transport as an infrastructure element. Trucks and vans are used for movement. A lack of road surface and severe weather conditions exclude even the possibility of using a sedan hearse because such a car simply would not be able to travel to most cemeteries. The lack of paved roads and communication paths between infrastructure facilities first led to the appearance of the truck hearse and then to the comprehension of long-term transportation as a necessary ritual action. As a result, in the case of contemporary Russia, it is the remoteness of infrastructural objects from each other and the need to get to each of them at a predetermined time that turn the funeral procedure into the process of the problematic transportation of the body between these objects, giving the road itself (or rather, the 'path' as a practice) structure-forming meaning.

The spatial and temporal characteristics of the infrastructure are closely related not only to the value of the road/path but also to infrastructure breakdown and repair. The many hours of movement of the funeral procession between infrastructural objects are spent solving problems of infrastructure dysfunction. The relatives of the deceased person consider the funeral procession to be a difficult but necessary obligation and the infrastructure problems as something natural. Such an approach turns the funeral into a kind of game quest when its participants have to solve difficult tasks at literally every infrastructure point in order to gain access to another one. One of these final points where local problems

are overcome is the cemetery. Using the cemetery as an example, the author uncovers some problems that the relatives of the deceased have to cope with.

Interaction with the cemetery as an infrastructure facility begins from the preparation for the funeral. Like the morgue, the cemetery is a must on the funeral route because a cremation service is not available for most residents of the Russian regions. The final cost of the funeral depends on the location of the cemetery, its accessibility for hearse transport, and the mode of operation.

*One of the first questions that funeral directors ask when organising a funeral is: where will the person be buried? This is a fundamental point for several reasons. It is clear that, firstly, funeral directors are trying to understand whether it is possible to make money by mediating the sale, searching for a burial site, etc. But they are worried to a much greater extent about how much time it will take to get there, how to carry a coffin there, how to dig a grave there, etc*. (Author's field diary, 16 May 2018; entry No. 87)

Digging a grave and preparing access to the burial site are the most important things to do in a cemetery. There might be several plans to follow. If the place is new, i.e., the deceased is not interred in an existing related grave, it is usually located in an open area. Accordingly, preparing the grave in this case can be complicated by the peculiarities of the soil and the potential for flooding with water. In this case, relatives need to find and obtain a place that will not be washed out by groundwater and floods. In addition, since 2011, sanitary standards have made it possible to dig a grave to any acceptable depth. In a number of cases, the author reported that the grave was dug to no more than 1.5 m deep (on the slope), which led to its crumbling and collapse. Therefore, it is necessary to choose a place where one can dig deep enough. The place should also be free of trees and have free access, and it is desirable that it be closer to the passage. If there is already a related burial nearby, the preparation of the site becomes more complicated. The process of digging a grave includes dismantling nearby fences, benches, and other objects that obstruct access. As noted above, the process can be complicated by the peculiarities of the soil, temperature, and 'burial history'.

*Today they dug the grave for almost 5 h. They began early in the morning, at six o'clock. It was dark and cold, not to mention the fact that the cemetery was far away and you could not easily drive to it. With flashlights on their foreheads, they began to clear the place. The fence was moved so that they could approach it. Then, the top layer was hollowed with a crowbar <...> While digging the earth, they were coming across some bones, pieces of iron, and the gravedigger's most terrible problem—stones. Today they met a large cobblestone and barely got it out. It took them another hour. The bones were folded nearby*. (Author's field diary, 3 January 2017; entry No. 153)

It should be noted that in most cases, municipal cemeteries are not registered in the cadastre, which means they are ownerless. Cemeteries are simply not looked after, and no one is responsible for what happens there. As a rule, even old and registered cemeteries do not pass requirements, i.e., no clear boundaries of burials, and even their number has not been defined. Sometimes this has led to paradoxical situations:

*We were driving to the cemetery for 1.5 h along a country road, although it seemed to be located next to the federal highway. The graves in most cemeteries are located chaotically, they do not have a clear size and boundaries, and access to them can often be limited not only by fences but also by fallen trees, household rubbish, and simply by the features of the landscape. Paradoxically, the process of preparing the burial site includes even cleaning the path to the grave. On the way to it, you can break your legs in ravines, bumps, some incomprehensible trenches. There are no paths there. Those who bury the deceased in warm and dry weather are lucky. In the snow or in the downpour, it is impossible to walk there. It takes two days just to prepare the approach to it without starting digging the grave. I am watching them bringing special sand in order to sprinkle the path; otherwise, the relatives will fall on ice and snow*. (Author's field diary, 3 January 2017; entry No. 154)

In a number of cases, the author managed to watch the funeral team transporting the coffin with the body in their arms because the hearse transport could not drive to either the grave or the cemetery, located in the depths of the forest, where the car risked skidding. There are also some other unexpected infrastructural problems that a cemetery can present. For example, a grave is always dug under a specific coffin. The width of the shoulders, i.e., the widest part of the coffin, does not matter less than its length. As already noted, there is no centralized production of coffins in Russia, nor is there a system for monitoring their quality and compliance with state standards. Therefore, coffins are often made in arbitrary shapes.

Thus, all activities in the cemetery must be closely monitored so that the infrastructure does not get out of control and break down. This belongs to the sphere of responsibility of the funeral agency, which has undertaken the organisation of the funeral, and the relatives, who must observe and control the preparation process. Relatives have a serious distrust of funeral companies based on the belief that they can firstly deceive and secondly overlook and miss something important that will affect the funeral. The cemetery is not unique in terms of possible infrastructural problems. They also occur in the morgue, where refrigerators fail and infrastructure capacity cannot cope with the flow of dead bodies, when the body must be transported to the morgue but state sanitary services may not have enough gasoline or cars to do this on time. The same happens with the installation of gravestone monuments when the earth crumbles and collapses because the coffin is made of plywood and is quickly squeezed under the weight of the earth.

The infrastructure of the funeral industry continually breaks down, turning interactions with it into a special practice. According to informants, this state of affairs is regarded, of course, as 'abnormal', and people complain about the appalling roads, cemeteries, etc. However, no attempts have been made to structurally change this situation; on the contrary, the symbolisation and even rationalisation of constant repair are ongoing: 'The completion of the funeral is regarded as a successful operation to deliver the deceased to the cemetery' (Author's field diary, 14 August 2016; entry No. 117).

#### **4. The Infrastructure of Maternity Care in Russia**

Spatial and temporal aspects are also significant characteristics of how the infrastructure of maternity care in Russia is arranged, although it has completely different timing. The 'preparatory' stage of childbirth usually lasts several months, but in some cases (for example, if it includes planning a pregnancy), it takes more than a year. Pregnancy monitoring is mandatory in Russia. As a rule, it occurs in budgetary antenatal clinics and includes a whole set of mandatory procedures and tests—observation by an obstetrician and other medical specialists, three ultrasounds, regular blood tests, and other check-ups. The very moment of childbirth, with the exception of planned caesarean sections, is an emergency situation requiring medical care in obstetric hospitals, and hospitalisation is often carried out via personal transport or ambulance (home births in Russia are illegal). With the exception of large regional centres, where there may also be private maternity homes, such hospitals comprise the maternity wards of district hospitals or perinatal centres. The last stage of maternity care is the return home of the mother with the new-born, which is not officially covered by insurance, i.e., it is organised not by state services but by young families themselves.

Thus, getting maternity care begins for rural women with the registration of a pregnancy with a local obstetrician-gynaecologist or a paramedic/midwife. Such a specialist is the main 'guide' in the maternity care system since he/she not only observes pregnancy but also determines the risk of complications, depending on which a woman can be referred to a facility of a certain level. According to the order of the Ministry of Health, there are three levels of maternity care in Russia. They are small (but closely located) maternity wards of the first level that provide assistance in normal childbirth, second-level institutions with more developed infrastructures of care (intensive care units and round-the-clock access of specialists) for certain types of pathologies and complications, and large maternity hospitals

or perinatal centres (third level) that are the most technically advanced hospitals located in regional centres and provide assistance for the most difficult cases of pregnancy and childbirth. Legally, a woman can choose the place of her childbirth, and it will be officially free for her. However, the arrangement of childbirth in a place of choice often presupposes personal negotiations with a maternity facility's staff in advance, and unofficial payments are involved in these negotiations in some cases. Hence, reaching the desired place is not always easy.

*Well, on the day of birth we came to the hospital, I was about to give birth, I had labour pains, and it turned out that there was a man, Alexey Mikhailovich [it was his shift on that day]. Naturally, I was in panic [as she did not want to give birth with a male obstetrician]. I was lucky that an acquaintance of mine worked in the ambulance, so he brought me to Vypolzovo with those flashing lights on. As we arrived, we were asked, 'Why have you come?' It was just a few minutes past eleven and he [an obstetrician] said, 'Why on earth have you arrived? Couldn't I arrange it earlier?' I said, 'I don't know anything! I have a certificate, take me, I don't know anything".* (Interview dated from 14 August 2019 with a mother of three children who lives in Bologoye)

Although in the case described above, the woman had the opportunity to move to another facility and successfully did so, the network of maternity care facilities is not wide and pregnant women from remote areas prefer to get to the nearest institutions themselves in order to minimize the time and costs of travel. However, if a woman has been diagnosed with some kind of pathology or the risk of complications in childbirth is determined to be high, she will be obligatorily routed to the maternity facility of an appropriate level. Sometimes, women resort to the strategy of waiting until the last moment (i.e., the onset of labour) when their transportation will be assessed as more dangerous than giving birth in inappropriate settings.

*He is handing in a referral to me [to the perinatal centre]. Well, all documents and that kind of thing. Childbirth should be within a week, so I tell him, 'I've said it. I'll give birth here' [the city the mother lives in]. But he started lecturing me. I started boiling, so I said, 'You don't want to take me, you are intimidating me! I'll come to you to give birth, I'll come with contractions, I'll wait until my water breaks'. Well, he said: "I'll send you there by ambulance!' And I replied: 'I'll start giving birth in the ambulance car, do you understand? And there is nothing, yes, there is nothing in your cars. They can't do anything in their ambulance cars, they hang by a thread. That's it'*. (An interview dated from 14 August 2019 with the mother of three children who lives in Bologoye)

Mothers-to-be try to reduce the period of liminality (literally the transition between the place of living and the place of birth) because they are sure that the transport infrastructure is not safe and reliable. However, emergency hospitalisation in a maternity hospital is not always an intentional strategy for pregnant women that is used to end up in the hospital where they would like to give birth. Sometimes childbirth begins earlier than the expected date of delivery and even earlier than the date of planned hospitalisation. In such circumstances, the distance, the state of the transport infrastructure, and the equipment of the nearest maternity facility are decisive and vital for choosing the types of medical care to be provided and, consequently, critical for the condition of a woman in labour and her child. An obstetrician-gynaecologist, head of the consultative and diagnostic department with a mobile team of the perinatal centre, described the inadequacy of this infrastructure for assistance in emergency situations the following way.

*We (in obstetrics) consider placental abruption as an absolute contraindication to transportation. Well, usually pregnant women die of that. It's a regional hospital, where there is no operating room and anaesthesiologist. Well, they have a gynaecologist there. They don't have the rest there, though. Imagine, the ambulance brought in a bleeding woman in labour. A diagnosis is a placental abruption. What's next? Do we call for air medical service? Now here's the real kicker because air ambulance is not teleportation. (...) So, if you need to go by air to a remote area in our country, the preparation... Well, I mean*

*by helicopter, of course. It'll take at least two hours. This time is enough to die twice or three times. Okay, let's go further... Well, let's say there is a doctor who can perform an operation. He can take an anaesthesiologist, but this does not mean that there is an anaesthesia machine on site, or there are sterile instruments in the operating room to be used in this case... I mean there might even be no opportunity to do that. (...) Therefore, they make the only possible decision to transport such a patient to the nearest facility where they can provide assistance. Well, the last case with such a patient was at the nearest hospital no further than the ninth of May, it's 50 km away from here. Well, naturally it ended with a caesarean section on a dead foetus because the foetus died during this time.* (Interview dated from 15 May 2019 with an obstetrician-gynaecologist)

Key facilities in the obstetric care system are as significantly separated from each other as in the funeral system, and the transport system does not necessarily adequately compensate for these infrastructure gaps (both the network of the roads themselves and the availability of public transport). In the emergencies described above, this is critical and vital, but even during routine care, this state of infrastructure has significant impacts on the experiences of pregnancy and childbirth. Although women are legally entitled to choose the place of monitoring of pregnancy and delivery, their choice of a specialist or institution greatly depends on distance.

*...we have an obstetrician [the city the woman lives in]. I mean, well, he can care for a pregnant, he does; but later he sends, decides where to send her. (* ... *) I mean, I wanted to be going to see a doctor in Torzhok, who, well, I wanted to give birth to, but again, I would have to get there somehow. Well, it would take time. I mean, I would have to go there every two weeks, and it was really hard. So ... So, I decided to* stay here. (An interview from 15 August 2019 with the mother of three children who lives in Spirovo)

Transportation during pregnancy and on the eve of (during) childbirth is an integral part of the entire maternity care system. Women and their families regularly have to not only move between key points but also build whole strategies on how to overcome significant distances between them. Thus, bad infrastructure is expected and understood as inevitable part of childbirth, and young families prepare to deal with this liminality by elaborating a kind of 'repair' or compensation of the infrastructural gaps.

*It happened in the evening (November). It usually gets dark early here. The rain was pouring. And here there was no road at all. When they built that fish farm between Romanovo and us, they made an embankment, and only a tractor could run there. I foresaw those difficulties. So I put her (his pregnant wife) behind the wheel of Niva (ATV), and I took the wheel of the tractor. (* ... *) I had to find a safe place for the car so that I could go on the road at any time. Here, if something had happened at night, I would simply not have taken her [pregnant wife] out at night in any way. No way. So, I hooked the car to the tractor and it started floating on this mud. (...) There were some stumps, some roots, dirt round me. I saw that everywhere through the windows. Well, finally I dragged it [the car] to Romanovo'.* (Interview dated from 5 March 2019 with the father of three children who lives in the village)

Pregnant women and women in labour do not only encounter infrastructure faults arising during spatial movements. The obstetric care system has turned out to be extremely heterogeneous between different levels of institutions. Perinatal centres are the largest maternity hospitals that are exclusively located in regional centres and large cities, so patients there, as a rule, receive assistance in renovated (or recently rebuilt) premises that are comfortable and technically equipped. However, other institutions belong to maternity wards of the first and second levels, and their conditions can be very different—there might be dilapidated walls and old renovations of the late Soviet period, with common delivery rooms (where several women in labour can give birth at the same time), malfunctioning bathrooms, and other technical restrictions. One of the participants in the study described such conditions as follows.

*[a woman after a caesarean section needs to find] two pairs of male hands to be taken to the second floor. No time for baths, which simply do not exist. But, humanly, they treat you well... although the conditions are awful* ... *(* ... *) After giving birth, I could not take a shower because there was no one, although I really wanted to wash myself. There was a bidet with a broken tap. So I couldn't sit down on it just like I normally would... I couldn't do anything. I had to stretch my legs far apart trying to find a comfortable position. We would go with a bottle of water there (* ... *) There was nothing on the second floor but toilets... (...) and no bidets. I mean, you wipe your upper body with napkins somehow or a wet towel. As for the lower body, you have to water it from a small glass jar because as you turn on that tap, the jet hits in an unpredictable direction. It was not a tap, but just a stream*. (Interview dated from 4 March 2019 with the mother of one child who lives in Vyshny Volochyok)

The repair of devices and the invention of technical solutions, which compensate for the broken utilities described above, are integral to the experiences of birth, at least in women's narratives. It is noteworthy that poor infrastructure concerns not only the premises, living conditions, and technical devices necessary for the provision of maternity care but also the direct medical support of maternity units:

*'Suddenly, there was a call. It was a local gynaecologist, He asked, 'I have an ectopic pregnancy. What should I do?' I said, 'What do you have to do? Start performing an operation.' He says, 'But we do not have an operating room. What to do?' Then he adds that they made a decision to take her to another place. Well, the nearest place is Bologoye (...) I say, 'Guys, the woman is generally not transportable. I'm going to call Bologoye.' I called Bologoye and said, 'Now they will bring you a patient with an ectopic pregnancy.' A woman on the other end answers me so casually. 'Well, so what? What's the point to bring her here? We don't have an anaesthesiologist, anyway!*' (Interview dated from 15 May 2019 with an obstetrician-gynaecologist)

The data from the interviews, quoted above, show that both mothers-to-be and health providers perceived the not-working infrastructure of maternity care in remote areas as a regular (at least expected) state of the system. As previous research has demonstrated, the multiplicity of organizational and infrastructural gaps in maternity care provision comprise its intrinsic characteristics and have remained unchangeable even under multistage state reforms (Novkunskaya 2020).

#### **5. Discussion: Overcoming in Russian Culture**

In this article, we examined funerals and maternity care as non-religious systems, which are arranged in different ways and do not necessarily implicate symbolic and sacred meanings. Although the funeral industry primarily functions as a market and maternity care in remote areas mostly functions as state-funded service, we have shown that there are many similarities in the ways they work, mainly because the infrastructure is managed by the state in contemporary Russia in both cases. Such practices necessarily involve spatial transition, which quite often implies interaction with broken infrastructures and which we conceptualize as liminality. The need to constantly repair these breakdowns, although not designed, has become their integral part. Users of both systems expect that birth and death consist of multiple breakdowns. As we have argued, the need to repair broken infrastructure comprises the stage of transition itself and is thus symbolically functional. Thus, we show that the ritual can be framed not only by materiality but also by the peculiarities of its work: the state of normal functionality/breakdown is mediated by culture and technical dysfunctions are interpreted through symbolic meaning. In other words, it is important to consider not only the configuration of the infrastructure itself but also the usual modes of operation/interaction with it: the breakdown of the infrastructure may be necessary because it performs a function in the ritual.

How does repair acquire symbolism in rites in contemporary Russian culture? In her brilliant book 'Russian Talk', Nancy Ries describes how ordinary people talk to each

other, discussing the everyday difficulties of the Perestroika era. Ries notes that the central core of these conversations are complaints, which she calls litanies. 'Litanies are speeches in which a speaker expresses his/her complaints, grievances, anxiety about all sorts of troubles, difficulties, misfortunes, illnesses, losses' (Ries 1997, p. 164). Ries draws attention to the fact that litanies are built according to fairy tales, where the character, as a rule, is the narrator himself who encounters many difficulties; by overcoming them, he acquires the status of a hero. In the eyes of the narrator, even a simple trip to the grocery store turns into a brave adventure with an open ending. Ries believes that these discursive practices create the main communication environment of post-Soviet culture, where difficulties have become the desired state. We believe that the principle described in the litanies of Ries is also implemented in the practices of interaction with the infrastructures in contemporary Russia. Thus, we have answered our question regarding the impact of persistent infrastructure dysfunctions on the funeral/birth experiences in the following ways. The constant overcoming of difficulties or infrastructural breakdowns has become actualized in practices and conversations as something natural and has become the central element of narratives on funeral rituals or preparations for childbirth. Any failures in the life-cycle rituals in infrastructure require being smart, demonstrating the ability to handle them, and using the necessary social connections to solve them. As a result, the state of the infrastructure has become one of the codes of the life-cycle rituals in contemporary Russia.

#### **6. Conclusions**

We argue that contemporary Russian funerals and childbirths represent a specific format for the interaction of its participants with the infrastructural environment. As a result of this interaction, the problems of the functionality and accessibility of infrastructures are solved, wherein participants consider the dysfunctional infrastructure environment to be a natural condition. This has been clearly recorded in conversations between actors and ethnographic interviews. The problems that arise during the preparation and conduct of life-cycle rituals are actualised (and accepted) by the participants as special forms of necessary tests. For example, informants say that problems 'are everywhere, and they always existed—either the trees fill the cemetery, or the road is washed away, or the gravedigger is drunk' (Author's field diary dated from 14 August 2016; entry No. 117). The head of the League of Patients' Rights Defenders articulated the same problem with the following phrase: 'Well, let me put it this way, people don't want to complain. They might be afraid. I don't know. Or they are happy with everything, I can conclude that everything is fine'. These troubleshooting infrastructure failures are carried over to symbolic meanings. Informants describe this state as 'abnormal', but the constant 'repair' or patching infrastructural gaps is so total and possesses ontological features, which have led to the formation of a special 'repair culture'.

Infrastructure failure not only is a communicative function in the process of organizing a funeral or monitoring pregnancy and preparing for childbirth but also has an important symbolic meaning that turns funerals and obstetrics into full-fledged rites of passage associated with overcoming infrastructural problems.

**Author Contributions:** Conceptualization, S.M. and A.A.N.; methodology, S.M. and A.A.N.; formal analysis, S.M. and A.A.N.; investigation, S.M. and A.A.N.; resources, S.M. and A.A.N.; data curation, S.M. and A.A.N.; writing—original draft preparation, S.M. and A.A.N.; writing—review and editing, S.M. and A.A.N. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Data sharing is not applicable because no new data were created or analysed in this study.

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

#### **References**

Anand, Nikhil. 2012. Municipal disconnect: On abject water and its urban infrastructures. *Ethnography* 13: 487–509. [CrossRef]

Chipchase, Jan. 2005. Local Repair Cultures. Available online: https://www.cityofsound.com/blog/2006/07/local\_repair\_cu.html (accessed on 20 July 2021).

Dant, Tim. 2010. The Work of Repair: Gesture, Emotion and Sensual Knowledge. *Sociological Research Online* 15: 1–22. [CrossRef]


## *Article* **Reconciling the Uniquely Embodied Grief of Perinatal Death: A Narrative Approach**

**Tamarin Norwood 1,\* and John Boulton <sup>2</sup>**


**Abstract:** The death of a baby, stillborn or living only briefly after birth, is a moral affront to the cycle of life, leaving parents without the life stories and material objects that traditionally offer comfort to the bereaved, nor—in an increasingly secularized society—a religious framework for making sense of their loss. For the grieving mother, it is also a physical affront, as her body continues to rehearse its part in its symbiotic relationship with a baby whose own body is disintegrating. Attempting to forge continuing bonds with her child after death makes special demands upon the notion of embodied spirituality, as she attempts to make sense of this tragedy in an embodied way. This paper, which reconciles the distinct perspectives of bereaved mothers and children's doctors, proposes that the thoughtful re-presentation of medical insight into pregnancy and fetal development may assuage parents' grief by adding precious detail to their baby's life course, and by offering the mother a material basis to conceptualize her own body as part of the distributed personhood of her baby.

**Keywords:** grief; bereavement; death; pregnancy loss; secular; embodiment; metaphor

#### **1. Introduction: The Uniquely Embodied Grief of Perinatal Death**

The aim of this paper is to show how perinatal death makes special demands upon the notion of embodied spirituality, and how these demands can be addressed through ad hoc metaphorical re-imaginings of certain insights from medical science. These ideas arise from the search for a common understanding between two distinct perspectives: the objective/clinical perspective of the children's doctor and the subjective/poetic perspective of the grieving mother. Thus, in the following pages, we use two registers to describe the death of the baby: the first summarizing the facts, figures, and emotional consequences of this tragically commonplace event; the second describing the uniquely corporeal experience of perinatal death. The purpose of this reconciliation of viewpoints is to create a model that can be used by parents in practical ways to assuage their grief by coming to understand the ways in which an unbroken lineage of bonds can be seen to exist all the way from conception to interment and beyond.

We use the term "embodied spirituality" to describe the notion, which we achieve through our human capacity to suspend disbelief, that the essential yet invisible force that gives each their unique personhood must somehow be expressed in their flesh. In this view, far from hindering spiritual flourishing, the body and mind play an equal part "in bringing self, community, and world into a fuller alignment with the Mystery out of which everything arises" (Ferrer 2008). Given the Western pluralistic and secularised context of this paper, we re-interpret "Mystery" here in a non-religious sense to denote a sense of meaning and connectedness that goes beyond rational understanding. Given our focus on perinatal loss, this paper identifies especially with the tenth feature of embodied spirituality discerned by Ferrer in his essay on the subject: the "integration of matter and consciousness", which we return to in the Conclusion (Ferrer 2008). As Wojtkowiak demonstrates in her study of embodied spirituality in secular ritual at the start of life,

**Citation:** Norwood, Tamarin, and John Boulton. 2021. Reconciling the Uniquely Embodied Grief of Perinatal Death: A Narrative Approach. *Religions* 12: 976. https:// doi.org/10.3390/rel12110976

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 1 October 2021 Accepted: 2 November 2021 Published: 8 November 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

embodiment plays an especially important role in making meaning of pregnancy and birth (Wojtkowiak 2020). As we will see, this role is amplified when a baby dies.

Of all pregnancies, one-quarter are lost before 12 weeks, and many before the woman has recognized that she was pregnant. The death of a baby from 28 weeks and/or over 1000 gm is defined by the WHO as a stillbirth and includes babies who die from birth to 28 days of age in perinatal deaths. The perinatal mortality risk falls from 20 weeks, but with 60% of stillbirths occurring between 20 and 26 weeks. The incidence of stillbirths and neonatal deaths in high-income countries is 3 per 1000 births and, for low-income countries, 23 and 26 per 1000, respectively (Australian Institute of Health and Welfare 2021). For comparison, the infant mortality rate for babies in high-income countries is now as low as 3 per 1000 live births. For example, in Australia, the incidence of neonatal death fell from 3.2 to 2.4 per 1000 between 1999 and 2018. Post-neonatal deaths (from 29 days until 12 months of age) were between 0.5 and 1.0 per 1000, with congenital abnormalities being the main cause (Australian Institute of Health and Welfare 2021). The terminology of fetal and neonatal death is complex. For simplicity, in this paper, we will refer to all of these deaths as 'perinatal death' and will use the word 'baby' regardless of gestational age.

The figures of the burden of mortality do not convey the burden of grief. The grief from perinatal death weighs immediately and heavily on the midwives and doctors attending the delivery; tears are hidden behind surgical masks. The expected trajectory of pregnancy and labour is the joyful arrival of a baby, not the failure that is death. This effect is described as "moral injury" by a psychiatrist in relation to the distress suffered by her colleagues caring for young people dying of COVID-19: a death that violates their moral code and individual beliefs about what is right or wrong and causes feelings of shame, guilt, and anger amongst such caring health professionals (Alexander 2021).

For its family, the death of a baby can cause greater grief than the death of a spouse or parent (Sanders 1980). Added to this is a social constraint to the expression of grief as a result of social and systemic underestimation of the significance of such a loss, as the following summary makes clear:

"In stark comparison with other types of losses, when a pregnancy is lost there are no communal rituals for grieving, no customary religious or social gatherings, no condolence cards or flowers, nor is there even a death certificate, burial, or gravestone for the lost baby. [ ... ] Perinatal loss [ ... ] is the *only* type of loss in Western society for which there are no culturally sanctioned rituals or traditions to help the bereaved say good-bye." (Markin and Zilcha-Mano 2018)

Markin and Zilcha-Mano make a convincing case that "Western culture as a whole invalidates perinatal grief", shrouding it in a silence that amounts to a powerful taboo which forces parents to "grieve in isolation" (ibid.). Studies of perinatal grief show how the mother feels that in losing her baby she has lost part of herself (Littlemore and Turner 2020), that she suffers a loss of personal competence, the risk of losing her valued place in the family, and feelings of guilt, with one quarter of mothers blaming themselves (Christ et al. 2003). This has the effect of placing much importance on knowing the cause of the loss, for which there is often no clear answer (Moulder 2001). No clearer is the parents' sense of who their baby was or might have become, nor, in many cases, their sense of whether or not they perceive themselves—or are perceived by others—to be parents at all, if they have no living offspring (Murphy and Cacciatore 2017). All these ambiguities mean pregnancy loss can be described as an example of "disenfranchised grief", which "is not or cannot be openly acknowledged, publicly mourned, or socially supported" (Doka 1989). In these circumstances, mothers may find themselves permanently preoccupied with the loss of their baby, may experience visual, auditory, or physical hallucinations of its presence, and any emotional conclusion to their grief may be inhibited; the aim of therapeutic support is therefore reconciliation with her grief (Christ et al. 2003).

In seeking reconciliation with any bereavement, there is a deep human need to continue rather than relinquish bonds with the deceased (Klass et al. 1996). These bonds are principally ephemeral: keeping the relationship alive by treasuring and sharing memories, continuing to mark significant anniversaries, or spending time with the memory of the deceased in prayer or imagined conversation. However, material objects and practices also play their part: Clothing may be treasured for the familiar touch or scent of a loved one, and possessions may spark memories and support the feeling of continued lineage from the life of the deceased to the lives of those they leave behind. This network of meaningful objects comes to stand for the deceased loved one and can be understood as contributing to their "distributed personhood", a term used to describe "a model of the individual which transcends the boundaries of the body" (Hockey et al. 2010).

Such is the power of the material in the face of grief that when a baby dies, bereaved parents are encouraged to create a material legacy not yet accumulated over the course of a life so brief. Many hospitals now provide memory-making boxes containing blankets, teddies, and materials for creating hand and footprints. Just as many are comforted by viewing the body of a loved one at the end of a long life, so bereaved parents are supported in hospitals to spend time engaging in "parenting practices" such as bathing, dressing, and holding their baby after death (Bleyen 2010; Schott et al. 2016). This helps parents create embodied memories of the material 'realness' of a baby only just welcomed into the world and too soon to be lost to cremation or interment (Layne 2000).

We can think of these objects as "materially grounded metaphors" (Hockey 1990). In his historical study of the materialities of stillbirth, Bleyen examines the role material objects and material practices can play in keeping an absent baby present in its parents' lives (Bleyen 2010). Building upon Nisbet's description of metaphor as "a way of proceeding from the known to the unknown" (Nisbet 1969) and Hockey's observation that materially grounded metaphors can make sense of death and grief, he shows how certain objects chosen by families—a ceramic mushroom set as a headstone, a doll, a cradle—can "enable fragments of life to converge into 'things' that give a sense of wholeness", making both the unknown baby and the ungraspable reality of its death tangible and knowable within the home and in the continuing life of the family (Bleyen 2010).

Knowable, but still ambiguous. Following Littlemore and Turner (2020), in the metaphors surrounding pregnancy loss, "it is not always possible to identify a clear source and target domain" (61). In the material metaphor of the doll, for example, the doll (given to a four-year old girl after her baby brother died) is the source domain, but the target domain is not quite clear. The doll is not exactly a metaphor for the lost baby, but for something "both absent and present" (Bleyen 2010):

"Although the toy was treated as if alive, appearing to make her daughter's 'little brother' a tangible reality, the 'little brother' nonetheless remained intangible. Each time the mother and the daughter touched the doll, 'little brother' would slip through their fingers." (ibid.)

There is something else unique about the material realness of the deceased when a baby dies, which plays a profound and under-acknowledged part in the mother's efforts to establish continued bonds with her baby after its death. Physically, a newborn baby should be inseparable from its mother. Had it lived, they would have remained "a single 'psychobiological organism'" for some months after birth (Phillips 2013), so when a baby dies, the mother feels its absence physically. Her lonely continuation of their co-dependence is illustrated by the following quotations:

"I felt a real physical loss because she was attached to me for her whole life—then she was gone. And then I had all this milk and there was no baby. I felt as though a part of me had been cut out . . . " —Jessie (Davis 1996)

"For a couple of weeks after the triplets were born, I could still feel them kicking inside me. [ ... ] it's a nightmare because I know the kicks aren't real." — Georgia (ibid.)

"My arms just ached. I've read about this and it's hard to believe, but to me there was actually a physical emptiness. I could almost feel my arms cradling, but there wasn't anything there." —Meryl (ibid.)

The reality of the baby's disintegrating remains—the very different journey its body takes from that of the grieving mother—is conspicuously overlooked in therapeutic literature on pregnancy loss. It might seem "unpleasant", "morbid", or even "ghoulish" to anticipate parents having this concern in mind. Indeed, these are the very words used to describe the concerns of mothers preoccupied with the physical condition of their babies who had died in utero as they awaited an induced birth (Forrest 1983), although clinicians' perceptions of such concerns are now much more sympathetic: (Jonas-Simpson and McMahon 2005; Malm et al. 2011). Yet these feelings, unpleasant indeed, are real, and they are no less real after a baby's burial:

"I've had nightmares about him, what he is like in the grave, digging him up, things like that. [ ... ] Every once in a while I think about what's happening in the grave, and I don't know why I do that. [ ... ] I think I'm just obsessed." —Desi (Davis 1996)

How is a mother to come to terms with this nightmarish reality and, moreover, to nurture a sense of continuing bonds with her baby when their bond is so intimately situated within her own body? Littlemore and Turner's recent study of metaphor use in pregnancy loss, which finds through qualitative metaphor analysis of interviews with bereaved parents "that pregnancy loss is construed as an embodied experience", reveals one strategy. They note that many of their respondents had had tattoos associated with their babies "in order to compensate for this loss", with one mother reporting: "I wanted to get [the tattoo] as soon as possible. I was like *putting her on my body* again." (Littlemore and Turner 2020).

#### **2. Methods: Researcher as Instrument**

In this paper, we explore another strategy that may help mothers notionally return their baby to their body, this time based on narrative approaches to medicine. Narrative has long been drawn upon in therapeutic contexts, and more recently has been acknowledged in medicine and healthcare as a resource for making sense of complex experience (Hurwitz and Bates 2016), for instance, lending a sense of structure to the "biographical disruption" that is a chaotic illness trajectory (Kleinman 1989) or binding it into meaningful story elements that might otherwise seem meaningless. If, as Verghese attests, "story helps us make sense of events in our lives" (Verghese 2001), then metaphor helps us plumb the depths of these events, allowing the communication of "meanings otherwise elusive" (Charon 2006). Littlemore and Turner's study of language use in baby loss focuses on metaphor not only because people experiencing especially painful emotions tend to draw heavily upon metaphor to understand and express their experience (Gibbs 1994) but because metaphor is especially adept at expressing meaning that seems to exist beyond words, including meaning that is, in some way, corporeally bound.

