The psychological effects of stillbirth and neonatal death on fathers: systematic review

Posttraumatic Growth and Continued Bonds in Fathers Receiving Bereavement Photography Following Perinatal Loss: A Mixed-Methods Study

Research exploring fathers' experiences of using bereavement photography after perinatal loss is lacking. Using continuing bonds theory, this study aims to investigate fathers'experiences of bereavement photography and predictors of posttraumatic growth (PTG). Mixed methodology was employed with participants (n = 29). A hierarchical regression showed that there were no significant associations between continuing bonds and PTG, but time since death predicted PTG in bereaved fathers. Further, a t test indicated that there was no significant difference in PTG for mothers and fathers. A thematic analysis was conducted on the qualitative data from an open-ended survey question (n = 23) and semi-structured interviews (n = 3) with fathers. The qualitative analysis of fathers' responses showed themes relating to bonding/connection, capturing memories, recommendations to receive photography help with grieving, validation, memory-making and continuing bonds, and engagement with photos. Fathers valued bereavement photographs as it enabled them to integrate grief over time.

Maternal Perception of Pregnancy Loss: Protocol for a Thematic Synthesis

Introduction

The number of women who present this perineal loss is high. Identifying the existing knowledge about the women's experiences and perceptions of pregnancy loss is essential to understand the impact of the phenomenon on women. This identification is also crucial to adapt and improve the healthcare provided.

Subjects and Methods

A systematic literature review, meta-synthesis, of qualitative studies will be developed with the goal of obtaining a comprehensive understanding of mothers' perception of pregnancy loss and identifying their specific support needs.

Inclusion Criteria

This review will consider qualitative investigations that study the perceptions or experiences of adult women who have suffered prenatal loss. All studies published in English, Spanish or Portuguese between January 1, 2012, and December 31, 2022 will be considered. This systematic review will follow the Joanna Briggs Institute statement for systematic reviews of qualitative design. The Psychology and Behavioral Sciences Collection, Scopus, CINAHL®, MEDLINE® and Cochrane Database of Systematic Reviews (CDRS) databases will be utilized for research. Data extraction will be performed in-peers by the researchers, using the Joanna Briggs Institute model. Finally, the available data will be analysed using a meta-aggregation approach.

Conclusion

A better understanding of this phenomenon will be useful, identifying, on the one hand, the support needs of women who have suffered fetal loss and, on the other hand, also identifying the support and interventions that can be implemented by health professionals.

Systematic Review Registration Number

PROSPERO® (CRD42023407314).

Bereavement care guidelines used in health care facilities immediately following perinatal loss: a scoping review

OBJECTIVE

The objective of the scoping review was to explore the evidence and describe what is known about perinatal bereavement care guidelines provided within health care facilities prior to discharge. Additionally, the review sought to identify what is known about parents' mental health outcomes, and map these outcomes to the characteristics of the bereavement care guidelines.

INTRODUCTION

Perinatal loss poses a serious risk of emotional trauma and mental health sequelae. Conflicting evidence for international bereavement care guidelines and inconsistent implementation, a lack of experimental studies, and older syntheses with a limited focus or population made synthesis complex. Therefore, a scoping review was undertaken to determine the breadth and depth of the existing literature on this topic.

INCLUSION CRITERIA

Sources pertaining to bereavement care guidelines used in health care facilities immediately after perinatal loss (miscarriage, stillbirth, or neonatal death) and parents' mental health outcomes were included. Sources pertaining to family members other than parents, perinatal loss occurring outside of a health care facility, and physical care guidelines were excluded.

METHODS

The review was conducted using JBI methodology for scoping reviews. The team considered quantitative and qualitative studies, practice guidelines, case reports, expert opinions, systematic reviews, professional organization websites, and gray literature. CINAHL (EBSCOhost), PsycINFO (EBSCOhost), SocINDEX (EBSCOhost), Cochrane Library, JBI Evidence-based Practice Database (Ovid), Embase, PubMed (NLM), ProQuest Dissertations and Theses A&I (ProQuest), Web of Science Core Collection, and Epistemonikos were the major databases searched. OpenGrey, Google Scholar, and organizational websites were also searched. The earliest empirical study publication found (1976) served as the starting date limit. After pilot-testing the screening process, data were extracted, collated, and presented in narrative form as well as in tables and figures. The search was first conducted in September and October 2021, and an updated search was performed on February 9, 2023.

RESULTS

The results provide a broad view of bereavement care guidelines to support grieving parents' mental health. The included sources (n = 195) were comprised of 28 syntheses, 96 primary studies, and 71 literature review/text and opinion. From the studies that specified the number of participants, 33,834 participants were included. Key characteristics of bereavement care guidelines were categorized as i) making meaning/memories, ii) good communication, iii) shared decision-making, iv) effective emotional and social support, and v) organizational response. Parents' reported mental health outcomes included both negative outcomes, such as depression, anxiety, anger, and helplessness, and positive outcomes, including coping, healing, recovery, and well-being.

CONCLUSIONS

Conceptually the characteristics of published guidelines are fairly consistent across settings, with cultural variations in specific components of the guidelines. Despite the exponential increase in research pertaining to bereavement care after perinatal loss, there is a gap in research pertaining to certain characteristics of bereavement care guidelines accepted as best practice to support parents' mental health outcomes. This review provides support for future research given the trauma and mental health risks following perinatal loss. Policies ensuring consistent and appropriate implementation of bereavement care guidelines are essential to improve parents' mental health outcomes.

Hurricane-Force Grief: A Mirror of Fathers' Love

A child's death is a traumatic experience that profoundly impacts parents' psychological, physical, and social wellbeing. The literature describes gender differences in grief response associated with child loss, yet less is known about fathers' grief in comparison that of mothers due to fathers' underrepresentation in bereavement research. There is a need for scholarly exploration to advance understanding of fathers' grief. This article presents selected findings on fathers' grief responses that emerged from a larger qualitative study, which aimed to describe fathers' lived experience of bereavement after a child's death. Profound grief emerged as one essential theme of fathers' bereavement experience. Participants described the meaning of their grief, their multidimensional grief responses, their grief triggers, and their grief intensity. Findings deepen understanding of fathers' grief associated with child loss and advance the body of parental bereavement literature.

Developing text-messaging support for fathers after perinatal loss

BACKGROUND

Perinatal loss is a devastating occurrence for expecting parents. Although both parents are affected, research on fathers' grief has not resulted in effective support services for fathers.

AIM

To describe a multi-stage co-design process for developing text messaging support for fathers experiencing perinatal loss.

METHODS

Co-designed text messages were developed in collaboration with a perinatal bereavement organisation, mothers and fathers with lived experience of perinatal loss, and clinicians working with bereaved parents. Bereaved parents responded to a survey about bereaved fathers' information needs (stage 1). A qualitative descriptive data analysis created topics for the generation of text messages (stage 2). Parents with lived experience and clinicians evaluated the messages on importance and clinical fit (stage 3). Messages were revised (stage 4), followed by parent and clinician evaluation and final message revision (stage 5).

FINDINGS

There were 959 survey respondents; the majority agreed that support for fathers would have been useful; 539 provided comments. Qualitative analysis created twelve topics within three themes, leading to the generation of 64 text messages. Messages were evaluated by 27 lived experience parents and 19 clinicians as important (91.6%) and understandable (91.3%), and 92.5% of clinicians agreed the messages fitted clinical guidelines. Message revision resulted in 59 messages across three themes. The final evaluation by 12 parents and 14 clinicians led to a final revised set of 52 messages.

