International comparison of studies using the perinatal grief scale: a decade of research on pregnancy loss

Miscarriage Australia: the use of a human centered design approach to design and develop a website for those affected by miscarriage

Background

Past research has shown that Australians affected by miscarriage want a website specific to both miscarriage and their local region that is accessible, comprehensive, evidence-based and informed by experts. The aim of this study was to design, develop and evaluate the Miscarriage Australia website using human centered design.

Methods

A four stage human centered design approach was used to develop the Miscarriage Australia website which aimed to: (1) Understand the issue and why users need a website; (2) Define users' specific needs; (3) Design solutions to meet those needs; and (4) Evaluate the design by testing with end users. Across the four stages, various types of data and data analysis were developed and utilized including interviews, desktop research, development of personas and tone of voice, followed by usability testing. Process and content were guided by designers, developers and an expert advisory committee of key stakeholders.

Results

Analysis and synthesis of user research across Stages 1 and Stage 2 found 11 key themes pertaining to user's miscarriage experiences and support needs. Using the themes, common experiences, goals, motivations and behaviors of users were identified and similar user types grouped and used to inform the development of two personas. Using the personas and user research findings, design elements (Stage 3) including the "tone of voice guidelines" were developed recommending the Miscarriage Australia website be calm, empathetic, hopeful and authoritative. The tone of voice guidelines guided branding and over 100 pages of content was informed by the research team and reviewed by a 13-member Expert Clinical Advisory Committee over two rounds to ensure it was evidence based and reflected best practice. Using a contextual inquiry approach, usability testing was undertaken with 8 end users to test a low fidelity mockup and high-fidelity prototype of the website. Overall, end users reported the website was highly acceptable in terms of the design, content, layout, language and terminology, describing it in line with the intended tone of voice. Users reported the website was easy to use and navigate and provided useful and appropriate content and resources. Minor areas for improvement included slight changes to specific images, improved links for navigating sections, and a title change to one section heading.

Conclusion

The Miscarriage Australia website was successfully implemented and commended by users as meeting their needs. As a result of using human centered design, the Miscarriage Australia website provides an ideal template or blueprint on how to develop a successful and useful digital resource for users, particularly around sensitive women's health issues.

The impact of the COVID-19 pandemic on perinatal loss among Italian couples: A mixed-method study

Background

Perinatal bereavement is an event that greatly impacts the emotional, psychological, and psychosocial aspects of those who want to have a child.

Objectives

Since there are few studies on the psychological impact of the COVID-19 pandemic on couples grieving for perinatal loss, this research aimed to survey this experience.

Participants

Between 2020 and 2021, in Italian provinces highly affected by the COVID-19 pandemic, 21 parents participated: 16 mothers (76%; mean age 36.2; SD: 3.1) and 5 fathers (24%; mean age 40.2; SD: 3.4), among which there were 4 couples.

Methods

A mixed-method design was used through self-report questionnaires and in-depth interviews. Accompanied by a sociodemographic form, the following questionnaires were administered: Prolonged Grief-13, the Parental Assessment of Paternal Affectivity (PAPA) (to fathers), the Parental Assessment of Maternal Affectivity (PAMA) (to mothers), the Dyadic Adjustment Scale short version, the Daily Spiritual Experiences Scale, and the Impact of Event Scale-Revised. The texts obtained through the in-depth interviews underwent thematic analysis.

Results

Fifty per cent of participants suffered from Post-Traumatic Stress Disorders (PTSD) symptoms and 20% suffered from relational dyadic stress. Four areas of thematic prevalence emerged: psychological complexity of bereavement, the impact of the COVID-19, disenfranchisement vs. support, and spirituality and contact with the lost child. Participants interpreted their distress as related to inadequate access to healthcare services, and perceiving the pandemic restrictions to be responsible for less support and lower quality of care. Furthermore, they needed psychological help, and most of them were unable to access this service. Spirituality/religiosity did not help, while contact with the fetus and burial did.

Conclusion

It is important to implement psychological services in obstetrics departments to offer adequate support, even in pandemic situations.

Multicountry study protocol of COCOON: COntinuing Care in COVID-19 Outbreak global survey of New, expectant, and bereaved parent experiences

INTRODUCTION

Globally, the COVID-19 pandemic has significantly disrupted the provision of healthcare and efficiency of healthcare systems and is likely to have profound implications for pregnant and postpartum women and their families including those who experience the tragedy of stillbirth or neonatal death. This study aims to understand the psychosocial impact of COVID-19 and the experiences of parents who have accessed maternity, neonatal and bereavement care services during this time.