To gain insight into the depth of such experience we draw upon a personal maternal account of anticipated neonatal death by one of the authors of this article (T.N.). This is necessarily a personal, subjective, and anecdotal source of information which is also richly metaphorical in nature. While such a source has its limitations, in the context of embodied spirituality after pregnancy loss, we believe it has a place. In her study of loss and bereavement in childbearing, Mander argues persuasively for the value of a researcher's subjectivity and emotional involvement in conducting semi-structured fieldwork interviews on pregnancy loss because of the emotive and intimate nature of the subject, and notes that her "personality constitutes part of the research instrument, in contrast with the usual need for the researcher to be a neutral 'non-person' to avoid bias" (Mander 1994). The subjective first-person voice of lived experience, and the irreplicability of the anecdote in particular, has come to be valued in the medical and health humanities because they bring what Walter Benjamin has described as a "pathos of nearness" into otherwise data-oriented decision-making processes. Finally, we propose that the bereaved mother's voice is a welcome one when "many parents are still silenced and discouraged

from expressing the reality of their grief and sadness" (Benjamin 1999; Jonas-Simpson and McMahon 2005).

The following account, and the commentary that runs through it, plays three roles. First, it sets out in real terms the mother's profound connection to the corporeality of her baby not only before birth but after death and, consequently, the urgency of the maternal need to reconcile the unacceptable problem of her baby's remains. Second, it indicates the limitations of certain (medical and religious) conceptual frameworks available to her for attempting this reconciliation. Third, it offers one example of an effective (ad hoc and privately meaningful) framework for such reconciliation, which we theorize as an expansion of embodied spirituality to include an acknowledgement and acceptance of the material remains of the baby in continuity with the living body of the mother.

The objective medical perspective cannot be reconciled with the mother's, but it can inform an approach to how metaphor could support a shift in the subjective inchoate perspective of the realness of the baby's body into one of "symbolic immortality", but with the caveat that if seeking a metaphor there should be vigilance in maintaining the boundary between the symbolic and literal (Lifton and Olson 2018).

#### **3. Results: The Mother's Grief**

In the following extract, which recalls the late months of pregnancy with a terminal fetal diagnosis, the mother's experience of bonding with her baby is imagined as an exchange of messages between herself (outside, above) and her baby (inside, below): a line of communication dropped between them:

"I sang and swayed with Gabriel too. It was easy to feel he and I were engaged in a shared project of growing closer and closer together, a kind of neural and cellular falling in love. I imagined the soft-edged sounds of my speech reaching into his world as the soft-edged forms of his limbs reached into mine. I pressed against the uterine wall and imagined him pressing in return, hands meeting palm-to-palm in dreamlike mirror forms. I sent my songs to him, my movements, my love, and received in return the warmth of the plastic vials [of amniotic fluid, following an amniocentesis], the shadows on the ultrasound screen, the neural pathways pressing on and on towards me as I press and press to imagine his underwater world. I imagined the food I ate was a line dropped down to him, the goodness of which and the vestige of its flavour might be detected in his cells.

I sent him words too; not only the sounds of my voice, but writing. The writing was another line dropped down to him, and I knew he would leave this line behind when he was gone. It was a comfort to think I could continue write to him, just as I was now, after his death. We talk to the dead in their absence; Gabriel's absence was already here." (Norwood 2020b)

The prospect of continuing to write to the baby after its death introduces an emerging confusion over the site of the baby's presence. When perinatal death is anticipated, the baby's inaccessibility whilst within the womb is mirrored by its inaccessibility after death, and the womb and the grave begin to seem almost interchangeable. There follow several unsuccessful attempts to make sense of the realness of the dying and deceased baby through a number of conceptual frameworks at the mother's disposal: first, a medical perspective of fetal development, its lens "no use" to the grieving mother:

"The studies I was reading about fetal development all seemed to observe the period of gestation through a lens positioned at its conclusion: pregnancy seen through the fulfilment of its promise in birth and infancy and the span of new life. Prenatal prosody promises grammar, prenatal touch promises proprioception, even the mother's attachment to her unborn baby is the making of a promise, assuring her bond to an infant whose survival depends on her care. This lens was no use to me. My attachment to Gabriel was not the beginning of something else; it was happening now, before he was born. It was a promise being kept in

the making. And in the same way, surely, even in the oxygen-deprived, sleepy, incomplete, even unconscious mind, even if the activity of the brain was more physical than cerebral, surely something was being made that counted now and not only for later. I wanted an underwater lens that pressed against him, that would move with him as he grew, that would feel the feelings of the unborn mind to understand how his promises are experienced in the making, that would tell me if there was wonder, fear, pleasure, the dark impression of something gathering. These studies could tell me no such thing." (ibid.)

After the baby's death, caretakers of his body employ the commonly-used metaphor of death as sleep. In this case, the body of the dead baby is presented as the body of a sleeping baby—first by the midwife who prepared his body for viewing the day after the birth:

"A little hand had been posed where the blanket was folded as if to grip it, to give the impression of a baby asleep. Perhaps the midwife had arranged him thus in desperation, not wanting to present us with a baby so dead, but she needn't have worried. It wasn't being alive that made us love him. Dying had been Gabriel's way since the very beginning." (Norwood 2020a)

—and later by the undertakers who had custody of his body between autopsy and burial, a period which included the week of Christmas:

"They had sent us a letter confirming arrangements for the funeral, the modern, sombre flourish of a monogram introducing the careful scripting of what amounted to a story they wanted to tell us about our son. 'Your precious baby son', it read, 'who had fallen asleep' at the hospital, had been collected and brought into their care where he would stay until the day of the funeral. 'Will stay with me', were the exact words.

'And don't worry,' she said when I phoned her: 'we're taking good care of him. Over Christmas we put toys in the cots of all the babies we look after.'

'That's lovely,' I said. 'Thank you.'

I didn't ask her to remove the toys. I didn't say that he is dead and will never play and never had, having only known things graver than toys, principally love and death." (ibid.)

If the metaphor of sleep brings little comfort, neither—for this non-religious mother does the promise of eternal life:

"The undertaker's letter was twinned with another that had arrived around the same time. They made a pair on the shelf, neither one more or less adequate to the task. The second was from the diocese: no note, just a certificate of baptism printed on plain A4, signed twice in biro and stamped just off-centre with the seal of the cathedral. Nothing ceremonial, and no mark of condolence because the baptism was for the beginning of life, not for its end. In this letter there was no end in sight. No death, just everlasting life." (ibid.)

Meanwhile the mother's body, prepared for nurture, mirrors the realness of the baby's body, and this lingering corporeal bond begins to open itself to symbolic interpretation:

"Still my body seemed to wait for him. It was natural to me to imagine that the darkened nipples, the womb crimping when I miss him, the colostrum eking out, the blood still gulping down were the expressions of a body gentle and dumb, ready to care for him, longing for his weight and smell and needing to be tricked by simulations. When my arms would rise to my chest to hold him and felt the emptiness there, I could bundle up his blanket and hold it to my chest, or to my shoulder, and all my limbs would relax and the pressure on my neck would be released for a while. When ribbons of blood fell from my womb I would reply *I love you too* just as I had when he used to kick. My body knew otherwise, but in

my mind he must have returned to the resting place of my womb and sent me bloodlines from there." (ibid.)

An imagined reunion with her baby after death—not in an afterlife but in the soil indicates how corporeal is the mother's loss, as she longs, with little hope, for their bodies to embrace again:

"I could only understand one way to return to him: to get down into the soil where he stays, my grave level with his, and wait until my coffin and tissue disintegrate and then hope that shifts and lurches in the soil over hundreds of years will bring me to him, bring me around him, lay him back in the crock of my pelvis, bog bodies finally returned to one another, and there we would embrace. But in a crowded graveyard might not strange bones drift into our embrace unbidden, might we not drift apart and not together? Who is to say how bones and soil behave?" (ibid.)

At this point, the earlier confusion over the location of the baby comes to the fore, as the baby is addressed as though he were still in the womb from whence the blood descends. At this point, the baby has two locations: the womb and the soil, and they seem to be imaginatively one and the same, with the mother sending lines down to either:

"And just as I used to sing and sway with him, speak to him and write to him, now I planned to send him a ribbon of my own. Because his coffin was so light they would lower it into the ground with lengths of a ribbon I could choose myself if I wished, and in the ribbon I saw a dull possibility: looped around his box it would have to stay with him in the soil, and there lay some comfort." (ibid.)

#### **4. Discussion: Biological Analogues of Love**

This glimpse of the innermost thoughts of the mother illustrates her preoccupation with maintaining a bond to her baby's body when neither the metaphor of eternal sleep nor the claim that "your child is safe in the hands of God" is of comfort (Mottram and Bevan 2015). While the framework above is particular to its author and her experience, it was effective for this mother because it did not flinch from the material realness of her baby's body, nor did it shy away from acknowledging its continued importance to her and indeed to her own body after his death. In the exceptionally corporeal grief that follows baby loss, solace can be found in stories of the body as much as stories of the soul, and when all, or almost all, of the baby's life has taken place within the mother's body, the life stories one might ordinarily turn to for comfort remain largely inaccessible, being for the most part unseen, unfelt, or taking place upon a molecular and chemical level.

This is where clinical narratives can intervene to make a difference. Where life-stories are lacking, precious information can be gleaned from the detailed insights of medical research into pregnancy, the life course of the fetus, and the mother's post-partum body provided they are presented in a thoughtful way. Here, we present three stages from the life-course of a pregnancy and demonstrate how each might bear the possibility of symbolic resonance for bereaved parents and might even contribute resources for the distributed personhood of the lost child.

Firstly, there is the permanent presence in the mother's bloodstream of blood cells (lymphocytes) from the fetus, which remain part of her blood stream for the rest of her life (Schröder and De la Chapelle 1972). This phenomenon of a mixture of cells from two individuals within the blood stream, without any response (termed immunological tolerance) of the host (mother) to such foreign cells, is called micro-chimerism. This can be shown only for cells from a male fetus because these contain a Y-chromosome, which can be differentiated from female cells. The function of these longed-lived lymphocytes is unknown although there is evidence that they have a subtle beneficial influence on the mother's health in reducing her risk of cancer and adding longevity (Kamper-Jorgensen et al. 2014).

The life-long presence of fetal lymphocytes amounts to a literal embodiment of the fetus within the mother and can be imagined as a material analogue to the mother's lifelong metaphysical bond with her deceased child. Coupled with the imaginative resources of the mother, we see below one example of the impact of such insight, as it contributes to an appreciation for her baby's realness having continued presence *both* within her body *and* in the soil:

"Almost every day after Gabriel died I wrote to him: my imaginary friend returned to me at last. My imaginary child, I thought, neither real before his birth nor after his death, and only very briefly real between.

But as I continued to write I began to understand I was mistaken. He was not imaginary, nor had he ever been, and nor was he quite the same child I had written to before his birth. The simplicity of the baby I had imagined before his birth was resolving itself after his death into the subtler quality of being elemental. Gabriel was, I believed, profoundly of the matter of the world, having emerged from matter and then returned to it almost without a breath—and in between, I chose to believe, secure in his mother's arms, all he encountered of the world that was not matter was Love.

In my mind this made him a creature composed completely of Love. Not only the feeling of Love but the material fact of it: the Love that is the blooming of life from bonded cells to vaulting structures built on the furthest shores of the mind, the Love that concentrates in those mealy places that incubate life, among them most of all the blood and the womb and the soil. In this way Gabriel was elemental. In this way he wasn't an imaginary friend, he was Love itself, squirming and pushing and kicking to take up its place in the world. So I wrote to him, and spoke and wept into the blanket of him. I no longer sang or swayed but still I laid my hands where he had lived, and to the ribbons of blood that came I replied *I love you too*, just as I had when I used to feel him kick. *I love you too*: here is my declaration of faith." (Norwood 2020a)

In this passage, the metaphor is Love, but the realness of the baby's presence after death is neither metaphorical nor imaginary but physically real.

Secondly, there is the role of the placenta as an interlocutor between the mother and the baby in her womb and as the liminal zone between them. The placenta emerges from the ball of cells (the morula) that quickly forms from the fertilized egg with its genetic code setting it on its own brief trajectory. It has the task of mediating the respective needs of the mother and the baby, with its insatiable demand for nourishment being tempered by the gentle constraint to its growth from maternal influences that preserve her homeostasis (Wells 2003). These roles play out according to the dictates of its neuro-chemical clock, for by 40 weeks, its destiny is complete: Without capacity to continue, it must separate from the womb.

The placenta's literal mediation of maternal and fetal demands can be imagined as a material analogue for the mother's ambiguous feeling of interdependence yet being separate from the fetus and of her body's ability to send messages through the sensory medium of song, rhythm, and the food she eats. Perhaps the tempering of one set of needs against the other and the gentle constraint from the mother's body might be imagined as the first of what would have been many jostling negotiations over the life course of their relationship together. Slim pickings indeed, but the need of a bereaved parent is great and the resources of metaphor infinite. The symbolic resonance of the placenta is formally acknowledged in many societies where the placenta itself is buried; its return to the earth being symbolic of the site of the child's kinship origins; for example, in Maori Te ¯ Reo, whenua (placenta) also signifies land.

Thirdly, there is the protean social development of the baby in the womb. Babies recognize and prefer not only the sound of their mother's voice but the rhythms of their native language; knowledge they will use after birth to "bootstrap the acquisition of the grammar and the lexicon" of that language (Gervain 2018). By the third trimester, they can recognize the touch of the mother's hand against the skin of her belly, and will reach out to the uterine wall to meet her touch for significantly longer than they will for the unfamiliar touch of a stranger (Marx and Nagy 2017). This early touch and recognition of the mother has been theorized as the early development of proprioceptive awareness: "a form of self-consciousness of the embodied self" (Gallagher 1995) which, in shared moments of touch through the uterine wall, constitute "a form of shared sympathy" (Marx and Nagy 2017). These and many other characteristics of fetal development indicate that the very first stages of socialization take place before birth.

Rather than viewing these stages as necessary for the later "bootstrapping" of cognitive developments after birth, a change of focus can emphasize to parents that already, before death, their baby was becoming socialized into the life of the family: that—to quote the account above—"something was being made that counted now and not only for later". It is evidently important to parents to have a sense of the infant's state of mind when they die, as we see in the following epitaph from Arretium, dated 407 C.E.:

"Here lies the infant Candidilla

who, although not a full two years,

Had understanding and so she has found rest." (Mazzoleni 2015)

When equipped with an idea of the degree of brain development—of 'understanding' their baby might have had at the time of its death—families can add further detail to the stories they create for their babies: details which, again, are founded not in metaphor but the realities of fetal development.

#### **5. Conclusions**

In the aftermath of pregnancy loss, parents endure not only the death of their beloved baby but also an absence of the narratives and social scripts that ordinarily accompany death, as funeral, death certificate, and even social acknowledgement of their loss and consequent emotional support may not be forthcoming (Markin and Zilcha-Mano 2018). In an increasingly secularized society, they may also lack a religious framework to help make sense of their loss. In many cases, no less lacking are the precious possessions the deceased usually leave behind at the end of life, which, as a form of distributed personhood, offer comfort to the bereaved. Faced with such painful absences, parents bereaved at birth are sorely in need of a narrative to help them navigate their loss (Norwood 2021).

In this paper, we have shown that an under-explored resource can be found in the wealth of existing medical knowledge of pregnancy and fetal development which, if made accessible and presented thoughtfully, can offer precious insight into the brief but meaningful life course of the baby. Support packages for parents bereaved at birth often include written materials offering advice on a range of subjects including memory-making, accessing specialist bereavement support, making funeral arrangements, and post-partum physical exercise. We propose that an additional resource sharing medical knowledge in an appropriate way could benefit parents. Such details—including, for instance, the lymphocytes, the placenta, and the in utero social development of the baby—can be conceived as the source domains of open-ended metaphors which leave the target domains unspecified, so that they are open to parents to complete in their own way. The material and corporeally bound nature of these open metaphors might be especially comforting given that, for its mother, the loss of a baby prompts an exceptionally corporeal experience of grief. Learning the biological detail of her baby's life before birth and its emerging socialization into the culture of its family may not only help add detail to the picture of an unknown child but also offer the mother a material basis to conceptualize her own body as part of the distributed personhood of her child, whose presence will literally (in its lymphocytes), as well as symbolically, be with her always.

To sift through medical information for insights that might be resonant or meaningful to parents; to translate the language of the clinician into the language of the parent; to transpose the orientation of the clinical focus from the future life of a fetus to the present moments of a life too brief: this is creative and empathic work, demanding close collaboration between the sciences and the humanities. As such, this work would represent a meaningful application of the insights of critical medical humanities, which emphasize the value the humanities can bring to medicine over and above its capacity to illustrate or simplify medical ideas (Viney et al. 2015).

Meeting spiritual needs with detailed biological information, spanning from conception to interment, gets to the heart of our own interpretation of embodied spirituality and the "integration of matter and consciousness" it entails (Ferrer 2008). By presenting a secular and poetically open-ended basis upon which to reconcile the ambiguous but material realness of perinatal death with its profound spiritual significance, this encounter of medicine and the humanities may offer comfort to bereaved parents where other available narratives fall short.

**Author Contributions:** T.N. and J.B. have contributed equally to the writing of this article. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

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

#### **References**


Gibbs, Raymond. 1994. *The Poetics of Metaphor*. Cambridge: Cambridge University Press.

Hockey, Jenny, Carol Komaromy, and Kate Woodthorpe. 2010. *The Matter of Death: Space, Place and Materiality*. London: Palgrave Macmillan.

Hockey, Jennifer Lorna. 1990. *Experiences of Death: An Anthropological Account*. Edinburgh: Edinburgh University Press.


Kleinman, Arthur. 1989. *The Illness Narratives: Suffering, Healing, and the Human Condition*. New York: Basic Books.


## *Article* **The Function of Ritualized Acts of Memory Making after Death in the Neonatal Intensive Care Unit**

**Inger Emilie Værland 1,2,\*, Anne Beth Gilja Johansen <sup>3</sup> and Marta Høyland Lavik 1,2,4**


**Abstract:** (1) Background: Some infants die shortly after birth, leaving both parents and nurses in grief. In the specific setting where the data were collected, the bereaved parents receive a scrapbook made by the nursing staff in the NICU, and a box made by a local parent support group. Making a scrapbook and a box when an infant dies in the NICU can be regarded as ritualized acts. The aim of this study is to explore the functions of these ritualized acts of making a scrapbook and memory box when an infant dies in the NICU. (2) Methods: Focus group interviews were performed with experienced nurses in the NICU, and with members of a parent support group. Reflexive thematic analysis was used to interpret the data. (3) Three main themes were constructed: "Making memories", "showing evidence of the infant's life and of the parenthood", and "controlling chaos". (4) Conclusions: Through the ritualized acts of making scrapbooks and boxes, nurses and members of the parent support group collect and create memories and ascribe the infant with personhood, and the parents with the status of parenthood. In addition, the ritualizing functions to construct meaning, repair loss, relieve sorrow, and offer a sense of closure for the makers of these items.

**Keywords:** memory making; function of ritualized acts; ritualization; neonatal intensive care unit (NICU); new-born; death; bereaved parents; nurses; parent support group; existential

#### **1. Introduction**

When infants die shortly after birth, parents are left in shock and grief (Berry et al. 2021), and nurses can also experience sorrow (Gibson et al. 2018). Birth shares some of the experiential and existential qualities of death (Wojtkowiak and Crowther 2018). Beginning and ending of life, experienced as biologically radical, are entangled. These two transitions can illuminate each other in the sense that presence of death can be more distinct when life begins, and life more distinct when death approaches (Prinds et al. 2019).

#### *1.1. Memory Making in the NICU*

When an infant dies shortly after birth, parents leave the neonatal intensive care unit (NICU) without their child, and nursing interventions become important (Pueyo et al. 2021). In the specific Norwegian NICU where the data collection was carried out, it has over the last decades become common to make scrapbooks when an infant dies. The book is an ordinary A5 size writing book where the nurses write in second person singular ("you") to the infant, reporting medical information about the treatment, but also sometimes including a self-made text, or a poem. Photos of the infant and its parents are usually included in the book, as well as ink foot- or handprints on a cartoon, hair, and EKG electrodes. In addition to this, foot- and handprints are made with plaster, and given to the parents when they

**Citation:** Værland, Inger Emilie, Anne Beth Gilja Johansen, and Marta Høyland Lavik. 2021. The Function of Ritualized Acts of Memory Making after Death in the Neonatal Intensive Care Unit. *Religions* 12: 1046. https:// doi.org/10.3390/rel12121046

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 1 October 2021 Accepted: 17 November 2021 Published: 25 November 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

leave the NICU. Comparable practices are also known from other studies. Memories are made through photos taken by parents or staff, or through the creation or collection of mementos in a memory box containing objects of significance (Pueyo et al. 2021; Thornton et al. 2019). The making of footprints with ink, foam or alginate plaster is another way to create remembrances (Levick et al. 2017). Physical and tactile items such as blankets, clothes or a clay footprint, which were directly connected to the infant can also hold special significance (Thornton et al. 2020). It is known from other studies that parent support groups sometimes provide bereaved parents with a support package when an infant dies (Aho et al. 2014). This is also true for our context. A local parent support group for bereaved parents provide the hospital with a support package which takes the form of a box filled with brochures of information together with various items. The box has space also for objects which belonged to the infant if the parents wish to keep these. In agreement with the hospital, the box is handed out by the nurses in the NICU when bereaved parents leave the hospital.

In general, when an infant dies in the NICU, health professionals can act as ritual inventors and experts when supporting bereaved parents (Jørgensen et al. 2021). Memory making through the creation of a scrapbook and memory box can be regarded as ritualization when an infant dies in the NICU. In line with this, we wanted to investigate what functions the ritualization by nurses and members of the parent support group might have. The research question was: what are the functions of the ritualized acts performed by nurses and members of the parent support group in the course of an infant's death in the NICU?

#### *1.2. Theoretical Framework*

"Ritual is as old as humanity" (Grimes 1995, p. xxiv), and rituals have been studied for decades. The ethnographer van Gennep (1960) was the first to identify that in all cultures there are ceremonies that mark an individual's transition from one status to another within a given society. These rites are connected to birth, maturity, reproduction, and death. Because of the importance of these rites, he called them rites of passage. After further studies, he also found it meaningful to subdivide them into rites of separation (preliminal rites), transition rites (liminal rites) and rites of incorporation (postliminal rites) (van Gennep 1960, pp. 10–11). The different ceremonies' essential purpose was to enable the individual to pass from one defined position to another (van Gennep 1960, p. 3). Building on van Gennep, the anthropologist Turner further developed the concept of liminality, and argued that being in the transition phase means that you are no longer classified and still not yet classified (Turner 1996, p. 511). This indicates that the liminal phase is an ontological and socially insecure and unstable position to be in (Grimes 2000, p. 6; Jørgensen et al. 2021, p. 3). We can also consider it as a critical phase because it raises the question whether one will be accepted and incorporated into the new state or not. Building on the insights from van Gennep and Turner, ritual theorists today investigate how rites of passage are practiced and experienced around the world. Grimes, the founder of the interdisciplinary field of ritual studies, is for instance interested in how people "[... ] can fruitfully reflect on their own experiences of passage" (2000, p. 8). The performative and individual sides of rituals have, in this way, gradually become more emphasized, cf. the following broad definition: "Very generally, ritual is any activity—sacred or secular, public or private, formal or informal, traditional or newly created, scripted or improvised, communal or solitary, prescribed or self-designed, repeated or one-time only that includes the symbolic expression of a combination of emotions, thoughts, and/or spiritual beliefs of the participant(s) and that has special meaning for the participant(s)" (Castle and Phillips 2003, p. 43).

When it comes to understanding the function of rituals, the findings from the social anthropologist Brottveit (2003) are relevant to this study as he has studied grief and death rituals in a cross-cultural perspective. He points to three main functions: (1) Therapeutic function—make the unreal real, relieve the grief and repair the loss. (2) Cosmological

function—give death a meaningful frame and define the deceased's new place and identity. (3) Social function—redefining the roles and resume normalcy. In the present article, we elaborate mostly on the first and third functions. An ordering function of rituals is emphasized by Driver, Professor of Theology and Culture: "In its ordering function, ritual performs the world, bringing it from chaos and the limbo of potentiality into actualized (actionful) form" (Driver 2006, p. 136).

It is common to distinguish between ritual and ritualization: "A ritual is often conceived as a text or a formula that is used in a religious context or in other contexts where something needs to be expressed symbolically. Carrying out the ritual means enacting the ritual script and making it as vital as possible in a performative act. By ritualizing, we mean symbolic activities people take part in in order to derive meaning. For ritualizing, people can use written rituals, but they can also create new symbolic activities that they use in their meaning-making efforts" (Danbolt and Stifoss-Hanssen 2017, p. 355). According to the religious studies scholar Catherine Bell, ritualization must be understood in connection with context, as it "[ ... ] always takes place within a larger and very immediate sociocultural situation" (Bell 1992, p. 100).

The academic study of ritual is complex and gives insights into a field "[ ... ] upon which multiple viewpoints are focused" (Grimes 1995, p. xxvi). In the discussion, it will become evident that we interpret our data material in light of ritual and ritualization theory. However, we are not investigating rituals and ritualization within traditional religious contexts. Our interest lies in understanding what functions the ritualized acts performed in the course of an infant's death in the NICU have. The terminology "ritualized acts" is taken from Bell (1992, p. 140) who goes beyond former definitions of ritual in defining ritual as "the production of ritualized acts". In line with her understanding, we investigate practices surrounding birth and death in the NICU and regard these as ritualized acts. To understand the functions of these practices, we are indebted to classical works in the field, but even more to recent works on rituals and ritualization around birth and death, and especially to the works of Jørgensen et al. (2021) and Wojtkowiak (2018, 2020). The aim of the study is therefore to explore the functions of the ritualized acts of making a scrapbook and memory box when an infant dies in the NICU.

#### **2. Materials and Methods**

The study has a qualitative, explorative design. The interview guide was designed to explore experiences, practices, and reflections.

Our overall analytic approach has been hermeneutical. The parts and the whole of the data material have been interpreted in light of each other in order to gain a "thick" description (Geertz 2017, pp. 3–33). Insights from hermeneutics have been applied both in the search for understanding the research participants' experiences, practices, and reflections, but also in our search for understanding each other's professional backgrounds as researchers, and how these impact our interpretations of the data set. According to the German philosopher Hans-Georg Gadamer, being aware of one's own preunderstandings and prejudices are vital in the act of interpreting, as prejudices are present in all understanding (Gadamer 2011).

A hermeneutical approach can include various methods, and in this study, it is combined with the method of reflexive thematic analysis. Reflexive thematic analysis aims at constructing and categorizing essential themes which form the data, and at the same time emphasising the active role of the researcher in this process (Braun and Clarke 2006; Braun et al. 2019, p. 848).

#### *2.1. Sample and Data Collection*

This study was conducted in a hospital in the Southern part of Norway. The participants lived in the same area. Data were generated through three focus group interviews with altogether 12 participants (eleven women and one man). The data collection was carried out with two groups of nurses, and one group of members of a parent support group.

Five members were recruited by contacting the parent support group, but only three turned up at the date of the focus group interview. Although they were few, they provided us with substantial data on the topic. The other participants were nine experienced nurses working in a level 3 NICU. To give all nine participants sufficient time to speak, two focus group interviews were performed. In order to anonymise the participants alias names were used.

The first author was the primary investigator in terms of obtaining the right permissions to undertake the study, and of recruiting participants to the three focus group interviews.

#### *2.2. Interviews*

The main objective in the focus group interviews was to examine the functions of the ritualized acts of making a scrapbook and box.

Through the group discussions, the specific experiences and practices were reflected on from nurses and members of the parent support group. These provided us with new knowledge about how memory making in this sense can be seen as forms of ritualized acts. The same interview guide was used for both groups, but questions were slightly adjusted to fit the specific group in focus. The interview guide was made based on the recommendations of Krueger and Casey (2015, pp. 44–46). The guide was organised with an opening question where the participants briefly presented themselves. The next introductory question dealt with how the idea about making a scrapbook and memory box came into being. The transition question pursued how the participants experienced the work with the respective items to be included in the scrapbook and memory box. The key question examined the contents of the scrapbooks and memory boxes, respectively, and the significance and meaning the contents had to the research participants. The ending question was directed towards the participants' understanding of rituals and ritualization.

All three researchers were present at all focus group interviews. One researcher was moderator, while the others asked additional questions and summarized the discussions. The interviews were recorded and transcribed verbatim by the researchers. All groups were interviewed once, and each interview lasted approximately one hour and thirty minutes.

#### *2.3. Analysis*

Reflexive thematic analysis according to Braun and Clarke (2006, 2019; Braun et al. 2019) was used to construct, describe, and interpret themes. According to Braun and Clarke, a reflexive thematic analysis consists of six phases: (1) All researchers read through and became familiar with the data. (2) Initial codes were generated, based on a deductive approach. The researcher made these codes, respectively, and agreed about which were most relevant. (3) The dataset was searched for themes based on temporary themes. The first author developed temporary themes, and these were discussed with co-authors. (4) The temporary themes were further scrutinized and reorganized. (5) The themes were developed around topics aiming to provide a diversity of meanings. The team of researchers discussed and examined the themes and the dataset throughout the entire process. (6) Finally, the article text was written (Braun and Clarke 2006; Braun et al. 2019, pp. 852–57). Meaning-based patterns were conceptualized to themes. The patterns of meaning were found after exploring, developing and examining the dataset. The data was developed using latent thematic analysis. Latent thematic analysis was used as we sought for a broader, more implicit meaning. The themes were regarded as pattern of shared meaning supported by a core concept (Braun and Clarke 2019). We sought to offer a comprehensive and convincing interpretation of the given data. Our professional background as chaplains and nurses, in addition to our interest in ritualization, influenced the process.

#### *2.4. Ethical considerations*

As topics around death and life can touch upon existential issues in the individual, we formed our interview guide in a way which allowed the individual to protect themselves and not share more than they wanted to share in the course of the focus group discussion. The study followed the Helsinki declaration (World Medical Assosiation 2018), and the participants were granted confidentiality. The Norwegian Centre for Research Data (NSD) approved the study (ref. no: 697560). The participants received written and oral information explaining the aim of the study and gave their written consent to take part in the study.

#### **3. Results**

*3.1. Making Memories*

3.1.1. There Was a Life

A decade or two ago, one of the nurses in the ward initiated the making of the scrapbooks. This practice has ever since been performed. The nurses start on the scrapbook immediately after an extreme premature and/or critical ill infant is admitted in the NICU, or when a long stay is expected. Nurse Fiona explains:

"We try to start taking photos quite straight away when the infant is admitted, if we think it is very premature or seriously ill."

The motifs may be the incubator, medical equipment, the infant, and the parents. The infant's weight, length, head circumference and the parents' names are added. The scrapbook can at this stage be regarded as a celebration of the birth. However, the seriousness of the situation signals that what starts out as a diary of a new-born life, becomes a memory book if the infant dies. They start writing to the infant using second person singular ("you"). However, if the infant dies, the nurses continue writing to the infant, but then have the parents and potential siblings in mind when it comes to content. Nurse Mona says:

"Most times, we write to the infant during the whole stay. If the infant dies, I write to the infant, then finally to the parents."

They may describe that the infant's condition is critical. Other times they try to find suitable poems appropriate to the situation with the intention of comforting the parents and siblings. The pages are decorated with various stickers and photos. As parents may forget what happened when the infant was seriously ill, the scrapbook is intended to help them to remember. Nurse Gina explains:

"It becomes like a journey through the NICU, through life, if life ends at the ward. There was a life."

When it comes to the box, one of the members of the local parent support group initiated the making of the memory boxes. The group wanted bereaved parents to be provided with better information and grief care than they experienced when they lost their child. One of the members of the parent support group had the idea of using a box for the purpose of collecting information and mementoes. In addition to brochures with information, the group decided that the box should contain a small teddy bear, a laminated poem and a small transparent jewelry bag with symbolic items: a candle, a security pin, an angel, and a heart.

#### 3.1.2. Not Leaving the Hospital Empty-Handed

The scrapbooks and the memory boxes are tactile objects. The members from the parent support group hoped that the memory box would be a touchable memory. Beth, who herself had experienced loss, says:

"I am very concerned that you should not leave the hospital empty-handed ... I found it very difficult; I call it something touchable, something that you can show to others."

The nurses emphasize the scrapbook as a physical evidence of the infant's life. Nurse Hannah explains:

"The scrapbook is something that you hold, and that is what they [the parents] have left."

The nurses try to create memories when there is no hope for an extended life. They make a testimony of the time the family had together, even when life is very short. They collect and make other tactile memories as blankets, haircuts, hand- and footprint on paper and in plaster. They also save the pacifiers and other things that have been close to the infant. Nurse Linda states:

"Even the shortest lives will get [a book]; we always manage to complete the books."

The nurses emphasize the importance of photos chosen for the scrapbook. They try to capture different scenarios as soon as possible when an infant arrives. Sometimes they start when the infant gets the initial treatment. The photos should reflect important moments in the family. Milestones such as the parents holding or bathing the infant for the first time, or grandparents or siblings visiting are such moments. When the parents are present, pictures of the infant grabbing the parents' finger, or parents' and infant's hands together are other important moments to capture, according to the nurses. Special characteristics such as for instance long eyelashes are perpetuated. Nurse Mona wants to capture this and:

" . . . to take a photo of the love and the longing . . . "

When an infant is admitted in the NICU, this in itself means that the parents are experiencing a severe crisis. Some mothers may not be able to visit their new-born infant due to their own critical condition. The parents' time together with the infant is sometimes very limited. The nurses try to highlight the bonding between infant and parents. Olivia explains:

"I remember it well as it was on Christmas Eve. The parents had dressed up and the father wore a tie. The infant was so weak that he could not grab. When the father holds the infant, he grabs the tie. I took a photo of the three together. I heard that they used the photo as Christmas card."