CONCLUSION

Text-based support for bereaved fathers can be developed in a co-design process to accord with clinical practice, from topics suggested parents with lived experience.

Men don't cry: The supporting role as necessary for women's well-being after termination of pregnancy

OBJECTIVES

The present study investigated similarities and differences of grief between men and women as part of the parental couple 1 year after termination of pregnancy (TOP) following a diagnosis of fetal anomaly.

METHODS

We applied a method triangulation approach. We assessed several aspects of perinatal grief, depressive symptoms, posttraumatic stress, and anxiety as well as health-related quality of life. In addition, we conducted qualitative interviews with the men to explore the fathers' roles in the partnership during pregnancy, the time of the diagnosis, TOP, and afterwards.

RESULTS

Women showed a more elevated grief response compared with men. Qualitative data revealed that men in our sample were mainly concerned with their partners' well-being and concentrated on supporting their partners rather than on their own emotions. In addition, the supportive role of the male partner plays a central role in the well-being of women and the man's coping with the situation.

CONCLUSION

In clinical work, but also when developing new questionnaires, the specific role of the male partners needs to be considered more thoroughly. Particular attention should be paid to identify the men who find it difficult to assume the supporting role.

The burden of stillbirths in low resource settings in Latin America: Evidence from a network using an electronic surveillance system

OBJECTIVE

To determine stillbirth ratio and its association with maternal, perinatal, and delivery characteristics, as well as geographic differences in Latin American countries (LAC).

METHODS

We analysed data from the Perinatal Information System of the Latin American Center for Perinatology and Human Development (CLAP) between January 2018 and June 2021 in 8 health facilities from five LAC countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic). Maternal, pregnancy, and delivery characteristics, in addition to pregnancy outcomes were reported. Estimates of association were tested using chi-square tests, and P < 0.05 was regarded as significant. Bivariate analysis was conducted to estimate stillbirth risk. Prevalence ratios (PR) with their 95% confidence intervals (CI) for each predictor were reported.

RESULTS

In total, 101,852 childbirths comprised the SIP database. For this analysis, we included 99,712 childbirths. There were 762 stillbirths during the study period; the Stillbirth ratio of 7.7/1,000 live births (ranged from 3.8 to 18.2/1,000 live births across the different maternities); 586 (76.9%) were antepartum stillbirths, 150 (19.7%) were intrapartum stillbirths and 26 (3.4%) with an ignored time of death. Stillbirth was significantly associated with women with diabetes (PRadj 2.36; 95%CI [1.25-4.46]), preeclampsia (PRadj 2.01; 95%CI [1.26-3.19]), maternal age (PRadj 1.04; 95%CI [1.02-1.05]), any medical condition (PRadj 1.48; 95%CI [1.24-1.76, and severe maternal outcome (PRadj 3.27; 95%CI [3.27-11.66]).

CONCLUSIONS

Pregnancy complications and maternal morbidity were significantly associated with stillbirths. The stillbirth ratios varied across the maternity hospitals, which highlights the importance for individual surveillance. Specialized antenatal and intrapartum care remains a priority, particularly for women who are at a higher risk of stillbirth.

Parents' experiences and need for social support after pregnancy termination for fetal anomaly: a qualitative study in China

OBJECTIVE

The aim of this study was to explore the experiences and need for social support of Chinese parents after termination of pregnancy for fetal anomalies.

DESIGN

A qualitative study using semistructured, in-depth interviews combined with observations. Data were analysed by Claizzi's phenomenological procedure.

SETTING

A large, tertiary obstetrics and gynaecology hospital in China.

PARTICIPANTS

Using purposive sampling approach, we interviewed 12 couples and three additional women (whose spouses were not present).

RESULTS

Four themes were identified from the experiences of parents: the shock of facing reality, concerns surrounding termination of pregnancy, the embarrassment of the two-child policy and the urgent need for social support.

CONCLUSION

Parents experienced complicated and intense emotional reactions, had concerns surrounding the termination of pregnancy and an urgent need for social support. Paternal psychological reactions were often neglected by healthcare providers and the fathers, themselves. These findings suggest that both mothers and fathers should receive appropriate support from family, medical staff and peers to promote their physical and psychological rehabilitation.

The Role of Perinatal Palliative Care in Fetal Neurology

OBJECTIVES

Many serious or life-threatening neurologic conditions are first diagnosed during the fetal period, often following a routine ultrasound or sonographic evaluation after an abnormal aneuploidy screen. Such conditions represent a worrisome or unexpected finding for expectant parents, making the perinatal period a critical time point to engage and empower families encountering complex neurologic clinical scenarios. This review covers the role of perinatal palliative care in these settings.

STUDY DESIGN

This study is a topical review RESULTS:  The prenatal identification of structural abnormalities of the brain or spinal cord, radiographic signs of hemorrhage or ischemic injury, or evidence of genetic or metabolic conditions should prompt involvement of a fetal palliative care team. The inherent prognostic uncertainty is challenging for prenatally diagnosed neurologic conditions which have difficult to predict short and long-term outcomes. While many of these conditions lead to the birth of an infant with neurodevelopmental challenges, few result in in utero demise. Palliative care beginning in the perinatal period provides an additional layer of support for families navigating complex decision-making during their pregnancy and provides continuity of care into the newborn period. Palliative care principles can help guide discussions around genetic and other diagnostic testing, fetal surgery, and birth planning. A multidisciplinary team can help support families with decision-making and through bereavement care in the setting of fetal or neonatal death.

CONCLUSION

Early palliative care team involvement can provide a more holistic approach to counseling, facilitate planning, and ensure that a family's goals and wishes are acknowledged throughout an infant's care trajectory.

KEY POINTS

· Many serious or life-threatening neurologic conditions are diagnosed during the fetal period.. · Palliative care principles should be incorporated in the fetal period for affected patients.. · Palliative care clinicians can aid parents and clinicians in shared decision-making.. · Palliative care principles should be employed by all care providers in relevant cases..

The economic burden associated with stillbirth: A systematic review

BACKGROUND

Evidence on the economic burden of stillbirth is limited. In this systematic review, we aimed to identify studies focusing on the economic burden of stillbirth, describe the methods used, and summarize the findings.

METHOD

We performed a systematic search in Medline, EMBASE, Cochrane library, and EconLit from inception to July 2021. Original studies reporting the cost of illness, economic burden, or health care expenditures related to stillbirth were included. Two reviewers independently extracted data and evaluated study quality using the Larg and Moss checklist. A narrative synthesis was performed. Costs were presented in US dollars (US$) in 2020.

RESULTS

From the 602 records identified, a total of four studies were included. Eligible studies were from high-income countries. Only one study estimated both direct and indirect costs. Among three cost-of-illness studies, two studies undertook a prevalence-based approach. The quality of these studies varied and was substantially under-reported. Four studies describing direct costs ranged from $6934 to $9220 per stillbirth. Indirect costs account for around 97% of overall costs. No studies have incorporated intangible cost components.

CONCLUSIONS

The economic burden of stillbirth has been underestimated and not extensively studied. There are no data on the cost of stillbirth from countries that bear a higher burden of stillbirth. Extensive variation in methodologies and cost components was observed in the studies reviewed. Future research should incorporate all costs, including intangible costs, to provide a comprehensive picture of the true economic impact of stillbirth on society.

Dads in Distress: symptoms of depression and traumatic stress in fathers following poor fetal, neonatal, and maternal outcomes

BACKGROUND

This study aims to explore the prevalence of symptoms of depression and traumatic stress in fathers in the setting of poor fetal, neonatal, and maternal outcomes.