METHODS AND ANALYSIS

An international, cross-sectional, online and/or telephone-based/face-to-face survey is being administered across 15 countries and available in 11 languages. New, expectant and bereaved parents during the COVID-19 pandemic will be recruited. Validated psychometric scales will be used to measure psychosocial well-being. Data will be analysed descriptively and by assessing multivariable associations of the outcomes with explanatory factors. In seven of these countries, bereaved parents will be recruited to a nested, qualitative interview study. The data will be analysed using a grounded theory analysis (for each country) and thematic framework analysis (for intercountry comparison) to gain further insights into their experiences.

ETHICS AND DISSEMINATION

Ethics approval for the multicountry online survey, COCOON, has been granted by the Mater Misericordiae Human Research Ethics Committee in Australia (reference number: AM/MML/63526). Ethics approval for the nested qualitative interview study, PUDDLES, has been granted by the King's College London Biomedical & Health Sciences, Dentistry, Medicine and Natural & Mathematical Sciences Research Ethics Subcommittee (reference number: HR-19/20-19455) in the UK. Local ethics committee approvals were granted in participating countries where required. Results of the study will be published in international peer-reviewed journals and through parent support organisations. Findings will contribute to our understanding of delivering maternity care services, particularly bereavement care, in high-income, lower middle-income and low-income countries during this or future health crises.

Spontaneous Miscarriage Management Experience: A Systematic Review

BACKGROUND

The estimated frequency of spontaneous miscarriage is about a quarter of all clinically identified pregnancies in the United States. Women typically go to the emergency department (ED) or outpatient clinic when they experience symptoms, including but not limited to vaginal bleeding, abdominal pain, and contractions. The care that is provided varies from place to place.

METHODS

Researchers searched articles from 2010 to 2021 for reports mentioning treatment for spontaneous abortion. Search terms included "miscarriage aftercare" and "spontaneous abortion care," seeking articles addressing the psychological effects of miscarriage and reporting patient experiences in different clinical settings. Data were independently reviewed, graded for evidence quality, and assessed for risk bias using the AMSTAR checklist.

RESULTS

The search strategy yielded 2,275 articles, six of which met the inclusion criteria. Conservative, medical, and surgical management were provided, with surgical management being more common among women with higher education and socioeconomic status. All qualitative studies reported dissatisfaction with care provided in the emergency department, partially due to a lack of emotional support. Structured bereavement intervention was beneficial for women experiencing early pregnancy loss and led to fewer reports of despair. The quantitative studies referenced interventions that aided patients in coping with pregnancy loss and identified several factors influencing the type of treatment received as well as the patient's ability to cope with feeling depressed following a miscarriage.

CONCLUSION

Psychological management is not regularly addressed in the emergency department, and protocols including bereavement education for healthcare providers as well as patient involvement in management would improve the overall patient experience with spontaneous miscarriage care.

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.

Uncovering Prolonged Grief Reactions Subsequent to a Reproductive Loss: Implications for the Primary Care Provider

Introduction

There is a paucity of clinical guidelines for the routine assessment of maladaptive reproductive grief reactions in outpatient primary care and OB-GYN settings in the United States. Because of the disenfranchised nature of perinatal grief reactions, many clinicians may be apt to miss or dismiss a grief reaction that was not identified in the perinatal period. A significant number of those experiencing a reproductive loss exhibit signs of anxiety, depression, or post-traumatic stress disorder. Reproductive losses are typically screened for and recorded numerically as part of a woman’s well-visit intake, yet this process often fails to identify patients emotionally troubled by a prior pregnancy loss.

Materials and Methods

A summative content analysis of 164 recent website blogs from female participants who self-reported having experienced a miscarriage or abortion in their lifetime was conducted. The narratives were reviewed for details regarding the time span between the pregnancy loss and the composition of the blog post. The stories were analyzed for subsequent relationship problems and detrimental mental health conditions. Maladaptive reactions were contrasted for those that indicated a greater than 12 months’ time-lapse and those who had not.