Important motifs are when parents and infant are physically close, such as when the parents hold the infant or touch the baby after death has occurred. Nurses emphasize that they try to take photos before the infant's color changes and make sure the parents hold the infant before it becomes cold. The participants emphasize the concreteness of the scrapbook and the boxes. It is a reminder and a memory of the life and death of the infant.

3.1.3. The Ambiguity of Making and Collecting Memories

The nurses are well aware that memories are not always desired, and that they can even hurt the parents. Gina means:

"Well, I think that none of the parents have expected or know that we are making a scrapbook. In a way, it is something that we inflict on them."

The nurses do not know whether the scrapbooks can make the pain of the loss remain longer, prevent the parents from moving on, or if it at all relieves the pain. At the same time, they know that even if the parents find it difficult to look in the scrapbook straight after the death of their infant, they may appreciate it after some time. They know that some parents do not look at the book for years.

When taking photos, the nurses are physically very close to the parents and the infant. They may feel that they disturb the time the family have together. They persuade the parents to hold their dead infant and take photos. Olivia refers to an experience where she guided the parents to hold the dead baby:

"So, I asked whether we pushed them [the parents]; sometimes I feel we take too many photos, that we are too much around them, and encourage them to hold the infant. [The answer was] if you had not told me to hold the infant, I would not have done it."

The parents' cultural background influences how parents meet the death of their infant. Mona found it difficult to provide an immigrant couple with what she thought was a dignified ending when they did not want any memories to be collected or created:

"It happened very suddenly and the parents did not want to hold the infant, to have photos; anything. The infant should just be forgotten."

The members of the parent support group do not meet the bereaved parents, as the parents receive the memory box via the nurses in the NICU. The participants from the parent support group do not know whether the contents of the box are helping the bereaved parents. Regardless, they have heard that some parents experienced that the symbolic contents of the jewelry bag enabled them to get in touch with their emotions. They are at the same time aware that some of the nurses remove the jewelry bag before giving the box to the parents and interpret this as a sign of different preferences. Beth realizes in her own grief that good intentions from other people are not always easy to contain:

" ... I also know that things were said with a good intention. However, I just cannot take it. So I think we are at our most vulnerable state."

The members of the parent support group are aware of that what they perceive as support for bereaved parents is not always welcomed. Beth and Anne have for instance met parents in their private settings who neither wanted to receive a box nor photos of the dead infant. This reaction was unfamiliar to them, but they realize that not everyone wants the kind of grief care that is intended by the box.

#### *3.2. Showing Evidence of the Infant's Life and of the Parenthood*

#### 3.2.1. Bringing Infant and Parents Together

Some parents have a limited time to bond when the new-born infant dies shortly after birth. The nurses nevertheless try to encourage the bonding, and to personify the infant when writing in the scrapbook. Nurse Gina explains:

" ... I always mention the parents when writing, that mother and father have stayed with you a lot. Moreover, mother comes with her milk."

As the NICU is an unknown and unfamiliar setting for the parents, the nurses urge them to touch, to become acquainted with and to see their infants behind all the medical equipment. When the nurses realize that the infant is dying, they find it important to highlight that the parents had a relation to the infant, even if the infant's life was very short. Some parents are holding the infant the first time after it is dead. This may be the only moment the parents and infant share privately together. The nurses try to facilitate bonding in this situation. Nurse Pia underlines:

"To create a relation, so that the parents get a feeling that they bonded to the infant; afterwards; when they hold; that they are a family."

To capture the infant's look, photos are taken of the dead body from different angles. The scrapbook shows that the parents actually had some experiences with the infant, as nurse Fiona says:

"To show ... that there was an infant, which the parents can be acquainted with in a way, through the scrapbook. They may not be able to take photos themselves or describe what they lived through . . . "

The parents may find it hard to grasp that they actually had an infant. Knowing that they have the scrapbook with the memories may help the parents to realize what happened:

"You have a proof. You have something physical, not only an infant that disappeared." (Pia)

#### 3.2.2. It Is a Closure

When the infant is dead, the nurses finish the scrapbook. It is a last farewell to the infant and the parents. The nurses emphasized that it was important for them to write some greetings in the book. Gina says:

"It is a closure for me. Moreover, a start of the parents' sorrow, if it can help them start. In addition a summary over what happened."

When writing, they prefer to sit alone in a room, away from the ward and the noise. They regard the finishing of the book as their last act of care towards the infant and its family. Gina continues:

" ... a last act of caring that you are giving ... that you want it to be some words that are good to read afterwards."

The nurses realize that they are among the few people who knew the infant and sometimes they are very close to the parents. If an infant dies whom they have been involved with, they find it frustrating if they are unable to write some last words in the scrapbook. The nurses' memory making may not be finished when the parents leave the ward for the last time as the parents or other relatives often agree to come back and collect the memories. Linda underlines the importance of closure:

"I think they understand that we need to say goodbye. We have been a part of their life in the NICU."

*3.3. Controlling Chaos*

3.3.1. Contribute When Parents Are in Their Worst Crisis

The nurses as well as the members of the parent support group explain that they want to help parents getting through an existential crisis. The members of the parent support group hope that they can provide some practical help and comfort with the boxes. After Beth had lost an infant, she asked herself:

"Can I turn this into something good? Can I do something that will let others– they will not have less pain–may come through the experience in a better way?"

The members of the parent support group have experienced chaos following the loss of an infant. In this chaos they had to make a lot of choices, and experienced they did this on a poor basis. They had missed information about practical tasks, and about how they could make informed decisions about burial place, funeral ceremony, tombstone, etc. Anne explains further:

"I wish I had got a box with information and all the brochures. Because you fumble in the dark–where to start?"

In their view, it should not be random what bereaved parents are informed about. The parents, who live through a severe crisis, should be able to make choices based on balanced information. Charles stresses that the information needs to be the same to everybody:

"You never plan to bury your infant ... so in a way you get a choice: "You can do it in this way or that" and "this is allowed" ... that the information reaches everybody and that they get the same information."

The nurses understand that working with the scrapbook is part of their task and a way of caring for parents and infant. In addition to helping the parents, working with the scrapbooks and memory collection was a very meaningful task for them. Mona explains:

"You are doing a very important job in that situation, when you gather infant and parents and make memories. You feel that you are quite privileged ... that you are coming so close to someone that is in such a situation. Through making memories, you feel that you are doing a good job."

The nurses accentuate that when the infant's life was short, they were among the few people that knew the infant:

"The parents share their infant with us in a way." (Linda)

Writing the scrapbook and creating memories could be exhausting when the infant was seriously ill as they had many other duties in a hectic and critical situation. However, contributing when being among the few who knew the baby felt like an obligation.

#### 3.3.2. Is It a Ritual?

We are aware that it is our task as researchers to interpret the collected data material. However, we were curious about the participants' own reflections about what they are doing might mean, and thus asked them at the very end of the interviews whether they had ever thought that the work they do can be seen as some form of ritualization. Although most participants had not reflected on this previously, they seemed to reflect there and then on this way of understanding their acts. The nurses pointed at the intended function of the book to help bereaved parents with the transition from life to death, and with personifying the infant also for friends and family, and they underlined that the scrapbook was a way of making the infant visible:

"We take photos and create memories; so it has to be visible."

It also becomes evident that the closeness with the infant does something to the nurses, and that the work with the book makes sense also in their process of coming to terms with their own loss. Fiona and Gina point to the function the making of the scrapbooks have for themselves:

"It is our ritual". "It is something that we give to them. It is our ritual."

Some nurses saw some relations to more traditional rituals in broader society. Gina explains that the scrapbook can resemble a condolence protocol, and Olivia had asked the chaplain to write some words in the scrapbook. The parents appreciated the gesture as the same chaplain had baptized their infant. Mona sees some similarities with a condolence protocol, but does not think that the scrapbook as such is a condolence protocol:

"You write more personally than just condolence; it is something more."

The members of the parent support group hope that the box could help bereaved parents when they experience the transition from life to death, from hospital to home, and in the grieving process. They were aware that some parents do not use the box while others would put it in a visible place in the home. Whether the term ritualization could be used about the making of memory boxes, some participants were hesitant, as they were not sure about the content of the term and mixed it with the term sacrifice. Beth, on the other hand perceived the act of preparing boxes as some kind of ritualization, and picked up on something she had said earlier about the need for help in the transition from life to death, and also in making the unreal real:

"I mentioned the concreteness, to have something to show, to have something to talk about."

#### **4. Discussion**

"People know what they do, and they know why they do what they do, but they do not know what what they are doing does." (Foucault quoted in Bell 1992, p. 108).

A recent study indicates that rituals taking place in the NICU establish the human potentiality of the infant, as well as offer the bereaved parents' status as mother and father of the infant (Jørgensen et al. 2021). What are the functions of the ritualized acts performed by nurses and members of the parent support group in the course of an infant's death in the NICU referred to in this article? In the following, we will try to answer this question within the theoretical framework of rituals and ritualization.

#### *4.1. The Making of Scrapbooks and Boxes as Ritualized Acts*

In our interpretation, both healthcare professionals and members of the parent support group perform ritualized acts when they make the objects scrapbooks and boxes (cf. Grimes 1995, p. 28). In fact, they act as ritual experts when they invent the scrapbook and the box (Jørgensen et al. 2021). They have not been asked by their respective organizations to make these in the course of an infant's death in the NICU–they have invented these acts as they see a need for bereavement care (Thornton et al. 2019). However, the hospital setting enables nurses to develop such ritualized acts and give the members of the parent support group the opportunity to provide the hospital with a box to be handed out to parents when an infant dies in the NICU. In our interpretation, the making of scrapbooks and boxes are ritualized acts intended for bereaved parents, but they also carry meaning for the ones who perform these acts. As this study did not investigate how the scrapbooks and boxes were experienced on the receiving end, we can only suggest the intended meaning from the makers' side, and the meaning experienced for those who make the scrapbooks and boxes, respectively.

#### 4.1.1. Ritualization as a Way of Constructing Meaning for the Bereaved Parents

"Rites of passage are ways of embodying meaning [ ... ]" (Grimes 2000, p. 9). The task of a ritual is to acknowledge life-changing events, and to potentially transform the participants (Wojtkowiak 2018). In our material, it is our clear impression that the nurses and members of the parent support group regard their making of scrapbooks and boxes, respectively, as something which is urgently needed and which have the potential to make a difference for the bereaved parents: "Ritual and meaning-making processes are not causally driven but driven by the 'meaningful'" (Wojtkowiak 2018). In the interviews it became clear that the scrapbook and box have the intention of guiding the bereaved parents in the transitions they go through both as parents, and on behalf of their dead infant (Jørgensen et al. 2021). As the makers of these items through memory making "[ . . . ] form the body of the child into a person or human potential" (Jørgensen et al. 2021), this is intended to create meaning for the bereaved parents. In their ritualized act they are "[ ... ] cocreators of the ontological status of the child" (Jørgensen et al. 2021). In addition, they are cocreators of the social status of parenthood. This will be further elaborated on below.

#### 4.1.2. Is This Kind of Ritualization Related to Traditional Rituals in the Societal Setting?

The invention of new rites never happens in a vacuum: "Even if our desire is to create new rites of passage, we do so with the materials at hand, with the stuff of our cultures and traditions" (Grimes 2000, p. 4). As we interpret the findings within the theoretical framework of rituals and ritualization, a timely question is whether or not the act of making a scrapbook and a box reveals reference to any traditional rituals surrounding life and death? In the Norwegian context, there is no traditional birth or death ritual which directly underpins the practice of making a scrapbook and a box in the course of an infant's death. However, there exists a ritualized act in Norwegian society of placing a condolence protocol at a table outside a ceremonial room, or at another adequate site when significant people die, or when ordinary people die suddenly. In such cases the condolence protocol can be signed by all who are present. In the interviews, it was explained that after the death of an infant, also other than nurses may write in the scrapbook. The book seems to undergo a transition from being a diary of the infant's life written by the nurses, to becoming something similar to a condolence protocol where for instance the hospital chaplain can write a last greeting. When it comes to the box, the societal custom of placing the dead body in a coffin before the funeral can give associations to the small box. However, the members of the parent support group actively try to avoid this association by not providing the hospital with white boxes. Another association to a traditional ritual is Medieval Norwegian graves where archaeologists have excavated material objects placed together with the dead body. The box can give associations to this custom as belongings of the infant is put into the box. A difference though is that the box is not buried with the child but preserved by the bereaved parents. What is evident is that these new forms of ritualization presented here seem to negotiate with existing or traditional rituals in a complex way (Bell 1992; Wojtkowiak 2020).

#### *4.2. The Intended Function of the Ritualized Acts from Those Who Make the Scrapbook and Box*

What is the intended function of the scrapbooks and boxes? Although the ritualized acts from nurses and members of the parent support group interviewed here did not follow guidelines from the hospital or the national support group, their specific way of assisting bereaved parents and families with memories is also seen elsewhere: "The collection of mementos, such as photographs, personal items, clothing, of footprints, has also become common in practice and is recommended throughout perinatal and neonatal palliative care guidelines" (Thornton et al. 2019, p. 352). Studies have showed that the care strategy of collecting memories from the infant "[ ... ] is one of the principal interventions that have been developed to date" (Pueyo et al. 2021). Being provided with objects of significance allows the bereaved parents and siblings to still maintain a connection to the family member who is dead–in their processing of the loss (Levick et al. 2017; Pueyo et al. 2021).

Whether or not these intentions are achieved at the receiving end is not investigated in this project. However, the interviews revealed a feeling of ambiguity, both in nurses and members of the parent support group of making and collecting memories for bereaved parents (see Section 3.1.3). This shows an awareness of also potential negative outcomes of ritualization: "Rites can not only fail to achieve what they purport to do, they can also become a means of oppression, so we cannot afford to view them through a fuzzy, romanticized lens" (Grimes 2000, p. 7).

#### 4.2.1. Ritualization as a Way of Making Memories

Both the scrapbook and the box are regarded by nurses and members of the parent support group as ways of creating, collecting, and preserving memories about the lost infant. The loss of an infant transforms a "[ ... ] usually joyous life transition into pain and heartbreak" (Berry et al. 2021, p. 26). Both nurses and members of the parent support group describe the act they perform as having the meaning of making memories about the infant. The memory making is regarded an important part of bereavement care for the parents. As many parents feel unprepared to create mementoes with their infant, they need guidance through the process of making memories (Thornton et al. 2019). The reason why memory making is seen as important by the participants is not clearly defined in the interviews. However, it seems to be connected to the social integration of the new-born who is now dead into family and society (Thornton et al. 2019), and on a deeper level to give the child an ontological status as a human being, and not leaving the hospital empty-handed: "memories became fundamental as parents could take only these with them, not the baby they were expecting" (Thornton et al. 2019). By making memories of the child, the short life is given meaning (Levick et al. 2017), and the parents are intended to be helped in their processing of the loss. This is achieved through the collection of tangible items (Pueyo et al. 2021; Thornton et al. 2019). As already said, in the box there is space for clothes, blanket and other items which belonged to the child. The book contains photos, poems, documentation of what the infant has undergone medically, and texts written in second person singular. Together with hand and/or footprints, all this literally functions to show the footprint the infant made on earth. As both members of the parent support group and the nurses emphasize the need to make memories, this underlines that the liminal phase in which both infant and parents find themselves risk the danger of social invisibility (Jørgensen et al. 2021). To avoid this social invisibility, and to help parents and infant into their new statuses, memories are collected and preserved. The collected items also make it possible for people outside the closest family to get to know the new-born, its short life on earth, and the impression the baby left (Thornton et al. 2019, 2020).

#### 4.2.2. Ritualization as a Way of Personifying the Infant and Making Parenthood Real

When a child is born, parents and child undergo transitions: Parents grow into their new status as parents, and the child enters into family and society and gets the status of a new member of these settings (Wojtkowiak 2020; Jørgensen et al. 2021). When death occurs shortly after birth, the infant is deprived of this socialization process, and the parents' process of evolving into the status of parenthood is disturbed. Both parents and infant are left in a liminal state. As already said, the liminal phase is an ontological and socially insecure and unstable position to be in (Turner 1996, p. 511), and also a critical phase because it raises the question of whether one will be accepted and incorporated in the new state or not (Grimes 2000, p. 6; Jørgensen et al. 2021, p. 3). The infant is in a double liminality as both new-born and dead, and two transitions are thus needed—an integration into family and society, and an integration into "the land of the dead" (Jørgensen et al. 2021). As in other western secularized societies (Wojtkowiak 2018), also in Norway, informal and formal ritualized acts are performed to visualize that a newly born child belongs to something bigger than only the immediate family: people pay visits and give complements, they provide the baby with presents, and after some days, weeks or months baptism, name giving, or circumcision may occur (Wojtkowiak 2020). When an infant dies in the NICU, this transition into family and society is impossible to complete, and infant and parents are left in a liminal space.

In our interpretation, the ritualized acts from the nurses and members of the parent support group have several functions. First, the brochures and symbolic items included in the box document parenthood. Second, the way the scrapbook documents the infant's life through text and photos gives the infant the status of a human being belonging within family and society (Thornton et al. 2019). The documentation also "[ ... ] honors the relationship between the new-born and the family" (Thornton et al. 2019). In addition, the fact that somebody outside the closest family have seen the infant and made a relation with the child adds to giving the infant the status of a human being. The scrapbook and box together are intended to serve to personify the infant, to make parenthood visible and real, and function as an attempt to help parents with the integration into society at the same time as they leave the child among the dead.

#### 4.2.3. Ritualization as a Way of Making Order out of Chaos, and Making the Unreal Real

All human beings are aware that it belongs to the human condition that we all one day will die. However, parents who experience the loss of an infant are confronted with the unpredictability of life, and the shocking experience when death comes in proximity to birth and happens unexpectedly: "When birth brings death, it is a paradox, and dead new-borns are potentially very frightening—they remind us of the fragile boundary between life and death and disturb the cherished narrative of linear progress" (Jørgensen et al. 2021). In such a chaotic situation, it is difficult for the parents to take in what has happened, and from the focus groups interviews it is evident that the nurses function as guides along the road of making order out of chaos (Driver 2006, p. 136) and making the unreal real (Brottveit 2003). However, how do they help the parents to define and comprehend a human being who had a very short time on earth? As part of the nurses' status as ritual experts (Jørgensen et al. 2021), the interviews revealed that parents are intended to be helped when they experience uncertainty and fear about what they are allowed to do with the dead baby (Jørgensen et al. 2021). The members of the parent support group shared the feeling of not being at home in the hospital setting and at the same time going through a shocking experience when they lost their children. They regarded the healthcare professionals to be in the position of defining what is culturally accepted in this liminal situation. Through encouraging parents to bond with the dead baby, and through the making of the scrapbooks, the nurses intend to assist parents in taking in what has happened, give words to their experiences, and as such gradually assist the bereaved parents in making the unreal real.

#### *4.3. The Experienced Function of the Ritualized Acts for Those Who Make the Scrapbook and Box*

What function does the making of scrapbooks and boxes have for those who make them? "Rituals are by all means embodied enactments of meaning [ ... ]. What is more, rituals aesthetically translate reality into symbolic form" (Wojtkowiak 2020). Although Wojtkowiak here talks about rituals which are performed in a social, collective setting, much of the same is true for the acts referred to here and performed by nurses and members

of the parent support group. Traditional religious rituals have decreased in contemporary Western, secularized societies, and new ways of meaning making are enculturated (Wojtkowiak 2020). In our data material, it is evident that the need for ritualization becomes pressing when birth and death occur close in time, and "[t]hese new rituals are introduced by those who are at the center" (Wojtkowiak 2020). The ritualized acts are targeted towards the individuality and uniqueness of the dead infant (Wojtkowiak 2020). The book is made different from infant to infant, capturing the distinct circumstances around the individual. The sense of community around the ritualization discussed here–which is pertinent when traditional rituals are performed–is captured to some extent by the nurses as they all share the experience of losing an infant at the ward. The community side and social collaboration (Wojtkowiak 2018) is also imminent in the ritualized act from the members of the parent support group as they together fill the boxes with contents. Not having experienced appropriate bereavement care themselves (Thornton et al. 2020) make them eager to create something valuable for others.

#### 4.3.1. Ritualization as a Way of Constructing Meaning for Nurses and Members of the Parent Support Group

Neonatal care has over the years improved due to technological development. However, when death still occurs close to birth, what can help nurses and parents then? According to Grimes, "Technology without ritual (or worse, technology *as* ritual) easily degenerates into knowledge without respect. [ ... ] It matters greatly not only *that* we birth and die but *how* we birth and die" (Grimes 2000, p. 13, his emphases). In our interpretation, the ritualized act of making the book functions as a way of attempting to make meaning of what the nurses live through at work (cf. Levick et al. 2017), and to get in touch with "[ ... ] the rhythms of the human life course" (Grimes 2000, p. 3). The nurses establish a relation to the infant and the parents, and they go through a process of grief when an infant dies in the NICU (Gibson et al. 2018). This shared sorrow between parents and staff in the hospital becomes visible in the book, and the book functions as a place for collective healing between parents and nurses (cf. Levick et al. 2017).

For the members of the parent support group, the making of the box help them in their own re-working and digestion of their private loss and doing this together increases social cohesion (Wojtkowiak 2018). Through providing others in a similar situation with what they missed, they experience to perform a meaningful act to others, but also to themselves.

The quote which opened the discussion section deals with peoples' ritualized practices, and how they can be interpreted: "People know what they do and they know why they do what they do, but they do not know what what they are doing does" (Foucault quoted in Bell 1992, p. 108). In our interpretation, what they are doing are ritualized acts, and these acts do something to the bereaved parents, but also to themselves. Their invention of rituals surrounding an infant's death underlines that birth and death are major transitions in life, which require not only practical procedures and information, but ritualized actions. The birth and death of an infant is not only a private tragedy but is an event that is intimately interwoven with existential, social, and cultural webs of meanings (Wojtkowiak 2020; Prinds et al. 2019). The examples of ritualization studied here seems to be a necessity for the participants: "The grounds of ritualization as a human necessity are ecological, biogenetic, and psychosomatic. We cannot escape ritualization without escaping our own bodies and psyches and thus rhythms and structures that arise on their own" (Grimes 1995, p. 42). What the participants do (cf. Foucault) effects not only to the bereaved parents and themselves, but also to society's understanding of life and death.

4.3.2. Ritualization as a Way of Repairing the Loss, Relieving the Sorrow and Making a Closure

As the transition from life to death had no official ritual attached to it in the NICU, the ritualization was invented to attend to the major life events in an adequate way. Although not stated explicitly, this was perhaps done to avoid the state Grimes describes in the following quote: "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" (Grimes 2000, pp. 5–6).

As already mentioned, nurses can experience similar grief responses as family members, in addition to stress and physical and emotional exhaustion when infants they have cared for die (Gibson et al. 2018). That healthcare professionals are personally and professionally affected by their close relations to patients, is known also from other studies (Ådland et al. 2021). For the nurses in our interview material, we interpret the ritualized act of making the scrapbook as a way of digesting what they have experienced and witnessed (cf. Levick et al. 2017, p. 458). As nurses in the NICU are sometimes the only ones who have seen the infant awake, the only ones who have given the infant milk, and the only ones who have given the baby a bath–they have been responsible for holding the life in their hands and feel connected to the infant through this relation (Levick et al. 2017). Through the actual making of the scrapbook the nurses rework and process the suffering and sorrow they go through after having witnessed the death of an infant they had a relation to. In our interpretation, the ritualized act of making the book creates an "aesthetic distance" to the event, and "offers a contained way of expressing emotions" (Wojtkowiak 2018). Through this ritualized act they make a closure for the relation with the infant who died, and they try to enable themselves to move on to the next admission. Although the practices referred to here do not take place in an open, communal setting as rituals often do, the acts are still performed within a specific time and place, they have a concrete beginning and end, and this makes them a unique event every time the acts are performed (Wojtkowiak 2018).

For the members of the parent support group, much of the same applies. The loss of an infant is experienced as a traumatic and life-altering experience which affects them for the remainder of their lives (Berry et al. 2021). As perinatal loss experiences are often difficult to recognize for friends, family and colleagues (Berry et al. 2021), the members of the parent support group find solace in meeting one another in the group setting when they fill the boxes with contents. Through the making of the box, the members process their own loss, and feel a sense of relieve of the sorrow as they are in a space where their emotions and reactions are recognizable and contained.

#### **5. Conclusions**

The question of this article was: what are the functions of the ritualized acts performed by nurses and members of the parent support group in the course of an infant's death in the NICU? We have sought to answer this question within the theoretical framework of rituals and ritualization.

From the focus group interviews, it is evident that the ritualized acts have a dual function. First, the scrapbooks and boxes are intended to create memories, and to help the parents not to be stuck in the frightening unstable liminal phase, but to help them move over to a phase where their status as parents is confirmed, and the dead new-born is socially recognized. Second, the interviews made it clear that the ritualized acts of making scrapbooks and boxes have a function also for those who make them. These ritualized acts serve to help both nurses and members of the parent support group to construct meaning, repair the loss, relieve the sorrow and to make a closure, in other words: to digest what it means to have been in a relation to a human being who died.

#### **6. Recommendation for Practice and Future Research**

The making of scrapbooks after the death of an infant is, in our interpretation, a ritualized act invented by nurses in the NICU. The practice of making rituals when something is at stake has followed humankind throughout history (Danbolt and Stifoss-Hanssen 2017). Studies have showed that nurses experience personal grief after the death of an infant in the NICU (Gibson et al. 2018), and a recommendation for practice is thus to provide a framework in the NICU to help nurses interpret and understand what it means and takes to be exposed to death at work.

There is need for future research to evaluate how bereaved parents experience interventions after death in the NICU, such as those described here: a scrapbook and a box. This is important in order to provide bereaved parents with interventions designed in response to their needs and values (Thornton et al. 2019), and to avoid oppression and other negative outcomes (Grimes 2000, p. 7). More research is thus needed on how culture, religion, and spirituality influence parents' preferences for bereavement care (Thornton et al. 2019). Being sensitive to these areas is paramount in memory making practices as "cultural, religious, and spiritual practices are elements that are inherent to the grieving process and can constitute an effective coping mechanism in the event of a perinatal loss" (Pueyo et al. 2021).

**Author Contributions:** Conceptualization, I.E.V., A.B.G.J. and M.H.L.; methodology, I.E.V., A.B.G.J. and M.H.L.; validation, I.E.V., A.B.G.J. and M.H.L.; formal analysis, I.E.V., A.B.G.J. and M.H.L.; investigation, I.E.V., A.B.G.J. and M.H.L.; data curation, I.E.V., A.B.G.J. and M.H.L.; writing—original draft prepa-ra-tion, I.E.V.; writing—review and editing, I.E.V., A.B.G.J. and M.H.L.; funding acquisition, Stavanger University Hospital. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received funding from Pediatric research group, Stavanger University Hospital and Professional Relations in Health and Welfare, University in Stavanger.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Stavanger University Hospital (eProtocolnumber: 2358-2358 and date of approval).

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

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to confidentiality.

**Acknowledgments:** We are grateful to the participants who took part in this study. We would also like to thank the reviewers for their careful reading of the manuscript and their constructive remarks.

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

#### **References**


Driver, Tom F. 2006. *Liberating Rites: Understanding the Transformative Power of Ritual*. North Charleston: Booksurge.


Grimes, Ronald L. 1995. *Beginnings in Ritual Studies*. Columbia: University of South Carolina Press.


## *Article* **In between Birth and Death, Past and Future, the Self and the Others: An Anthropological Insight on Commemorative and Celebrative Tattoos in Central Italy**

**Federica Manfredi**

Institute of Social Sciences, University of Lisbon, 1600-189 Lisbon, Portugal; federicamanfredi@hotmail.fr

**Abstract:** European society has been described more than once as poor in shared rites of passage. The manipulation of skin seems to be an increasingly popular solution to fulfil perceived cultural gaps. Can contemporary tattoos be interpreted as tools of commemorating life events, especially in the occasion of births and deaths? This article analyses meanings associated with tattoos collected during two ethnographies in central Italy. Based on qualitative interviews and participant observation, the first fieldwork focuses on death-commemorative tattoos, while a 2020 (n)ethnography investigates birth-celebrative tattoos. Data confirm that the body is the mirror of the self and the skin works as the plastic stage where the embodiment of mourning and other emotions meets the social world. Tattoos are attempts of personalized spiritualities, where births and deaths become key-moments of existence that are elected pillars of the self. However, they are not (only) a private affair. This paper addresses the intersubjective valence of tattoos and their communicative purpose. In parallel with references related to both the self and the others, ethnographical data support an interpretation of tattoos as modern self-making strategies, applied to re-ordinate the past and to project a suitable self for the future.

**Keywords:** tattoo; body-modification; rite of passage; embodiment; identity; self-construction

#### **1. Introduction**

In an anthropological perspective, societies elaborate cultural models to face sensible changes in the life path of individuals. Rituals are collective moments of attention, providing perspectives and specific rules to think and process crucial passages which have been theorized by Arnold Van Gennep ([1909] 2012) in terms of rites of passage. The beginning of adulthood or gender identities are examples of thresholds traditionally recognized and generally corresponding to new rights and obligations (V. Turner [1967] 2001; Allovio 2014; Mead [1935] 2003; Busoni 2000; Forni et al. 2006), sometimes visualised with body-decorations or dress-codes that officially move the individual in a new stage of life noticed by the community.

Rites of passage have a collective matrix. Therefore, symbols and values connected to them are accessible by the other members of the group. For instance, as the work of Chiara Pussetti (2005) shows, the *ekentro* is chest-scarification performed by male Bijagó of the Guinea Bissau, and is an occasion to demonstrate courage and acceptance of the *manras*, the law, and all of the obligations related to the rules of the community. When a man can flaunt the *ekentro*, his community knows he has been initiated to new life phases that progressively allow him to access to marriage and exercise property's rights.

Anthropologists also started to look at everyday life activities in a ritual approach, such as taking a flight, riding the subway, or surfing (Pitt-Rivers 1986; Augé 2010; Nardini 2021), and exploring embodied methods of qualitative research, as performed by Loïc Wacquant with his fieldwork in a boxing gym in the North American city of Chicago. Sharing hours of sweaty training and painful blue ecchymosis have been interpreted as a

**Citation:** Manfredi, Federica. 2022. In between Birth and Death, Past and Future, the Self and the Others: An Anthropological Insight on Commemorative and Celebrative Tattoos in Central Italy. *Religions* 13: 46. https://doi.org/10.3390/ rel13010046

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 27 October 2021 Accepted: 15 December 2021 Published: 4 January 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

key ethnographical experience to access to the meanings of the gym culture, inaugurating what he called a *carnal* approach (Wacquant 2000).

Bodies work excellently to manifest cultural values, social status, or other messages readable by those who share a common cultural background and are aware of their meanings, as also confirmed by subcultural studies in reference to hairstyles or clothing (Hebdige 1979; Thornton 2013). Beyond a communicative purpose, rites involving body modification ontologically shape the individual and what is considered a proper human being, an adult, a marriable individual, or a legitimate progeny, depending on the purpose of the intervention. The Italian cultural anthropologist Francesco Remotti (1996), with the theory of the *anthropo-poiesis* (from the classic Greek *poiein*), highlights the fabrication of human beings through the intervention cultures. The constructionist process is particularly visible when rituals involve body manipulations that leave long-term marks on the skin. The humanity is not surrendered decisively: the biological incompleteness requires cultural interventions (Geertz 1998), moulding both the flesh and the cultural idea of personhood.

Rituals, and especially their meanings, are, therefore, (re)produced not only through traditional dances, songs, or coded succession of actions during ceremonies, but also on bodies. Body marks encapsulate selected experiences lived by the people who carry them, elected to be *enfleshed* (Sobchack 2004) according to the importance such episodes signify in the lifespan. They are transmitted across generations, with consequential effects on a person's sense of identity and affiliation to a group.

Facing dramatic life changes in a collective dimension offers the occasion to elaborate upon potentially upsetting events, breaking the fear of the unknown and the isolation of those that are more affected by the event. During funerals in Western societies1, for example, a traditional formula of condolences express closeness and empathy, letting a widower recognize the emotional support of these connections through symbols such as flowers and black cloths (Sozzi 2009). Death is debatably one of the most important and painful life-event individuals are called to face, and cultures have to provide tools to think and manage what occurred: the tragedy of a loss demands cultural strategies to "domesticate" death, turning the unknown in something more human (Gorer 1967).

Cultures try to heal from death, as noted by Ernesto De Martino (1958), re-incorporating sufferers into community social life with sets of rules, ceremonies, and other coded actions aiming to restore the order challenged by death. Sometimes even the online space can support the griever, as reported by Davide Sisto, who explored death announcements, anniversaries, and mourning on social media platforms such as Facebook (Sisto 2018).

Tattoos, piercings, implants, scarification, and other body modification performed in Europe and North America in contemporary time seems to similarly work as devices to manage crucial life changes, also defined as crises.

"Each transition tends to become an identity crisis ( ... ). The lifespan, in fact, is constructed in terms of the anticipated need to confront and resolve such crisis phases, at least where an individual's reflexive awareness is highly developed". (Giddens 1991, p. 148)

"The transformative power of tattoo is especially useful for individuals experiencing crisis in their lives. Women, especially, speak of situations involving domestic abuse, the breakup of primary relationships, or serious illness. These women see in the tattoo the power to handle such crisis". (DeMello 2000, pp. 166–67)

Beside an aesthetic valence, tattoos can safeguard personal meanings, such as memories of crucial events or meetings that an individual elects as pillar of the personality, or "knot of the existence" in Victor Sergio Ferreira's terms (Ferreira 2011). A sexual abuse, being fired, or a divorce have been defined as crucial changes which the individual can elaborate as being a defining moment in their life. The existential valance of body modification has been largely witnessed by social scientists (Le Breton [2003] 2005, Le Breton [1995] 2007; Sweetman 2000; Featherstone et al. 1991; Featherstone 2000; DeMello 2000; Fusaschi

2013), and their popularization inspired Carlos Trosman in indicating the human skin as the "cartography" of our relationship with the world (Trosman 2013).