METHODS

A prospective mixed-methods study was conducted at an outer metropolitan public teaching hospital in Brisbane, Australia, with quantitative results presented here. Subjects included 28 fathers whose male partners had experienced pregnancy or childbirth complicated by a significant congenital abnormality or aneuploidy, termination of pregnancy, fetal death in-utero, stillbirth, admission to the neonatal intensive care unit or special care nursery or significant maternal morbidity, such as a postpartum haemorrhage or an emergency postpartum hysterectomy. These experiences were classified into two groups: anticipatory (time to prepare) and sudden (no warning). The fathers were screened using the Edinburgh Postnatal Depression Scale (EPDS) and the Impact of Events Scale-Revised (IES-R) to assess subjective distress at 2-3 weeks (timepoint 1) and 3-4 months (timepoint 2) after the event.

RESULTS

Data for both the EPDS and IES-R scales was available for 26 fathers (92.9%) at timepoint 1 and for 15 fathers (53.6%) at timepoint 2. High overall EPDS scores (≥10) were noted in 16/27 (59.3%) fathers at timepoint 1 and 6/15 fathers (40.0%) at timepoint 2. High overall IES-R scores ≥33 were noted in 12/26 (46.2%) fathers at timepoint 1 and 4/15 fathers (26.7%) at timepoint 2. A higher percentage of fathers who experienced anticipatory events had EPDS and IES-R score above these cut-offs at timepoint 1 (8/13 or 61.5%) compared to those experiencing sudden events (8/14 or 57.1%), however, percentages were similar between groups at time point 2 (2/7 or 28.6%% and 4/8 or 50.0%, respectively). More fathers who experienced anticipatory events had IES-R scores ≥33 at timepoint 1 (7/13 or 53.8%) compared to those experiencing sudden events (5/14 or 38.0%).

CONCLUSION

Our study indicates high rates of distress in fathers exposed to poor fetal, neonatal, and maternal outcomes, which can persist for months after the event. Increased support for fathers in this setting may be required to prevent poor mental health. Further research on the long-term effects of these adverse events is warranted.

Women's experiences of a pregnancy whilst attending a specialist antenatal service for pregnancies after stillbirth or neonatal death: a qualitative interview study

Aim: Pregnancy after the death of a baby is associated with numerous, varied psychological challenges for pregnant women. This study aimed to explore women's experiences of pregnancy whilst attending a specialist antenatal service for pregnancies after a perinatal death.Methods: Semi-structured interviews with twenty women in a subsequent pregnancy after a perinatal death were conducted and analyzed taking an inductive thematic analysis approach.Results: All women expressed a heightened "awareness of risk". Two subthemes demonstrated how increased awareness of risk affected their experience and their desire regarding antenatal and postnatal support. Women talked about stillbirth being a "quiet, unspoken subject" causing them internal conflict as they had an awareness of pregnancy complications that other people did not. Navigating subsequent pregnancies relied on them "expecting the worst and hoping for the best" in terms of pregnancy outcomes. Women viewed specialist antenatal care in pregnancy after perinatal loss favorably, as it enabled them to receive tailored care that met their needs stemming from their increased awareness of and personal expectations of risk.Conclusion: Women's experiences can be used to develop models of care but further studies are required to determine to identify which components are most valued.

"Your heart keeps bleeding": lived experiences of parents with a perinatal death in Northern Uganda

Background

Worldwide, two million babies are stillborn and 1.8 million babies die before completing seven days of life. Approximately 4% of pregnant women in Uganda experience perinatal death. The response following a perinatal death tends to be socio-culturally constructed. Investigating the unique personal experiences of parents from a low-income setting with unique cultural beliefs and practices is crucial for the design and implementation of appropriate interventions.

Objective

To describe the lived experiences of parents following perinatal death in Lira district, Northern Uganda.

Methods

A qualitative study was carried out drawing on the tenets of descriptive phenomenology. We conducted 32 in-depth interviews in Lira district, Northern Uganda between August 2019 and September 2020 with 18 women and 14 men who had experienced a stillbirth or an early neonatal death within the preceding 2 years. Participants were selected from different families and interviewed. A local IRB approved the study. All in-depth interviews were audio-recorded, transcribed, translated, and data were analysed using a content thematic approach. Key findings were discussed based on Worden’s Four Tasks of Mourning theory.

Results

The themes that emerged from the analyses included reaction to the perinatal loss and suggestions for support. The participants’ immediate reactions were pain, confusion, and feelings of guilt which were aggravated by the unsupportive behaviour of health care providers. Men cumulatively lost financial resources in addition to facing multiple stressful roles. Delayed reactions such as pain and worries were triggered by the sight of similar-age-babies, subsequent pregnancy losses, and marital challenges. Participants recommended emotional support and management of postnatal complications for parents faced with perinatal loss.

Conclusion

Losing a baby during the perinatal period in a resource-constrained setting negatively affected both gender. In addition, men suffered the loss of financial resources and the burden of multiple stressful roles. Acknowledging the pain and offering support to the grieving parents reinforce their coping with a perinatal loss. In addition to family and community members, health care providers need to provide emotional support and postnatal care to parents who experience perinatal death.

Termination of pregnancy for fetal anomaly: a systematic review of the healthcare experiences and needs of parents

BACKGROUND

Improved technology and advances in clinical testing have resulted in increased detection rates of congenital anomalies during pregnancy, resulting in more parents being confronted with the possibility of terminating a pregnancy for this reason. There is a large body of research on the psychological experience and impact of terminating a pregnancy for fetal anomaly. However, there remains a lack of evidence on the holistic healthcare experience of parents in this situation. To develop a comprehensive understanding of the healthcare experiences and needs of parents, this systematic review sought to summarise and appraise the literature on parents' experiences following a termination of pregnancy for fetal anomaly.

REVIEW QUESTION

What are the healthcare experiences and needs of parents who undergo a termination of pregnancy following an antenatal diagnosis of a fetal anomaly?

METHODS

A systematic review was undertaken with searches completed across six multi-disciplinary electronic databases (Medline, Embase, PsycINFO, CINAHL, Web of Science, and Cochrane). Eligible articles were qualitative, quantitative or mixed methods studies, published between January 2010 and August 2021, reporting the results of primary data on the healthcare experiences or healthcare needs in relation to termination of pregnancy for fetal anomaly for either, or both parents. Findings were synthesised using Thematic Analysis.

RESULTS

A total of 30 articles were selected for inclusion in this review of which 24 were qualitative, five quantitative and one mixed-methods. Five overarching themes emerged from the synthesis of findings: (1) Contextual impact on access to and perception of care, (2) Organisation of care, (3) Information to inform decision making, (4) Compassionate care, and (5) Partner experience.

CONCLUSION

Compassionate healthcare professionals who provide non-judgemental and sensitive care can impact positively on parents' satisfaction with the care they receive. A well organised and co-ordinated healthcare system is needed to provide an effective and high-quality service.

TRIAL REGISTRATION

PROSPERO registration number: CRD42020175970 .

"It's a lot of pain you've got to hide": a qualitative study of the journey of fathers facing traumatic pregnancy and childbirth

BACKGROUND

This study aims to explore the emotional and behavioural responses and coping strategies of fathers or expectant fathers who faced a significant traumatic event during a partner's pregnancy, labour, or the postpartum period.

METHODS

This prospective qualitative study of 24 fathers was conducted at a public teaching hospital in Brisbane, Australia. 'Traumatic pregnancy' was defined as a pregnancy complicated by life-threatening or severe risk to the mother and the fetus, termination of pregnancy, intrauterine fetal death or stillbirth. Semi-structured interviews of participants were conducted 3-4 months after the traumatic event. An initial qualitative analysis with automatic coding was performed using Leximancer and later followed by a six-phase manual thematic analysis.