Results

More than a third (39.6%) of the women reported in the narrative that at least one year or more had passed since experiencing the miscarriage or abortion. For those women, the median time span between the loss and composing the blog was 4 years with a range of 47 years. Mental health conditions attributed to the reproductive loss by those who reported longer bereavement times included subsequent relationship problems, substance misuse, depression, suicidal ideation, and PTSD. The percent of reported maladaptive issues was more than double (136.9% vs. 63.6%) for those who reported that a year or more had passed since the loss of the pregnancy.

Discussion

Grief reactions following the loss of a pregnancy may be prolonged or delayed for several months which can contribute to adverse biopsychosocial outcomes. Recognition and treatment of maladaptive grief reactions following a pregnancy loss are critical. Screening methods should be enhanced for clinicians in medical office settings to help identify and expedite the appropriate mental health assistance.

Stillbirth and infant death: mental health among low-income mothers in Mumbai

Background

India has the highest number of stillbirths and the highest neonatal death rate in the world. In the context of its pronatalist society, women who experience perinatal loss often encounter significant social repercussions on top of grief. Furthermore, even when pregnancy outcomes were favorable, adverse life circumstances put some women at risk for postnatal depression. Therefore, perinatal loss and postnatal depression take a heavy toll on women’s mental health. The purpose of this study is to assess mental health among a sample of Mumbai slum-dwelling women with a history of recent childbirth, stillbirth, or infant death, who are at risk for perinatal grief, postnatal depression, or mental health sequelae.

Methods

We conducted a mixed method, cross-sectional study. A focus group discussion informed the development of a comprehensive survey using mainly internationally validated scales. After rigorous forward and back-translation, surveys were administered as face-to-face structured interviews due to low literacy and research naiveté among our respondents. Interviews were conducted by culturally, linguistically, gender-matched, trained research assistants.

Results

Of our reproductive age (N = 260) participants, 105 had experienced stillbirth, 69 had a history of infant death, and 25 had experienced both types of loss. Nearly half of the sample met criteria for postnatal depression, and 20% of these women also met criteria for perinatal grief. Anxiety and depression varied by subgroup, and was highest among women desiring an intervention.

Conclusions

Understanding factors contributing to women’s suffering related to reproductive challenges in this pronatalist context is critically important for women’s wellbeing.

Perinatal Grief Among Poor Rural and Urban Women in Central India

PURPOSE

Given the pressures surrounding women's reproductive role in India, and persistent high rates of perinatal death, the purpose of this study is to describe and compare poor rural and urban Indian women's experiences of perinatal grief.

PARTICIPANTS AND METHODS

Two cross-sectional studies were compared on shared quantitative variables. Poor rural (N = 217) and urban, slum-dwelling (N = 149) Central Indian women with a history of stillbirth, and/or infant death were recruited with the aid of local community health workers. Trained, local, gender, and linguistically matched research assistants conducted the structured interviews. Shared quantitative variables include demographics, Social Provision Scale, Shortened Ways of Coping-Revised, Perinatal Grief Scale, social norms and autonomy.

RESULTS

While similar with respect to SES, age, number of living sons and perinatal loss experiences, these samples of poor women differed significantly across many variables, most notably women's household position, joint family living, number of live daughters, religious coping, autonomy, and degrees of perinatal grief. While perinatal grief was significantly associated with many variables bi-variably, most lost their relative influence in our stepwise multivariable modeling within site (rural/urban), with only social norms and social support remaining significant for rural (31% of variance) and wishful thinking and social norms for urban participants (38.4% of variance). In the combined sample household position, social support and social norms remained significant and explained 53.6% of the adjusted variance.

CONCLUSION

In both samples, perinatal grief was high following perinatal loss. Both groups of women with perinatal loss have increased risk of mental health sequelae. Notably, the context affected how they experienced perinatal grief, with rural women's grief being higher and more affected by their societal pressures and isolation. Such nuances are important considerations for much-needed tailored approaches to future interventions.

Grief reaction and psychosocial impacts of child death and stillbirth on bereaved North Indian parents: A qualitative study

BACKGROUND

Grief following stillbirth and child death are one of the most traumatic experience for parents with psychosomatic, social and economic impacts. The grief profile, severity and its impacts in Indian context are not well documented. This study documented the grief and coping experiences of the Indian parents following stillbirth and child death.

METHODS

This exploratory qualitative study in Delhi (India) included in-depth interviews with parents (50 mothers and 49 fathers), who had stillbirth or child death, their family members (n = 41) and community representatives (n = 12). Eight focus group discussions were done with community members (n = 72). Inductive data analysis included thematic content analysis. Perinatal Grief Scale was used to document the mother's grief severity after 6-9 months of loss.