But what happens when a society is poor of rites of passage? In other words, what happens when members of a group do not possess cultural tools (or tools perceived as appropriated) in order to think, deal and process crucial life changes? Are body modifications attempts to re-place cultural gaps to elaborate important episodes?

Modern times are characterized by an increasing interest of social researchers on personalized, new, or intime rites of passage, especially in Western societies. They are usually connected to a supposed lack or inefficiency of traditional and collective rituals: they do not fulfil the purpose of supporter in the transition of the liminality (V. Turner [1967] 2001) and a consequential raising of individualistic "do-it-yourself" rituals have been noticed (Segalen [1998] 2002; Le Breton 2005; Han 2021). For instance, Brenda Mathijssen describes contemporary tattoos in the Netherlands: they are created by mixing the ink with the ashes from the cremation of a relative, an emotional process to elaborate the mourning (Mathijssen 2017) seen as an extreme attempt of embodiment of the departed person that is not learnt from the parent generation. The initiative is not inscribable in the set of the local traditions, challenging researchers to theorize new tanks or sources for modern intime rituals.

Questioning the balance in between subjectivity and communal body projects, tattoos and tattooing have been analysed focusing on their transformative capacity (Kloss 2020), highlighting traces of the technique in different cultures and historical times (Castellani 1995). The diffusion of tattoos did not prevent a stigmatisation of bearers (Caplan 2000; Kosut 2006), showing heterogeneous significations, from deviancy to art-piece. In the case of the memorial tattoo, it is interpreted as *embodied grief* by the research team of the Tattoo Project, a qualitative investigation involving the creation of an online archive of visual material as complementary method (Davidson 2017). Tattoos are visual representations of the change in bearer's identity, also defined as "adjustment" in reference to their valance as emotional supporter in processing the loss.

According to Bryan S. Turner (2000) body marks as tattoos have significative differences when they are realized in post-modern or traditional societies. In his approach, the latter are characterized by thick internal relationships marked by solidarity, while western tattoos would have been transformed in *cold* societies due to urbanization and industrialization, with weak emotional connections among members. The classification is an ideal-typical exercise. It evokes the nostalgic memory of the myth of the 'noble savage', where the Others are idealized and primitivized in a post-colonial approach as an example of a better version of humanity. On the other hand, modernity becomes a corrupter of citizens who regret their past, still visible looking at the Others. This approach implies a way to think of cultures as on a scale of development, rejecting multiple paths of evolution. Post-modern individuals are defined as post-emotional by Turner, and tattoos are limited to cosmetic purposes, superficial decorations on marketable bodies, and far removed from meanings of solidarity or emotional connections that are indicative of the tattoos of traditional societies.

Taking distance from a romanticization of times and emotional scale to look at societies, the present article presents a reflection on Western tattoos interpreted as intersubjective devices able to represent, (re)produce, and visualize relationships in emotional terms, going beyond an ego-centric, post-emotional, or superficial approach of body marks. This is especially evident in the case of death and birth tattoos, corresponding to personalized rites of passage where symbols arbitrarily chosen and the events are embodied. Body signs are not alternative strategies to create a contact with spirituality: they coexist with traditional forms of religiosity enhancing the agency of the individual in commemorating what deserves to be re-marked.

The analysis is based on the examinations of two sets of data originated by two fieldwork experiences that have been developed in the same geographical area but on different occasions. Both research projects adopted a qualitative approach, based especially on qualitative semi-structured interviews to a similar sample of selected informers, diversified in terms of gender, academic qualification, and social origin, and comparable for the purpose of the present reflection.

#### **2. Between the Self and the Others**

Almost a decade ago, this author explored meanings associated to commemorative tattoos in central Italy (Manfredi 2015), interviewing a sample of 12 men and women, aged between 22 and 56 years old who were joined by the decision to tattoo an image explicitly dedicated to a deceased loved one. Qualitative semi-structured interviews were conducted face-to-face, along with 18 sessions of participative observation in four tattoostudios in the Rome district from April 2011 to September 2012. Tattooists were included as selected informers, especially in reference to their professional experience as creators of commemorative tattoos. They were the only people wearing protective masks, in a pre-COVID time. In this paper, I will re-address that ethnographical data, dedicating special attention to the social dimensions of commemorative tattoos which emerged after the second ethnographic experience that the next session will explore.

The initial research showed that tattoos were interpretable as attempts to elaborate the tragedy of death: the images included the desire to express and to socialize the loss. The bodywork is more than cosmetic decoration: it is the attempt to process the pain of the loss, creating a permanent space ready to share memories about the dead person, as Carlo's episode is going to highlight.

Carlo is the fictionalized name2 of a father who lost his daughter in early 2000. He decided to get a tattoo of her portrait on his internal forearm, with the upper side of the image close to his elbow and the lower one near the wrist. When I met him, I was surprised by the position of the portrait since I could perfectly admire it standing in front of the man, while he had an up-side-down vision.

*I decided to get this tattoo a few months after the funeral, and it's the first and only one I have. I do not have other tattoos although I have a lot of friends who had tattoos during the army or for Totti [football player]. I do not want other tattoos, especially now: she is the only thing that matters. Any other topic or image would be useless compared to this. My wife did not tattoo herself like me, she hates needles. But we are very different people. Maybe I needed this tattoo and the pain that came with* ... *I don't know. This part of the body is nice because it is exposed and immediately visible. I see it [the tattoo] every day, I see her every day, and everyone can see it. She is always here, with me, looking at me and being here. When someone asks me about the tattoo, it's like if she was close to me while I talk... I can see her when she was playing at the park or when we were walking in the street, holding her hand in mine. You know, people say we never leave our beloved until we hold them in our heart and talking about my daughter is a way to keep her memory alive. My wife was upset when I decided to get the tattoo, she was not happy at all. Seeing her face all the time, you know, it's hard for a mother, even if we have pictures of her all around at home. Anyway, she was worried I could stay too attached in the dark, you know the painful part of thinking about her.* Interview with Carlo, May 2012

Carlo's tattoo became a break in the taboo of death (Gorer 1967; Davidson 2017), offering him the occasion to talk and socialize private memories of his daughter. The remotion of death in Western societies is a phenomenon that has been analysed by several scholars (Ariès 1985; Thomas 1991; Baudrillard 1993; Sozzi 2014), underlining the paucity and the progressive disappearance of collective rituals that were supposed to guide in mourning.

The tattoo appears as Carlo's strategy to evade from the silence, an attempt to insert the private pain in a collective dimension. Even if a traditional funeral took place for the girl, it was not enough. To be supported in the loss, he decided to realize the daughter's portrait a few months later. The decision was not shared by the mother of the girl, but Carlo's signified the pain of the tattooing as an instrument of a sensitive plan to process his emotions. The action was not finalized to forget, on the contrary: the embodiment aimed to process the pain of the loss, bringing it in the social dimension through something Carlo never left: his forearm.

The presence of the memorial tattoos, something that is tactile and visual for the individual, is counterposed with the absence of the dead person (Kloss 2020), indicating a valence of the body sign as a continuity bond between the bearer and the person who was passed away (Davidson 2017). Nevertheless, griever and dead person are not the only actors involved. The position of the tattoo, oriented to a frontal observer, highlights the social purpose of the bodywork, addressed to the other people connected to Carlo's life. He preferred to sacrifice his point of view, the eye-perspective on his own arm, to privilege the onlookers of the tattoo. In other words, the tattoo project included an estimation of the perception of the mark besides the bearer, thinking about its impact on a public, as every social performance must do (V. Turner [1986] 1993).

Terence Turner coined the expression *social skin* (T. S. Turner 1980) to emphasize the intersubjective valence of body marks and the penetration of the social structure in the individual through the embodiment of cultural value. Even if the scholar refers to the Kayapò of Brazil, the terminology applies to Carlo's tattoo since the skin is confirmed as "the symbolic stage upon which the drama of socialization is enacted" (ibid., p. 112). If the author recognizes the influence of the community in body-signs among Kayapòs, the central Italy research offered the occasion to note the need of the community behind images that the individual decided to realize on the skin.

If some interlocutors showed large portions of skin dedicated to memorial tattoos (Figure 1), with names, date, and portraits that have a more explicit commemorative purpose, others interviewees chose to be tattooed with butterflies and stars that an outsider can easily interpret as general decorations. The bearer is in charge to decide what and how much to share about the meaning of his mark: "Sometimes I just say that the butterfly is for my love of nature, or because I like the bugs. Only if I am in the mood I start to talk about my father, but sometimes I just say that it is for a special person, not even mentioning his death", as Adelia said caressing her blue mark (Figure 2).

**Figure 1.** Chest commemorative tattoo. Picture by the author.

**Figure 2.** Adelia's commemorative tattoo. Picture on courtesy of the interviewee.

The tattooed symbol, in virtue of the polysemic valence of images, can be adapted to different self-narratives according to the audience, the emotional state of the tattooed person or the social occasion, just to mention a few variables. The privacy of a loss can also be safe-guarded choosing a body's part generally covered by clothes, as Riccardo and Francesca stated. The siblings tattooed the same image in the memory of their mother, a verse of a poem that the woman was used to tell them during childhood, and they both positioned the tattoos on their left ribs, close to the heart, since ... "We didn't want to have it always under the eyes or to have to explain it to everyone". Additional to memorial meaning, Riccardo and Francesca signified the two identical marks as a visual representation of the brotherhood, even stronger with the orphanage.

Commemorative tattoos do not only have a communicative purpose: they ontologically mould the person who carries them. Following the anthropo-poietical perspective, the tattooed people (re)produces themselves, electing the death of the beloved ones as knot of their existence, as one of the major events of the life that shaped who they are. The body is hence confirmed as the mirror of the self, and modifications correspond to intentions in the production of a specific desired self (Shilling 1993; Giddens 1991). The individual addresses his corporality as a project able to host actions directed to define who they want to be, in a constructionist and individualist approach.

In Carlo's case, the commemorative tattoo celebrates not only his daughter and the pain of her death, but also Carlo himself, as a mourning father. The departure of a close person causes grief not only for the separation from the dead, but also because a portion of ourself dies too. When a beloved person passes away, we must separate also from the part of our identity that we experienced in the relationship. In this sense each mourning corresponds to a double separation to emotionally deal with and commemorative tattoos are linked to both: the one who left this world and the self who fights to survive, linking them despite the imposed separation. Creating a memorial tattoo can hence be interpreted as an act aiming to anchor the self against the aftermaths of a dramatic event.

The post-modern identity has been examined as a process in continuous construction (Baumann 1999; Giddens 1991), a responsibility of the individuals who need to constantly perform the best version of themselves as authentic, unique, competitive, and possibly young, beautiful, and healthy (Jarrin and Pussetti 2021). The identity is a product influenced by the values of the society where we live, those that we learnt in the family context and during the lifespan. Therefore, several factors shape how a person perceives themself, including the specific effort people dedicate towards how they are perceived by others. In this sense, it's interesting to remember Carlo's tattoo position, explicitly oriented to his interlocutors: he presents himself through the image of his departed daughter, being the forearm a well visible body part for much of the year in the warm weather of Central Italy.

Commemorative tattoos do not inform only about a person who died, but also narrate about the individual who survives and about how the person aims to be perceived, in relation to that particular life-event. The identity is a process involving others as much as the individual; a commemorative tattoo is a performance acted on the social skin to construct an identity facet deeply influenced by the selected episode. The collective and individual dimensions are so deeply connected in commemorative tattoos, where multiple selves try to be combined, saved, and processed.

#### **3. Between the Life and Death**

In 2020, the occasion to re-examine findings related to commemorative tattoos arrived. A relevant portion of new contacts, met during my ongoing doctoral project, mentioned body-marks dedicated to both mourning episodes and new births. The doctoral project "Learning to Fly", in course of development at the Institute of Social Sciences at the University of Lisbon, investigates body suspensions in Europe: the social practice involves the insertion of metal hooks in the skin as temporary piercing; hooks are connected to ropes and to an above scaffolding, and (pulling the main rope) a person is elevated for as long as wished.

Body suspension practitioners are extensively modified with a wide range of techniques, highlighting the continuity of suspensions with other forms of body manipulations, especially tattoos. Preliminary results show that suspensions are inserted in a life-long path where bodies are approached as an identity's map, where each mark is connected to a relevant episode that the person recognizes as influence in the making of the self. In other words, the body intervention celebrates the arbitrary selection of a moment, or a meeting, as crucial for the definition of the personality in a self-reflexive perspective (Giddens 1991).

During interviews exploring meanings related to body suspensions, research-partners were used to narrate their life story, caressing their tattoos as emotional switches able to re-activate intimate memories: many skin-signs were dedicated to the death of important people, relatives, or friends, while tattoos connected to children were not rare for those who were parents.

At the beginning of the pandemic, when Italy was just at the end of the first lockdown to contain COVID-19's spread in 2020, I extended my doctoral sample exploring meanings of birth-tattoos performed by people not extensively modified; the aim was to create a pole of comparison for the data collected among body suspension practitioners. This article's session focuses on findings originated by the mentioned segment of the doctoral fieldwork, from May 2020 to the summer of the same year, in a comparative exercise with findings on commemorative death tattoos previously presented.

Members of the two samples have in common the geographical localization (the Rome district), the age-range, and being clients of the same tattoo-studios. The presence of tattoos on their bodies is not extended as suspension practitioners and are not located on the face or hands, resulting in body-marks that can be covered by clothing.

Due to lockdown conditions, many of the research-settings characterizing the former research were not repeatable, such as the participative observation. I maintained the qualitative methodology with semi-structured interviews, this time mainly performed by phone and text-messages, with a few of face-to-face interviews in late 2020. The sample of four men and six women was recruited from a Facebook group of parents based in the town where the former research was conducted and with a snowball effect. I posted a call for interviewees in the bulletin board (Figure 3) informing about the purpose of the research, presenting myself as mother and anthropologist, and providing following details for informed consent in the first contacts we had in private, usually through the platform of Messenger. A group of 22 people reacted to the call, mainly with private messages that migrated from the group discussion. Excluded people did not correspond to the criteria of the study or they withdrew their availability during the research, while other selected informers have been recruited from personal contacts.

**Figure 3.** Post from Facebook's group recruiting interviewees3.

The ethical choices related to the online investigation correspond to those adopted in the doctoral research, and they have been positively valued by the Ethics Board of the Institute of Social Sciences of the University of Lisbon.

The purpose of the study was to investigate if tattoos were suitable tools to celebrate life events usually defined as opposite to death—the births—and if similar meanings and characters were involved, compared to commemorative tattoos. Curiously, data showed that those who realized tattoos to celebrate the birth of their children had commemorative tattoos too, as in the case of Isabella, a schoolteacher in her early 30s. She decided to tattoo the name of her son on her wrist as soon as the breast-feeding was concluded. This precaution was not motivated by local regulations, but Isabella was concerned for possible allergic reactions or skin infections that would require antibiotic treatments or other medicament assumptions that could compromise breast-feeding. Another source of concern was the contraction of blood infections, a sufficient motivation to wait few extra months before arranging the tattoo appointment.

The decision to celebrate a baby's arrival with a tattoo has often been narrated as a desire started during the pregnancy, especially in case of parents with one or two antecedent tattoos. The long-term project, elaborated during the baby's gestation and the breastfeeding, shows that the decision is not impulsive and requires, on the contrary, a long period of premeditation. Investigating the existence and meanings of Isabella's previous tattoos, she mentioned a first one when she turned 18 years old, with a decorative purpose that probably today she would not do again. The second tattoo, the one preceding the celebrative one, was instead dedicated to the voluntary interruption of a pregnancy she experienced seven years before.

*"It's on one of my feet, little and discreet. I did it when I voluntary interrupted a pregnancy that I was not able to face. It was voluntary but it was a sufferance anyway. It was a very difficult moment, but I had to do that. I did not want to forget that moment, even if it was very painful, and so I decided to make this tattoo. When I went to the tattooist, I was accompanied by a person who didn't know the meaning of the tattoo. It was important for me to be with someone, but I was not ready to share all the emotions behind that mark. There are very few people who still know about it today".* Interview with Isabella, May 2020

Isabella recognises in the tattoo a difficult decision she had to take, but also her capacity to survive the emotions connected to the abortion. Even if unpleasant, the episode is embodied, engraved in the memory and in the flesh, and the permanence of the mark subtracts the episode from the obliviousness of the time. Death and birth find their space and co-exist in Isabella's body, as well as in the story of her life. Both are perceived as key-moments of her lifespan; they are experiences defining who she is today.

Paul Sweetman notices that body-marks can be understood as strategy to anchor the self (Sweetman 2000), or to stabilize how the person perceives themself: the identity is not a fixed entity but something incessantly in motion and influenced by meetings, conversations, and discoveries we made or, more generally, by our experiences. Every day, we are a little different from who we were yesterday, and Antony Giddens, inspired by Bourdieu's studies (Bourdieu 1995), writes about the exigence of the individuals in highlighting the continuity of the self-versions through time to maintain a sense of continuity (Giddens 1991). Francesco Remotti evidenced efforts made to construct immutable identities, also named as "identity obsessions" (Remotti 2010), exasperated during dictatorships or when the definition of a common enemy was based on the counter-position of national or racial based identities.

The concept of crisis can hence be extended and reflexively applied to any event perceived as connected to the sense of identity, including positive changes, such as births or life-lessons, and occasions of personal growth.

"A 'crisis' exists whenever activities concerned with important goals in the life of an individual or a collectivity suddenly appear inadequate". (Giddens 1991, p. 186)

#### **4. Between Past and Future**

Stabilizing the self with a tattoo can be analysed as a strategy to deal with the precariousness of human life, a reaction against the precarity of living in a *liquid society* (Baumann 1999). The action, even if a palliative solution, relieves from the incessant flow of events characterizing life and it creates a safe-port that will persist independently of future new changes. A baby's birth deserves to be positively celebrated as a fundamental life change. Sometimes the body project is performed by the parents together, with the same image or selecting the same body part for the mark, similarly to what Riccardo and Francesca did when the mother passed away.

Stefano and his wife are the parents of a little boy and they both have tattoos celebrating his arrival, but with different images and positions. Despite differences in body marks, they both feel that the tattoo of the partner is connected to themselves since they share the parenting experience. Whilst the mother preferred the shoulder, the father chose that the entire forearm would be the suitable place for the name of the son in italic (Figure 4). The writing is decorated with rolling dice since: "It was my best lucky-strike", as Stefano said. The couple want to have more children and Stefano is already planning a second tattoo on the left forearm when a little sister or brother arrives.

**Figure 4.** Celebrative birth-tattoo. Picture on courtesy of the interviewee.

*"He is the best thing I did in my life, the biggest joy I experience every day except the love for his mother. I feel I'm really a lucky man and the tattoo reminds me that, every time that I need it".* Interview with Stefano, June 2020

The parents do not self-define as "proper people of church", as they assert, since "we do not attend the Mass every single Sunday morning, but we try to do our best to be good people" (from fieldwork notes, June 2020). In this sense they signify the choice to organize the Christian ceremony for the sacrament of the baptism in the first year of life of their child. After the religious rite, the parents organized a party inviting all family members. The celebrative tattoos are not linked as connected to the religious ceremony, neither an alternative strategy to fulfil the entrance of the baby in his community. They are a personal and intimate act of devotion to mark a life episode that was perceived as exceptional and life changing, probably more connected to the person who carries the tattoos rather than to the child.

The tattoo is a celebration of a new life, that of the baby, but also a praise for the beginning of a new life section for Stefano: the paternity. The tattoo tells the story to those who want to hear that: Stefano, his wife and all of the people that will look at his arm in the future. Several audiences are hence involved. As noted by Jerome Bruner (2015), the self-construction is a process that is developed through the narration and research findings demonstrating that tattoos work in this direction. The storytelling can be an opportunity to create order, to overcome a crisis since it organizes the past, stabilizing versions of the self in accordance with the present one and those of the future. The individuals directly create themselves, portraying the episodes that shaped them, moulding the flesh as direct evidence of their influence. The operation is an arbitrary selection in balance between the memory and the imagination for the wished self that, in the reported case of study, involves the paternity.

Birth-tattoos, as death-ones, are connected to the exigence to remember and experience the meaning of the body mark in everyday life, not necessarily in a private way. As Stefano said, the tattoo functions to *remind*, or to anchor a facet of the identity potentially destabilized by the flow of the time. The ink under the skin saves the event and the self who experienced it, protecting them. The meaning is safeguarded in the future of the person, especially the awareness of them, and the skin acquires the responsibility to maintain such progression in the personal life-journey. The pain is not signified in cathartic ways as it was for commemorative tattoos; in a few cases the painful process for the creation of the tattoo was expressed as the demonstration of the commitment for being a good parent for the baby, a proof of dedication, but generally it did not host relevant meanings.

The position of birth-tattoos is variable but ethnographical data shows that the choice of visible body parts is connected to projects of socialization of tattoo's meanings, similarly to findings exposed for commemorative body-marks. The hair stylist Laura had her two children when she was 21 and 25 years old, and today each one has a tattoo dedicated on her skin; she chooses the images of two Disney characters, which correspond to the theme of the baptism she organized. At the time of the interview, she was pregnant and was already planning the topic and the position for the next birth-tattoo of her upcoming third child. Before those marks, she embodied other important relationships related to two members of her family, tattooing the initial latter of her husband's name and a little butterfly when her mother was in coma. Laura's tattoos are all realized on her feet or the internal-upper part of her arms, since: "I can easily cover them when I work, but they are also well visible when I'm at the beach or when I can informally dress myself, when I am with my friends and I can show the tattoos without worries" (Interview with Laura, April 2020).

Preoccupations concerning the exposition of tattoos to selected audiences are connected to preventive strategies to face stigmatization processes (Kosut 2006), as well as the indication that not anyone is able to have publicly visible tattoos, or share its meaning. More than one version of the self needs to be promoted, both the proud mother and the professional. The latter would be compromised with visible tattoos. Therefore, the decision to be tattooed, as well as the dimension and the position of the marks, are aspects involved in the projects of the corporality and on plans of enhancement of the self toward the community where the social actor lives.

When I asked Laura why she got her tattoos, she did not fully understand: "They are a clear expression of my joy in being a parent, don't you see?". The expression of emotions, especially the pride of parenting, was a common trait in data collected. Elisa's case was an exception: she always wanted a tattoo, but she never felt sure enough about an image to think she would never stop to love to have it on her body for the rest of her life. This thought changed when her little girl was born.

*"Elisa: I was so worried I would get tired! I always wanted a tattoo, but every subject gave me the idea to be something ephemeral, that I would regret after a while. Years ago, I had an appointment in a tattoo-studio but then I had to postpone, and then the tattoo artist didn't show up, so I took it as a sign of bad-luck, and I gave up. Then Aurora was born, and I understood that was the good moment. She is a love that I can't get tired. Her name is simply perfect!*

*Ethnographer: But this tattoo is more for her or for you?*

*Elisa: I never thought about it, but I believe it is for me. I spent years thinking about a good subject to tattoo and then she gave something so deep and immortal, deserving an indelible mark on my skin. Even my father has a tattoo about my daughter, but he is a tattoo-addicted [laughs]. He loves his grandchild and beside the tattoo he demonstrates it in a thousand of ways".* Interview with Elisa, July 2020

Elisa's tattoo is dedicated to her child but in a different way from those previously exposed: the realization is based on a decorative interest and the experience of parenting legitimizes the irreversibility of the mark. Elisa's assumption is based on a social construction of parenting that romanticized maternity as a never-ending love (Badinter 2012; D'Amelia 2005), so a solid concept that can protect the tattooed subjects against Elisa's loss of conviction. Additionally, if carrying a tattoo can be a controversial choice since of risks of stigmatizations, a mark connected to a socially unblamed role guarantees more tolerance compared to tattoos which were chosen for solely their aesthetic purpose since they are perceived as superficial. The love of a parent for a new born and the pain of a griever are licit subjects elevating the person who carries them and enhancing the body performativity in a logic of excellence (Pussetti 2021).

#### **5. Conclusions**

This article exposed reflections on contemporary tattoos related to birth and death episodes, analysed in terms of intimate and self-centred acts, going beyond an aestheticdecorative perception. The embodiment of relationships characterizes the meaning that the individual connects to the body-marks, offering the occasion to reflect on the skin as *social stage* (T. S. Turner 1980). The presence of the Others, and the intersubjective dimension, is taken into account in the strategies of positioning tattoos, as well as the desire to socialize the experiences and emotions that the individual symbolizes with the body-sign, operating on the continuity of the bond with the dead person and with social connections still around them. In a reflexive approach, the skin and its modifications are the tools enhancing the individual and their social performativity through the body, being tattoos as public demonstrations of the acceptance of legitimate emotions or new roles.

The body is constructed through the incision of the skin and the self, resulting in a product confirming the entrepreneurship of the self (Foucault 2005) in front of specific audiences: the body is subject of long-term investments, in a life-long commitment to self-development and respecting the logic of excellence. The projectivity of each mark is extended beyond the bearer's skin and, in this sense, the collective and the individual dimensions are co-existing in meanings attributed to tattoos.

Ethnographical data supports an interpretation of contemporary tattoos investigated in Central Italy as strategies of self-narration: the body-sign stabilizes a life episode signified as crucial for the development of the person, namely a mourning or the birth of a child. Tattooing is an act that freezes time, the relationship with the subject-person but also the individual itself against the continuous flow of events. At the same time, the act projects

a suitable self in the future, revealing the constructionist process constituting it and the power, responsibility, and importance of individual choices in producing a specific form of self.

Finally, the comparative exercise in between two ethnographic experiences dedicated to the exploration of birth-celebrative and death-commemorative tattoos, revealed the complementation of personal rites of passage and traditional religious ceremonies, as well as a connected perception of new lives and deaths.

**Funding:** This article originates from the doctoral project "Learning to Fly. A Trans-spatial Ethnography on Body Suspensions in Europe", supported by the European Social Found (ESF) and the Portuguese Foundação para a Ciência e a Tecnologia (FCT grant SFRH/BD/131914/2017). The research is also inscribed in the project «EXCEL—The Pursuit of Excellence. Biotechnologies, enhancement and body capital in Portugal», that received funding from the Foundação para a Ciência e a Tecnologia (grant agreement nº PTDC/SOC-ANT/30572/2017), coordinated at the Instituto de Ciências Sociais da Universidade de Lisboa by PI Chiara Pussetti.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Acknowledgments:** This article was enriched by suggestions of peer-reviewers and academic editors, the support of the Religions editorial team and the English revision of Gina Mann. I extend my gratitude as well to research partners who cooperated during the fieldwork, in particular to Håvve Fjell, for the kind concession to letting me use "Learning to fly" as title of my doctoral dissertation.

**Conflicts of Interest:** The authors declare no conflict of interest and the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

#### **Notes**


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## *Article* **"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**

**Lynne McIntyre \*, Bruna Alvarez and Diana Marre**

Department of Social and Cultural Anthropology, Autonomous University of Barcelona, 08193 Barcelona, Spain; mariabruna.alvarez@uab.cat (B.A.); diana.marre@uab.cat (D.M.)

**\*** Correspondence: lynne.mcintyre@uab.cat

**Abstract:** 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.

**Keywords:** ritual; rite of passage; personhood; motherhood; pregnancy loss; miscarriage; stillbirth; abortion

#### **1. 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

**Citation:** McIntyre, Lynne, Bruna Alvarez, and Diana Marre. 2022. "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. *Religions* 13: 336. https://doi.org/10.3390/ rel13040336

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 15 February 2022 Accepted: 15 March 2022 Published: 9 April 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

their pregnancy as a child, nor do they ask if the embryo or fetus has a name, or if the patient considers herself their mother. Despite this, our research indicates that women in Catalonia are using ritual and other embodied practices to confront and process prenatal loss. Moreover, they are doing so without any established cultural script and often in the presence of active resistance to such practices. Women in Catalonia appear to be devising ways to personify the entity they have been gestating and claim the role of mother, even if they have no other living children. They are enacting rituals that are in some cases brandnew, in others traditional to their culture or borrowed from another, and they are engaging in embodied practices that materially demonstrate to themselves, their families, friends, communities, and society, that something happened, that someone was here, and now they are not, and that matters. Essentially, these women are engaging in ritual and embodied practice at the precise moment when the two most important life events, birth and death, occur simultaneously. In so doing, they are individually and collectively breaking centuries of silence around a subject that has been at turns too common, or too shameful, to be considered worthy of being shared.

#### **2. 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 [1909] 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 [1912] 1968; Leach 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.

#### **3. 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).

#### **4. Ritual and Prenatal Loss**

#### *4.1. 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.

#### *4.2. 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.

#### *4.3. 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.

#### **5. 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.


**Table 1.** Descriptive Statistics.

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.

#### **6. Results and Discussion**

#### *6.1. 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.

#### 6.2.2. 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.

#### 6.2.3. 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.

#### 6.2.4. 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).

#### 6.3.2. 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] 1968; Douglas 1966; Stephenson 2015).

#### 6.3.3. 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).

#### 6.3.4. 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.

#### 6.3.5. 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.

#### 6.3.6. 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).

#### **7. 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 [1909] 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.

**Author Contributions:** Conceptualization, L.M., B.A. and D.M.; methodology, L.M. and D.M.; formal analysis, L.M. and D.M.; investigation, L.M.; data curation, L.M. and D.M.; writing—original draft preparation, L.M.; writing—review and editing, L.M., B.A. and D.M.; supervision, B.A. and D.M.; funding acquisition, B.A. and D.M. All authors have read and agreed to the published version of the manuscript.

**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.

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## *Article* **Ritualizing Abortion: A Qualitative Study on Ritual and Its Meanings in The Netherlands**

**Kiki Biel 1,\*, Arjan W. Braam 2,3,\* and Joanna Wojtkowiak 3,\***


**Abstract:** The present study investigates ritualizing abortion in the Netherlands. Explorative, qualitative research was conducted with semi-structured interviews (n = 13) with women who looked for counseling and 43 online personal stories about the abortion from the website of a national care and expertise center. The results reveal three main categories of ritualizing: (1) creating and using symbols privately and online, (2) remembering or honoring the experience and (3) embodied ritualizing. The data reveal that respondents find meaning in the ritualizing through sharing the experience with others, expressing various feelings through symbolic and ritual forms, fostering a connection with the child-to-be, showing respect, seeking closure and transforming the experience in a meaningful way. This research reveals types of ritualizing practices in relation to a meaningful life event such as abortion. For a specific group of women experiencing decision difficulty or existential concerns in relation to the abortion, ritualizing might be an interesting tool to be incorporated into post-abortion care practices.

**Keywords:** ritualizing; abortion; qualitative research; The Netherlands

#### **1. Introduction**

While rituals are often associated with tradition and institutionalized religion, there is increasing attention paid towards the active form of ritualizing, referring to the reinvention and redesigning of rituals (Bell 1999; Grimes 2002, 2014). Ritualizing often happens in the margins, is not an established form of ritual and is seen as a way of processing life events characterized by ambiguity (Driver 1997; Grimes 2002; Romanoff and Terenzio 1998). Ritualizing is observed, for instance, when ritual elements are added to the ritual (e.g., clapping during a funeral or choosing a personal symbol for the mourning card) or when an entire ritual is redesigned (e.g., silent or protest march after acts of violence). Ritualizing does not necessarily refer to a "complete" ritual or a ceremony with a clear beginning and end but fits more into intuitive, imaginative, material and embodied dynamics with ritual and ritual-like activities. Ritualizing offers an interesting lens to study lived, embodied religiosity and spirituality (McGuire 2008), as rituals are embodied, active ways of focusing attention on an experience, without "solving" the underlying question of meaning (Moore and Myerhoff 1977).

Abortion is, in the Netherlands, a legal, private life event, which is generally not ritualized. In Japan, for instance, mizuko kuyõ, a ritual for the aborted fetus, is chosen by approximately 15–20% of women after abortion (Grimes 2002, p. 310; Klass and Heath 1996; Yamagata-Montoya 2021). The ritual is embedded into the cultural and spiritual traditions in Japan (Yamagata-Montoya 2021). While in most Western contexts, abortion rituals are not common, in a Swedish study, almost half of the women felt the need to ritualize the abortion experience, such as doing "something special" (Stålhandske et al. 2012, p. 59) or

**Citation:** Biel, Kiki, Arjan W. Braam, and Joanna Wojtkowiak. 2022. Ritualizing Abortion: A Qualitative Study on Ritual and Its Meanings in The Netherlands. *Religions* 13: 592. https://doi.org/10.3390/ rel13070592

Academic Editors: Martin Hoondert and Denise Starkey

Received: 13 December 2021 Accepted: 14 June 2022 Published: 25 June 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

"to mark the abortion as an event, end the process, become reconciled with the situation, let off steam, or ask for forgiveness" (Stålhandske et al. 2012, p. 59). While most women feel relief after the abortion and decision rightness afterwards (Brauer et al. 2019; Rocca et al. 2020) and do not show long-term psychiatric symptoms (van Ditzhuijzen et al. 2018), ritualizing might offer meaningful ways to put one's emotions into symbolic form before and after the abortion (Stalhandske 2009; Stalhandske et al. 2011a, 2011b). There is a group who experiences decision difficulty, which might be related to questions of meaning, such as "struggling between head and heart" and how women view the abortion (Brauer et al. 2019, p. 1987; Halldén et al. 2005, 2009). The decision making in this group takes a bit longer and is more complex, but finally, the group of women who were experiencing decision difficulty do feel satisfied with the decision (Brauer et al. 2019). What is more, in processes of meaning making, different emotions (e.g., gratitude and sadness) can occur at the same time, as meaning making is a complex, multilayered and ambiguous process (Wojtkowiak 2018). Ritualizing offers an interesting study lens to analyze how women cope with abortion.