RESULTS

A pregnancy-related traumatic event had significant mental and physical impacts on fathers. Participants' reactions and coping strategies were varied and influenced by their background history, pre-existing vulnerabilities, and the gap between expectation and reality. Most fathers described a fluctuating state between their needs 'not being met' and 'being met'. These needs were conceptualised using Maslow's hierarchy and Calman's gap theory to construct a composite thematic model to depict the universal requirements of men facing a traumatic pregnancy or childbirth.

CONCLUSIONS

A greater understanding of the needs of men and gaps in their care is urgently needed. A targeted effort is required to make maternity services father-inclusive. This approach may assist in preventing long term consequences on fathers, partners, and their children.

When a Child Dies: Racialized Father's Experiences of Objectification During Hospital Care

Understanding the meaning of loss for racialized immigrant fathers and addressing their experiences in a culturally competent manner is important in an increasingly ethnoculturally diverse country like Canada. Culture, customs and rituals influence fathers' grief and culture impacts how individuals discuss death and dying as well as how they perceive the death of a child. This article is part of a qualitative research project, which examined the experiences of racialized immigrant fathers who experienced the death of a child. Guided by Charmaz's constructivist grounded theory, the methodological aim was to develop a theoretical framework grounded in fathers' experiences of child death within the hospital setting. Findings suggest that for racialized immigrant fathers their migration experience compounds their losses in unexpected ways and that experiences of objectification or 'othering' in hospital and by health care staff were significant.

Overwhelming and unjust: A qualitative study of fathers' experiences of grief following neonatal death

Limited research has examined the grief experiences of fathers following neonatal death. Using a qualitative research design, ten fathers were interviewed, and thematic analysis resulted in three overarching themes: 'A complicated grief experience: Neonatal death is highly emotional', 'Grief is multidimensional' and 'Sense of injustice'. Overall, results showed that grief was a multidimensional experience for fathers, with expressions of grief including strong feelings of anger and guilt and the manifestation of grief in physical symptoms. In addition, the findings also indicated a sense of injustice that contributed to the disenfranchisement of grief for fathers. The results of this study contribute to developing a better understanding of the grief that fathers experience following neonatal death, and can inform improvements in healthcare practices after the death of a baby in the neonatal period, including father-specific programs and adequate provision of information.

Psychosocial Aspects of Gestational Grief in Women Undergoing Infertility Treatment: A Systematic Review of Qualitative and Quantitative Evidence

Women undergoing assisted reproduction treatment without being able to become pregnant, and experiencing pregnancy loss after assisted reproduction, are triggering factors for prolonged grief and mourning. This review aims to investigate the psychosocial aspects of gestational grief among women who have undergone infertility treatment. We searched the databases of MEDLINE/PubMed, EMBASE, CINAHL, Scopus, ScienceDirect, and Lilacs for works published up to 5 March 2021. The outcomes analyzed were negative and positive psychosocial responses to gestational grief among women suffering from infertility and undergoing assisted human reproduction treatment. Eleven studies were included, which yielded 316 women experiencing infertility who were undergoing treatment. The most frequently reported negative psychosocial manifestations of grief response were depression (6/11, 54.5%), despair or loss of hope/guilt/anger (5/11, 45.5%), anxiety (4/11, 36.4%), frustration (3/11, 27.3%), and anguish/shock/suicidal thoughts/isolation (2/11, 18.2%). Positive psychosocial manifestations included the hope of becoming pregnant (4/6, 66.6%) and acceptance of infertility after attempting infertility treatment (2/6, 33.3%). We identified several negative and positive psychosocial responses to gestational grief in women experiencing infertility. Psychological support before, during, and after assisted human reproduction treatment is crucial for the management of psychosocial aspects that characterize the grief process of women experiencing infertility who become pregnant and who lose their pregnancy. Our results may help raise awareness of the area of grief among infertile women and promote policy development for the mental health of bereaved women.

Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review

BACKGROUND

This systematic review aimed to provide an updated summary of studies investigating depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) in parents after stillbirth (from 20 weeks gestational age until birth).

METHODS

A literature search was conducted in the databases Web of Science and PsychINFO. Main inclusion criteria were 1) peer-reviewed, quantitative, English-language articles published from 1980; (2) studies investigating depression, anxiety, PTSD, or OCD among parents following stillbirth; and (3) studies defining stillbirth as equal to or after 20 weeks of gestation.

RESULTS

Thirteen quantitative, peer-reviewed articles were eligible for inclusion. Selected articles investigated depression, anxiety, and PTSD, while no studies on OCD met our inclusion criteria. The majority of studies investigated women, while only two studies included men. The results indicated heightened short- and long-term levels of depression, anxiety, and PTSD in parents after stillbirth compared to those of parents with live birth. Studies investigating predictors found that social support, marital status, negative appraisals, and variables related to care and management after stillbirth affected levels of symptoms.

CONCLUSIONS

Parents who experience stillbirth have a considerably higher risk of reporting symptoms of depression, anxiety, and PTSD compared with parents with live births. More longitudinal studies are needed to increase our knowledge of how symptoms develop over time, and more research on fathers, transgender, non-binary and gender fluid individuals is needed. Research on the association between stillbirth and OCD is also warranted. Knowledge of the severity of anxiety, depression, and PTSD after stillbirth, and predictors associated with symptom severity could provide healthcare professionals with valuable information on how to provide beneficial postpartum care.

The unheard parental cry of a stillbirth: fathers and mothers

PURPOSE

Our objective was to compare the prevalence of depression, anxiety, stress, and domestic violence among parents after a stillbirth vs. livebirths and assessing of the need for psychological and pharmacological interventions for the affected individuals.

METHODS

This was a prospective cohort study conducted in a tertiary care public sector hospital Northern India. 150 consecutive couples with a recent stillbirth (group 1) and 150 couples with a recent live birth (group 2) were enrolled. They were screened for depression (EPDS scale), anxiety (GAD-7), stress (PSS). Apriori sample size was calculated. Screen positive mothers and fathers were compared for the presence of depression, anxiety and stress, domestic violence, and need for treatment interventions.

RESULTS

Depression was higher in group 1 mothers (39.3 vs 14.0%, p < 0.001) as well as fathers (18.1 vs 6.7%, p value = 0.022). Anxiety and moderate to severe stress were also significantly higher in stillborn than liveborn groups respectively. Characteristics associated with higher risk are analyzed. Domestic violence was found in 6.7% in group 1 and 2.7% in group 2 mothers (p value 0.169). Pharmacotherapy and counselling were required by 11.3 and 18.0% in stillbirth versus 3.3 and 18.7% in livebirth group, respectively.

CONCLUSION

Couples suffering stillbirths are at higher risk of depression, anxiety, and stress. We highlight this obstetrical public health issue, especially for the low middle income countries (LMIC) and advocate development of health policies for mental health screening of couples suffering stillbirths.

Psychosocial interventions on psychological outcomes of parents with perinatal loss: A systematic review and meta-analysis

BACKGROUND

Perinatal loss can occur due to miscarriages and ectopic pregnancies, among other circumstances. Psychological health of parents can deteriorate due to perinatal loss. Parent's negative psychological outcomes include depression, anxiety, and grief.

OBJECTIVE

To evaluate the effectiveness of psychosocial interventions in reducing depression, anxiety, and grief among parents after perinatal loss.

