Perinatal loss in low-income African American parents

Parent decision making for life support for extremely premature infants: from the prenatal through end-of-life period

Most deaths of extremely premature infants occur in the perinatal period. Yet, little is known about how parents make life support decisions in such a short period of time. In the paper, how parents make life support decisions for extremely premature infants from the prenatal period through death from the perspectives of parents, nurses, and physicians is described. Five cases, comprised of five mothers, four neonatologists, three nurses, and one neonatal nurse practitioner, are drawn from a larger collective case study. Prenatal, postnatal and end-of-life interviews were conducted, and medical record data were obtained. In an analysis by two research team members, mothers were found to exhibit these characteristics: desire for and actual involvement in life support decisions, weighing pain, suffering and hope in decision making, and wanting everything done for their infants. All mothers received decision making help and support from partners and family, but relationships with providers were also important. Finally, external resources impacted parental decision making in several of the cases. By understanding what factors contribute to parents' decision making, providers may be better equipped to prepare and assist parents when making life support decisions for their extremely premature infants.

Model for the First NIH-funded Center of Excellence in End-of-Life Research

Centers of excellence are widely acknowledged as a mechanism to promote scientific advances in a particular field of science, but until recently there have been no end-of-life or palliative care research centers funded by the National Institutes of Health (NIH). The purpose of this article is to describe aims, framework, and organizational structure of the first NIH-funded Center of Excellence on end-of-life research, the Center for End-of-Life Transition Research (CEoLTR), and the advances in end-of-life research that the CEoLTR will facilitate. The teams of researchers involved in the CEoLTR have grown impressively since it was funded in 2007. Collectively, the teams are on target to accomplish all of the original goals for this five year award.

Interconception care for couples after perinatal loss: a comprehensive review of the literature

Perinatal loss can be emotionally devastating for couples who experience miscarriage, fetal or neonatal death. Nurses in a variety of settings can assist couples through their grief by providing emotional support, giving information about the grief process, and in planning for a future pregnancy or deciding to forego future childbearing. This article explicates the relationship between grief and perinatal loss and its effects on couples, specifically in the interconception period, when the initial grief and distress have begun to subside. Interconception care focuses on bridging the couple from the end of the postpartum period to the subsequent pregnancy or decision not to conceive again. Nurses assist couples in distinguishing between uncomplicated grief, complicated grief, and depression, and make appropriate referrals. Openness to expressions of grief, helping couples mobilize support, considering readiness for another pregnancy, and directing couples to useful Internet sites are essential nursing interventions.

Supporting parents' decision making surrounding the anticipated birth of an extremely premature infant

Parents who are at risk for giving birth to an extremely premature infant, defined as 22 to 25 weeks' gestation, can find themselves faced with urgent treatment decisions for their unborn infant that have life-altering consequences. Despite the recommendation for involving parents in decision making for these infants, there is limited evidence regarding guidelines for involving parents. In this article, we describe a case from a larger collective case study that examines the decision making and the decision support needs of parents regarding life support decisions made over time (prenatally and postnatally) for extremely premature infants from the perceptions of parents, physicians, and nurses. For this case study, we describe decisions that were made during the antenatal hospitalization of the mother whose infant was stillborn, the support the parents received, and advice for healthcare professionals for improving care to families. For this case, the mother and father, a physician, and 2 nurses were interviewed before the birth of the infant. The findings in this case study demonstrate the importance of the nurse being present when information is given to parents, of informing with compassion, and helping parents to understand treatment options and decisions.

Effectiveness of bereavement interventions in neonatal intensive care: a review of the evidence

The provision of bereavement care is an important part of neonatal intensive care. This systematic review of the effectiveness of interventions to support families and facilitate emotional adjustment following the death of a baby suggests that, while these are largely appreciated by parents who have participated in research, there has been little rigorous evaluation of their effectiveness. This review reflects on possible reasons for this; for example: NICU-led bereavement care is changing, the effectiveness of bereavement care is difficult to measure, concepts of effectiveness are not static, and ethical concerns complicate experimental research. Bereavement interventions are compassion-led and generally considered to be beneficial. New research questions and new methodological challenges are discussed with reference to two examples of evolving practice: bereavement photography and the use of ritual. Future research using innovative and sensitive RCTs and consensus amongst relevant stakeholders is suggested.

Events after stillbirth in relation to maternal depressive symptoms: a brief report

BACKGROUND

Actions taken after a stillbirth can affect long-term psychological morbidity. Our objective was to study how infant bonding and maternal actions after stillbirth are associated with ensuing depressive symptoms.

METHODS

Using the population-based Swedish Medical Birth Register, we identified all 380 Swedish-speaking women who gave birth to singleton stillborn infants in Sweden in 1991. Of these, 314 (83%) completed a postal questionnaire 3 years after the stillbirth. Items included actions taken to bond with the baby and demographics. The association between care-related factors and later maternal depressive symptoms was quantified using relative risks estimated using multivariable regression.

RESULTS

We observed an almost sevenfold increased risk of depressive symptoms for mothers who reported not being with their babies as long as they wished (adjusted risk ratio [RR] 6.9, 95% CI 2.4-19.8). Compared with women who became pregnant again within 6 months, those with no later pregnancy were at higher risk of depressive symptoms (adjusted RR 2.8, 95% CI 0.9-8.4). In addition, compared with women who experienced a stillbirth in their first pregnancy, stillbirth occurring with an infant who was third in the birth order was related to a twofold risk of elevated depressive symptoms (adjusted RR 2.2, 95% CI 0.8-6.4). Furthermore, stillbirth occurring in a fourth or later pregnancy was associated with an almost sevenfold risk of depressive symptomatology (adjusted RR 6.7, 95% CI 2.2-20.5). No evidence of an association was found between other care-related actions and subsequent maternal depressive symptoms.

