"Getting it right when it goes wrong - Effective bereavement care requires training of the whole maternity team"

Good practices in perinatal bereavement care in public maternity hospitals in Southern Spain

OBJECTIVE

To assess the attitudes and care practices of midwives and nurses in the province of Granada in relation to death care and perinatal bereavement, to determine their degree of adaptation to international standards and to identify possible differences in personal factors among those who best adapt to international recommendations.

DESIGN

A local survey of 117 nurses and midwives from the five maternity hospitals in the province was conducted using the Lucina questionnaire developed to explore professionals' emotions, opinions, and knowledge during perinatal bereavement care. Adaptation of practices to international recommendations was assessed using the CiaoLapo Stillbirth Support (CLASS) checklist. Socio-demographic data were collected to establish their association with increased compliance with recommendations.

FINDINGS

The response rate was 75.4%, the majority were women (88.9%), with a mean age of 40.9 (SD=1.4) and 17.4 (SD= 10.58) years of work experience. Midwives were the most represented (67.5%) and reported having attended more cases of perinatal death (p = 0.010) and having more specific training (p<0.001.) Of these, 57.3% would recommend immediate delivery, 26.5% would recommend the use of pharmacological sedation during delivery and 47% would take the baby immediately if the parents expressed their wish not to watch them. On the other hand, only 58% would be in favour of taking photos for the creation of memories, 47% would bathe and dress the baby in all cases, and 33.3% would allow the company of other family members. The percentage that matched each recommendation on memory-making was 58%, 41.9% matched the recommendations on respect for the baby and parents, and 23% and 10.3% matched the appropriate delivery and follow-up options, respectively. The factors associated with 100% of the recommendations, according to the care sector, were being a woman, a midwife, having specific training and having personally experienced the situation.

KEY CONCLUSIONS

Although the levels of adaptation observed are more favourable than in other nearby contexts, serious deficiencies are identified in the province of Granada with respect to internationally agreed recommendations on perinatal bereavement care. More training and awareness-raising of midwives and nurses is needed, which also considers factors related to better compliance.

IMPLICATION FOR PRACTICE

This is the first study to quantify the degree of adaptation to international recommendations in Spain reported by midwives and nurses, as well as the individual factors associated with a higher level of compliance. Areas for improvement and explanatory variables of adaptation are identified, which allow support for possible training and awareness-raising programmes aimed at improving the quality of care provided to bereaved families.

Unmasking grief: Reflections on the complicated relationship between moral distress and grief

Perinatal loss often occurs in the context of discovery of a medical condition that presents patients and healthcare providers (HCPs) with difficult choices. Treatment choices are influenced by medical technology, however inescapable prognostic uncertainty, coupled with shared decision-making can lead to ethical dilemmas (Graf et al., 2023) [1]. When patients experience perinatal loss HCPs must grapple with their own emotions. Their sense of grief arises from their empathic connection with patients, bearing witness to their grief. This grief may compound HCP moral distress. Moral distress has an element of emotion, however it is more than distress in tragic situations. Moral distress is linked to HCPs feeling responsible to take action (Dudzinski, 2016) [2]. In situations of perinatal loss, it is essential to acknowledge the grief and explore how it influences the experience of moral distress. This article will reflect on the impact of HCP grief in ethically complex situation of perinatal loss.

Silent Tears of Midwives: 'I Want Every Mother Who Gives Birth to Have Her Baby Alive'-A Narrative Inquiry of Midwives Experiences of Very Early Neonatal Death from Tanzania

BACKGROUND

Midwives working in settings with limited clinical resources experience high rates of very early neonatal deaths. Midwives manage the impact of this grief and trauma almost daily, which may affect patient care and their own well-being.

RESEARCH AIMS

To explore how midwives are impacted by and cope with high rates of very early neonatal deaths. To document midwives' insights and local solutions that may reduce very early neonatal deaths in limited resource settings. To document the stories of midwives in order to create awareness and garner support for midwives and their critical work in low resource settings.

METHODS

Narrative inquiry utilizing semi structured interviews. Twenty-one midwives with at least six months experience who had experienced or witnessed very early neonatal death were interviewed. Data were audio recorded and transcribed, and reflexive thematic analysis of transcripts was conducted.

RESULTS AND DISCUSSION

Three themes were identified: (1) deep sadness resulting from very early neonatal deaths leading to internal struggles; (2) use of spirituality, including prayer and occasional beliefs that unexplainable deaths were 'God's plan'; and (3) development of resilience by seeking solutions, educating themselves, taking accountability and guiding mothers. Participating midwives noted that inadequate staff and high caseloads with limited basic supplies hindered their clinical practice. Participants articulated that they concentrated on active solutions to save babies during labour, such as vigilant foetal rate heart monitoring and partogram. Further, reduction and prevention of very early neonatal death is a complex problem requiring multidisciplinary teams and woman-centred care approaches to address issues contributing to the health of mothers and their new-borns.

CONCLUSIONS

Midwives' narratives highlighted ways of coping with grief and deep sadness, through prayer, and further education of both mothers and fellow colleagues to achieve better antenatal and intrapartum care and outcomes. This study gave midwives an opportunity for their voices to be heard and to generate solutions or insights that can be shared with colleagues in similar low-resource settings.

The unspoken grief of multiple stillbirths in rural Pakistan: an interpretative phenomenological study

Background

Pakistan has the highest rate of stillbirth (30.6 stillbirths per 1000 total births) as compared to other South Asian countries. The psychological impact of stillbirths on bereaved women is well documented; however, there is a dearth of literature on lived experiences of women with multiple stillbirths in Pakistan.

Objective

The purpose of this research is to understand the lived experiences of women who had multiple stillbirths in Thatta, Pakistan.

Methods

An interpretative phenomenological study was conducted in district Thatta with eight women who experienced more than one stillbirth. A semi-structured in-depth interview guide was used for data collection. The data were analyzed by using thematic analysis approach.

Results

The results of this study show that experiencing multiple stillbirths has a devastating impact on women’s mental and social wellbeing. The women who experienced multiple stillbirths are stigmatized as “child-killer” or cursed or being punished by God. They are avoided in social gatherings within the families and community, because of these social pressures these women seek spiritual and religious treatment, and struggle to conceive again to deliver a live baby. It was observed that the psycho-social and medical needs of these bereaved women remain unaddressed not only by the healthcare system but also by the society at large.

Conclusions

The physical, social and mental well-being of women who experience multiple stillbirth are at stake. These women are being considered social outcast. Health care providers including physicians, lady health workers, and traditional birth attendants should be trained on provision of psychosocial support along with the routine care that they provide in communities and health facilities. The health care providers should also inform the bereaved women about the biomedical causes of stillbirths that would be helpful to mitigate the stigma associated with stillbirths. Moreover, the health care providers should also counsel family members especially in-laws of these sorrowful women about the biomedical causes of stillbirths that would also be helpful to mitigate the stigma associated with stillbirths.