RESULTS

The four themes emerged were grief anticipation and expression, impact of the bereavement, coping mechanism, and sociocultural norms and practices. The parents suffered from disbelief, severe pain and helplessness. Mothers expressed severe grief openly and some fainted. Fathers also had severe grief, but didn't express openly. Some parents shared self-guilt and blamed the hospital/healthcare providers, themselves or family. Majority had no/positive change in couple relationship, but few faced marital disharmony. Majority experienced sleep, eating and psychological disturbances for several weeks. Mothers coped through engaging in household work, caring other child(ren) and spiritual activities. Fathers coped through avoiding discussion and work and professional engagement. Fathers resumed work after 5-20 days and mothers took 2-6 weeks to resume household chores. Unanticipated loss, limited family support and financial strain affected the severity and duration of grief. 57.5% of all mothers and 80% mothers with stillbirth had severe grief after 6-9 months.

CONCLUSIONS

Stillbirth and child death have lasting psychosomatic, social and economic impacts on parents, which are usually ignored. Sociocultural and religion appropriate bereavement support for the parents are needed to reduce the impacts.

Factors contributing to men's grief following pregnancy loss and neonatal death: further development of an emerging model in an Australian sample

Background

Historically, men’s experiences of grief following pregnancy loss and neonatal death have been under-explored in comparison to women. However, investigating men’s perspectives is important, given potential gendered differences concerning grief styles, help-seeking and service access. Few studies have comprehensively examined the various individual, interpersonal, community and system/policy-level factors which may contribute to the intensity of grief in bereaved parents, particularly for men.

Methods

Men (N = 228) aged at least 18 years whose partner had experienced an ectopic pregnancy, miscarriage, stillbirth, termination of pregnancy for foetal anomaly, or neonatal death within the last 20 years responded to an online survey exploring their experiences of grief. Multiple linear regression analyses were used to examine the factors associated with men’s grief intensity and style.

Results

Men experienced significant grief across all loss types, with the average score sitting above the minimum cut-off considered to be a high degree of grief. Men’s total grief scores were associated with loss history, marital satisfaction, availability of social support, acknowledgement of their grief from family/friends, time spent bonding with the baby during pregnancy, and feeling as though their role of ‘supporter’ conflicted with their ability to process grief. Factors contributing to grief also differed depending on grief style. Intuitive (emotion-focused) grief was associated with support received from healthcare professionals. Instrumental (activity-focused) grief was associated with time and quality of attachment to the baby during pregnancy, availability of social support, acknowledgement of men’s grief from their female partner, supporter role interfering with their grief, and tendencies toward self-reliance.

Conclusions

Following pregnancy loss and neonatal death, men can experience high levels of grief, requiring acknowledgement and validation from all healthcare professionals, family/friends, community networks and workplaces. Addressing male-specific needs, such as balancing a desire to both support and be supported, requires tailored information and support. Strategies to support men should consider grief styles and draw upon father-inclusive practice recommendations. Further research is required to explore the underlying causal mechanisms of associations found.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03514-6.

Protective and risk factors for women's mental health after a spontaneous abortion

Objective:

to examine personal and contextual protective and risk factors associated with women’s mental health after a spontaneous abortion.

Method:

a cross-sectional study was carried out where 231 women who had experienced spontaneous abortions in the past 4 years answered a self-reporting online questionnaire to assess their mental health (symptoms of depression, anxiety, perinatal grief) and to collect personal as well as contextual characteristics.

Results:

women who had experienced spontaneous abortions within the past 6 months had higher scores for depressive symptoms than those who had experienced spontaneous abortions between 7 and 12 months ago, while anxiety level and perinatal grief did not vary according to the time since the loss. Moreover, low socioeconomic status, immigrant status, and childlessness were associated with worse mental health after a spontaneous abortion. In contrast, the quality of the conjugal relationship and the level of satisfaction with health care were positively associated with women’s mental health.

Conclusion:

women in vulnerable situations, such as immigrants, women with a low socioeconomic status, or childless women are particularly vulnerable to mental health problems after a spontaneous abortion. However, beyond those personal and contextual factors, the quality of the conjugal relationship and the level of satisfaction with health care could be important protective factors.