DESIGN

A systematic review and meta-analysis of randomized controlled trials DATA SOURCES: English language articles published from database inception to 19 November 2019 were systematically retrieved from eight electronic databases (CINAHL, Cochrane, EMBASE, ProQuest Dissertations and Theses Global, PsycINFO, PubMed, Scopus, Web of Science).

REVIEW METHODS

The Cochrane Risk of Bias tool was used to conduct quality appraisal of each individual article and data was analyzed using Review Manager 5.3. A meta-analysis of randomized controlled trials was conducted using a random-effect model.

RESULTS

Among this review's 17 included studies, 15 studies' results were included in the meta-analyses. The remaining two studies were summarized narratively. Meta-analyses revealed that psychosocial interventions significantly reduced depression (95% CI: -0.64 to -0.29, Z = 5.17, p = <0.00001), anxiety (95% CI: -0.50 to -0.18, Z = 4.21, p < 0.0001) and grief (95% CI: -0.71 to -0.32, Z = 5.12, p < 0.0001).

CONCLUSION

Psychosocial interventions are effective in improving depression, anxiety, and grief amongst parents with perinatal loss. Psychosocial care can be provided by medical healthcare professionals and expanded with technology-assisted implementation.

STUDY REGISTRATION NUMBER

CRD42019145526.

Recurrent pregnancy loss: a shared stressor---couple-orientated psychological research findings

OBJECTIVE

To compare the psychological impact of recurrent pregnancy loss (RPL) on affected men and women and to determine risk and protective factors in both partners.

DESIGN

Cross-sectional study.

SETTING

University-affiliated fertility center.

PATIENT(S)

Ninety female/male couples and 14 women.

INTERVENTION(S)

Participants completed a questionnaire covering psychological risk factors (ScreenIVF), experience of pregnancy losses, coping strategies, and partnership satisfaction.

MAIN OUTCOME MEASURE(S)

Comparison of psychological risk factors, perception of RPL, and coping strategies between both partners and analysis of the influence of risk and protective factors.

RESULT(S)

In the ScreenIVF, 47.7% of women versus 19.1% of men showed a risk for anxiety, 51.7% versus 19.1% a risk for depression, and 28.1% versus 30.7% a risk for limited social support. The use of avoiding coping styles seems to be less favorable with regard to the psychological risk than active strategies. Having a child together and a satisfying partnership correlated with a lower risk for depression. Sharing the experience of RPL with others and being in a satisfying relationship correlated with a higher social support.

CONCLUSION(S)

Both men and women affected by RPL show high risks for developing depression and anxiety, underlining the importance of also including the male partners. The factors of communication with others, a satisfying relationship, and already having a child together correlate with decreased psychological risks. We advocate for health care professionals to implement screening for anxiety, depression, and social support for both partners and support them in dealing with RPL.

REGISTRATION NUMBER

The study is registered in the German Clinical Trials Register (DRKS), number DRKS00014965.

Impact of Perinatal Death on the Social and Family Context of the Parents

BACKGROUND

Perinatal death (PD) is a painful experience, with physical, psychological and social consequences in families. Each year, there are 2.7 million perinatal deaths in the world and about 2000 in Spain. The aim of this study was to explore, describe and understand the impact of perinatal death on parents' social and family life.

METHODS

A qualitative study based on Gadamer's hermeneutic phenomenology was used. In-depth interviews were conducted with 13 mothers and eight fathers who had suffered a perinatal death. Inductive analysis was used to find themes based on the data.

RESULTS

Seven sub-themes emerged, and they were grouped into two main themes: 1) perinatal death affects family dynamics, and 2) the social environment of the parents is severely affected after perinatal death.

CONCLUSIONS

PD impacts the family dynamics of the parents and their family, social and work environments. Parents perceive that society trivializes their loss and disallows or delegitimizes their grief.

IMPLICATIONS

Social care, health and education providers should pay attention to all family members who have suffered a PD. The recognition of the loss within the social and family environment would help the families to cope with their grief.

Men's grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model

BACKGROUND

Emotional distress following pregnancy loss and neonatal loss is common, with enduring grief occurring for many parents. However, little is known about men's grief, since the majority of existing literature and subsequent bereavement care guidelines have focused on women. To develop a comprehensive understanding of men's grief, this systematic review sought to summarise and appraise the literature focusing on men's grief following pregnancy loss and neonatal loss.

METHODS

A systematic review was undertaken with searches completed across four databases (PubMed, PsycINFO, Embase, and CINAHL). These were guided by two research questions: 1) what are men's experiences of grief following pregnancy/neonatal loss; and 2) what are the predictors of men's grief following pregnancy/neonatal loss? Eligible articles were qualitative, quantitative or mixed methods empirical studies including primary data on men's grief, published between 1998 and October 2018. Eligibility for loss type included miscarriage or stillbirth (by any definition), termination of pregnancy for nonviable foetal anomaly, and neonatal death up to 28 days after a live birth.

RESULTS

A final sample of 46 articles were identified, including 26 qualitative, 19 quantitative, and one mixed methods paper. Findings indicate that men's grief experiences are highly varied, and current grief measures may not capture all of the complexities of grief for men. Qualitative studies identified that in comparison to women, men may face different challenges including expectations to support female partners, and a lack of social recognition for their grief and subsequent needs. Men may face double-disenfranchised grief in relation to the pregnancy/neonatal loss experience.

CONCLUSION

There is a need to increase the accessibility of support services for men following pregnancy/neonatal loss, and to provide recognition and validation of their experiences of grief. Cohort studies are required among varied groups of bereaved men to confirm grief-predictor relationships, and to refine an emerging socio-ecological model of men's grief.

TRIALS REGISTRATION

PROSPERO registration number: CRD42018103981.

Posttraumatic stress and affecting factors in couples after perinatal loss: A Turkish sample

PURPOSE

We aimed to determine the posttraumatic stress levels and the factors affecting them in couples (154 women and 154 men) after a perinatal loss in Turkey.

CONCLUSIONS

In women, an ending of the pregnancy between gestational weeks 30 and 37 and being employed reduced the posttraumatic stress level. In men, seeing the baby after birth, having no alcohol, and having high education and income levels decreased the posttraumatic stress level.

PRACTICE IMPLICATIONS

Knowledge of the factors affecting posttraumatic stress may help identify those couples in whom the probability of this disorder occurring is increased.

Stillbirth memento photography

Research into stillbirth memento photography shows the practice to be welcomed by the bereaved. The visual attributes and content of stillbirth memento photographs are yet to be rigorously analysed however, representing a significant gap in current understanding. This study seeks to address this. 51 professionally produced stillbirth memento photographs have been sampled, anonymised and analysed. Using a content analysis methodology, imagery was characterised by aesthetic and semantic properties. The results were then cross-referenced against existing stillbirth scholarship, data from an interview study with people who had experienced pregnancy loss, and against image theories. The content analysis identified four distinctive image tropes in the sample: images of mother, father and baby, with the baby being held and the parents touching; macro photography of the baby; portrait photographs of babies lying alone with little or no physical trauma evident; and images of a parent, usually the mother, cradling the baby. The analysis also identified specific attributes, present across the sample, that appeared significant and distinctive of stillbirth memento photography. These were: (1) stylistic attributes, (2) acknowledgement and validation, (3) identity construction, (4) ambiguity and (5) embodiment.