In this article, we want to study the notion of ritualizing in more detail by focusing on a specific sample of women in the Netherlands who have sought counseling during the abortion process and have contacted a national expertise center. The aim is to investigate what role ritualizing plays after abortion. The present study addresses the research question: What kind of ritualizing after abortion can be found, and what meanings are ascribed to the ritualizing? The question will be answered by explorative, empirical research with women who have experienced abortion and who have sought counseling and/or were looking for some ritual closure. This means that the sample is by no means representative of all women who experience abortion but specifically focuses on women who experienced some existential concerns or need in relation to the abortion and who dealt with the experience in a symbolic and ritual way. It is not our intention to judge or stigmatize the experience in any way but rather to explore and investigate what rituals have to offer when dealing with embodied life events, such as abortion.

#### **2. Methods**

#### *2.1. Population and Sampling*

The research population consisted of women who contacted Fiom1, which is the Dutch center of care and expertise in unintended pregnancy. Fiom is not religiously affiliated and states as its mission that "every woman being unintendedly pregnant must be able to make an informed choice that is in line with her life, values and future." Fiom provides information and counseling in the decision-making process and after the abortion. The women in this sample sought some form of care or platform to share their experiences. The sample existed of three subsamples: (1) eleven interviews with women who participated in an online abortion care module in 2016, (2) two interviews with women who participated in a womb healing ritual, and (3) 43 personal accounts posted anonymously by women on the website of Fiom. Three different subsamples were chosen due to the exploratory character of this research. As there is little research on ritualizing abortion in Western societies, it was not known beforehand if the women who were contacted through Fiom were likely to ritualize their experience.

The three subsamples were collected in different ways (see Table 1). The respondents in Subsample 1 were recruited through an invitation e-mail to 163 women having participated in an online abortion care module developed by Fiom. The online abortion care module is developed to help women who experience psychosocial concerns after the abortion (e.g., sadness, anger or feelings of emptiness). Women participating in the online module write assignments and receive feedback from professional abortion care specialists. It is worth noting that the module contains a writing assignment asking questions about symbolic ways of saying goodbye and therefore encourages women to ritualize. The respondents in Subsample 2 were invited through a ritual counselor who organizes womb healing rituals. The aim of this ritual is to heal painful experiences in relation to womanhood. Finally, Subsample 3 consisted of 43 personal accounts about the abortion that were selected from the databank of 158 accounts uploaded on the Fiom website, stemming from 2013 to 2018.


**Table 1.** Types of data.

Subsamples 1 and 2 included women aged eighteen to sixty-three, with diverse educational backgrounds and life orientations. Eleven women had a first-trimester abortion, and two women had a second-trimester abortion. Respondents2 were asked about their life orientation during the interviews, as this information is relevant to the study of rituals. Most of them did not fit one religious or spiritual category but described themselves as searching in matters of life orientation. A majority mentioned their dislike of dogmatic moral values. Two respondents came from a strict protestant and two from devoted catholic backgrounds. All four had stopped going to church on a regular basis but still practiced religious rituals, such as lighting candles on significant occasions. About two-thirds of the respondents had an interest in spirituality. Some practiced yoga or meditation. Three of these respondents had interests in paranormal manifestations, modern witchery or shamanism. About one-third of the respondents said to have a "no-nonsense" ("nuchter" in Dutch) mentality in spiritual matters and described their outlook on life in terms of humanist moral values. Some had a partner and/or children. Most of the interviews took place within a few months after the abortion. Some respondents had had contact with mental health care specialists following the abortion care module. The women in Subsamples 1 and 2 all had a Dutch background.

Subsample 3, the online personal accounts, does not allow a complete description of social backgrounds. In some accounts, references to age, education, family situation, mental state, spirituality, gestational age or time lapse between the abortion and publishing the account were found. In general, the women seemed younger and more often following some sort of education. Some women mentioned having other children. In two personal accounts, women wrote about suffering, respectively, from AD(H)D and depression. Four women referred to their religious faith (three Islamic and one Christian). There were more references to first-trimester abortions but also a few to second-trimester abortions. The time frame between the abortion and writing the personal account seemed to vary from a few days to more than ten years.

Eleven of the thirteen interview respondents (Subsamples 1 + 2) expressed that the choice for abortion was the best choice in the given situation. One woman explicitly stated regretting her abortion. In Subsample 3, 9 women out of the 43 accounts selected for this study stated regretting their decision about the abortion. Frequently, women spoke of the choice for abortion in terms of an internal conflict of emotion and rationality or " head" and "hart". Rationally the choice for abortion was the right choice, but on the emotional side, there were also feelings of attachment to the embryo/fetus or to the idea of becoming a mother. Reasons for abortion mentioned were missing support, financial problems, care for other children, physical violence, psychological problems, other life plans, not wanting children and feeling unprepared.

Women also had diverse feelings and representations of the embryo or fetus. In line with ambiguous feelings about the pregnancy, they also had complex feelings towards the "peanut/life/child/heap of cells/soul/pea" inside of them. Some women, for example, were sure that the aborted fetus had not been a child but still struggled with the responsibility of having stopped the process of growing it into a child, wondering how it would have been.

The sample is thus not representative of all women undergoing abortion but specifically those who seek out help, counseling or some ritual closure. The aim of this research is not to give a representative analysis of all abortion experiences but rather to specifically focus on those possibly having existential concerns and seeking some form of ritualizing.

#### *2.2. Data Collection and Analysis*

The interviews lasted between 60 and 120 min (mean = 95 min) and were conducted in the home of the respondents or on location at Fiom. Most of the respondents mentioned during or after the interview that sharing their stories was not easy for them and that they needed to be sure that their stories would be treated anonymously. The interviewer paid great attention to informing respondents about the research procedure, especially ways to guarantee anonymous data processing and to create a safe environment for the conversation. One respondent asked the researchers not to publish quotes from her story in the research report. All respondents signed an informed consent form.

During the interviews, a topic list was used to investigate possible ritualizing. After a section on the abortion experience, the perception of the potential child and existential concerns, respondents were asked whether they had enacted some symbolic or ritual processing or had felt the need to. They were asked to describe their ritualizing experiments, how they had experienced them and whether they had intentions or expectations in relation to the ritual.

The interviews (Subsamples 1 and 2) were transcribed verbatim and uploaded together with the personal accounts (Subsample 3) in the qualitative data analysis and research software Atlas.ti. Consequently, the data were read and coded by deductive and inductive coding, which, respectively, refers to coding from theory and intuitive coding from the data (Boeije 2005; Corbin and Strauss 2008). In the first round, the interview subsamples were deductively coded, using pre-established codes from a provisionary code list. In the second inductive coding round, the data were reread several times in order to find forms and meanings of ritualizing that emerged from the data. These were added to the code list. This list was used to analyze the personal accounts. The abortion stories were not included in the first two rounds because it was initially hard to recognize concepts of ritualizing in them.

Ritualizing was coded in the data on the basis of the following inclusion criteria: (1) the description refers to an active form/action, (2) it includes a symbolic element that translates the experience, and (3) it includes at least two ritual elements as described by Grimes (2014), such as ritual actions, ritual actors, ritual places, ritual times, ritual objects, ritual languages and ritual groups. When, for example, a woman kept the image of the ultrasound, put it in a special box in her room and looked at it on the due date, we counted a ritual actor (the woman), a ritual act (safe-keeping), a ritual object (the ultrasound image), a ritual place (the box) and a ritual time (the due date). Two elements were chosen as minimum because ritual actor "alone" does not count as a ritual, and there needs to be at least some ritual action involved (Grimes 2014). Quotes about the intentions and needs of women related to their ritualizing and about its outcomes were coded to analyze possible ritual meanings. In this round, the elements of ritualizing and meanings were sorted into three main categories that will be discussed in the following section.

#### **3. Results**

Three main categories were found that summarize the various forms of ritualizing: (1) creating and sharing symbolic expressions privately and online, (2) remembering or honoring the experience and (3) specific embodied ways of ritualizing. These categories are not exclusive and show considerable overlap but were chosen to reveal the central aspect of the ritualizing. In Table 2, the main categories and examples of these categories' meanings are listed. In the result section below, quotes stemming from the interviews

(Subsamples 1 and 2) are referred to by R1, R2, R3, etc., while quotes from the personal accounts (Subsample 3) are referred to by 1/2016, 2/2017, etc., indicating the year in the Fiom database from which they were collected.

**Table 2.** Types of ritualizing abortion and ritual meanings.


#### *3.1. Creating and Sharing Symbolic Expressions*

The most common way of ritualizing was creating and using various symbolic expressions. Some of these symbolic expressions are shared in public, digital space (the website of Fiom), while others remain private.

#### 3.1.1. Privately Acknowledging through Symbolic Expression

Research participants ritualized in private ways, such as giving a name to the imagined child or using creative expression (drawings or collages). Some women engaged in internal conversations with an imagined child-to-be (more than thirty times). One important aspect of this is to imagine the child-to-be in a symbolic way as an angel, butterfly, star or flower.

*It is now a little star in the sky, or a butterfly, or an angel on my shoulder, or something like that. That's how I see Jonas.* (R6)

Research participants also addressed the potential child, internally or spoken out loud, and often transmitted messages. After the abortion, some women had internal images of the potential child, even seeing it growing up. Frequently women connected these images to a form of reincarnation or paradise or experienced the presence of the potential child in their lives.

*My daughter says many times: 'That is my little sister'. And then she gestures towards the chair. And that is fantasy. But she does that since a few months; suddenly she speaks about her little sister (* ... *) 'Does your little sister want to eat with us?'. I join her in her*

#### *play thinking it is fantasy. But it keeps crossing my mind: could it work like that, is that possible?* (R1)

Related to these efforts to continue, the bond was the gesture of giving a name to the potential child. About one-fourth of the research participants named the potential child. This could be a name that could be given to a baby or a more symbolic name, as in the following citation:

#### *Hope, that is what I called you.* (5/2013)

Name giving occurred during pregnancy or after the abortion. Among those who came up with a name, some did this intentionally, hoping for it to have a healing effect on their coping process. Frequently, they chose a boy's or a girl's name in accordance with their intuitive feeling about the sex of the child-to-be. Some women gave a name together with their partner and used the name in their communication about it. However, there were research participants who explicitly mentioned not wanting to name the potential child for diverse reasons.

Furthermore, it is worth noting that some women acknowledged their experiences in artistic ways. In the online personal accounts, this showed mostly in poems. The interview respondents also spoke about expressing their feelings in drawings, collages, videos and even more complex art projects.

Other ways of symbolically acknowledging the abortion experience were found in the use of symbols that the research participants discovered during the broader abortion process that they found appealing or helpful. One woman chose to have her abortion in a clinic next to the sea because she associated her experience with the ebb and flow of the ocean and liked the thought that she symbolically gave her child to the sea. Another woman felt a strong connection with the logo of the clinic, a magnolia blossom. Searching for and retaining symbols from music lyrics occurred as well:

*I had to wait for the abortion lying down in a bed and listened to 'Kiss from a rose' from Seal. That was the last song we were able to listen to together. And it was so right. 'You became the light on the dark side of me.' After that I was called to the operation room.* (10/2016)

A final way of symbolizing the experience found was that of caring for a pet as a symbolic substitute for the child-to-be. One respondent did this in a dedicated way. She described how she adopted a kitten and adapted all the rituals that are usually respected with child delivery. She made a birth card, sent it to family and friends and invited them to visit. A few friends and relatives did so and brought presents. Another woman adopted a pup. She experienced the coming of this new family member as a fresh start after hard times.

Ritualizing with forms of imagining, naming, addressing and symbolically substituting the child-to-be possibly mean that women need to connect and foster connections with the potential child. Seventeen quotes in the online personal accounts showed this fostering of connection. Affirmations of love and longing were frequently found.

*Her name would be Jip, and dear Jip, I love you.* (3/2016)

*My unborn child is called Butterfly and I see her every day in my sleeping room. I have a frame with a butterfly in it. When I smoke a cigarette outdoors, I look at the sky and choose the most beautiful star. That is my Butterfly. Even if I never met you* ... *I love you & I shall never forget you. In my heart I take you along with me until we hopefully see each other again.* (1/2016)

In the interviews, research participants mentioned eleven times how they seek to foster connection with the potential child through ritualizing.

*And I don't believe that it just stops here. I believe that there is another side, another life, how must I explain it? (* ... *) We burn a candle to show that we did not forget. That we still think about it.* (R3)

In both public and private ritualizing, the ritual enabled women to express diverse feelings. For most of the research participants, the abortion appeared to be a complex experience. The intense and often ambiguous feelings were difficult to understand, let alone be shared sufficiently with other people. Ritualizing can in that case offer a space where these women can express feelings and help them to process the experience.

Some research participants also tried to connect to the potential child to express their remorse:

*From time to time I think about it and then I address that child mentally: 'I am sorry that I took your life, because you were there'. I've seen it with my own eyes huh. That is awful, yes.* (R8)

Affirmations of love and longing for the potential child should not be assimilated with regretting the abortion, as the following quote clearly shows:

*I don't regret my decision, I am still firmly convinced that it was the best thing to do for all of us. But regret is not necessary to feel pain (* ... *) But the pain will have a place in my life, just as you. We have to move on, we can't linger on. I need to enjoy carefree life and fulfill my dreams, for you. (* ... *) I would have loved to meet you, dear little one. But it could not be. I love you, and I will. Take care.* (1/2015)

3.1.2. Sharing One's Personal Story with Symbolic Expressions Online

The selected online accounts revealed the same symbolic expressions that are discussed in private ritualizing, with the additional dimension that these symbols and symbolic actions were also shared in an online community on the Fiom website. Various symbolic elements were found, such as poems or letters to the imagined child, symbols of significant aspects of the experience and forms of imagining the potential child. Two interview respondents published symbolic accounts of their experiences too.

The online personal accounts also contained a few examples of honoring or embodying rituals, but the focus lies here mainly on the aspect of sharing symbolic expressions in written form, as this relates to the medium of the personal story.

The following poem was published by one of the interview respondents on the web. It shows an aesthetic translation of the ambiguous feeling of loss as a result of the conscious choice for abortion.

*You knew you had to choose But actually had no choice Had to lose a piece of yourself So small, is now a gaping hole* (R1)

By publishing symbolized accounts of the experience, research participants found ways to share their stories outside of the private environment. However, the personal stories are published anonymously, remaining a private layer within these public accounts. All here selected online accounts, the blogs and published poems were social acknowledgments of the ritualizing, as they were shared in an online community. They were expressions of the need to share and bring the abortion experience up for discussion. Sometimes these publications were meant to sensitize and educate the public by sharing the feelings and considerations behind an abortion experience, as the following quote shows:

*Look, if only one person thinks 'ah, so it is not that simple', then that is already something.* (R1)

In other cases, research participants stated wanting to break the taboo that lies in talking about abortion:

*And then I started to write for myself. And at a certain moment, I thought maybe I have to publish it online, break through. I had read on the Fiom website that there are 30,000 a year (* ... *). I felt this taboo must be broken, I have to do something about it. I want to do something because I want to help others as well and we have to be able to talk about this.* (R3)

By sharing their stories, the research participants also created a network of support: *Dear ladies please ask for help on time. Nobody deserves to feel like this. You are not alone!* (9/2016)

In the online accounts, advice and support for others frequently occurred in addition to showing others that they are not alone. Both women who participated in the *womb healing* ritual especially appreciated the connection they felt to other women in the same situation. The community aspect of online sharing seems of importance to those who want to publish their stories online.

#### *3.2. Rituals of Remembering and Honoring*

Many research participants expressed the need to "do something" to remember and honor the potential child-to-be and/or the abortion experience with its ambiguous meanings, such as keeping meaningful objects as a reminder and in many cases giving them a special place. Of all 56 research participants, 22 (personal accounts and interviews) kept the image of the ultrasound made before the abortion. Most of these women asked for it in the clinic. Others were asked by a medical professional if they wanted to have it or just simply had received it from the staff:

*I was allowed to look at the ultrasound and saw a real little wonder. We took the image home and since then I keep it in my purse. It is a part of me and that's why I carry it with me.* (4/2014)

Most of these women kept the image in a meaningful place and looked at it on special occasions. Some interview respondents spoke about their "memory box": a nice box where they kept the ultrasound image together with other objects reminding them of the pregnancy or the potential child, such as the positive pregnancy test, drawings of the potential child, letters and cards from friends. In the following quote, a woman described how she experienced creating a memory box.

*- Can you tell me something about how you arranged that box? How was it to do that?*

*- It was less bad than I expected. I expected that I would do it in tears and so. But actually it was peaceful and quiet. Sort of, I give you a place to be.* (R6)

Another way of remembering or honoring the abortion experience that women used, was to mark symbolic data by paying special attention to certain dates relating to the pregnancy and abortion. For some women, this was the date of the abortion, and for others, the due date or the date they discovered that they were pregnant. Of the 56 research participants, 15 underlined that these dates had a special meaning to them. These dates were also frequently chosen for their ritual actions. For some, choosing the day had a specific symbolic meaning as shown in the following citation:

*I really wanted to do something, and I wanted to celebrate life, because I experienced it that way. The pregnancy was also some kind of sign and confirmation of my body, that manifested to me, do not worry, you can become pregnant (* ... *) That is why I didn't celebrate or commemorate on the day of the abortion, but on the due date.* (R9)

Some rituals of remembering or honoring are examples of more complex ritualizing. Nine women described how they invented rituals to honor and remember what had been. One interview respondent recounted how she sang and offered white flowers into a lake on a yearly basis. Sometimes women were joined by their partners who participated in the ritual. One respondent went to the beach with her partner, and, together, they released a balloon with a wish for the child-to-be. Together with their partners, two others developed the habit of burning candles and making wishes for the potential child, in churches or at home.

A final and specific way of honoring that was found was that of burying the embryo. In the following quote, an interview respondent described her burying ritual:

*My mama had a white stone shaped like a star. We buried it together in the flowerbed in the garden, and the white star lays there, on top of it.* (R8)

When it comes to the meaning of the honoring rituals, different aspects were mentioned. One of them was showing respect for the existence of the embryo/fetus or child-to-be:

*I made those photos and had them printed (* ... *) and also that stick that shows that I am pregnant. Those kinds of things I kept, they make me think that it really existed (* ... *) so the memory, but also to honor it, that it had really been.* (R9)

Two respondents explicitly mentioned that they experienced their rituals as celebrations for the pregnancy.

*I wanted to celebrate the birthday. Weird, huh? (* ... *) On the day that I was due, I invited all my friends for dinner. And I wrote a letter to thank them for their support.* (R7)

*It is gone and it is hard, and I feel guilty (silence). No, I want to ponder on the positive side (* ... *) That gives me a warm feeling and makes me feel like a mother (laughs) and then I can connect to how I want to be a mother (* ... *) and what I like about life. Yes.* (R9)

Research participants also expressed feelings of appreciation or gratitude for the support they received. One woman described how she read a letter to her friends:

*I wrote down mostly that I was really grateful for them, and how I experienced that period and that I am processing it all now. And that it will probably take some time. But also that I am so grateful for the support they've been back then.* (R7)

Another possible meaning of honoring the experience is establishing closure.

*That is what I experienced as the most difficult task. How can you say farewell to something you've never seen?* (R3)

Some research participants expressed a need for closure. This need was expressed through ritualizing and put into words. In the personal account below, a woman narrated how she burned the stick showing the positive test result and a letter to her potential child that helped her to move on with her life.

*And there I stood. Crying, watching how my letter and the test faded slowly. Only after the last burning flames I went inside again. It was weird. But I felt relief. This had been a nice farewell. After that I felt a little better every week and I was able to put up the thread of my life again. With the three of us, but nevertheless very happy.* (4/2017)

Abortion also brought up the realization of not wanting to have children at all. One woman described her emotional response to the closure she experienced in relation to her abortion during the womb healing ceremony:

*And there were heaps of emotion during the ceremony. That was some kind of farewell, some kind of grief for a part of yourself or a kind of life that will not be realized.* (R13)

#### *3.3. Embodied Ritualizing*

Abortion is a physical intervention with an impact on the body. Some research participants were searching for ways to involve their bodies in the rituals they came up with. A frequent form of embodied ritualizing was getting a tattoo with a symbolic meaning. The tattoo is a painful but aesthetic way of marking the body and a way of showing visibly the transition women went through. Four of the thirteen interviewed women took a tattoo after their abortion, and in the personal accounts, this form of ritualizing was mentioned once. Two other women considered the possibility of getting a tattoo but decided against it to avoid questions about its meaning. In the following quote, one woman described how the tattoo symbolizing the abortion experience had become a symbol of mental strength to her:

*That's what this tattoo stands for. (* ... *) When I look at it, when life is hard, then I think, if I made it through the abortion, then I can do this as well, you know.* (R6)

Another way of ritualizing in an embodied way was to wear jewels with a symbolic link to the experience. Two interview respondents and one woman in her personal account discussed receiving or choosing necklaces or bracelets that symbolize some aspect of their experience.

*I got a necklace as a present. I wear it every day. (* ... *) I got it from my mother on the 20th of august, the day that I was due. (* ... *) I didn't take it off for one day, since then.* (R7)

A few women described how they ritualized the abortion in a directly physical way. Two interview respondents had participated in a *womb healing* ritual, which is not necessarily aimed at abortion experiences but at the female body more generally. In this ritual, women are led into a guided meditation to mentally and emotionally explore their womb and to consider with self-compassion what they experience. Other physical forms of ritualizing found were the touch of the belly or the conscious attempt to sense the potential child in one's womb before the abortion. In the following quote, a woman described how she experienced a pregnancy massage as a farewell ritual:

*- They really gave me a pregnancy massage. I lay down on my side, and they treated all the spots where you experience backpain in pregnancy. It was good too.*

*- And how was that? To receive such a massage, the day before?*

*- I don't know. Maybe, our moment together. I enjoyed it too, you know.* (R7)

The embodied ritualizing contained many references towards transforming the experience. This might translate the need of research participants to integrate the abortion experience into their lives. Through this specific womb healing, ritually transforming the experience, women emphasized the positive aspects of the abortion experience, such as their appraisal of the experience of being pregnant or the support they received but also the personal growth they experienced through getting to know themselves and their desires and goals in life.

For some research participants, transforming the experience meant better self-care. The pondering over and carefully choosing a nice bracelet became for this woman a symbol of self-compassion and new chances for happiness in life:

*It goes through my head a lot these last weeks. (* ... *) Allowing myself to move on and that jewel (* ... *) That is very symbolic. I don't know why I keep thinking about that, but that is what I want really badly.* (R10)

Next to transformation, there was also evidence of a sense of healing. Some women discuss recognizing the abortion as an event with an impact on the body. Both women who participated in the womb healing ritual gave this meaning a central role. They characterize the abortion as a physical intervention that asks for healing on a mind–body level. According to them, this cannot happen through cognitive coping such as talking or rituals such as writing letters. The embodied component is necessary here to heal one's body and mind.

*Something has been removed in an aggressive way. I felt that there is something that really needs healing. And that has more impact than you would think sometimes. Because I usually think: no remorse.* (R13)

These women talked about their rational attitude towards the abortion: they wanted it, it was their right, and it was just a small beginning of life. However, on the level of their bodies, that had invested in feeding and letting the embryo grow, they still experienced an impact.

#### **4. Discussion**

The present study gives insight into the diversity of ritualizing after abortion in the Netherlands. It must be made clear that the data analyzed here represent a specific group of research participants who actively sought counseling and needed ritualizing. This research is not a representation of all abortion experiences. The examples of ritualizing found here reveal ambiguous feelings. Ambiguity does not mean regret or dissatisfaction with the decision. Only 1 respondent in the interviews and 9 of the 43 online stories mentioned regretting the decision. Many women expressed that they made the right decision but experienced feelings of mourning or loss of a potential child they had wanted under other circumstances. Many research participants also stated feeling gratitude for the chances they received by choosing abortion, such as study, work, opportunities for personal growth or relationships, travel or taking proper care of their children.

The ambiguity that many women experienced might also be related to the fact that many of them were still searching in matters of life orientations, tentatively believing in "something between heaven and earth", the existence of souls or concepts such as fate or reincarnation. Ritualizing, and especially the form of fostering a connection to the childto-be, as well as the aspect of honoring, might be an expression of their need to explore these beliefs and to experiment by integrating them into their lives. At the same time, ritualizing can evoke certain spiritual feelings, such as a connection with a transcendent notion. In general, this study does not allow theorizing about the link between spirituality and ritualizing. The variety in life orientations in Subsamples 1 and 2 shows that women with different outlooks on life might be inclined to ritualize.

While for some research participants in this sample, sharing their personal stories in the public space was important, others preferred to privately ritualize the abortion (e.g., celebrating specific dates and keeping memorial objects). In both cases, symbolic, creative or aesthetic translations were found and ritually enacted, such as using keepsakes, imaginative conversations with the potential child or writing down letters. Finally, the more "literal" embodied ritualizing, such as taking a tattoo or participating in the womb healing, shows more complex ritual meanings that seem to refer to ritual transformation. The ritual meanings are, again, not related to regret but a need to pay special attention to one's body after the abortion and to mark the event as meaningful. The ritualizing found here shows a symbolic and ritualistic negotiation of one's own narrative and body. The meanings of the womb healing ceremony differ from the Japanese *mizuko kuyo¯* in the sense that the "Dutch" ritual focuses on the woman's body and the processes involved, while the rituals in Japan focus more on the fetus and the relationship with its "mother" and, in the past, have added to the normalization of abortion in Japan (see Yamagata-Montoya 2021).

Ritualizing the abortion experience seems a fitting way to deal with this life event in a secular context such as the Netherlands, at least for some, as ritualizing is a new, explorative way of giving attention and marking significant experiences. In ritual, various meanings are accepted and expressed in the chosen symbols and symbolic language, as symbols communicate more than one meaning at the same time (Cupchik 2002; Moore and Myerhoff 1977; Scheff 1977; Wojtkowiak 2018). Symbolic figures were used in addressing or describing the fetus, for instance, angels, stars or butterflies. All these symbols have beautiful attributes and, at the same time, are out of reach, far away or of short existence. Even the two mentioned pets became "liminal beings" in the sense that they were associated with human-like or child-like characteristics and treated as such (e.g., birth card for pet).

Some of the ritual and symbolic expressions found here show striking similarities with other life events, such as grief after stillbirth and grief interventions more generally (Manfredi 2022; Romanoff and Terenzio 1998; Wojtkowiak et al. 2021). The use of tattoos and the symbols used here (star, butterfly), as well as keeping the bond with the imagined child, has been repeatedly found in other research on grief (see, for instance, Manfredi (2022)). While the ritualizing reveals sad, difficult emotions (such as loss and guilt), it also reveals positive emotions (during and after the ritualizing), as well as relief afterwards. Our study is in line with previous research, showing that images about the fetus influence how the abortion experience is interpreted. Imagining the fetus as a child can lead to temporal feelings of loss, but generally, afterwards, the abortion is not considered an experience of loss (Brauer et al. 2019; Stålhandske et al. 2012).

Ritual and ritualizing seem to offer interesting forms of materializing and representing abortion (Hurst 2021), which might be useful in abortion (after) care for those who are looking for meaningful ways to address the experience. While the women in this sample sought counseling and ways to find closure, the ritualizing stimulated positive emotions as well. It must be made clear that these ritualizing forms arose within a specific sample and cannot be generalized to all abortions. Our study is small and not representative, as the interview data result from a sample of women who looked for counseling, and Fiom offers care where various emotions are addressed, and a symbolic and ritual approach is given as an example. Ritual and ritualizing might be meaningful to specific women, while others might appreciate a neutral care approach.

More research is needed on private and public forms of ritualizing, as well as how ritualizing is related to decision difficulty and rightness. The social and cultural context needs also to be considered in abortion studies. The Netherlands is a liberal, secularized country, where abortion is legal and ritualizing also occurs in other domains, such as spiritual care, collective commemorations and funerals, which might partially explain the openness towards new ritual and spiritual practices found in this sample. We hope that this explorative study contributes to our understanding of embodied spirituality in ritualizing life events, such as abortion.

**Author Contributions:** Conceptualization, K.B., A.W.B. and J.W.; Data curation, K.B.; Formal analysis, K.B., A.W.B. and J.W.; Investigation, K.B. and A.W.B.; Methodology, K.B., A.W.B. and J.W.; Project administration, K.B.; Resources, K.B.; Software, K.B.; Supervision, A.W.B.; Validation, K.B., A.W.B. and J.W.; Visualization, K.B. and J.W.; Writing—original draft, K.B. and J.W.; Writing—review & editing, K.B., A.W.B. and J.W. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Ethical review and approval were waived for this study due to close collaboration with certified professionals in the field and written informed consent obtained from all interview respondents.

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

**Data Availability Standards:** Data available on request due to restrictions, e.g., privacy or ethical. The data presented in this study are available on request from the corresponding author. The data are not publicly available due to the concern of keeping respondents' anonymity.

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

#### **Notes**


#### **References**

Bell, Catherine. 1999. *Ritual. Perpectives and Dimensions*. Oxford: Oxford University Press. Boeije, Hennie. 2005. *Analyseren in Kwalitatief Onderzoek: Denken en doen*. Amsterdam: Boom Lemma Uitgevers. Brauer, Marieke, Jenneke van Ditzhuijzen, Hennie Boeije, and Carolus van Nijnatten. 2019. Understanding Decision-Making and

Decision Difficulty in Women with an Unintended Pregnancy in the Netherlands. *Qualitative Health Research* 29: 1084–95. [CrossRef] [PubMed]


Driver, Tom F. 1997. *Liberating Rites: Understanding the Transformative Power of Ritual*. Oxfordshire: Routledge.

Grimes, Ronald L. 2002. *Deeply into the Bone. Re-Inventing Rites of Passage*. Berkley: University of California Press.

Grimes, Ronald L. 2014. *The Craft of Ritual Studies*. Oxford: Oxford University Press.


Hurst, Rachel Alpha Johnston, ed. 2021. *Representing Abortion*. London: Routledge.


Moore, Sally F., and Barbara G. Myerhoff. 1977. *Secular Ritual*. Assen: Van Gorcum.


## *Article* **Religion, Nonreligion and the Sacred: Art and the Contemporary Rituals of Birth**

**Anna M. Hennessey**

Berkeley Center for Study of Religion, University of California, Berkeley, CA 94720, USA; amhennessey@berkeley.edu or amhennessey@gmail.com

**Abstract:** This paper looks at the role of art and material culture in the rituals of birth, first taking into consideration research on material culture in traditional rituals of birth and then turning to the primary topic, which is how art in the contemporary rituals of birth often holds sacred meaning even when the ritual is of a nonreligious nature. A discussion about the sacred in the context of a nonreligious ritual hinges upon an understanding of that which is "sacred"; thus, the paper looks at research on modern theology and the sacred to examine the term in the context of birth as a contemporary rite of passage. Giving examples of how material culture has been important in several traditional birth rituals from different cultures, the paper then traces a similar occurrence in which participants in contemporary nonreligious rituals of birth also uphold art and material culture as sacred elements of the rituals. The paper provides the reader with description of a rich array of art and material culture used across cultures in different rituals of birth. Taking into consideration the numerous contributions that scholars have made to the emerging field of birth and religion, including the interdisciplinary importance of theories related to birth as a rite of passage, the paper also presents new research on the materiality of the contemporary rituals of birth.

**Keywords:** African birth ritual; ancestor worship; art; birth; birth altar; birthing justice; ceremony; child; childbirth; Chinese birth ritual; contemporary art; humanism; indigenous birth ritual; material culture; mother; nonreligion; nonreligious; pregnancy; religion; re-sacralization; rite of passage; ritual; sacred; secular; secularity; spirituality; symbol; traditional birth

#### **1. Introduction**

This paper looks at the role of art and material culture in the rituals of birth, first taking into consideration research on material culture in traditional rituals of birth and then turning to the primary topic, which is how art in the contemporary rituals of birth often holds sacred meaning even when the ritual is of a nonreligious nature. A discussion about the sacred in the context of a nonreligious ritual hinges upon an understanding of that which is "sacred"; thus, the paper looks at research on modern theology and the sacred to examine the term in the context of birth as a contemporary rite of passage. Giving examples of how material culture has been important in several traditional birth rituals from different cultures, the paper then traces a similar occurrence in which participants in contemporary nonreligious rituals of birth also uphold art and material culture as sacred elements of the rituals. The paper provides the reader with description of a rich array of art and material culture used across cultures in different rituals of birth. Taking into consideration the numerous contributions that scholars have made to the emerging field of birth and religion, including the interdisciplinary importance of theories related to birth as a rite of passage, the paper also presents new research on the materiality of the contemporary rituals of birth.

In her seminal work on ritual, *Ritual: Perspectives and Dimensions* (Oxford University Press, 1997), religious studies scholar Catherine Bell states that the ways in which a traditional society experiences birth ritualistically influences that society's development of other ritualistic traditions (95). Traditions that stem from a culture's birth rituals, including

**Citation:** Hennessey, Anna M. 2021. Religion, Nonreligion and the Sacred: Art and the Contemporary Rituals of Birth. *Religions* 12: 941. https:// doi.org/10.3390/rel12110941

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 1 October 2021 Accepted: 26 October 2021 Published: 29 October 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

rituals related to death, emphasize how material objects are integral to the way that the meaning of the rituals is conveyed to the participants and observers.

This paper briefly examines a few such examples from different traditions. The intent here is to first demonstrate the point that Bell makes about the impact that birth rituals can have on the development of other cultural forms and ritual life. The cases cited have been chosen because they offer concrete examples of how traditional rituals of birth have an impact on a society's development of other ritualistic traditions. After that, the paper turns to a discussion of the contemporary rituals of birth, looking both at how religious objects have the capacity to become re-sacralized in a new way during birth as a rite of passage, as well as at how nonreligious objects become sacred of their own accord.