Providing Psychological and Emotional Support After Perinatal Loss: Protocol for a Virtual Reality-Based Intervention

The loss of an infant during the perinatal period has been recognized as a complex and potentially traumatic life event and can have a significant impact on women’s mental health. However, often times, psychological aftercare is typically not offered, and manualized interventions are rarely used in clinical care practice and have seldom been evaluated. In recent years, a growing number of studies have demonstrated the efficacy of virtual reality (VR) interventions to facilitate the expression and coping with emotions linked to a traumatic event. The objective of the proposed paper is to present the protocol of a randomized control trial aimed to assess a novel VR-based intervention for mothers who experienced a perinatal loss. We hypothesize that the VR-based intervention group will show significantly reduced symptoms related to grief, postnatal depression and general psychopathology after treatment relative to a treatment-as-usual (TAU) group. Participants would be randomly assigned to the TAU + VR or to the VR + TAU condition. The TAU condition as well as the VR-based intervention will last 3 weeks, after which women will complete a post-assessment. The proposed VR-based intervention will consist in three weekly sessions focused, respectively on: (1) collect information about the loss and psychoeducation about perinatal grief, and introduction to the virtual environment; (2) through the use of the virtual environment, women will be assisted in the elaboration and acceptation of loss; (3) recreate, using the specific features of the virtual environment a positive metaphor representing woman’s future life. VR has proved to be a valid intervention tool in clinical psychology, and in the last years VR technologies have become more affordable to be used in clinical practice. With the present study we propose to answer to the unquestionable need for interventions addressed to ameliorate the emotional effects in women who experienced perinatal loss, by exploiting also the therapeutic opportunities offered by a new technology as VR.

Pre-loss personal factors and prolonged grief disorder in bereaved mothers

BACKGROUND

Identifying characteristics of individuals at greatest risk for prolonged grief disorder (PGD) can improve its detection and elucidate the etiology of the disorder. The Safe Passage Study, a study of women at high risk for sudden infant death syndrome (SIDS), prospectively examined the psychosocial functioning of women while monitoring their healthy pregnancies. Mothers whose infants died of SIDS were followed in bereavement.

METHODS

Pre-loss data were collected from 12 000 pregnant mothers and analyzed for their associations with grief symptoms and PGD in 50 mothers whose infants died from SIDS, from 2 to 48 months after their infant's death, focusing on pre-loss risk factors of anxiety, depression, alcohol use, maternal age, the presence of other living children in the home, and previous child loss.

RESULTS

The presence of any four risk factors significantly predicted PGD for 24 months post-loss (p < 0.003); 2-3 risk factors predicted PGD for 12 months (p = 0.02). PGD rates increased in the second post-loss year, converging in all groups to approximately 40% by 3 years. Pre-loss depressive symptoms were significantly associated with PGD. Higher alcohol intake and older maternal age were consistently positively associated with PGD. Predicted risk scores showed good discrimination between PGD and no PGD 6-24 months after loss (C-statistic = 0.83).

CONCLUSIONS

A combination of personal risk factors predicted PGD in 2 years of bereavement. There is a convergence of risk groups to high rates at 2-3 years, marked by increased PGD rates in mothers at low risk. The risk factors showed different effects on PGD.

Maternal Satisfaction with Healthcare after Perinatal Loss in Monochorionic Twin Pregnancy

INTRODUCTION

The analysis of patients' satisfaction with healthcare is recognised as being useful in the evaluation of health outcomes and perceived quality of care. Little is known, however, about how the psychological status of women who experience perinatal complications may affect their perceived satisfaction with care.

METHODS

We assessed healthcare satisfaction in 52 women who had undergone intrauterine surgery during a complicated monochorionic twin pregnancy and examined the influence that fetal loss and sociodemographic, clinical, and psychological factors had on the degree of satisfaction. Data were gathered in an individual interview and through the administration of the Medical Patient Satisfaction Questionnaire, Beck Depression Inventory, and State-Trait Anxiety Inventory. Relationships between variables were analysed using a chi-square test, Spearman's rho, Student's t test, and the Mann-Whitney U test, in accordance with the metric nature of the variables and the assumptions fulfilled.

RESULTS

Age and level of education were not associated with the degree of healthcare satisfaction. Negative but non-significant correlations were observed between the level of satisfaction and symptoms of anxiety and depression. Satisfaction with healthcare was high in the sample as a whole, although it was significantly higher among women who had not experienced fetal loss. There were no differences in satisfaction with services involving direct contact with medical staff, whereas satisfaction with indirect services was lower among women who had experienced perinatal loss.