Variables associated with grief and personal growth following the death of a child from cancer: A mixed method analysis

This mixed method study explored parent and child characteristics that impact grief and personal growth in parents (n = 119) after a child dies from cancer in Australia. Medical components of a child's cancer care including radiation treatment, referral to palliative care, and location of death had a significant impact on levels of grief. Parents' gender, religious affiliation, and education level had a significant impact on levels of personal growth. This study further enhances our understanding of the impact of specific parent and child characteristics throughout a child's cancer treatment and end of life that may influence their families' experience of bereavement.

Comparison of Parametric and Nonparametric Estimators for the Association Between Incident Prepregnancy Obesity and Stillbirth in a Population-Based Cohort Study

While prepregnancy obesity increases risk of stillbirth, few studies have evaluated the role of newly developed obesity independent of long-standing obesity. Additionally, researchers have relied almost exclusively on parametric models, which require correct specification of an unknown function for consistent estimation. We estimated the association between incident obesity and stillbirth in a cohort constructed from linked birth and death records in Pennsylvania (2003-2013). Incident obesity was defined as body mass index (weight (kg)/height (m)2) greater than or equal to 30. We used parametric G-computation, semiparametric inverse-probability weighting, and parametric/nonparametric targeted minimum loss-based estimation (TMLE) to estimate the association between incident prepregnancy obesity and stillbirth. Compared with pregnancies from women who stayed nonobese, women who became obese prior to their next pregnancy were estimated to have 2.0 (95% confidence interval (CI): 0.5, 3.5) more stillbirths per 1,000 pregnancies using parametric G-computation. However, despite well-behaved stabilized inverse probability weights, risk differences estimated from inverse-probability weighting, nonparametric TMLE, and parametric TMLE represented 6.9 (95% CI: 3.7, 10.0), 0.4 (95% CI: 0.1, 0.7), and 2.9 (95% CI: 1.5, 4.2) excess stillbirths per 1,000 pregnancies, respectively. These results, particularly those derived from nonparametric TMLE, were highly sensitive to covariates included in the propensity score models. Our results suggest that caution is warranted when using nonparametric estimators to quantify exposure effects.

Pain without reward: A phenomenological exploration of stillbirth for couples and their hospital encounter

Stillbirth constitutes a unique form of grief related to the death of an unborn child. This study explores the experiences of eight couples who lost a child to stillbirth, from the time they suspected something was wrong to their release from the hospital and beyond. Couples were interviewed conjointly and data were analyzed qualitatively using a phenomenological approach. Analysis revealed themes of positive and negative encounters with hospital staff, grief and loss, relationships with spouse and family, and long-term impacts. Implications for clinicians are discussed, including gender differences in the grief process for fathers and mothers.

Added value of chromosomal microarray analysis over conventional karyotyping in stillbirth work-up: systematic review and meta-analysis

OBJECTIVE

To assess the added value of chromosomal microarray analysis (CMA) over conventional karyotyping to assess the genetic causes in stillbirth.

METHODS

To identify relevant studies, published in English or Spanish and without publication time restrictions, we performed a systematic search of PubMed, SCOPUS and ISI Web of Science databases, The Cochrane Library and the PROSPERO register of systematic reviews, for case series of fetal loss ≥ 20 weeks of gestation, with normal or suspected normal karyotype, undergoing CMA and with at least five subjects analyzed. To investigate quality, two reviewers evaluated independently the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. For the meta-analysis, the incremental yield of CMA over karyotyping was assessed by single-proportion analysis using a random-effects model (weighting by inverse variance). We assessed heterogeneity between studies and performed a sensitivity analysis and a subgroup analysis of structurally abnormal (malformed or growth-restricted) and normal fetuses.

RESULTS

Included in the meta-analysis were seven studies involving 903 stillborn fetuses which had normal karyotype. The test success rate achieved by conventional cytogenetic analysis was 75%, while that for CMA was 90%. The incremental yield of CMA over conventional karyotyping based on the random-effects model was 4% (95% CI, 3-5%) for pathogenic copy-number variants (pCNVs) and 8% (95% CI, 4-17%) for variants of unknown significance. Subgroup analysis showed a 6% (95% CI, 4-10%) incremental yield of CMA for pCNVs in structurally abnormal fetuses and 3% (95% CI, 1-5%) incremental yield for those in structurally normal fetuses. The pCNV found most commonly was del22q11.21.

CONCLUSIONS

CMA, incorporated into the stillbirth work-up, improves both the test success rate and the detection of genetic anomalies compared with conventional karyotyping. To achieve a genetic diagnosis in stillbirth is particularly relevant for the purpose of counseling regarding future pregnancies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The forgotten father in obstetric medicine

The role of fathers prior to conception, during pregnancy, and in the post-partum period has generally not been a key consideration for Obstetric Physicians. However, this view may need challenging. This paper outlines the key importance of fathers in all phases of obstetric medical care. We review the contribution of paternal factors such as genetics, health, and lifestyle to fetal development, pregnancy complications, and maternal and neonatal wellbeing. The role of fathers in complex care decisions during pregnancy is also reviewed. Postpartum, fathers have a substantial role in shaping the future of the family unit through encouraging breastfeeding and creating a supportive environment for motherhood. This review proposes areas for future research and recommends an evidence-based change in practice in obstetric medicine that focuses on recognizing the role of fathers in the pregnancy journey.

Australian Heterosexual Men's Experiences of Pregnancy Loss: The Relationships Between Grief, Psychological Distress, Stigma, Help-Seeking, and Support

This study explores experiences of pregnancy loss via a questionnaire completed by a convenience sample of 48 Australian cisgender heterosexual men. The questionnaire included measures of support following pregnancy loss, recognition of loss, perceived utility of help-seeking, perceived stigma attached to help-seeking, perinatal grief, and depression and anxiety. The questionnaire also included open-ended questions focused on help-seeking and support. Higher levels of grief were related to higher levels of both depression and anxiety. Perceptions about stigma were related to the perceived utility of help-seeking. While a majority of participants had accessed formal support services, feeling supported was unrelated to either grief or depression. Participants emphasized the utility of men's groups where members have experienced pregnancy loss, though barriers to support were also identified in terms of the unavailability of support or the perceived need to focus on a partner's loss.

Is partners' mental health and well-being affected by holding the baby after stillbirth? Mothers' accounts from a national survey

Objective: This study aimed to assess the effects on partners’ health and well-being of holding a stillborn baby.

Background: Findings from quantitative and qualitative studies have produced inconsistent results concerning the effects of holding a stillborn baby on parents.

Methods: Secondary analyses were conducted on postal questionnaire data relating to 455 partners of women who had a stillbirth. Women answered questions about their partners’ behaviour, perceptions of care, mental health and well-being at three and nine months after the stillbirth. Demographic, clinical and care characteristics were compared between partners who, according to the mothers, did and did not hold their baby. Sub-group analyses assessed hypothesised moderating effects.

Results: Mothers reported that most partners saw (92%) and held (82%) their stillborn baby. However, partners born outside the UK were less likely to have held their baby. Higher gestational age, shorter time interval between antepartum death and delivery, and mother’s holding the baby all predicted a higher rate of partner’s holding. There was a consistent negative effect of holding the baby across mental health and well-being outcomes, although after adjustment only higher odds of depression (OR 2.72, 95% CI 1.35–5.50) and post-traumatic stress type symptoms (OR 1.95, 95% CI 1.01–3.78) at 3 months were significantly associated with having held the baby following stillbirth.

Conclusions: This study is the first to assess the impact of holding the baby on partners’ mental health and well-being. The prevalence of depression and anxiety were high, and the negative effects of holding the baby were significant 3 months later.