#### **2. Results**

#### *2.1. Material Culture in Traditional Rituals of Birth*

Ethnographic studies such as those conducted by the late anthropologist Gene Cooper (1946–2015), a professor and scholar who worked extensively on Chinese folk customs, provide a view into how birth rituals are highly influential to a culture's other ritualistic traditions. Cooper's research on the rituals of birth and other life cycle rites of passage as they occur in the context of Dongyang County, China, shows the strong influence that birth rites can have on a culture's other rituals. In the context of Dongyang culture, beginning with birth, all life-cycle rituals are focused on a theme related to longevity and a Chinese concern with the extension of mortal time: "One begins life with a longevity bowl secreted under the bed. One eats longevity noodles on birthdays and receives longevity couplets and longevity scrolls on 'big birthdays'" (Cooper 1998, p. 391). Historically, during China's late dynastic times, the woman's placenta was also placed in a clay pot underneath the bed, where it would stay until the child was grown up, a symbol of fertility (Cooper 1998, p. 375). This same theme of longevity and the extension of human mortality continues well past birth, shadowing people as a living motif throughout their ritual lives:

"One is buried in longevity clothes, in a coffin called a longevity box, decorated with the longevity character, and guests eat longevity rice at funerals. Women receive a longevity quilt on occasion of marriage. Chinese seem to be obsessed with extending the limits of human mortality, which while thus clearly recognized are at once mystified into nonrecognition in the ancestral cult and its rituals of death. The metaphor of the noodle as a longevity food suggests a conception of time similar to that of the West, and eating noodles to lengthen life is among a variety of ritual and symbolic measures and plays on words employed to influence fate and evade ill fortune; e.g., choosing auspicious days and times, marrying spirits, linking bags, serving peanuts, and begging" (391).

It is easy to note that in all of the rituals Cooper mentions, material objects are integral to the process of conveying the message of the ritual to those involved. The rituals cannot be separated from these objects—bowls, noodles, couplets, clothes, coffins, etc., the material means through which the ritual is performed. Cooper's research shows the extent to which the theme of longevity is embedded in the cultural understanding of mortality and in all life-cycle rituals in Dongyang, beginning with the longevity bowl and noodles after birth.

The case of Dongyang provides a good example of Bell's claim that themes embedded in the rituals of birth become infused in other rituals experienced by humans and their communities throughout the course of life, particularly in the context of traditional societies. The research also shows how material objects are central to ritualistic practices in their traditional context.

Herbert Cole's *Maternity: Mothers and Children in the Arts of Africa* (Cole 2017) is extensive and provides numerous images of mothers and children as they occur across different timeframes in Africa. Cole shows how these mother–child images have maintained an ever-present existence in Sub-Saharan Africa across time and up through to modern and contemporary age representations. The objects are not mere representations of mothers and children, however, but are an important part of the fabric of African belief and ritual

action, tied to the sacred emphasis in the lives of African women to conceive and give birth. The images, while indeed connected to birth and mothering, are also a foundational part of the rituals of life in Africa.

In "Exploring Motherhood in African Arts," a 2018 article for ÌMỌ' DÁRA, a magazine and single site resource for African art. (Cole 2018) Cole also provides abundant information on the material culture of motherhood in Africa. Maternity figures and motherand-child imagery are central to the article, and Cole describes them as integral to African ritual life and in some contexts to life itself. Ala, "Earth," for example, is a maternal earth figure and important deity for the Owerri Igbo located in southeastern Nigeria. As Cole describes, "She is the true 'ground of being' for Owerri people, the font of both fertility and morality, the source of tradition and therefore, culture." Numerous rituals are connected to the deity, and as Cole explains in the section of the article titled, "Mbari: Art as Process in Igboland," large clay sculptures of the maternal figure Ala are found alongside smaller sculptures of children in mbari, which are sculpture-filled houses devoted to the deity. The deity is not just a fertility figure but is also connected to a rich variety of ritual and cultural life for the Igbo community.

Researchers at the Maryknoll Institute of African Studies (MIAS), located in Nairobi, Kenya, have conducted studies on pregnancy and birthing rites and rituals in the context of East African culture. The research on these rituals, found in Michael C. Kirwen's work, *African Cultural Domain No.1: Pregnancy and Birth* (Kirwen 2004), is a booklet in a series of fifteen. Similar to Cole's work, Kirwen's research shows that the rite of passage of birth in the context of African society is intimately bound to the broader cultural reverence for the ancestral spirits, and the theme of birth as connected to the ancestors is carried through the rituals of an individual's life, including those rituals associated with marriage and death. The rituals around birth, including proper disposal of the placenta, also have an impact on the future of the person and of the community (Kirwen 21).

Yet another scholar working in the context of traditional African birth rituals, Ogechukwu Ezekwem Williams, has also recently shown how in pre-colonial Nigeria, the traditions of birth were influential in the larger ritualistic traditions of Igbo culture and spirituality. As part of this continuation of ritual from the birth event was the increased spiritual role that women attained when they became new mothers. Perceived as imbued with spiritual powers after giving birth themselves, these women claimed new communal roles, which included the overseeing of fertility rituals and the partaking in midwifery practices themselves; thus, a cultural pattern stemmed from the event of birth, and women who gave birth became crucial participants in future rituals related to fertility and birth ( Williams 2018, p. 104). Williams explains how British colonialism ruptured the wholeness of this ritual life when missionaries changed the primary birthing space of Igbo women to that of the hospital. However, contemporary birth practices have begun to reincorporate spirituality and tradition into the rite of passage.

#### *2.2. Theories of Rites of Passage: From the Traditional to the Contemporary in the Rituals of Birth*

This paper now shifts attention from these traditional birth rituals to those of a secular or nonreligious setting found in many contemporary rituals of birth. A growing number of scholars have looked at the sacred in the contemporary rituals of birth. Some of these scholars include Alicia D. Bonaparte, Melissa Cheyney, Susan Crowther, Robbie Davis-Floyd, Marianne Delaporte, Ann Duncan, Jenny Hall, Pamela Klassen, Morag Martin, Julia Chinyere Oparah, Arisika Razak, and Joanna Wojtkowiak. The research of this paper specifically explores how the meaning of art and other material objects has the capacity to become sacred or re-sacralized in the context of the contemporary rituals of birth, similar to how art and objects become sacred in the context of traditional birth rituals, which are of a religious nature.

In *Birth as an American Rite of Passage* (University of California Press, 1992), cultural anthropologist Robbie Davis-Floyd famously describes a highly ritualistic nature as inherent in the technocratic model of an American hospital birth. Influenced by the extensive body

of work on rites of passage developed during the early and mid-twentieth century, found in the research of scholars such as French ethnographer and folklorist Arnold van Gennep (1873–1957), and British anthropologist Victor Turner (1920–1983), Davis-Floyd contends that even when secularized, contemporary rituals of birth resemble rituals attached to birth in traditional societies.

Looking briefly at Arnold van Gennep's classic model for the processes that make up a rite of passage as found in his major work, *The Rites of Passage* (van Gennep 1960 [Les Rites de Passage, 1909]), one notes that the model is characterized by a subdivision of the rite into three distinct stages: rites of separation, transition rites, and rites of incorporation (van Gennep 1960, p. 11). During the first phase, the individuals are separated from the identity held in their previous social states. The second stage represents a liminal phase during which time individuals exist neither in their former nor their future social states. The final stage, the rite of incorporation, represents a period during which the rite has been completed and the individual reenters society with a new sense of identity.

In the context of childbirth as a rite of passage and her study on pregnant women, Davis-Floyd describes early pregnancy, when a woman first realizes and fully acknowledges that she is pregnant, as the transition phase (Davis-Floyd 1992, pp. 22–23). The transition, or liminal phase, according to Davis-Floyd, is the longest period in the rite, encompassing the bulk of time during which the woman is pregnant, her experience of labor and childbirth, and the immediate postpartum period (23–41). The final phase of the rite, that of incorporation, happens gradually over the first few months of the newborn's life, at which point the woman is integrated into society as a new mother (41–43).

In *Blessed Events* (Princeton University Press, 2001), religious studies scholar Pamela Klassen points out that some feminist scholars have been critical of van Gennep's tripartite division of the rite of passage, which they see as too universalizing and andocentric of the human experience (Klassen 2001, p. 85). In the cases that she studies, Klassen agrees to some extent with this criticism of van Gennep, stating that for a number of the North American women at the heart of her study, the ritual of birth is one of intensification and not of a reversal of social position (85). However, Klassen still understands van Gennep's work on rites of passage as an important contribution to our understanding of the transformations that humans make during these rites, which are of a social nature and not just a physical one (85).

In the case of the art and material objects at the heart of my research, van Gennep's categories are relevant but of less significance in that the objects of discussion may become sacred before, during, or after the ritual of birth. Their sacredness is not necessarily dependent upon the physical status or social stage of the individuals involved. Rather, these individuals determine the meaning of the objects as sacred based on any of a number of factors and personal experiences that take place before, during, or after birth, or even before pregnancy. If a woman experiences issues with fertility, for example, then a particular charm or pendant may take on a different sense of the sacred than does the same object for a woman who is preparing for labor, or for another woman who has just given birth.

Influenced by the symbolic anthropology of Clifford Geertz, Davis-Floyd also emphasizes the crucial role that symbols play in transmitting the message of the ritual—both to the performers and to the receivers of that ritual (Davis-Floyd 1992, pp. 9–10; Geertz 1973). Objects used during birth, including items such as hospital gowns and instruments, she contends, can take on ritualistic import during the process of birth. Medical anthropologist Melissa Cheyney, who is also a midwife, has similarly researched how objects such as birth tubs used in homebirths also act crucially as symbols for participants during the ritual of birth (Cheyney 2011, pp. 535–36).

We can trace how across various historical, social, and cultural contexts, material objects that are part of the birth process become emotionally charged and ritualistically meaningful to women and participants before and after pregnancies, as well as during birth. Expanding on this assessment, this paper proposes that art and other objects associated with birth, whether they stem from a religious origin or are of a nature that is entirely

nonreligious, have the capacity to become sacred of their own accord. These material objects play a part in revering birth as a sacred event, and it is in this reverence for birth, and for mothering or parenting as well, that nonreligious objects become sacralized and treated as devotional items to be used in conjunction with birth as a sacred ritual.

I now turn to look at certain art and other objects used in the contemporary rituals of birth. It is through the rituals that these objects have the capacity to become sacred in a new way, transformed by their users.

#### *2.3. Birth Art, the Sacred, and the Contemporary Rituals of Birth*

Curiously, there are few representations of women giving birth found across the entire timeline of art history. This fact becomes particularly salient when comparing the large number of art images of death across time to the small number of art images of birth. Whether this dearth of birth imagery has to do with an original lack of interest in the subject or with a destruction of birth images that has occurred over the course of history is a topic of interest but will not be discussed here. I do discuss this issue at length in my work (Hennessey 2017, 2018). What is addressed here is the flourishing of so-called "birth art" in the twenty-first century, its relationship to new understandings of birth as a sacred act in itself, and the formation of nonreligious rituals of birth in which art is of central interest.

By the early 2000s, contemporary art and artisanship about pregnancy, birth, mothering, and parenting began to flourish, spreading across the internet through image sharing and online galleries, as well as on the ground in small gallery exhibitions. With a few exceptions, many of the artists creating this work are still not widely known. Their art is increasingly recognized within birth and midwifery communities around the globe, however, and there is a growth of interest in the work, some for its artistic merits alone. Since 2010, I have been collecting images of birth available online through an archive called Visualizing Birth (www.visualizingbirth.org, Hennessey 2010). The archive has in turn become a resource for those in the birth community while also providing me with interesting data on the types of images that those in the community are seeking out, utilizing, and creating. Google Analytics and other tracking services for the archive show me, for example, from which countries and locations visitors are coming, as well as the search terms that they use. Over the past decade, visitors to the site have come from a large number of countries across six continents around the world (Africa, Asia, Australia, Europe, North America, South America), pointing to the transnational and transcultural nature of using images in birth as a contemporary rite of passage.

This paper examines one primary aspect of these contemporary pieces, which is how the artists and artisans who are creating the work invite their viewers to enter the works with an understanding that the events depicted are sacred. In these works, the sacred and the secular merge, creating a new visual form of nonreligious sacrality as integral to the meaning of the objects. In conveying the meaning of the artworks to their viewers, these artists often explain the symbolic function of the art as related to an expression of birth as a sacred act, typically of a nonreligious or humanistic nature, even in those cases in which religious iconography is utilized. Before turning to the works, however, this paper briefly looks at theories of the sacred, and how something may be both nonreligious and sacred at the same time.

Gordon Lynch's theory of a sociology of the sacred, which itself stems from French sociologist Émile Durkheim's theories of a sacred–profane dichotomy at the heart of human experiences of religion and the world, is helpful in determining the difference between that which is "religious" and that which is "sacred." Lynch, a professor of modern theology, has worked extensively on the topic of a sociology of the sacred, differing the sacred in this context from how it might be found within a sociology of religion. While forms of religious life, including the ways in which practices, ideas, objects, and symbols are associated with religion have a wide sociological variety, so do cultural forms of the sacred. In *The Sacred in* *the Modern World: A Cultural Sociological Approach* (Oxford University Press, 2012), Lynch determines that these cultural forms exist separately from forms of religious life:

"While there is clearly a degree of overlap between these two sociological projects, there are also important differences. Contemporary sacred forms often have a significant religious past, and sacred forms associated with particular religious traditions and communities play a part in the multiplicity of sacred forms within contemporary society. But the wider range of sacred forms that exert considerable influence over contemporary life cannot be easily encapsulated within the concept of 'religion'" (6).

Lynch emphasizes how understanding the sacred forms of contemporary life entails not conflating them with forms of religious life, even though there may be some overlapping of the two:

"Gender, human rights, the care of children, nature, and the neo-liberal marketplace all have sacralized significance in modern social life, but our understanding of the nature and operation of these sacred forms is not helped by framing these as 'religious' phenomena" (6).

Lynch's theory of a sociology of the sacred offers an understanding of the sacred as a rich category inclusive of many cultural forms that, while not religious, are special in a unique way that demarcates them from the sphere of the profane. In his book *On the Sacred* (Lynch 2012), Lynch explains that the sacred goes beyond that which is attributed high value by an individual or a community, and is rather, "a way of communicating about what people take to be absolute realities that exert a profound moral claim over their lives" (11) or "the meaning of fundamental realities around which our lives are organized" (26). Lynch studies different types of sacred forms across culture and history. One form that he finds prevalent in modern thought and policy is the sacredness of humanity, of being human (83). This form of the sacred developed during the last half of the eighteenth century, contends Lynch, when theories of universal human rights began to flourish in philosophy and political thought, leading eventually to the mid-nineteenth century to present day rise of humanitarian organizations (85–86).

I maintain that the way in which art and other objects become sacred when participants use them during the contemporary rituals of birth rests in communal agreement that birth is an important if not foundational act in the human experience. Agreeing with Lynch again along Durkheimian terms, I contend that the sacred involves transcendence of mundane reality. Used ritualistically during birth, art and other objects become a transcendent part of the ritual, understood as sacred both personally by individuals as well as through a shared social reality connecting individuals who share in their devotion to the birthing process.

#### *2.4. Sacred and Re-Sacralized Objects in the Contemporary Rituals of Birth*

Over the past twelve years, I have researched a wide variety of art, imagery, and other objects used in birth as a rite of passage. For the purposes of this paper, I have selected a small number of these art objects. Many more may be viewed on the Visualizing Birth website or in my book, *Imagery, Ritual, and Birth*. Here, the paper looks at five objects, some of which stem from an original religious context and have been re-sacralized in the context of birth, and others of which become sacred in their humanistic connection to birth as a rite of passage.

#### 2.4.1. Pachamama

The first art object discussed is that of Pachamama (Figure 1), or "Earth Mother," a female goddess representing fertility and abundance in Inca mythology. I look briefly at the origins and history of the Pachamama figure, as well as how participants in birth as a rite of passage utilize the figure in the contemporary rituals of birth.

**Figure 1.** Pachamama, Pachamama Museum, Amaicha del Valle, Argentina. Photo by Bernard Gagnon, copyright 2018 Wikimedia Commons (Creative Commons: CC BY-SA 1.0).

Even after the Spanish conquest of the Inca Empire during the sixteenth century, representations of Pachamama were preserved and continue to permeate Andean culture, found in the contexts of art, religion, and everyday life. Pachamama is in fact the central figure of Andean religion today, viewed as the earth itself and therefore as the nurturer of life, but also as connected to death through the earth's power to kill through natural disasters such as lightning and earthquakes (Bolin 1998, p. 32). She is also acknowledged within this same cultural context as an intercessor against evil or of the devil, and is the focus of rituals utilized for protection (Taussig 2010, p. 208). When it comes to actual childbirth, Pachamama in this same original cultural context has a direct connection to the event. She is seen as the figure that gives children spiritual life after birth, as well as the one that will eventually take humans back into the womb when they die (Bolin 2006, p. 29).

During the colonial period of the sixteenth, seventeenth, and eighteenth centuries, some artists in Peru represented Pachamama as encompassing the body of a mountain while also merging her image with that of the Virgin Mary (Black and Gravestock 2003, p. 189) This style developed from within the Cuzco School of Peru, a Roman Catholic tradition of painting through which indigenous artists such as Quechua painter Diego Quispo Tito (1611–1681) used some European painting techniques while also merging Christian subject matter with that of their own symbolic imagery of Andean sacred landscape (see, for example, the Virgen del Cerro, an eighteenth-century painting by an anonymous artist, currently located at the Museum Casa Nacional de Moneda, Potosì, Bolivia).

In the context of a contemporary birth community, images of Pachamama and references to her are often associated with the act of birth itself. Sorayya Kassamali Rickicki, a New York City student midwife, doula, lactation consultant, prenatal yoga teacher, and mother of three, for example, has incorporated the name "Pachamama" into the name of her company, "Pachamama Birth," which provides birth doula and lactation services (Kassamali Rickicki 2017b). Of Tanzanian and Ecuadorian heritage, Kassamali Rickicki describes a heritage of birth knowledge as having been passed to her through her female relatives when she was a girl.

In my correspondences with Kassamali Rickicki, which date to 2017, she explains the symbolic importance of Pachamama in relationship to pregnancy and birth, describing her personal use of the figure's symbolism in her practice. She is similarly interested in other religious symbolic functions, even though she does not have her own religious beliefs associated with the symbols:

I chose Pachamama because I am of Ecuadorian heritage and Pachamama is an important symbol in Andean indigenous culture. It loosely translates as "Mother Earth," and has a powerful significance in relation to birth ... I don't have any religious beliefs associated with the word or the imagery but I like what it represents and I use it along with other imagery on my site. I have integrated that imagery with a Dhamma Wheel, pregnant body, lactating breasts, etc. because it all symbolizes the circle of life and the birth of all things."

Kassamali Rickicki re-sacralizes Pachamama when utilizing the figure with pregnant clients. For her, the symbolic function of the traditionally religious image relates specifically to childbirth. She focuses on Pachamama as a sacred birth figure and emphasizes the figure's connection to the act of birth.

In a medical article about the history of different positions for labor and birth used across cultures, Cuban doctors Miguel Lugones Botell and Marieta Ramirez Bermudez make reference to the figure of Pachamama, although not for the purposes of explaining her religious signification. Rather, they show an image depicting a woman who squats while giving birth to a crowning baby (Lugones Botell and Ramirez Bermudez 2012). The purpose of their article is not to advocate any one position for labor or for birth, but to describe the different practical benefits of all birthing positions, including vertical and seated positions, as well as those that a woman uses when she receives an epidural or other medical intervention. The article includes three other images, each coming from a different cultural, religious, and historical context. These include a picture of the Aztec deity, Tlazolteotl, an Ancient Roman relief of a woman giving birth, and an ancient ceramic piece from Peru's Moche Culture (Lugones Botell and Ramirez Bermudez 2012). In each case, the focus of the authors' data is on the actual positioning of the body used during birth.

The same image from the Cuban medical journal is subsequently referred to in several Spanish-language articles on birth and mothering. All of these are written for a popular audience and focus not on religion but on ideal positions for women to use during labor and childbirth (Paris 2011, 2017).

One of the most popular images of Pachamama used across the web is a small watercolor and pen drawing that depicts the goddess smiling with a baby shown upside down and ready to be born. The artist who created the image is unknown and thus publication of the work is therefore not possible due to copyright laws (please see: visualizingbirth.org/pachamama-fertility-goddess-and-mother-earth). The image is found on over one hundred websites, including English- and Spanish-language pages about birth, as well as social art files such as those found on Pinterest and Tumblr. The main topic on many of these websites is devoted specifically to birth and to providing women with information on birth positioning or to promote positive images of the event. Most of the sites do not describe the image other than to name it as an image of Pachamama. The image appears, for example, numerous times on Pinterest on pages that offer the viewer a look at art imagery of birth. Websites focusing on birth art and the use of art for childbirth purposes also frequently include the image.

On the Global Economic Symposium blog (GESblog), the same image also appears in the article titled, "How to empower women through religion" by Brazilian journalist Yohana de Andrade (de Andrade 2014). In this case, the author makes a direct connection between the religious origins of Pachamama, as well as to the religious origins of other female deities, emphasizing how knowledge of these figures relates to a sense of empowerment for women. The writing transforms the meaning of the Pachamama figure from the sphere of religion to a broader and more secular understanding of Pachamama as a representation of empowerment for women.

In the case of Sorayya Kassamali Rickicki, the owner of Pachamama Birth discussed earlier, she includes Pachamama as one symbolic religious figure among others (such as the dhamma wheel), for example, to be used by women as they connect more deeply to the cycle of life and prepare for birth as a rite of passage (Kassamali Rickicki 2017a, correspondence). While these connections may not be of a religious nature, they are woven with an understanding that the physiological passage of birth is a sacred passage.

It is worth noting that Kassamali Rickicki has worked with a wide variety of women in the New York City area. In addition to her clients from the United States, she has served women from West Africa, Mexico, the Dominican Republic, Ecuador, and Colombia. Other women she has helped through the birth process include new immigrants, orthodox Jewish women, single mothers, and women on Medicaid (Kassamali Rickicki 2017a, correspon-

dence). These demographics are important, contributing to data that suggest a variety of women of different racial, ethnic, religious, and socioeconomic backgrounds are utilizing images during the rituals of birth.

Different Pachamama figures and images are found for use or purchase through various vendors. Shawna Hawk Rose, one such artist and vendor, sells small Pachamama statues that she makes out of clay and other materials. The figurines are marketed as pieces to use as gifts within the birth community or in honor of birth and conception. Yet as in the previous cases, the meanings of these objects are not understood as existing within a secular vacuum from which the sacred has been removed. Instead, the object is identified with the sacred. This sacredness, however, is understood primarily through its associations with birth and the divine feminine and not with the sphere of religion.

The use of the name "Pachamama" occurs elsewhere within today's birth community, found readily online, including for doula, midwifery, prenatal care, and other services related to pregnancy and birth. These contemporary usages involving Pachamama, the religious and cultural figure, often emphasize the Incan goddess as a powerful female figure who connects women to an inner or spiritual self in relationship to fertility and the rituals of birth.

#### 2.4.2. The Woman of Willendorf

Other objects associated with religious cultural life are similarly re-sacralized in the context of the contemporary rituals of birth. Some of the earliest forms of sculpture known to humankind are found in a type of statuette created by the Gravettian culture, which existed between 28,000–20,000 BCE and was located most prominently in what is today central Europe. These small statues are made of limestone and depict the female body in the full round (de la Croix et al. 1991, p. 36). Archaeologists have in the past referred to these figurines as "Venus Figures," considering the objects to have symbolized fertility for ancient peoples of the Old Stone Age. The most famous of these statuettes is the "Woman of Willendorf" (also called the "Venus of Willendorf") (Figure 2). Standing 4 1/8" tall, the Woman of Willendorf displays large breasts and hips and belly that are exaggerated in their voluptuousness. Her vulva is also large and full. With no facial features, she does not depict a particular woman but instead represents a symbol, possibly of fertility (de la Croix et al. 1991, p. 36). Although the original purpose of the Woman of Willendorf is still unclear, scholars working on the object and other such figurines hypothesize that the items were associated with ancient fertility beliefs or shamanistic rituals (Wilford 2009).

**Figure 2.** Woman of Willendorf, Willendorf Venus Natural Museum, Vienna, Austria. Photo by Jorge Royan, copyright 2007 Wikimedia Commons (Creative Commons: CC BY-SA 3.0).

Today, images of ancient goddesses, fertility figures, and objects such as the Woman of Willendorf are found across the web on sites promoting topics related to pregnancy, birth, fertility, and sexuality. On the Birth Matters website, for example, a hub of information on birth in New Zealand, the figurine appears alongside the text that the object simply, "honours women's birthing abilities." As in the case of the Virgin Mary, a mother figure who is widely revered in the birth community but not discussed in this paper, numerous Pinterest pages providing viewers with images related to pregnancy and birth include the Woman of Willendorf. Through Pinterest, visitors can also link out to various shopping websites where they can purchase pendants and jewelry of the Woman of Willendorf as related to childbirth and pregnancy. Similarly, Facebook posts associated with childbirth education, doula, or midwifery service show the figure of the Woman of Willendorf and describe the object as a symbol of fertility and birth.

Numerous items marketed as Woman of Willendorf necklaces, figurines, pendants, and charms are also used in the context of fertility, pregnancy, and birth, often understood as sacred objects. Joanna Hajduk, a Polish artist who creates stone statuettes of the Willendorf figure, for example, describes her recreations as "shamanic figurines," to be used in relationship to fertility or the rituals of birth, and particularly as part of a sacred birth altar. Another artist, Jenna Danielle, sells printable adult coloring pages of the Woman of Willendorf, which she states can be used by women or by doulas who are helping other women prepare for birth as a way of celebrating a woman's own internal "fertility goddess." Other artists create metal or stone charms and jewelry of the figure, selling them through shopping websites such as Amazon and Etsy in the context of sacred birth items. The replicas of the Woman of Willendorf, as well as photos of the original Paleolithic figure, are also found in Pinterest collections devoted to the topic of sacred birth art.

In all of these cases, the meaning of the Woman of Willendorf has gone through a transformation. Its function relates neither exclusively to a religious or cultural history, nor to a secular purpose. Instead, there is a collective understanding within the birth community that the object is sacred in the humanistic context of birth and the contemporary rituals of birth.

#### 2.4.3. Labyrinths for Birth

Like Pachamama and the Woman of Willendorf, the labyrinth (Figure 3) is an important part of material culture used in the rituals of birth. Unlike a maze, which has multiple sometimes dead-end paths, a labyrinth is unicursal with a single path leading towards a center. Labyrinths have been used for various reasons in numerous cultures over the course of history, identified in the cultural and religious contexts of the Native Americans, Ancient Greeks, Chinese, Scandinavians, South Asia, and Ancient Peru, among others. Yet they are also used in the contemporary context of childbirth. Pregnant women visualize the labyrinth as a sacred path of emergence for both mother and child. In this context, labyrinths represent a mother's emotional and physical passage towards her child and can be used ritualistically by the pregnant woman as she prepares to labor and birth her baby.

Many midwives and others working within the birth community either walk labyrinths with pregnant clients or encourage them to do so on their own. In San Francisco, for example, the city where my own children were born, there are regular practices organized by the Bay Area Homebirth Collective (BAHC) during which time those who are pregnant walk one of the two labyrinths at Grace Cathedral (a large labyrinth inside the cathedral itself or a smaller one located in an exterior courtyard) with midwives, doulas, yoga instructors, and others. Sue Baelen, a licensed midwife and owner of Sacred Body Midwifery in San Francisco, is one of the regular organizers of this activity. Quoting Helen Curry's (2000) trade book, *The Way of the Labyrinth* (Curry 2000), Baelen's flyers describe the event as a place where, "the spiritual and physical merge into a walking meditation."

**Figure 3.** Edinburgh Labyrinth, George Square Gardens, Edinburgh, United Kingdom. Photo by Di Williams, copyright 2008 Wikimedia Commons (Creative Commons: CC BY-SA 3.0).

Pam England, a Certified Nurse Midwife and artist, has written prolifically for a popular audience on the use of labyrinths, mazes, and yantras as a way for those who are pregnant to prepare for labor and birth in a ritualistic way. Her 2010 book, *Labyrinth of Birth: Creating a Map, Meditations and Rituals for your Childbearing Year*, provides a basic guide to the history of labyrinths in world culture, and describes how visualization of the labyrinth can help pregnant women and people as they prepare for the contemporary rituals of birth. England describes and gives honor, for example, to the symbol of mother and child in the Hopi Tapu-at labyrinth. Tapu'at means "mother and child" (England 2010):

"It is unique because it has two entrances and contains two labyrinths, one within the other. Tapu-at is referred to as "Mother and Child" because the outer labyrinth holds the inner labyrinth, like a mother holding her child. This labyrinth is like the mother's womb enveloping the unborn baby. The unattached center line emerging from the entrance of Tapu'at represents the umbilical cord" (4).

This type of labyrinth is in the shape of a square and symbolizes a pathway between the terrestrial world and the world beyond (Gómez and Carlos 2016, p. 4). Walking the labyrinth, the design of which the Hopi see as similar to the path between mother and child when the child is in the womb, brings the participant from one realm to the other, representing a rebirth (Werness 2000, p. 197). England suggests that such labyrinths may aid in the visualization of birth. England describes the journey that one takes when walking a labyrinth:

"The labyrinth is an ancient, universal symbol representing our journey through life, ordeals and transitions. Its single, convoluted pathway begins at the opening, leads directly to the center and out again. The journey into the labyrinth's center is symbolic of letting go and of death (psychic or physical), and the journey from the center out of the labyrinth represents birth and rebirth. Walking or finger-tracing a labyrinth invokes a sensation of turning inward then outward, perhaps reminding us of our first journey from our mother's body into the world" (Introduction iv, 2010).

In her most recent book, *Ancient Map for Modern Birth* (England 2017), England broadens her discussion of labyrinths for birth to include sections on ceremonies and various rituals to use during pregnancy, birth, and the postpartum period. These include the construction of a birth altar for the mother or parents and the baby, the making of birth art during pregnancy, and the practice of breathing and visualization techniques often associated with Chinese Daoism. In all cases, these rituals have the capacity to become sacred in the context of birth as a rite of passage, religious or nonreligious.

#### 2.4.4. Silas Kayakjuak's Birth Sculptures

Silas Kayakjuak is an artist who began representing the event of birth during the twentieth century (Kayakjuak n.d.). His carvings have become more recognized into the twenty-first century, however, particularly within the birth community (Kayakjuak 2017). An Inuit artist from the Nunavut Territory of Canada, Kayakjuak comes from a family of carvers. He has carved many images of the human form into stone over the course of his career, and the themes of pregnancy, birth, and mothering recur in his work. There is a warmth and calmness to his carvings, found also in this small sculpture of a woman giving birth. In Kayakjuak's piece, *Birthing the Old Way* (Figure 4), the crowning baby emerges fully from the woman's form while her facial expression remains strong but serene. The woman's entire body concentrates on the birth of the baby, pressing forward and resting in a squatting position. Carved in serpentine, the sculpture is round and smooth, adding a tactile element to its sense of calmness. In our correspondences, Kayakjuak explained that the title of the work refers to the natural birth without medical intervention (Kayakjuak 2017).

**Figure 4.** *Birthing the Old Way*, serpentine carving. Copyright 1995, Silas Kayakjuak, used with permission.

Scholars Claire Dion Fletcher and Cheryllee Bourgeois describe the sacredness that is at the heart of Indigenous birth practices in their book chapter, "Refusing Delinquency, Reclaiming Power: Indigenous Women and Childbirth" (Fletcher and Bourgeois 2015):

"Pregnancy and birth are sacred events in Indigenous communities. Pregnant women are to be honored and cared for in their role in continuing the life of the family and community ... Women are considered to have a deeper connection to the spirit world when they are pregnant because of the spirit they are growing and caring for. Birth is understood as a ceremony in itself" (154).

Reflecting on his understanding of this sense of the sacred, Kayakjuak carves new work devoted to providing images of the birth event as a sacred event. Referencing the work of Kayakjuak and other Indigenous artists, Fletcher and Bourgeois point to the empowerment and sacredness that these contemporary images of birth provide to those who view them:

"Work such as the sculptures of Inuit artists Silas Kayakjuak and Mary Oashutsiaq depict Inuit women giving birth—babies quite literally at the threshold of new life with their heads born while the rest of the body is not yet out. These birth scenes with women helping other women place the experience and control of that moment in the hands of Inuit women. Paintings by Potawatomi artist Daphne Odjig and Metis artist Leah Dorian depict pregnancy, motherhood, and birth scenes firmly rooted in Indigenous perspectives, including physical and spiritual understandings of these experiences" (165).

While the sacredness represented in Kayakjuak's work is intimately connected to Inuit traditions, the artist refers to the representation as a piece that simply shows birth more generally as it has occurred in the past, before the arrival of medical intervention in the birth process. For Kayakjuak, the act of birth is sacred in itself. The sense of the carving's sacredness also derives from the viewers' collective nonreligious understanding that birth is a sacred event. Kayakjuak's artwork holds special meaning and power within the Inuit community. As our world becomes globalized, however, members of the international birth community view the artist's work as sacred when seeking out representations of the birthing process. For some, Kayakjuak's carvings of the event therefore celebrate birth as a sacred event in itself.

#### 2.4.5. A Merging of Justice and the Sacred in the Painting of Anoa Kanu

Artist Anoa Kanu is a Harlem-based water-media artist. She is also a Registered Nurse and a certified lactation consultant, and some of her artwork pertains to the theme of birth. The figures she depicts often include references to the sacredness of the pregnant or birthing form, as well as to how birth is connected to themes of justice for women, and especially marginalized women. In Kanu's *Girl in Bamboo Earrings* (Figure 5), the main figure squats amid lush vegetation, supported by warm brown shoots of bamboo behind her. Cradling her belly, the woman's arms and hands arch down and draw the viewer's attention to the soft swirl of a crowning baby at her vulva. She remains completely serene during this process of birth and emergence, her facial expression focused and calm. Her body and its processes are part of the natural world. The painting emphasizes the squatting position, an ideal manner of utilizing gravity as a natural aid in delivering one's baby. Unassisted in the birth, the main figure also reminds other pregnant women that they are part of a long lineage of women who have birthed before.