CONCLUSIONS

Our results suggest that a mother being with the stillborn baby for as long as desired and the birth order of the stillbirth may influence her later depressive symptomatology. Compared with mothers who became pregnant again within 6 months, those who did not have a subsequent pregnancy were at higher risk of depressive symptoms at 3 years' follow-up.

Normalizing the changes experienced during each trimester of pregnancy

In this column, the various physical changes that may occur during each trimester of pregnancy are introduced in an activity that involves participants in childbirth education classes or in a waiting room of a prenatal care clinic. This lesson is intended to educate and reassure women of the normalcy of the changes they may experience throughout a pregnancy.

Hospital Care for Parents After Perinatal Death

OBJECTIVE

To systematically review parent experiences with hospital care after perinatal death.

DATA SOURCES

An evaluation of more than 1,100 articles from 1966 to 2006 was performed to identify studies of fetal death in the second or third trimester and neonatal death in the first month of life.

METHODS OF STUDY SELECTION

Studies were limited to those that were in English, evaluated care in U.S. hospitals, and contained direct parent data or opinions.

TABULATION, INTEGRATION, AND RESULTS

Results were compiled on five aspects of recommended care: 1) obtaining photographs and memorabilia of the deceased infant, 2) seeing and holding the infant, 3) labor and delivery of the child, 4) autopsies, and 5) options for funerals or memorial services. Sixty eligible studies with over 6,200 patients were reviewed. In general, parents reported appreciating time and contact with their deceased infant, being given options about labor, delivery, and burial, receiving photographs and memorabilia, and having appropriate hospital follow-up after autopsy.

CONCLUSION

Although care after perinatal death often adheres to published guidelines, substantial room for improvement is apparent. Parents with perinatal losses report few choices during labor and delivery and inadequate communication about burial options and autopsy results. Hospitals, nurses, and doctors should increase parental choice about timing and location of delivery and postpartum care, encourage parental contact with the deceased infant, and facilitate provision of photos and memorabilia.

Psychological aspects of perinatal loss

After perinatal loss, parents experience painful grief. Fathers and mothers show the same pattern of symptoms, but generally mothers' distress is more intense. Grief should be sympathetically acknowledged by health professionals, and parents should be reassured that their feelings are normal and that recovery may take many months. Intense depression lasting more than 6 months may require psychological treatment. There is some evidence that delaying conception for a year may allow an easier pregnancy psychologically. The common practice of encouraging parents to have contact with a dead infant is not evidence-based and may have adverse effects, including inducing symptoms of post-traumatic stress disorder. A protocol of postnatal follow-up allows parents to get appropriate information about the loss, including possible problems and timing of another pregnancy. The subsequent pregnancy is stressful, and health professionals should recognize that parents may suffer significant anxiety.

Navigating care after a baby dies: a systematic review of parent experiences with health providers

INTRODUCTION

Health care providers are on the front lines of care when a baby dies, but there is no consensus about which behaviors are most helpful or harmful for families.

MATERIALS AND METHODS

This systematic review of more than 1100 English-language articles from 1966 to 2006 addressed fetal and early infant loss and extracted information about interactions with health providers.

RESULTS

Sixty-one studies, covering over 6000 parents, met criteria. Nurses were generally viewed as more emotionally supportive than physicians. Parents valued emotional support, attention to mother and baby and grief education. Avoidance, insensitivity and poor staff communication were the most distressing behaviors encountered.

DISCUSSION

Interactions with health providers has profound effects on parents with perinatal losses. Grieving parents perceive many behaviors to be thoughtless or insensitive. Physicians and nurses may benefit from increased training in bereavement support.

Perinatal loss: a family perspective

Perinatal loss is a profound experience for childbearing families. Examples of perinatal loss include miscarriage, ectopic pregnancy, stillbirth, neonatal death, and other losses. Perinatal loss engenders a unique kind of mourning since the child is so much a part of the parental identity. Societal expectations for mourning associated with perinatal loss are noticeably absent. Gender differences in response to such loss, as well as sibling and grandparent grief have been identified in the literature. Descriptive studies provide information on cultural responses to perinatal loss. Nursing interventions have been refined over the past two decades as research studies have been performed, in order to more fully promote health and healing in the face of perinatal loss. These include helping to create meaning through the sharing of the story of parental loss, the facilitation of sociocultural rituals associated with loss, the provision of tangible mementos, sensitive presence, and the validation of the loss. Outcome evaluations of such interventions are recommended.

Enacting a theory of caring to recruit and retain vulnerable participants for sensitive research

The recruitment and retention of research participants always presents challenges to researchers. This process is made more complicated when the research being undertaken is socially sensitive and the populations of interest are considered vulnerable. The purpose of this article is to illustrate how Swanson's middle-range theory of caring can be used as a framework for recruitment and retention for studies on sensitive topics that involve vulnerable participants. We provide an overview of the theory as well as illustrations from three separate studies that involved in-depth interviews with vulnerable participants. These studies included parents who had either experienced the death of their infant or were involved in life support decisions because of potentially giving birth to an extremely premature infant (22-25 weeks gestation).