Sudden infant death syndrome: the role of multidisciplinary teams. Experience of the SIDS-ALTE Center of Liguria Region

The aim of this paper was to highlight the importance of a multidisciplinary and multiprofessional management of SIDS for a complete approach to this tragic event. Both biomedical and psychosocial aspects are evaluated, focusing on the impact of SIDS diagnosis on the family. The paper describes the organization of our team, composed of a network of specialists involved in both prevention and management of SIDS. A protocol is proposed to improve SIDS diagnosis and management. In our team, the clinical pediatrician is the coordinator of specialists and the mediator between the family and the other specialists, thanks to his direct relationship with parents.

Effects of a family-support programme for pregnant women with foetal abnormalities requiring pregnancy termination: A randomized controlled trial in China

AIM

We examined the effects of a family-support programme for pregnant women with foetal abnormalities in terms of family support, depression, and post-traumatic stress symptoms.

METHOD

A randomized controlled trial was conducted from November 2016 to June 2017. A total of 124 pregnant women with foetal abnormalities were recruited and randomly assigned to the intervention group that received a family-support programme or control group that received only routine care. Self-reported questionnaires including the Family Adaptation Partnership Growth Affection and Resolve Index, the Edinburgh Postnatal Depression Scale, and the Impact of Event Scale-Revised were administered before and after intervention.

RESULTS

Relative to the control group, posttest Family Adaptation Partnership Growth Affection and Resolve Index scores and scores on the intimacy domain were significantly higher in the intervention group, the Edinburgh Postnatal Depression Scale and Impact of Event Scale-Revised scores and the scores on all subscales except the intrusion subscale were significantly lower in the intervention group.

CONCLUSION

The findings of this study suggest that family-support programme represents an effective and feasible support approach of improving family support and reducing depression and post-traumatic stress symptoms for pregnant women with foetal abnormalities requiring pregnancy termination.

Losing Thomas & Ella: A Father's Story (A Research Comic)

"Losing Thomas & Ella" presents a research comic about one father's perinatal loss of twins. The comic recounts Paul's experience of the hospital and the babies' deaths, and it details the complex grieving process afterward, including themes of anger, distance, relationship stress, self-blame, religious challenges, and resignation. A methodological appendix explains the process of constructing the comic and provides a rationale for the use of comics-based research for illness, death, and grief among practitioners, policy makers, and the bereaved.

Addressing Stillbirth in India Must Include Men

BACKGROUND

Millennium Development Goal 4, to reduce child mortality, can only be achieved by reducing stillbirths globally. A confluence of medical and sociocultural factors contribute to the high stillbirth rates in India. The psychosocial aftermath of stillbirth is a well-documented public health problem, though less is known of the experience for men, particularly outside of the Western context. Therefore, men's perceptions and knowledge regarding reproductive health, as well as maternal-child health are important.

METHODS

Key informant interviews (n = 5) were analyzed and 28 structured interviews were conducted using a survey based on qualitative themes.

RESULTS

Qualitative themes included men's dual burden and right to medical and reproductive decision making power. Wives were discouraged from expressing grief and pushed to conceive again. If not successful, particularly if a son was not conceived, a second wife was considered a solution. Quantitative data revealed that men with a history of stillbirths had greater anxiety and depression, perceived less social support, but had more egalitarian views towards women than men without stillbirth experience. At the same time fathers of stillbirths were more likely to be emotionally or physically abusive. Predictors of mental health, attitudes towards women, and perceived support are discussed.

CONCLUSIONS

Patriarchal societal values, son preference, deficient women's autonomy, and sex-selective abortion perpetuate the risk for future poor infant outcomes, including stillbirth, and compounds the already higher risk of stillbirth for males. Grief interventions should explore and take into account men's perceptions, attitudes, and behaviors towards reproductive decision making.

Child death and maternal psychosis-like experiences in 44 low- and middle-income countries: The role of depression

BACKGROUND

Studies on the effect of child death on the mental wellbeing of women in low- and middle-income countries (LMICs) are scarce despite the high child mortality rates. Thus, the aim of the current study was to assess the association between child death and psychosis-like experiences (PLEs), as well as the role of depression in this association.

METHODS

Data from 44 LMICs which participated in the World Health Survey (WHS) were analyzed. A total of 59,444 women who ever gave birth, aged 18-49years, without a self-reported lifetime psychosis diagnosis, were included in the analysis. The World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI) was used to establish the diagnosis of past 12-month DSM-IV depression, and assess four positive psychotic symptoms. Depression was defined as self-reported lifetime depression diagnosis and/or past 12-month depression. Multivariable logistic regression analyses were performed.

RESULTS

After adjustment for potential confounders, women who experienced child death had higher odds for all types of PLEs (when unadjusted for depression) (OR 1.20-1.71; p<0.05) and depression (OR=1.64; 95%CI=1.39-1.93). When adjusted for depression, only delusion of control was strongly associated with child death (OR=1.54; 95%CI=1.20-1.97).

CONCLUSIONS

Child death may be an important determinant of mental wellbeing among women in LMICs. Given the known adverse health outcomes associated with PLEs and depression, as well as the co-occurrence of these symptoms, mental health care may be particularly important for mothers who have experienced child loss in LMICs.

US term stillbirth rates and the 39-week rule: a cause for concern?

BACKGROUND

More than a decade ago an obstetric directive called "the 39-week rule" sought to limit "elective" delivery, via labor induction or cesarean delivery, before 39 weeks 0 days of gestation. In 2010 the 39-week rule became a formal quality measure in the United States. The progressive adherence to the 39-week rule throughout the United States has caused a well-documented, progressive reduction in the proportion of term deliveries occurring during the early-term period. Because of the known association between increasing gestational age during the term period and increasing cumulative risk of stillbirth, however, there have been published concerns that the 39-week rule-by increasing the gestational age of delivery for a substantial number of pregnancies-might increase the rate of term stillbirth within the United States. Although adherence to the 39-week rule is assumed to be beneficial, its actual impact on the US rate of term stillbirth in the years since 2010 is unknown.

OBJECTIVE

To determine whether the adoption of the 39-week rule was associated with an increased rate of term stillbirth in the United States.

STUDY DESIGN

Sequential ecological study, based on state data, of US term deliveries that occurred during a 7-year period bounded by 2007 and 2013. The patterns of the timing of both term childbirth and term stillbirth were determined for each state and for the United States as a whole.

RESULTS

A total of 46 usable datasets were obtained (45 states and the District of Columbia). During the 7-year period, there was a continuous reduction in all geographic entities in the proportion of term deliveries that occurred before 39 weeks of gestation. The overall rate of term stillbirth, when we compared 2007-2009 with 2011-2013, increased significantly (1.103/1000 vs 1.177/1000, RR 1.067, 95% confidence interval 1.038-1.096). Furthermore, during the 7-year period, the increase in the rate of US term stillbirth appeared to be continuous (estimated slope: 0.0186/1000/year, 95% confidence interval 0.002-0.035). Assuming 3.5 million term US births per year, and given 6 yearly "intervals" with this rate increase, it is possible that more than 335 additional term stillbirths occurred in the United States in 2013 as compared with 2007. In addition, during the 7-year period, there was a progressive shift in the timing of delivery from the 40th week to the 39th week. Absent this confounding factor, the magnitude of association between the adoption of the 39-week rule and the increase in rate of term stillbirth might have been greater.