**Figure 5.** Girl in Bamboo Earrings, watercolor.

In our correspondences, Kanu described the making of this image, and her words about its creation and meaning are powerful in understanding how the themes of both the sacred and justice are integral to her work. Kanu describes the empowerment of the marginalized and an ability to transcend space and time during the birth event. This explanation of birth is not related to an experience of the mundane world but of one inspired by a sense of awe, timelessness, and the sacred:

"I am a painter, but I also work in women's health with new mothers and babies in an urban environment. I see a lot of beauty, new life, beginnings. But I also see a lot of disempowerment, young women not knowing their rights, what questions to ask or that they could even ask."

"When I imagined this image in my mind's eye, I saw a young woman, birthing for the first time, knowing she was capable, transcending space and time. She is protected and is able to tap into her elemental self and ancestral memory. She transforms through the birth process into a new being, a more fully empowered version of herself."

"The first birth I had ever been to was a water birth, it was like this. The midwife was not intrusive. The mother was fully committed to the natural birth process. The spirit of the birth environment was palpable and womblike itself. She was mostly quiet but also moaned and grunted when she needed to. She moved as she wished. It was clear she had gone into a very deep place within herself. At the very end, she let out the most guttural of sounds. She birthed her baby. She was not delivered."

"Not every birth will be like this, there is no one way. But I know this exists, that it is possible. Reclaiming birth is an essential part of our liberation."

#### (Kanu 2016, email correspondence)

For Kanu, when a laboring woman is provided a safe environment in which she can go into a deeper place and realize birth as a timeless, sacred event, the woman's physiological processes have a better chance of unfolding. In this sacred space of birth, the woman is transformed, empowered, and liberated.

Kanu's work is especially pertinent in the context of how sacred images of birth are important for marginalized women. More broadly, however, Kanu represents the event of birth as a humanistic and nonreligious act that is sacred in itself.

#### **3. Conclusions**

With the art and other objects mentioned in this paper, there is spectrum of cultural appropriation occurring. In some cases, the item is created within its own cultural context; in others, there may be some level of connection to the original cultural context; and in others, connection to the original context is limited to as it occurs through the acts of birth or mothering. Contemporary artists working on the topic of childbirth are by nature living in a globalized community and in many cases influenced by traditions that may have a positive impact on the birth experiences of those who are pregnant or part of the contemporary rituals of birth. Whether those working in the birth community should have the right to utilize images that do not stem from their own tradition is an interesting moral question in need of a separate study and much more examination. As I discuss in my book, *Imagery, Ritual, and Birth,* however, moral categorization is complex when it comes to cultural appropriation in the context of childbirth, especially as the issue relates to physiological transformation and the bettering of health for those who are pregnant, giving birth, or in a postpartum condition.

There are many other examples of art and material culture that depict themes of birth and are deemed as "sacred." In our globalized world, many of these images are widely accessible through website collections, museums, and online galleries, as well as in person through local birth and medical communities. This paper has pointed to evidence that some of these objects historically identified as religious have been re-sacralized within the contemporary rituals of birth. Furthermore, in other cases where the objects are entirely of a nonreligious nature, artists or members of the birth community may present the items as sacred from the outset. This sacredness is based exclusively on the artwork's relationship to the humanistic act of birth as a rite of passage.

This research demonstrates how participants in the contemporary rituals of birth view art and other objects related to the processes of pregnancy, labor, birth, mothering, and parenting as sacred objects. While the artists of these works sometimes utilize religious iconography, they are not replicating an original religious object. Instead, they are creating brand-new work in which the human self who births or parents is represented as a sacred self.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The author declares no conflict of interest.

#### **References**


Cole, Herbert M. 2017. *Maternity: Mothers and Children in the Arts of Africa*. Brussels: Mercatorfonds.


## *Article* **Rituals and Embodied Cultural Practices at the Beginning of Life: African Perspectives**

**Magdalena Ohaja 1,\* and Chinemerem Anyim <sup>2</sup>**


**\*** Correspondence: magdalena.ohaja@nuigalway.ie

**Abstract:** Cultural beliefs and practices find expression through rituals. Rites of initiation or passage are some of the most common rituals among the indigenous African societies. Pregnancy and Childbirth are not only biological events, but also socially and culturally constructed with associated symbols that represent the social identities and cultural values of Africans. Birth is a rite of passage, and children are perceived as special gifts from the Supreme Being. As such, pregnancy and childbirth are special events cherished and celebrated through varied rituals. Drawing on empirical literature and relevant commentaries, this paper aims to discuss selected rituals and embodied practices surrounding the start of life (pregnancy, birth, and early motherhood). The paper will specifically focus on the following aspects: pregnancy rituals; birth songs and dancing; the *omugwo* (care after birth); the cord and placenta rituals; and the naming ceremony. Some of the pregnancy rituals are purificatory in nature and therefore beneficial for maternal and infant health. The celebrations surrounding the birth of a child are community events, marked with singing and dancing. Following childbirth, the new mothers are not expected to participate in house chores to allow them time to recuperate. In all, discourses concerning the beginning of life, i.e., pregnancy and the periods surrounding it, are filled with rituals which are embodiments or expressions of cultural values, customs, and beliefs.

**Keywords:** rituals; pregnancy; birth; cultural practices; Africa

#### **1. Introduction**

In most African nations, as in many other societies, once married, women are expected to get pregnant and bear children for the expansion and continuation of the family lineage from one generation to another (Chukwu and Ume 2020). Human existence is a journey with series of changes from the time of birth until the time of death, the two most important times in a person's life. Birth, the start of a new life is a special and unique life event, which occurs within a cultural and social context (Nwadiokwu et al. 2016; Wojtkowiak 2020). In other words, childbirth is not only a biological event, but it is also socially and culturally constructed with associated symbols and rituals that represent the social identities and cultural values of any given society (Van Beek 2002). In many communities, childbirth is "a life cycle and a communal event associated with rites of passage" (Siwila 2015, p. 64). Put differently, rituals and or cultural practices are deeply embedded with rites of passage at varied stages of a person's life: pregnancy, birth, naming ceremonies, puberty/adolescence, marriage, death, and burial (Nwadiokwu et al. 2016; Ehimuan 2021). The rituals that accompany these rites of passage play a role in giving meaning to people's ways of being (Mogawane et al. 2015), as well as the importance of indigenous knowledge in pregnancy and birthing discourse in Africa (Siwila 2015). It is also important to acknowledge the role of religion and spirituality in women's ways of being during pregnancy, childbirth, and early motherhood (Ohaja et al. 2019; Ohaja and Murphy-Lawless 2017), given that religion and spirituality are contextual practices which also find expression through rituals

**Citation:** Ohaja, Magdalena, and Chinemerem Anyim. 2021. Rituals and Embodied Cultural Practices at the Beginning of Life: African Perspectives. *Religions* 12: 1024. https://doi.org/10.3390/rel12111024

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 30 September 2021 Accepted: 6 November 2021 Published: 22 November 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

(Ehimuan 2021). As asserted by Kanyoro (2002, p. 60), the rites of passage are performed to affirm the place of an individual within a cultural and religious setting. Christianity and Islam, the two major religions practiced in Africa (Westoff and Bietsch 2015), have influenced these practices in some places (Nwoye 2014). However, it is beyond the scope of this paper to discuss the impact of these religions on pregnancy and birth rituals rather it highlights the fact that most of these practices are still ongoing. As such, the paper is not a representation of religion in Africa.

Embodiment of pregnancy has been described by Neiterman (2012, p. 372) as an act of "doing pregnancy" which involves learning, adapting, and performing. Embodiment is not a fixed entity, rather it is as argued by Turner (2004, p. 71) "a life process that requires the learning of body techniques such as walking, sitting, dancing, and eating. It is the ensemble of such corporal practices, which produce and give a body its place in everyday life ... " During pregnancy women learn, negotiate, and renegotiate the usage of their bodies (Neiterman 2012), an experience they share with other women (embodied culture), highlighting the importance of social interaction. In other words, the pregnant women make continuous adaptation and practical adjustment to accommodate the needs of the body and by extension to maintain good health. The adjustments or changes occur in specific socio-cultural context and space which facilitates the incorporation of cultural and social meanings of pregnancy. Put simply, women learn "how to inscribe the culturally prescribed pregnancy practices on their bodies" (Neiterman 2012, p. 374). Culture is embodied in the activities of daily living, pregnancy and the periods surrounding it is no exception. In many societies, women's actions during this time are shaped by culture, and women are assisted and monitored by other female relatives in the 'doing' or 'performing' of pregnancy, birthing and early motherhood.

As noted above, discourses concerning the beginning of life, i.e., pregnancy and the periods surrounding it, are filled with rituals and cultural practices (Van Beek 2002). While some of the cultural practices are described as harmful, others have been acknowledged as having protective and therapeutic effects both for the mothers and their babies with huge benefits for the family and the community at large (Ayaz and Yaman Efe 2008; Beinempaka et al. 2015). Babies are cherished as special gifts from God the Supreme Being not only to the immediate family but also to the entire community (Chukwu and Ume 2020). As such, the birth of a child is usually announced and celebrated within the community (Igbokwe and Ahurumaraeze 2019), and the jubilation is followed by rituals which are embodied cultural practices (Beinempaka et al. 2015). Rites of passage are perceived as community building events, and not a way of diminishing individuals (Siwila 2015). van Bogaert and Ogubanjo (2008) suggest that as long as cultural beliefs and traditions do not cause harm, they should be respected and left alone, considering their spiritual role in alleviating anxiety, and enhancing a sense of purpose.

Drawing on evidence from the following countries: Cameroon, Ghana, Kenya, Madagascar, Mali, Niger, Nigeria, South Africa, Tanzania, Uganda, and Zambia, this paper will discuss rituals and embodied practices surrounding the start of life (pregnancy, birth, and early motherhood). The paper will specifically focus on the following aspects: pregnancy rituals; birth songs and dancing; the cord and placenta rituals; the *omugwo* (care after birth); and the naming ceremony. Given that the continent is known for its oral history, the paper will include relevant commentaries and editorials around the subject. We will begin by presenting an overview of rituals.

#### **2. Understanding Rituals: African Worldviews**

Africa is a continent with diverse ethnic groups, language, rituals, and cultural practices. Cultural beliefs and practices find expression through rituals, which existed prior to contact with the western world. Rituals in African cosmology are "symbolic, routine, and repetitive activities and actions through which we make connections with what we consider to be the most valuable dimension of life. They are often associated with significant events or places in our individual and communal lives" (Kyalo 2013, p. 35). As such, rituals are

considered the most repetitive and traditional form of performance, with all aspects of life celebrated and ritualised (Ehimuan 2021). Ritual practices are transferred from one generation to the other. Bamidele (2010, p. 7) emphasised that "we practice an inherited culture when our social habits still reflect what our forefather practiced in their days." Rituals are not outdated; they remain an ongoing and crucial aspect of African existence. As noted by Victor Turner (1962), wherever novelty and individualism abound, rituals can become a thing of history in a short period of time. For Turner, rituals sustain its function only in societies where technology has had little influence. Each region has unique community-based ways of expression. Etim (2019, p. 6) argued that the employment and efficacy of rituals among the people is premised on their "world view of harmonious monism, complementarity and integrated cosmology." Ritual does not only unite people to a community of shared values, but it also connects the body and mind, as well as emotions (Kyalo 2013).

Kyalo (2013) categorised rituals into two types: (1) rites which are linked to the human life cycle: namely, beginning of life (birth), marriage, and human crises, e.g., illness and end of life (death); (2) rites connected to fixed events, which can be either yearly or historical events. In the African context, the rituals connect us to our ancestors and therefore give meaning to our existence. Becoming a mother is among the most celebrated events in many societies (Siwila 2015). Laura Grillo (2012, p. 112) described ritual as "a means to negotiate a responsible relationship in the human community, with the ancestors, spirits, divinities, and cosmos." She went on to assert that "African rituals are reflexive strategies seeking practical ends: they establish identity, elicit revelation, access divinity to foster empowerment and effect transformation" (Grillo 2012, p. 112). The two most important times in a person's life are the birth and death of the person; both events are marked with symbolic rituals. However, contemporary Africa has witnessed alterations in the ways of being during pregnancy and birth, heralded by institutionalisation and medicalisation of pregnancy and the birthing process influenced by western civilisation, which, for the most part, results in the denigration of women's subjective experiences and indigenous knowledge. For example, there has been mounted effort from advocates of biomedicine to exterminate traditional healing rituals, some cultural practices such as the use of herbal medicine are condemned, and described as evil and harmful (Asamoah-Gyadu 2014; Ohaja and Murphy-Lawless 2017; Williams 2018). Nonetheless, the use of traditional healing rituals has gained fresh momentum among the Igbo people of Nigeria (Williams 2018). In Zambia "rituals, traditions, and beliefs still have an important position in constructing social gender, cultural, moral rules and taboos" (Honkavuo 2021, p. 3).

All stages of life in Africa are ritually celebrated. The series of rites and rituals serve as a preparation for the next phase in the life of an individual (Ezenweke 2012). There are many rituals and taboos observed by women during pregnancy in an attempt to keep the mother and baby healthy and safe. Most of the traditional ritual practices are observed after childbirth at which time the new mother's main role is to breastfeed the newborn. The rituals are representations of indigenous knowledge's systems and values, as well as ways of being.

#### **3. Pregnancy Rituals**

Celebration of a new entrant to the community begins with conception, and pregnancy is indicative of a new member of the family and society; hence, birth rituals start with the pregnant woman (Nwadiokwu et al. 2016). As explained by Chukwu and Ume (2020), the joy of a woman expecting a baby "knows no bound as she cheerfully sings and dance harmoniously, swerving her body mass tenderly from the right to the left unknown to her that her songs have enchanted neighbours" (p. 194). In many cultures, pregnant women observe different rituals or taboos that aim to protect the mother of the child from perceived evil attack. The taboos range from wearing protective bracelets to avoiding certain foods. In her recent ethnographic study of Zambian women's experiences of cultural and traditional health beliefs about pregnancy and childbirth, Honkavuo (2021) found that in addition

to prayers, women wore a protective band around the waist to wall off evil spirits. The study also showed that women avoid fish, birds' eggs, and meat during pregnancy while fruits and vegetables, shima (nutrient deficient cornmeal), and rice are recommended. In Abamba (Kenya), it is prohibited for pregnant women to eat beans, fat, and the meat of animals slaughtered with poisoned arrows during the last trimester of pregnancy. Dietary prohibition or proscription were reported to have protective benefits in Southern Cameroon (Elom 2019) and among the Maasai-Kenyan women (Mpoke and Johnson 1993). In addition, the Maasai women increased their water intake, and they also take bitter herbs and roots to induce vomiting. It is believed that this purifies the woman's bloodstream and cleans her stomach (Mpoke and Johnson 1993). Contrastingly, among the Ika tribe of Nigeria, expectant women can eat any food of their choice unless advised by elders or medical practitioners (Nwadiokwu et al. 2016).

Pregnant women are expected to achieve what Pourette et al. (2018, p. 57) referred to as 'culturally-defined ideal childbirth'. Based on their two anthropological studies conducted in Madagascar, culturally-defined ideal childbirth is characterised by avoidance of stillbirth or caesarean section, the baby not too thin or too big, and socially and financially inexpensive. Women achieve this by avoiding food like sweet potatoes, bananas, fatty foodstuffs such as peanuts, and salt, particularly in the third trimester. Drinking ice-cold water plays a role in the reduction of the weight and size of the foetus. The tendency by some societies to control what women can or cannot eat during pregnancy may also be harmful in the sense that such restriction on diet may deny women of useful nutritional food (Siwila 2015). That said, it can be argued that some of these taboos and rituals are purificatory in nature, provide protection for the mother and child from perceived evil powers, and are therefore beneficial for maternal and newborn health.

#### **4. Birth Songs and Dancing (***Egwu ọn˙ụ nwa***)**

Chukwu (2015) describes childbirth as an avalanche of blessing from nature to man. Throughout Africa, the news of the birth of a child is received with immense joy (Nwadiokwu et al. 2016). At the announcement of the birth of a child, women in the immediate and extended family and kindred gather to welcome the child with ululation, singing traditional songs and dancing. It is an expression of joy that the lineage is expanded. Birth songs (*egwu ọn˙ụ nwa*), as noted by Uzochukwu (2006), are sung in most cases, and the dancing rhythm of the songs makes them more fitting for the occasion, which enhances active participation of the audience (women) that gathered to celebrate the occasion given that childbirth is a communal event in nature. This is exemplified in the lyrics of some of the songs, which also signify that the newborn child does not only belong to the immediate family alone but to the entire community, and it is therefore the responsibility of every member of the community to care for the child. This is evident in the most popular song among the Igbo ethnic group of Nigeria. Through the song, all those around (women) are invited to join the celebration of the birth of the newborn as expressed in the birth song presented in Table 1.

**Table 1.** Birth Song 1.


(Adapted from Chukwu and Ume 2020, p. 198).

Childbirth songs do not only contain celebratory lyrics, the sex of a child is also announced with birth songs. It is also a medium of offering thanks to *Chineke* (God who creates or God the creator). Example is presented in Table 2.



(Adapted from Ebeogu 1992, p. 43).

The integrity of women and men's superiority as the guardians of society are often represented through songs (Ebeogu 1992). As such, *egwu ọn˙ụ nwa* offer women an opportunity to be heard. Even though it is beyond the scope of this paper to discuss the male and female child dichotomy, it is important to note that while the birth of every child is celebrated, the celebration is more elaborate and louder when the baby is a male child (Chukwu and Ume 2020). For the Basukuma people, who are described as the most joyful people in Tanzania, song and dance are naturally part of ritual ceremonies including childbirth (Mirambo 2004).

#### **5. The Umbilical Cord and Placenta Rituals**

The umbilical cord and placental practices form important aspect of discourse around rite of passage. These practices are often culturally controlled beliefs that function as spiritual means of control over the welfare of the infant, the mother, and the community in general (van Bogaert and Ogubanjo 2008). Kanu (2019) describes cutting of the umbilical cord as indicative of incorporating the child into the community. By this act, the child belongs to the entire community. In other word, "it is a rite of separation of the child from the world of the ancestors and incorporation into the world of human beings" (Kanu 2019, p. 26).

For decades, the human placenta has received traditional handling by various cultures around the world. In western medicine, the human placenta is typically viewed as just human waste. However, in many African societies, the umbilical cord and placenta are viewed as holders of extraordinary power (Adamson 1985), and therefore they are handled carefully. The placenta is referred to as a "traveling companion" which assists the ushering of the new baby from one world to the next as shown in a historical ethnographic study of the Sahel-Niger community (Cooper 2019). For the Ugandans, the placenta is regarded as another baby and therefore given formal burial (Beinempaka et al. 2015). In Kenyan Luo cosmology, the left side relates to vulnerability and impermanency while the right side indicates authority and permanency. Consequently, the placenta of a female infant is buried on the left-hand side of her mother's house, while the placenta of a male infant is buried on the right-hand side. Girl children are perceived as temporary or transient members of the community because they move outside the family for the purpose of marriage, but boys will remain in the family to maintain the ancestral lineage and continue as patriarchal authorities (Nangendo 2005; Mulemi and Nangendo 2001). Furthermore, the burial of the umbilical cord and placenta is believed to restore a woman's fertility, bring about healing of the womb, and preserve the future of the newborn.

There are varied burial sites for the placenta among the Tonga people of Zambia. Depending on the clan, it can be buried under the *mupundu* tree, on the veranda of the family hut, or at its centre. The *mupundu* tree is known as fertility tree, hence its link with women's fertility. Using the *mupundu* tree as a placenta burial site illustrates the connection between nature and birthing (Siwila 2015). This act is symbolic as it is "a way of evoking the spirit world through nature to continue blessing the womb of the woman so that she can be as fruitful as the *mupundu* tree" (Siwila 2015, p. 65). Similarly, the Igbo ethnic group

in Nigeria and the Ghanaians consider the placenta as the deceased twin of the newborn, and they bury it mostly under a tree, as trees symbolize ongoing life. In Ghana, burying the placenta at home is a way of preserving the child's destiny (Adatara et al. 2019).

For the Igbos, the tree where the placenta is buried belongs to the child, it connects the child and the earth. In Mali, it is believed that the placenta can influence the child's mind-set or even make the child sick. Therefore, the placenta is washed, dried, put in a bowl and buried by the man of the house. The Kikuyu people of Kenya places the placenta in an uncultivated field and cover it with grasses and grains (Liesje 2014). All in all, the placenta is highly revered in most African societies because of its biological and spiritual connection to a child's life cycle.

#### **6. The Omugwo Ritual (Care after Birth)**

The period after birth is known as the postnatal period and universally defined as lasting 40 days with striking similarities as well as differences between varied cultures (Eberhard-Gran et al. 2010). It is the custom in many countries for women to be cared for by their mothers or mothers-in-law, who take responsibility of the house chores as well as look after the new mother and her baby, thereby allowing the new mother time to recuperate (Umunna 2012; Igbokwe and Ahurumaraeze 2019). For the Igbo ethnic group of southeast Nigeria, this period is called the *omugwo* period, and the practice surrounding it is known as the *omugwo* ritual (care after childbirth), or "a special rehabilitation of the woman after childbirth" (Ekweariri 2020, p. 5). The duration of *omugwo* differs and ranges from a minimum of seven weeks to six months. Kelly (1967) noted that in Nigeria a woman and her newborn are confined to a 'fattening room' to facilitate rest and recuperation and weight gain (Kelly 1967).

Many African societies believe that it takes a village to raise a child. Communal living and togetherness are central elements of many societies and cultures. As highlighted by Umunna (2012, p. 9), "nowhere is this commitment to collective communal social responsibility more evident than in the *omugwo* practice." It is a feasting period marked with many rites such as ceremony of reincarnation, burying of the umbilical cord, circumcision, and naming of the child. The period culminates with the outing ceremony of the mother (Mbah 1993). It is in this spirit that the *omugwo* practice is so important in traditional Nigerian Igbo society, to the extent that the new mother is not allowed to participate in house chores, including cooking for the family, fetching water, and working in the farm, among others (Igbokwe and Ahurumaraeze 2019; Kanu 2019). Similarly, in Kenya and Tanzania, as reported by Bergsjø (1993), the Masai women are isolated and encouraged to take some respite, and to pay attention to their nutrition after childbirth. The mother of the new mother or other older female relatives take over these roles including caring for the newborn, which enhances the resting period of the new mother, and her role is primarily to breastfeed the baby (Chukwu and Ume 2020). The woman attending the *omugwo* of her daughter usually prepares some local delicacies, which will help the new mother's body to return to normal post childbirth (Ujumadu 2018). As noted by Chukwu and Ume (2020, p. 201) *"Womenfolk in the family and neighbourhood help out in preparing her food and generally keeping the home. Her food consists of hot, peppery, sumptuous soup with plenty of fish and spices like uda, utazi, nchuanwu and uziza. Hot food is believed to be good for the cleansing of the stomach. She is bathed and her stomach is massaged with hot water regularly to reduce the flab and return it to normal size."* In the Manxili area of KwaZulu South Africa, women observe a similar period of rest to promote recovery (Selepe and Thomas 2000).

Migration and western ways of life have had influence on cultural practices and rituals (Nwadiokwu et al. 2016). Women who gave birth outside their country of origin need to negotiate the maternity settings in their host or adopted countries to preserve and re-pattern their pregnancy and birthing cultural rituals. Despite some level of disruption by migration, *omugwo* practice remains a very crucial ritual for new mothers (Igbokwe and Ahurumaraeze 2019). Observation of cultural rites and rituals may not only act as a useful guide in terms of supporting women during pregnancy and birth experiences, but it also

has the potential for aiding women's transitions to motherhood. Dike (2019) carried out a qualitative study of the birth experiences of first-generation Nigerian women (FGNW) who are residents in London. The study aimed to explore the influence of cultural practices on women's birth experiences. The findings revealed the significance of cultural influence on the birth and maternity experiences of FGNW. The "*tradition of nourishing a new mother appear to be upheld with a measure of ritualistic significance orchestrated via the Omugwo ceremony (where rest and recuperation is maintained over a given period of about a month to three months with female relatives taking care of the new mother*)" (Dike 2019, p. 94).

The end of *omugwo* period is marked with a ceremony for the purpose of cleansing and purifying the new mother, who, at this point, is considered competent to resume her responsibilities within and outside the house (Anozie 2003). The rest period is followed by *Ukuphuca*—a celebration to mark the completion of the postnatal period in KwaZulu (Selepe and Thomas 2000). It can be argued that the most important benefit of the *omugwo* period is that it enhances maternal rest, the maternal–infant relationship, and the establishment of breastfeeding (Beinempaka et al. 2015).

#### **7. The Naming Ceremony**

All African societies believe that every new member of the society is unique with a specific mission, and that names have rich cultural content (Bamidele 2010). The newborn infant is initiated to the society and the world at large through the naming ceremony ritual. Therefore, the naming ceremony is a ritual performed to give a name, and to welcome the child to the community (Nwoye 2014).

While a baby is named after three days of birth in Akamba, Kenya, and parts of Tanzania, in Yoruba southwestern Nigeria, the naming ceremony occurs seven days after birth (Baiyewu 2020). For the Nri and Ihiala (Igbo) people, naming takes place on the 12th day (Nwoye 2014). Names represent people's personality or character, and sometimes directs the paths to follow (Baiyewu 2020). The circumstances that surround a baby's birth are taken into consideration when naming the child (Kanu 2019; Baiyewu 2020). Therefore, traditional African communities pay attention and select names carefully for their children. As asserted by Bamidele (2010, p. 9) "*an indigenous African name on the whole personifies the individual, tells some story about the parents and or the family of the bearer, and in a more general sense, points to the values of the society into which the individual is born.*"

In some cultures, the family and community contact the diviners to determine the infant's unique mission prior to the naming ceremony of a child. Leena Honkavuo (2021, p. 10) in her recent Zambian ethnographic study reported that the ancestors are contacted by the healer "to ensure the child's future with the name." The newborn inherits a name from the family. The name cannot be given if the child cries or is ill. It is the responsibility of the healer to discuss with the ancestor regarding whose name the child will be given (Honkavuo 2021). This is in line with the practice of the people of Omuma division in Imo State, Nigeria, who believe in reincarnation. They consult an oracle to determine who reincarnated (Anyachonkeya 2014). Kanu (2019, p. 39) argues that "naming is prophetic", i.e., the name is given as a prayer that aims to bless the child's future, or to counter bad luck, e.g., *Chidindu* (God lives). A name is an icon or monument for remembering an event or circumstances surrounding the period of birth. Therefore, names have a historical undertone (Kanu 2019).

#### **8. Discussion**

The primary aim of this paper was to discuss the rituals and embodied practices surrounding the start of life (pregnancy, birth, and early motherhood) drawing on evidence from the following countries: Cameroon, Ghana, Kenya, Madagascar, Mali, Niger, Nigeria, South Africa, Tanzania, Uganda, and Zambia. Migration has had an influence on cultural practices and rituals including pregnancy and birthing-related cultural practices. Worthy of note is that a number of rituals still remain in existence despite urbanisation and migration. Maalouf (2012) in a discourse of the complexities around identity noted that human beings

have two heritages. The first, a vertical heritage which has ancestral origin, popular traditions, and affiliation with religion, while the second heritage is horizontal in nature, and it is acquired by people through social groups and modern society. Rituals in Africa have both elements, ancestral origin, and passed from one generation to another. Cultural beliefs and practices find expression through rituals, which connect us to our ancestors and give deeper meaning to our existence. Rites of initiation or passage are among the most common rituals practiced by indigenous societies. In connection with the value of indigenous knowledge, a variety of rituals are performed by women until the birth of the baby and early motherhood (Siwila 2015). In this paper, we focused specifically on pregnancy rituals, and rituals performed after childbirth, namely, birth songs and dancing, the umbilical cord and placenta rituals, the *omugwo* ritual (care after birth), and the naming ceremony.

The first major African initiation rite is the rite of birth. As an act of eloquent expression, rituals are a means of transmitting cultural beliefs and values with dramatic effect and emotive force (Grillo 2012). Despite criticism regarding adherence to ritual practices and taboos, it has been shown that some of the pregnancy and birth rituals have purificatory effects, provide protection for the mother and child from evil powers, and are therefore beneficial for maternal and newborn health (Nwadiokwu et al. 2016; Honkavuo 2021). Dietary proscription is among the precautionary measures observed by women to promote health and ensure a normal and safe birth (Elom 2019; Honkavuo 2021).

In Africa, the birth of a new baby is often welcomed with jubilation. It is a special event celebrated by the family and the entire community with joy, singing, and dancing. Ebeogu (2017) opines that birth songs are so popular among the Igbo ethnic group of Nigeria to the extent that any discussion around the dominant types or categories of oral poetry which do not include birth songs would be faulted for neglecting a crucial aspect of that poetry. In most African societies an individual is non-existent without the community. The coming together of the community to welcome the newborn is indicative of the commitment to communal living, which is the essence of the traditional African way of life (Agulanna 2010).

The umbilical cord and the placenta are carefully handled and treated with great respect, signifying their value (biologically) as important part of an infant's life cycle. Burying of the placenta is seen as a life-giving ritual which symbolises the continuation of life. During this transition period, both the mother and child are said to be in a liminal space (Siwila 2015). The burial of the umbilical cord and placenta denotes connection to the ancestors or family lineage and mother earth. Put differently, burying the placenta connects the baby to the spirit world. It helps in preserving the child's destiny (Adatara et al. 2019). This is a special ritual which unites the members of the community. Their umbilical cord and the placenta which nurtured them as foetuses in the womb are buried in the same village.

The spirit of communal living and togetherness is also demonstrated in the *omugwo* ritual, whereby a new mother is cared for by her own mother, or mother in-law for a period of time. Other older female relatives also offer support by bringing food items as well as helping with house chores. This act of family and community support allows women the time to recover. This period of rest and recovery is a common practice in many cultures including Kenya and Tanzania (Bergsjø 1993), Nigeria (Igbokwe and Ahurumaraeze 2019; Kanu 2019; Chukwu and Ume 2020), and South Africa (Selepe and Thomas 2000). Evidence has shown that support given to new mothers has health benefits for women (Dennis et al. 2007; Dike 2019). In their systematic review of 51 studies carried out in more than 20 different countries, Dennis et al. (2007) found that organized support for the mother, periods of rest, recommended food to be eaten or avoided, hygiene practices, and infant care and breastfeeding are the postpartum period care or rituals which allowed "the mother to be 'mothered' for a period of time after the birth" (p. 487). These rituals facilitate the transition to motherhood and may have beneficial health effects for the women and their newborn babies (Umunna 2012; Beinempaka et al. 2015; Igbokwe and Ahurumaraeze 2019). Adequate support after childbirth has the potential of preventing anxiety, and by extension postnatal depression (Odinka et al. 2019). Migration has been acknowledged as presenting some challenges to the practice of the *omugwo* ritual (Dike 2019).

Most tribes believe that the circumstances surrounding the birth of a child also influence the name given to the child (Kanu 2019). Importantly, names are not only identity, but they also influence people's character and life in general. Some cultures consult the ancestors for assistance in determining what name best suits the child (Anyachonkeya 2014; Honkavuo 2021). Examples of pregnancy and birth rituals and reasons are presented in the Table 3 below.


**Table 3.** Some examples of pregnancy and birth rituals according to countries.

#### **9. Conclusions**

In this paper, we discussed rituals and embodied practices surrounding the start of life (pregnancy, birth, and early motherhood) in some African countries. Rituals are eloquent expressions of cultural beliefs and values passed on from one generation to another, and which have remained an ongoing and crucial aspect of African existence. Pregnancy and birth rituals are not only representative of an indigenous system of knowledge, but also

play a role in giving meaning to a people's ways of being. There are many documented benefits of pregnancy and birth ritual. While some of the rites and rituals facilitate safe birth and protect the mother and child from perceived evil powers, others offer the space for connecting with ancestral spirits. Crucially, birth-related rituals have spiritual connection, and they enhance togetherness, which is an important element of the African way of life. Women should be supported to observe the rituals that are beneficial to their health and that of their babies.

**Author Contributions:** Conceptualisation—M.O., writing—original draft preparation M.O. and C.A.: formal analysis M.O.; writing—review and editing M.O. and C.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

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

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### *Article* **Modern Teachers of** *Ars moriendi*

**Agnieszka Janiak <sup>1</sup> and Marcin Gierczyk 2,\***


**Abstract:** It is evident that a change is happening, a breakthrough, in perceptions of death; the next episode is being unveiled. After the stages Philippe Aries named *death of the tame* and then *death of the wild*, people today are finally experiencing the humanizing of death, which we call *sharing death*, whose influence is worth deep analysis. Our hypothesis is that today, *Ars moriendi*, meeting the needs of the dying, may be learned from the so-called death teachers, whose message is growing noticeably in society. This research shows a certain reversal of social roles that are worth noting and accepting. In the past, a priest was a guide and a teacher in the face of dying and death; today, he has the opportunity to learn *Ars moriendi* from contemporary teachers of dying, to imagine an empty chair standing by a dying person.

**Keywords:** priest; *Ars moriendi*; sharing death; death teacher

#### **1. Introduction**

One of religion's fundamental functions is the existential one. Each religious system facilitates facing existential dilemmas and provides tools to deal with the most incomprehensible and tragic aspects of human existence. J.M. Yinger, the American psychologist of religion, defines religion as "a system of beliefs and actions by which a community attempts to solve the most essential problems of human existence" (Yinger 1957; Piwowarski 1977, p. 14), among them dying, death and loss. In a classic work of thanatology, Vladimir Jankelevitch (1993) wrote that death has three aspects—three stages of initiation that successively reduce the distance between us and the mystery: (a) when we realize that everyone ("they") will die; (b) when we accompany someone's dying or experience the death of someone dear, we come to understand that "you" will die; (c) when I accept the fact that "I" will die.