CONCLUSIONS

Due to the unique characteristics of this population, specialised care teams of both professional healthcare and indirect services are needed. Although administrative aspects of healthcare are regarded as being of secondary importance, this may not be the case with more vulnerable populations.

'There was just no-one there to acknowledge that it happened to me as well': A qualitative study of male partner's experience of miscarriage

Miscarriage occurs in up to one in four pregnancies and can be a devastating event affecting both men and women. Unfortunately, the male partner’s experience of miscarriage is seldom researched, particularly within Australia. This qualitative study involved semi-structured telephone interviews with 10 Australian men, whose partners miscarried between three months and ten years ago. Participants were recruited through professional networks and support organisations. Interviews explored men’s general miscarriage experience and the support received or lacking from both healthcare providers and social networks. Online health seeking behaviour and opinions on online support were also discussed. Data was transcribed verbatim and analysed thematically. Most men described feeling significant grief following miscarriage and felt that there was little acknowledgment of their loss, both from healthcare providers and within their social networks. Feelings of sadness, devastation, powerlessness, fear, shock and a loss of identity were common. All men felt their primary role at the time of miscarriage was to support their partner. Most men did not want to burden their partner with their emotions or grief, and struggled to find people within their social networks to talk to about their loss, leading to feelings of isolation. Overall participants felt there was inadequate support offered to men affected by miscarriage. Men wanted information, informed professionals to talk to and male-orientated support networks. A website was one mechanism suggested by men which could adequately contribute to information and support needs during this time. Men are often greatly affected by miscarriage and yet there is all too often little acknowledgement or support available to them at this time. Men affected by miscarriage want and need further support, including reputable, Australian based information and resources tailored their needs.

Life after the loss: protocol for a Danish longitudinal follow-up study unfolding life and grief after the death of a child during pregnancy from gestational week 14, during birth or in the first 4 weeks of life

INTRODUCTION

After the death of a child during pregnancy, birth or in the neonatal period, parents often experience feelings of guilt, disenfranchisement, feelings of betrayal by one's own body and envy of others. Such bereavement results in high rates of distress: psychologically, emotionally, physiologically and existentially. These data are collected using a national, longitudinal cohort to assess grief in mothers and their partners after the death of a child during pregnancy, birth or in the neonatal period. Our aim is to achieve a general description of grief, emotional health, and existential values after pregnancy or perinatal death in a Danish population.

METHODS AND ANALYSIS

The cohort comprises mothers and their partners in Denmark who lost a child during pregnancy from gestational week 14, during birth or in the neonatal period (4 weeks post partum). We began data collection in 2015 and plan to continue until 2024. The aim is to include 5000 participants by 2024, generating the largest cohort in the field to date. Parents are invited to participate at the time of hospital discharge or via the Patient Associations homepage. Data are collected using web-based questionnaires distributed at 1-2, 7 and 13 months after the loss. Sociodemographic and obstetric variables are collected. Validated psychometric measures covering attachment, continuing bonds, post-traumatic stress, prolonged grief, perinatal grief and existential values were chosen to reach our aim.

ETHICS AND DISSEMINATION

The study was approved by The Danish National Data Protection Agency (no. 18/15684, 7 October 2014). The results will be disseminated in peer-reviewed and professional journals as well as in layman magazines, lectures and radio broadcasts.

Empathy and the Public Perception of Stillbirth and Memory Sharing: An Australian Case

Objective: Stillbirth devastates families and leaves them struggling to grieve the death of their baby in a society that expects grief symptoms to decrease over time. Previous research has suggested that increased memory sharing opportunities can lead to positive mental health outcomes. The aim of the current study was to examine people’s perceptions of stillbirth as well as the perceived appropriateness of affected parents sharing memories of their child. In addition, we examined whether manipulating empathy would have an effect on people’s perceptions of stillbirth.

Method: Participants included 200 Australian men and women 18 to 74 years of age (M = 36.76, SD = 12.59) randomly allocated to one of three experimental conditions (i.e., low empathy, high empathy, and control). The high empathy group watched a video about stillbirth and was instructed to imagine how the people portrayed felt; the low empathy group watched the same video but was instructed to remain detached; and the control group watched an unrelated video. Participants were then asked how much money they would be willing to donate to a fictional stillbirth organization, followed by the completion of questionnaires measuring (a) perceptions of stillbirth, (b) empathy, and (c) the appropriateness of parents sharing memories of a stillborn child with different groups of people over time.