CONCLUSIONS

Between 2007 and 2013 in the United States, the adoption of the 39-week rule caused a progressive reduction in the proportion of term births occurring before the 39th week of gestation. During the same interval the United States experienced a significant increase in its rate of term stillbirth. This study raises the possibility that the 39-week rule may be causing unintended harm. Additional studies of the actual impact of the adoption of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

Contact with the baby following stillbirth and parental mental health and well-being: a systematic review

OBJECTIVE

To collate and critically appraise extant evidence for the impact of contact with the stillborn infant on parental mental health, well-being and satisfaction.

DESIGN

Systematic review.

DATA SOURCES

A structured systematic search was conducted in 13 databases, complemented by hand-searching.

STUDY ELIGIBILITY CRITERIA

English language studies providing quantitative comparison of outcomes for parents who held their baby or engaged in other memory-making activities, such as having photos and handprints, compared to those who did not, were eligible for inclusion.

OUTCOME MEASURES

Primary outcomes included clinically diagnosed mental health issues, standardised assessment of mental health issues or self-reported psychological distress. Secondary outcomes included poor health, relationship difficulties and satisfaction with the decision to have contact with the baby.

RESULTS

Two authors independently screened abstracts, selected potentially eligible studies, extracted data and evaluated the quality of included papers. 11 eligible studies, reported in 18 papers, were included. Studies were heterogeneous, precluding quantitative synthesis, thus a narrative synthesis is presented. Studies presented high risks of bias, particularly in regard to sample representativeness, and confounder identification and adjustment. Results were mixed concerning the impact of holding the stillborn baby on mental health and well-being. One study found no significant effects, and two studies reported no impact on depression. Conflicting effects were found for anxiety and post-traumatic stress. Other memory-making activities were not found to have a significant association with mental health or well-being outcomes. Across studies, mothers were satisfied with their decision to hold their baby or engage in other memory making.

CONCLUSIONS

Evidence for the impact of holding the stillborn baby on mental health and well-being is sparse, and of poor quality. High-quality research guided by a priori hypotheses, with attention to potential confounders and moderating effects, is needed to provide more rigorous evidence to guide practitioners' and parents' decision-making for care following stillbirth.

REVIEW PROTOCOL NUMBER

PROSPERO CRD42014013890.

Stillbirth should be given greater priority on the global health agenda

Stillbirths are largely excluded from international measures of mortality and morbidity. Zeshan Qureshi and colleagues argue that stillbirth should be higher on the global health agenda.

Parental relationship satisfaction after the death of a child

This study describes Finnish parents' (n = 461) parental relationship satisfaction and examines factors associated with relationship satisfaction after the death of a child in the family. This reported study is part of a broader investigation concerning parents' experiences after the death of a child. Most respondents were very (36%) or quite satisfied (49%) with their current relationship. Lower relationship satisfaction scores were reported by older respondents, people with poorer subjective health and people who had other living children. Causes of death other than stillbirth, need for marriage counselling and moderate or poor marital relationship of the respondents' own parents in childhood were also related to lower relationship satisfaction.

Stillbirth and stigma: the spoiling and repair of multiple social identities

This study investigated mothers' experiences surrounding stillbirth in the United Kingdom, their memory making and sharing opportunities, and the effect these opportunities had on them. Qualitative data were generated from free text responses to open-ended questions. Thematic content analysis revealed that "stigma" was experienced by most women and Goffman's (1963) work on stigma was subsequently used as an analytical framework. Results suggest that stillbirth can spoil the identities of "patient," "mother," and "full citizen." Stigma was reported as arising from interactions with professionals, family, friends, work colleagues, and even casual acquaintances. Stillbirth produces common learning experiences often requiring "identity work" (Murphy, 2012). Memory making and sharing may be important in this work and further research is needed. Stigma can reduce the memory sharing opportunities for women after stillbirth and this may explain some of the differential mental health effects of memory making after stillbirth that is documented in the literature.

Impact of a Neonatal-Bereavement-Support DVD on Parental Grief: A Randomized Controlled Trial

This study tested the effect of a neonatal-bereavement-support DVD on parental grief after their baby's death in a Neonatal Intensive Care Unit compared with standard bereavement care (controls). Following a neonatal death, the authors measured grief change from a 3- to 12-month follow-up using a mixed-effects model. Intent-to-treat analysis was not significant, but only 18 parents selectively watched the DVD. Thus, we subsequently compared DVD viewers with DVD nonviewers and controls. DVD viewers reported higher grief at 3-month interviews compared with DVD nonviewers and controls. Higher grief at 3 months was negatively correlated with social support and spiritual/religious beliefs. These findings have implications for neonatal-bereavement care.

"A renewed sense of purpose": mothers' and fathers' experience of having a child following a recent stillbirth

Background

Most research has focused on mothers’ experiences of perinatal loss itself or on the subsequent pregnancy, whereas little attention has been paid to both parents’ experiences of having a child following late perinatal loss and the experience of parenting this child. The current study therefore explored mothers’ and fathers' experiences of becoming a parent to a child born after a recent stillbirth, covering the period of the second pregnancy and up to two years after the birth of the next baby.

Method

In depth interviews were conducted with 7 couples (14 participants). Couples were eligible if they previously had a stillbirth (after 24 weeks of gestation) and subsequently had another child (their first live baby) who was now under the age of 2 years. Couples who had more than one child after experiencing a stillbirth and those who were not fluent in English were excluded. Qualitative analysis of the interview data was conducted using Interpretive Phenomenological Analysis.

Results

Five superordinate themes emerged from the data: Living with uncertainty; Coping with uncertainty; Relationship with the next child; The continuing grief process; Identity as a parent. Overall, fathers' experiences were similar to those of mothers', including high levels of anxiety and guilt during the subsequent pregnancy and after the child was born. Coping strategies to address these were identified. Differences between mothers and fathers regarding the grief process during the subsequent pregnancy and after their second child was born were identified. Despite difficulties with bonding during pregnancy and at the time when the baby was born, parents' perceptions of their relationship with their subsequent child were positive.

Conclusions

Findings highlight the importance of tailoring support systems not only according to mothers' but also to fathers' needs. Parents’, and particularly fathers', reported lack of opportunities for grieving as well as the high level of anxiety of both parents about their baby's wellbeing during pregnancy and after birth implies a need for structured support. Difficulties experienced in bonding with the subsequent child during pregnancy and once the child is born need to be normalised.

Parents bereaved by infant death: sex differences and moderation in PTSD, attachment, coping and social support

OBJECTIVE

Parents bereaved by infant death experience a wide range of symptomatology, including posttraumatic stress disorder (PTSD) that may persist for years after the loss. Little research has been conducted on PTSD in fathers who have lost an infant. Mothers report most symptoms to a greater extent than fathers, but not much is known about other sex differences following infant death.

METHOD

The present cross-sectional study examined sex differences in PTSD and sex differences in the relationship between PTSD severity and related variables. Subjects were 361 mothers and 273 fathers who had lost an infant either late in pregnancy, during birth or in the first year of life. Participants filled out questionnaires between 1.2 months and 18 years after the loss (M = 3.4 years).

RESULTS

Mothers reported significantly more PTSD symptoms, attachment anxiety, emotion-focused coping and feeling let down, but significantly lower levels of attachment avoidance than fathers. Attachment anxiety, attachment avoidance and emotion-focused coping were significantly more strongly associated with PTSD severity in mothers than fathers, but only when examined alone. When all variables and time since the loss were examined together, there were no longer any significant moderation effects of sex.

CONCLUSIONS

Persistent posttraumatic symptomatology exists in both mothers and fathers long after the loss. There are several sex differences in severity and correlates of PTSD, and a few moderation effects were identified for attachment and emotion-focused coping. Overall, more similarities than differences were found between mothers and fathers in the associations between PTSD and covariates.