Owing to our expectations of religion that are related to giving meaning to life and coping with our mortality, the status of a priest prevents him from stopping in front of this second curtain, forcing him to open it. A priest directly encounters illness, dying, death and grieving in his everyday life and work: by visiting hospitals or hospices, giving patients the sacraments, hearing confessions and facing such questions as "How could God have let it happen?", conducting funeral services, teaching in schools (in Poland), and dealing with grieving students who have suffered a friend's suicide, an accident, a teacher's death, etc. Always treated as a specialist on ultimate issues, a priest is obligated to make moral judgments in ethically blurred situations.

The reflections in this paper arise from ponderings over Christianity, but they have a universal dimension (Janiak 2019a). Despite the waning universal significance of religion, each has served important functions and duties toward the ill, the dying and the bereaving. **Research questions.** The research questions of this paper are the following:


**Citation:** Janiak, Agnieszka, and Marcin Gierczyk. 2021. Modern Teachers of *Ars moriendi*. *Religions* 12: 695. https://doi.org/10.3390/ rel12090695

Academic Editors: Joanna Wojtkowiak and Brenda Mathijssen

Received: 13 June 2021 Accepted: 24 August 2021 Published: 30 August 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

tion with death, and how?

The findings on the subject of *Ars moriendi* teachers are situated within the Polish cultural context and the Catholic Church. A consequence of utilising an auto-ethnographic perspective is the use of male pronouns when referring to spiritual leaders—in the Catholic Church, these roles are only available to men. However, the concept of *ars* moriendi is universal, referring to more than Catholic texts from the Middle Ages.

#### *1.1. Priest's Role in the Dying Process*

The priest's connection with dying and death is extremely multidimensional and demanding. It is related to contact associated with regular visits to the hospital ward, to nursing institutions, or to homes of people who are bedridden, old or dying. Furthermore, it also implies contact with mourners in the parish office; participation in funerals; confession of desperate orphans and potential suicides; religion lessons at a school where a parent, teacher or a colleague has committed suicide, or has fallen victim of an accident or an incurable disease. Each environment expects that the priest will express a clear, well-argued sentence about such ethical dilemmas as euthanasia, abortion and transplantation. These contacts are very demanding and emotionally burdensome. The priest will be able to meet the expectations when he knows how and will be aware how importance his presence and skilful accompaniment are.

A priest who wants to immerse himself or is simply thrown into the reality of an ill person can do a lot not only for the patient, but also for the family and their environment: neighbors and acquaintances. The illness is a special time—a trial for bonds, revision, prioritization, intensive giving and taking. Often, it is the priest who is granted the ethical right to indicate duties toward the patient, to encourage expressions of solidarity, closeness, love and to common prayer.

The art of living with the ill, the dying and those in need of consolation and compassion is, therefore, a kind of mission or mission of religion and its churches, it determines the charism of many religious orders (e.g., the Brothers Hospitallers of Saint John of God or the Camillians) and is clearly inscribed in the history of, e.g., the Christian Church. Historical data confirms the fact that the church is a precursor of activities for people in need; it started organized health care by creating hospitals, hospices and care centers for the sick and orphans. Councils and synods, e.g., the Cartagena Council (309 A.D.) or the Synod in Tours (567 A.D.) managed the construction of such centers at the churches where people in need, the ill and the widowed will be welcomed and looked after. Around 370 A.D., Saint Basil, bishop of Caesarea Mazaca in Cappadocia in what is now Turkey, created an institution called Basiliada that was a real care team with a clinic, a refugee unit, a hospital and a shelter for lepers. At the same time, various types of hospitals were created: "*xenodochio* (sheltering pilgrims, wanderers and refugees), *nosocomio* (a hospital), *orfanotrofio* (an orphanage), *gerontocomio* (a shelter for the elderly). [ ... ] The church must help the ill and try to give meaning to their suffering ('Is anyone among you ill?' Jas 5:14). The Church should contribute to creating favorable conditions for life; it should stigmatize every attempt to kill life, and prioritize the values of understanding, listening, service and love", as the first bishop of the Brothers Hospitallers of Saint John of God, Jose L. Redrado (2010, pp. 84–85) emphasizez.

Accompanying those confronting death has a long, beautiful, significant and inspiring tradition in the Roman Catholic Church. Recommendations for dealing with death were formulated in the so-called *Ars moriendi*, *Ars bene moriendi*, popular textbooks on "good dying", written in Latin, that appeared at the beginning of the 15th century. They had the dimension of practical manuals of appropriate behavior toward the ill, the dying, mourners and clergymen. They provided "a kind of simplified" catechism for the dying and the people accompanying them and, at the same time, a simple instruction on what and when to do and to say (Machinek 2009, p. 81).

Machinek, who quite often reflects on contemporary duties and the shape of the service to the ill and the dying, points out: "It is obvious that modern times cannot directly reach for late medieval treatises which were developed on the bases of the mentality of that era, as well as the challenges of those times" (Machinek 2003, p. 249). Nevertheless, he legitimately sees inspiration flowing from *Ars moriendi* to the present in three areas, if we look at the art of dying: the art of living, the art of communing with God (deriving from concern for eternal salvation and revision of the attitude toward the world in the face of death), and practical help for the dying and their loved ones (Machinek 2003, p. 249).

#### *1.2. Understanding Ars moriendi*

Thanatologists notice several clearly distinguished stages in the history of understanding and responding to death.

#### 1.2.1. Attitude of Acceptance—Living with Death

From antiquity to the mid-19th century, death was treated simply as a natural and necessary element of life, accepted as part of everyday life; the general attitude toward death was determined by the awareness that everyone would die. What is important is that death was considered an existential phenomenon with its own ontology; it was treated as an independent liminal event, very important, worthy of being experienced consciously, and not the last failed, shameful stage of disease. Death was a social act that hurt the entire community; it was a public, open and visible matter, included in the framework of the socializing cultural ritual that set the framework for encounters with death, approached not without fear, but without panic—*a tamed death* (according to Ph. Aries). Religion and tradition helped in the "survival" of death. This time could be considered an era of faith, with theology as the dominant discourse, focusing its attention on death as an eschatological and social event.

People "lived with death", adopting an accepting and religious attitude, seeing death as a spiritual transition and a key moment often decisive in attaining eternal life. The priest was always called to the ill and the dying: he was a person with the highest social authority, whose presence and administration of the Last Rites could ensure salvation. Prayer was the strategy adopted to deal with the threat of death, and the prospect of a future meeting in heaven was the comfort for mourners (and motivation to achieve salvation). The priest was an undisputed authority for the dying and their families, and he himself felt confident in this role not only because of social recognition of it but also, thanks to real, practical help concerning what and how to do in the face of dying, the help provided by *Ars moriendi* manuals.

#### 1.2.2. Attitude of Rejection—Negation, Tabboisation, Denial, Fighting and Escape

This attitude toward mortality changed in the mid-19th century through individualization, secularization and the introduction of life-support machines. The process of individualization liberated people from family and tribal relationships, led to social atomization, and contributed to awareness of the senselessness of the world and human existence in it. It became the goal to "be one's true self" instead of participating in the community and the rituals that gave it cohesion and durability. Social rituals to tame death—the vigil at the deathbed and then with the corpse; the funeral, wake and manifestation of mourning—provided a pattern of conduct in the face of death and pointed to the eschatological dimension of human existence. Without faith in God and comforting rituals, death became devoid of meaning, function, place and value, and nowadays we have managed to cope with its terror by making death absent, a social taboo. Secularization awakened a fear of the reality of non-existence or death-nothingness, while resuscitation techniques began the process of medicine's appropriation of death. In the face of death, professional medical knowledge was given authority. Death is identified with illness and has ceased to exist in social consciousness as an element of nature with its own existence. It has lost its metaphysical, sacred significance, becoming an exclusively medical event—an illness that could not be cured, the doctor's failure. This understanding of death was called, in contrast to tamed death, feral death (Aries 1974). It is death repressed from individual and social consciousness. As a result of this denial, "it goes feral" and fills

people with increasing fear and terror. There is a conspiracy of silence. Death becomes a taboo, a new category of obscenity. It is hidden; its reality is denied, as well as its existence. This widespread conspiracy of silence has been sanctioned by the functioning of hospital ideology.

The new era of biomedicne, which lasted until the mid-1980s, kept death under control. Death no longer constituted the liberation of the soul, but a failure of the body (Conrad and Schneider 1992). Ensuring health was solely the experts' job. A man who is not an expert does not have the right to his own death (or birth) (Woodward and Woodward 2020); he must hand it over to specialists (among whom there is no place for a priest) and institutions (Curtin 2019). Being born and dying in hospitals has eliminated the idea of home from our culture. Because people no longer die at home, but in hospitals or hospices, the dying—previously members of the community—become dying patients of the hospital (Gawande 2014). However, they are not the protagonists of this final act; the doctors are, and they are the ones who own all the knowledge on illness and dying, which they may or may not (or not fully) share with the patient. In the face of death, the doctor, not the priest, is given authority (Walter 1996b, 2017). Mourners, often deprived of the opportunity to say goodbye to their loved ones (who were supposed to recover, in their minds) as well as a socially accepted and supported right to mourning, are offered sedatives and the advice to see a psychologist. Mourning, therefore, is considered a disease that should be cured by experts and isolated so that the sadness does not disturb other people.

#### 1.2.3. Attitude of Companionship—Raising Awareness; Living with the Dying

In the history of changes in attitudes related to death, another breakthrough is taking place as humanity has entered the next stage contributed by the publication of "On Death and Dying", by Dr. Elisabeth Kübler-Ross (1969), as well as Cicely Saunders's opening of the model hospice of St. Christopher in London in 1967 and her intense activity to popularize the hospice movement. "In the years immediately after World War II, good hospice care primarily meant concentration in the spiritual and psychological area. The initiator of this movement was Dame Cicely Saunders. In practice, this meant being with the patient, listening to them, understanding and respecting their dignity and meeting existential needs. With the increasing involvement and participation of medical staff, it turned out that the medical aspect of hospice care needed to be changed" (de Walden-Gałuszko 2011, pp. 197–201). The emergence and increase of hospices as places where help in dying is provided without unnecessary suffering (physical, spiritual and mental) overturned the taboo of dying and restored death to its due place in social space.

Since the 1970s in the United States and the mid-1980s in Europe, appeals and initiatives have advocated restoring the repressed awareness of death and *the right to face death in all its significance.* The postulate of the so-called ethics of care was formulated, in which the doctor's main ethical concern as not to fight ruthlessly for life, but to care for the dying. A new specialty emerged—the doctor of terminal care and then palliative medicine—and the conspiracy of silence was broken. The doctor is now obliged to inform the patient about a lethal prognosis (Article 17 of the Polish Code of Medical Ethics). At that same time, a scientific subdiscipline called death anthropology or humanistic thanatology was established in France and United Kingdom.

Dying, however, has not regained its public dimension, but has become a kind of personal death (Walter 1996b) that loved ones, in the age of Covid, even allow. What becomes public and generally available is the reflection on the intimacy of death, and on the importance to the dying of individual accompaniment; an indication of effective social communication tools in death; and the promotion of courage in undertaking this existentially significant act of intimate presence and being open to other people.

The answers that contemporary culture gives to the difficult question of how to die, we can concisely sum up in three phrases:


#### 3. Where and when you want, I'll take care of it.

It's important to point out that these three approaches are not isolated events. Although their prevalence is arranged in the order of succession (each of them dominates at a certain time), the emergence and dissemination of a specific attitude does not assume the disappearance of the attitudes preceding it. One should fully bear in mind, remembering about Weber's ideal types, that these attitudes are co-occurring today.

#### **2. Materials and Methods**

#### *2.1. Purpose of the Study*

This paper pursues two goals: the first is to encourage clergy members and strengthen them as teachers of dying. The second one is to reconstruct the figure of a modern teacher of dying. The humanizing of death movement, whose history goes back 70 years, has its teachers whose actions and social significance are promoted and strengthened by the media. Theoretical inspirations for reconstructing the figure of the contemporary teachers of death are found in the theses related to compassion, internal development and authority, especially among concepts of Martha Nussbaum, Margaret Archer and Carl Rogers.

#### *2.2. Theoretical Framework*

The concepts presented in the paper are based on observations, reflections and the textual analysis of the content of statements from those we call dying teachers. The figure of the teacher of dying first came to mind from our own experience. Our friend Kasia unexpectedly learned on the 27th of December 2016 that she was incurably and terminally ill, and painkillers were all that modern medicine could offer her. Kasia died on 20th of April; she was 49. She died at home, conscious, prepared, holding her children's hands, in the presence of all those closest to her. We had the honor and privilege of constantly accompanying Kasia during her illness, dying and the moment of her death.

Kasia was very active; she also practiced nordic walking. Every day we went to her, even for 15 min—to the hospital or her home—with the so-called stationary nordic walking. I brought in a thermos for special tea and lovely cups; we had "picnics on the quilt". We treated the therapy with a laugh. We dared our friends and neighbors—62 people—to go to Kasia for a prayer of constant hours every evening. We organised volunteers to do shopping and healthful cooking, make short daily visits and take Kasia to the doctor comfortably by car. Kasia let us into her privacy; she opened her home and then allowed us into her intimacy-helplessness and tearing off the dignity of the disease. We were aware that we were attending something great, the most important stage of life.

We attempted to make some sense of our experiences and to understand the question that life itself had presented us—how it was possible (and thanks to whom) that we were able to accompany Kasia during her journey towards death; an objective tragedy became one of the most cultured and beautiful existential experiences we had ever had. The autoethnographic approach led us to treat this moment as a call to action, something in need of understanding.

So, the conceptual starting point was our experience of confronting our friend's death, wanting to come to terms with its purpose: finding understanding, control and utilization from something that feels senseless. This biographical imperative led to the adoption of an autoethnographic research strategy. Autoethnography is a method used in qualitative research (Ellis 2004). Autoethnography is a research strategy (also widely regarded as a paradigm or, in turn, narrowly as a research technique) that finds and marks the person's place in the space of scientific exploration (Richardson 2000). Autoethnography is the opposite of directed theory, or a method of testing hypotheses based on positivist epistemology. In this sense, Laura Ellingson and Carolyn Ellis see autoethnography as a project of social constructivism that rejects the deeply entrenched dichotomy between researcher and subject, objectivism and subjectivism, process and result, self and others, art and science, and the personal and political (Ellingson and Ellis 2008).

Our autoethnographic process involved a few stages:


#### *2.3. Methodology*

Using the analytical autoethnography, we would like to point out (without analyzing and discussing) the situational factors, personality patterns and social competence needed in the three stages of the process of becoming a death teacher: experience, reflection, involvement. They have been constructed on the bases of books, personal testimonies, blogs and vlogs, interviews and media talks of those we treat as *modern death teachers*. The general reflection on the change in attitudes toward dying, death and mourning, as well as the expectations toward clergymen presented in the introduction, has been constructed largely based on research the first author has been conducting in Poland and USA. This work represents an analytical autoethnography in which it is assumed that the researcher conducts a reflective analysis of the group or social system of which he is a member. This type of autoethnography is best geared towards understanding broader social phenomena through theory (Anderson 2006); in the context of this study, information from the dying, as well as death teachers was paramount. We realise, like other researchers (e.g., Kacperczyk 2014; Kafar 2010), that there are many possible paths to acquiring knowledge, many paths to reach "understanding"—such as through art, shared experiences, poetry, film or working together.

#### **3. Results**

#### *3.1. Stage of Humanization of Death*

Paying attention to the stage of humanization of death, Walter (1992) gives credit to contemporary psychologists in this regard. Speaking of the secularization of the approach toward death and mourning, he uses an eye-catching, concise formula—*from theology to psychology* (Kubiak 2014, p. 30)—and advocates eliminating the eschatological dimension of death in the modern approach, replacing the theological reference with psychological one (Curtin 2019; Woodward and Woodward 2020). This thesis, however, seems too radical and unverified by the practice of social behavior in the face of death.

In Poland, a priest is asked far more often than a psychologist to accompany the dying—not because of tradition, but rather because the argument is that, at the end of life, greater peace of mind may be obtained not by psychotherapy which mainly proposes an analysis and expression of emotions in the course of a long-term therapeutic process, but thanks to religion, which helps forgive and accept one's fate. Kilpatrick, a psychologist of religion, points out:

[ ... ] a real test for a given philosophy or way of life is not whether they can alleviate the pain, but what they say about pain they cannot alleviate. This is where, I believe, psychotherapy turns out to be insufficient, and we find support in Christianity because from the point of view of psychology suffering has no meaning, while from the Christian point of view it means a lot (Kilpatrick [1983] 1997, p. 205).

#### *3.2. Religion and Psychology*

The relationship between religion and psychology has been subject to numerous discussions. To achieve *the art of co-existence* with the dying and their families, it seems a complementary attitude works much better than a confrontational one. Psychology focuses on human emotional well-being, theology on the transcendental sphere. It is easier, then, to be effective in religious service when this emotional well-being is taken care of in advance. A priest is not equivalent to a psychotherapist, but his knowledge of emotional states and

attitudes of suffering people will help him predict reactions, significantly facilitating or even enabling a satisfying relationship with the ill and their loved ones. Analogously, a psychologist or psychotherapist can help suffering people only when, apart from their experiences, emotions and beliefs, they take into account their spiritual life, faith, hierarchy of values and dilemmas of conscience.

In the spheres of sociological, psychological and healthcare researach, spirituality as a concept has been receiving increased attention over the past few decades. Two important factors in maintaining health and longevity are spirituality and religious coping. They also become important during the recovery process (such as from traumatic stress), during chronic and terminal illnesses, and during bereavement (Campesino and Schwartz 2006). In the Catholic faith, "spirituality" is used to mean living out the Christian way of life with fervor; though it is easy to see that not everyone in the same faith follows the same path.

There have been a variety of definitions used to characterise and express the boundaries of spirituality, including "the best of that which is human", seeking answers to existential questions, and the transcendent human dimension (Zinnbauer and Pargament 2005). True spirituality must be understood as something more than moralism or humanism, rather its main purpose is to help people develop a meaningful relationship with God (O'donnell 1982). Further research has shown to psychologists and other social scientists the importance and potential implications of spirituality for human functioning (Pargament and Mahoney 2012).

Father Lucjan Szczepaniak, a chaplain at University Children's Hospital in Kraków, emphasized some the phenomenon of depriving a priest of a particular role:

It is [ ... ] tempting to reduce the mission of a priest bringing God to the ill to the role of a sad comforter lost among people overwhelmed by suffering. A man seen as burdened by God with the encumbrance of his misunderstood priesthood. Embarrassed the cruel accusation of God whom he must continuously defend. Someone who has stopped confessing and giving Christ's body to the ill, but now only hears informal confessions and holds people's hands, if he has not abandoned his duties yet (Szczepaniak 2010, p. 73).

It is worth emphasizing a certain paradox. The clergyman's social status has weakened nowadays; the priest's authority has been questioned and is no longer granted by virtue of tradition or a shared religious worldview. Meanwhile, the expectations of the ill, their families and caregivers, or, in the case of a hospital or hospice chaplain, by members of the staff and therapeutic team; visitors and all those ones confronted with someone's dying have expanded. Among the difficult and obvious tasks a priest is expected to perform is to be an insightful theologian prepared to answer all the "why" questions, able to recognize and satisfy the spiritual and religious needs of those under his care and, if necessary, to summon an Orthodox or Protestant clergymen "to meet the ill and their family together. There is no better example of ecumenism than a meeting with the Bible in hand by the patient's bed" (Szałata 2010, p. 37).

Clergymen are also expected to be able to diagnose and alleviate spiritual suffering, for families and medical staff members as well as the dying; to be sensitive to and report symptoms of physical pain and discomfort; to know the patient's rights and make sure that they are observed (e.g., a privacy screen during nursing activities), to counsel the patient; to relieve tension and improve communication between the dying, their family and staff members; to know how to comfort others and give them hope. Łuczak, researching expectations among doctors and nurses, also stresses that "the range of activities of a chaplain—a clergyman [ . . . ] increases, as not only a 'soul' doctor, but also a confidant of the ill and their relatives, helpful in relieving somatic, mental and social suffering" (Łuczak 2010, p. 16).

What behavior is expected from a priest? Listen and hearing messages, including the nonverbal (gestures, body positions); being kind, cheerful and smiling; being always available; taking his time; being calm and composed, understanding the patient's needs and being forgiving, not moralizing and judging; not acting automatically or falling into a routine; being discreet; making contact easily; being able to remain silent. Among the features of a hospital chaplain expected in Poland, Archbishop Grzegorz Rys emphasizes:

He must be there for every patient, but also respect the attitudes of non-religious people and atheists. His ministry should concern not only the patients themselves (preferably before their hospitalization) but also their families, as well as doctors, nurses and the entire hospital team. Therefore, he must be a competent theologian, but also a priest more predisposed to the role of a spiritual guide; a man of deep prayer, but also easily establishing contact and open. He is expected to be available and generous when it comes to time and energy; to administer the sacraments, but also to operate the hospital chapel and run a library for the patient [and then be ready to initiate or engage in conversations about read books [complemented by A.J.]. He is to be a witness of faith: it would be good if his first contact with the ill did not concern sacramental (or even religious) matters; for example, he should be interested in the patient's living situation (Rys 2010, p. 97).

This list of expectations shows how important it is to look for places or people who will teach others how to meet them—not to bend under them, but to take into account their versatility.

Not every priest is suited to being a hospice chaplain, to let contact with powerlessness, suffering, illness, death and despair fill his days, and often nights. Not everyone has what Father Krakowiak calls *the Samaritan calling in his calling* (Krakowiak and Janowicz 2012, p. 155). However, almost anyone can learn to accompany the dying "painlessly" when it is one of the aspects of his work—maybe even every day—but not the only one.

#### *3.3. Death Teachers*

People we consider to be contemporary *death teachers* or *teachers of dying* work publicly, using various media and accompany the dying, or are fatally ill themselves, to propagate and (re)definine *Ars moriendi*. They use the media and are supported by them—especially blogs and vlogs, public interviews and media talks. Among them are, Bronnie Ware (https://bronnieware.com, accessed on 23 August 2021), Hunter 'Patch' Adams (https:// www.patchadams.org, accessed on 23 August 2021), Kathryn Mannix (@drkathrynmannix), Atul Gawande (http://atulgawande.com, accessed on 23 August 2021), Agnieszka Kaluga (http://www.zorkownia.pl, accessed on 23 August 2021).

They have become *teachers of dying* through intense professional contact with the dying and the mourning, on which they reflected and which they treated as an educational experience. Teachers of dying all take part in the helping profession, which can be defined as work in a constant, hands-on close contact with people, specifically those who require personal support in regard to existential questions and problems. Amongst their many responsibilities, it is important to point out that constant contact with the sick, dying and grieving requires a specific skillset.

They came to realize they had learned from the dying something significant, important and fundamental. Because of the importance of this experience and their conviction about its relevance, they became engaged in social education. Theoretical inspirations for the reconstruction of the contemporary death teachers are found in the theses related to contemporary categories of compassion, reflexiveness and authority, especially among these concepts:


and social life. It is humans' ability and duty to reflect on their emotions and ways to work effectively in the society.

• The pedagogy of Lech Witkowski (2011), whose monumental and erudite books *Stories of authority towards culture and education* and *Challenges of authority in social practice and symbolic culture* are devoted to pedagogical aspects of authority, understood as inspiration for in-depth reflection and mobilization to engage and inspire action.

There is a characteristic chain of alternation between educational and pedagogical roles: the dying (or mourner) becomes a teacher for the accompanying physician, caretaker or volunteer, and that student in turn becomes a teacher for the community, finding an audience for his message in lectures, interviews, books, articles and blogs. Kübler-Ross writes in her autobiography:

My dying patients taught me so many things other than—what's the feeling when you die. They gave me a lesson on what they could have done, what they should have done, and what they did not do until it was too late ( ... ). They looked back at their life and taught me everything that matters, but not in the context of dying . . . of living (Kübler-Ross [1997] 2000, p. 172).

Kathryn Mannix (2018) refers to this as a reinterpretation of a world that seemed fully known: when working with confused people, we can distance ourselves and hear their expressions of worry and hope. This allows those who work with people whose plight may seem hopeless to take a step back and see that for a dying person, life is still purposeful and valuable. Around the bed of a dying person, we can meet people who discover each other and find strength in their mutual closeness. We can also witness the emerging community between strangers in a hospital or hospice, who are connected by deeply emotional experiences of the end of life.

Another factor worth mentioning is complementarity, or the bringing together of formal and informal supervisors. The priest, the chaplain and the psychologist not only complete the goals and duties set beforehand, and do it with full empathy, but also work "extra hours". The informal supervisors are treated as professional because of their experience. Ware is presented as a nurse, although formally she is not:

I went through two quick courses. The first one taught me how to clean my hands, the second one how to help the ill and the disabled to get up. That was pretty much all my training before I became a nurse. Giving me the role of Stella's supervisor, my boss advised me to not tell the family that I only had experience with one palliative patient. She believed in me. So did I (Ware 2016a, p. 37).

It is worth noting that death teacher is a kind of profession in which there must be multitasked engagements—even at the risk that the teachers will lose their own family life. Nevertheless, the death teacher's status is open, available to everyone but requiring some social skills. Apart from the biographical experience and the attitude of *the reflective practitioner* (the concept of D. Schon and C. Arygyris), the requirements for a death teacher also include personality patterns and social competence. The personality patterns often comprise such characteristics as independence; full autonomy (or even unconventionality) in thinking and acting; vigor and resistance to failure. Social competence necessary for the death teacher consists of empathy; accompaniment (and its derivative, patience); listening, communication with a touch and a smile.

*Listening:* Listening, we learned that all the dying patients knew they were dying. And it was not the question "Shall we tell them?" or "Do they know?" The only question we can ask ourselves is: "Can I listen to them" (Kübler-Ross [1997] 2000, p. 124).

*Communication with a touch:* During consultations, we would sit on the patients' beds, hold their hands, and we talked and talked for hours. We learned that there is not a dying person who would not need love, touch and talk. The dying patients did not like the safe distance the doctors are used to keeping in their presence (Kübler-Ross [1997] 2000, p. 124).

*Smile:* A smile, an axiological declaration of friendliness and, at the same time, a meeting of faces (Kaluga 2014).

This personality pattern and social competence prove necessary in contact with the dying, but they also determine the carrying capacity of later social learning activities. What do the contemporary teachers of death teach us? What are their basic functions? The most obvious thing they teach is the ability and courage to accompany and the benefits of restoring the customs of mutual help.

#### **4. Discussion**

The movement to humanize death has its teachers and researchers. The death teachers are breaking the taboo, although they are still not making it a public matter. Even though death is not something embarrassing, to be overlooked and denied, there is still a notion of emphasizing its individuality and intimacy. Death, then, is still not entering the stage of public attention, but is rather becoming a kind of private death (Walter 1996a). The public stage, widely mentioned by the teachers of death, is the contemplation of the intimacy of death (Kubiak 2014, p. 43) writes about *placing an individual experience in the central place*.

Since 1991, Tony Walter, the founder of Centre of Death and Society at the University of Bath, has continuously emphasized the importance of this stage in humanizing death, giving credit to contemporary psychologists. The research about *sensitive communication* the first author has been doing since 2012 has aimed to verify the hypothesis that, arguably, more credit for the humanization of death from the psychology of mourning, "psychological expertise on grief", focused on minimizing the regret about living—brought and referred to "reflective practitioners", or teachers of death. Additionally, the first author's preliminary study points to our belief in their empirical knowledge and direct experience easily applied to social and individual practice.

In Poland, the priest is one of the professions that we expect to become a teacher of dying. One of, but not the only one who can and should become a teacher of dying, but is simply someone whom society expects to take on that role, knowing that priests have customarily fulfilled this role in the past. The contexts of religion often lead to priests being seen as the foremost experts on dying, seeing as how it is discussed in both religious texts and practices (across many religions); however, there are also secular groups and societies who have developed their own practices separate from religion, though they are not the focus of this text like: teachers, pedagogues, doctors, nurses, psychologists, social workers, court officers—in other words, those who we believe have felt the call to fulfill a certain profession—and society expects many things from them.

This research shows a certain reversal of social roles that are worth noting and accepting. In the past, a priest was a guide and a teacher in the face of dying and death; today he has the opportunity to become a student in modern *schola mortis* and is expected to take it. He has the opportunity to use an important media message—to learn *Ars moriendi* of contemporary teachers of dying, to imagine an empty chair standing by a dying person. That chair is waiting for him.

And although the social status of a clergyman has weakened—his authority questioned and no longer granted to him by tradition or a shared religious worldview—in the face of dying, the priest, using the message of contemporary teachers of dying, can and should ultimately become the teacher and companion of death. What we believe priest needs are preparation and courage: preparing and gaining confidence in contact with the ill and mourners; reducing stress resulting from his special job profile (frequent contact with illness, dying, death, mourning); recognizing and reworking emotions caused by this contact; equipping himself with methods and tools effective in communication with the ill, dying and mourners; replacing the paternalistic attitude with an attitude of partnership (resulting from the so-called care ethics); increasing the quality of dying and the satisfaction of skillful accompanying in dying that a priest may experience.

#### **5. Conclusions**

Responding to the two research questions posed at the beginning of this study, it can be said that contemporary attitudes towards death are changing, due to the increasing

push to humanize the dying process, oftentimes through the help of teachers of dying, who utilize physical communication and listening as resources that ease their patients' confrontations with death. People today are finally experiencing the humanizing of death, which we call *sharing death* (Janiak 2019a, 2019b). We define the term *sharing death* from two perspectives. First, from the perspective of a researcher in pedagogy, by sharing death we consider the appearance in the social space of many group activities relating to dying, accompanying and mourning, which perform functions focused on:


There are social actions, initiatives which fulfill the function of changing general awareness by improving social communication—giving people social communication tools effective and helpful in keeping contact with the dying and the mourning such as e.g.,: D2KDay (Dying To Know Day); TalkDeath.com; Death Café; Death Over Dinner. Educational activity is related to the importance of having accompaniment in dying, the awareness of the needs of the dying and the mourning, and the ways in which they may be satisfied, the patterns of behavior in the face of death.

Social actions and initiatives which promote social interest and are designed to facilitate social interaction: the extension of the labour market, bridging the gap (careers in death), making testaments of will, five wishes and aging with dignity, end-of-life decisions, End-of-Life University, donating our body, funeral pre-planning, green funeral trends like: water cremation (aquamation); greener flame cremation; body and tissue donation facilitation. In preparation of dying, there is a potentially important new form of community-based caregiving that may help those in need: end-of-life doulas (Krawczyk and Rush 2020). This new phenomenon, alongside the above-mentioned social initiatives, seeks to ensure that the wishes of the dead and dying are honoured (both spiritual and practical) and that conversations surrounding these topics are normalised (Jacobsen 2021).

The second perspective, as a researcher in cultural studies, find that by *sharing death* we understand such an attitude towards dying, which can be called, as Tony Walter (1996b, 2017) described it, living with the dying, taking into account and meeting the individual wishes of the dying and of the mourners. The animators and the promoters of this attitude are our teachers of dying.

So the term, the phrase *sharing death* has thus got a double meaning: It means the desire to accompany the dying and the mourning, on their terms, focusing on meeting their individual needs and being opened to death education—educational readiness, willingness to learn how to do it. This desire arises or is likely to implemented thanks to the appearance of the teachers of death.

It is also worth underscoring that contemporary teachers of death are recognized as those who publicly accompany the dying or terminally ill, promoting and (re) defining ars moriendi. Through the autoethnographic method, the authors identified three stages of the process (experience, reflection, commitment), situational factors, personality pattern and social competencies (such as openness to a meeting, accompanying, listening, communicating by touch) necessary to achieve the status of a death teacher. In addition to their social application, the activities of such people as Elisabeth Kübler-Ross, Bronnie Ware, Atul Gawande, Kathryn Mannix, Agnieszka Kaluga, Rev. Jan Kaczkowski, are also valuable in educating and contributing to the contemporary phenomenon of humanizing the experience of death (Neumann 2016; Butler 2019). The authors' research background one, a cultural expert and the other a pedagogue—allowed them to identify emerging social and cultural phenomena related to attitudes towards death through the use of an autoethnographic strategy, in which their experiences became a way of understanding the social world of people confronted with death and "a tool for analyzing the relationship between their experiences and broader social structures and processes" (Aull Davies 1999, p. 185), such as the humanization of death or the attitude of shared death, and the figure

of the death teacher. In our case, we found that autoethnography is a practical tool for changing the world. Reconstructing the figure of the teacher of dying has a dual social application intended by the authors: first, to encourage priests to take advantage of the education they offer, learn to accompany, listen and respond to the needs of the dying and mourners. Second, it is to embolden ourselves, to blunt the edge of the fear of death. It seems that when we find ourselves in need, we can easily find in our surroundings someone who is willing to teach and may even share in our experience. Just like we shared our friend Kasia's dying experience.

#### **6. Limitation**

This study, conducted as a qualitative paradigm, refers to the assumptions of social constructivism. Utilising this kind of paradigm, there is no 'ultimate truth' to be gleaned from the researched phenomenon. The study results are specific in nature and cannot be used to generalise about a whole population, nor are they representative of society (Shenton 2004). The knowledge obtained refers solely to teachers of dying and their role in society and cannot be divorced from its context.

**Author Contributions:** Conceptualization, A.J. and M.G.; methodology, A.J.; writing—original draft preparation, A.J.; writing—review and editing, M.G. All authors have read and agreed to the published version of the manuscript.

**Funding:** The research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

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

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