Results: The empathy manipulation had an effect on empathy and the willingness to help effected parents (high empathy vs. control). However, empathy did not have an effect on participants’ perceptions toward stillbirth nor appropriateness of sharing memories. The appropriateness of sharing memories decreased as time passed and social distance increased.

Discussion: Individuals who have experienced stillbirth need to be aware that societal expectations and their own expectations in relation to sharing memories may not correspond to each other and that they may need to educate their social group about their need to share memories. Removing the taboo surrounding stillbirth is vital for both parents and those to whom they would wish to communicate.

The presence and predictors of complicated grief symptoms in perinatally bereaved mothers from a bereavement support organization

The present study investigated the presence and possible predictors of complicated grief symptoms in perinatally bereaved mothers (N = 121) up to 5 years postbereavement. The presence of complicated grief scores in the clinical range was 12.4%, which is higher than in many other bereaved populations, and the presence of other living children may protect against the development of complicated grief symptoms. The majority of the women were able to negotiate a perinatal loss without developing complicated grief; however, there remains an important group of women who up to 5 years later score in the clinical range for complicated grief symptoms.

Women's persistent depressive and perinatal grief symptoms following a miscarriage: the role of childlessness and satisfaction with healthcare services

The objectives of this cross-sectional study were to determine whether depressive and perinatal grief symptoms vary according to time since miscarriage and to test whether childlessness and satisfaction with healthcare services influence symptom duration. A total of 245 women who had experienced a miscarriage answered a self-report questionnaire, indicating the date of their miscarriage and assessing their present level of depressive and perinatal grief symptoms. They also provided sociodemographic characteristics and indicated their level of satisfaction with healthcare services. One-way analyses of variance indicated that women who had miscarried within the past 6 months reported higher scores for depressive symptoms than did women who had miscarried between 7 and 12 months ago and more than 2 years ago. However, when controlling for childlessness and satisfaction with healthcare services, those differences became respectively marginal and non-significant, indicating that depressive symptoms are similar across time for more than 2 years after the loss. Regarding perinatal grief, results revealed that symptoms significantly decreased across time only for women with children and women who were satisfied with healthcare services. For childless women and those dissatisfied with healthcare services, perinatal grief symptoms did not vary according to time since miscarriage. Results suggest that, particularly for women who are childless and/or dissatisfied with healthcare services, depressive and perinatal grief symptoms persist long after a miscarriage. These results highlight the importance of paying particular attention to more vulnerable women and of improving healthcare services post-miscarriage.

Depressive disorder and grief following spontaneous abortion

BACKGROUND

Abortion is associated with moderate to high risk of psychological problems such as depression, use of alcohol or marijuana, anxiety, depression and suicidal behaviours. The increased risk of depression after spontaneous abortion in Asian populations has not been clearly established. Only a few studies have explored the relationship between grief and depression after abortion.

METHODS

A study was conducted to assess the prevalence and risk factors of depressive disorder and complicated grief among women 6-10 weeks after spontaneous abortion and compare the risk of depression with pregnant women attending an antenatal clinic. Spontaneous abortion group consisted of women diagnosed with spontaneous abortion by a Consultant Obstetrician. Women with confirmed or suspected induced abortion were excluded. The comparison group consisted of randomly selected pregnant, females attending the antenatal clinics of the two hospitals. Diagnosis of depressive disorder was made according to ICD-10 clinical criteria based on a structured clinical interview. This assessment was conducted in both groups. The severity of depressive symptoms were assessed using the Patients Health Questionnaire (PHQ-9). Grief was assessed using the Perinatal Grief Scale which was administered to the women who had experienced spontaneous abortion.

RESULTS

The sample consisted of 137 women in each group. The spontaneous abortion group (mean age 30.39 years (SD = 6.38) were significantly older than the comparison group (mean age 28.79 years (SD = 6.26)). There were more females with ≥10 years of education in the spontaneous abortion group (n = 54; SD = 39.4) compared to the comparison group (n = 37; SD = 27.0). The prevalence of depression in the spontaneous abortion group was 18.6 % (95 CI, 11.51-25.77). The prevalence of depression in the comparison group was 9.5 % (95 CI, 4.52-14.46). Of the 64 women fulfilling criteria for grief, 17 (26.6 %) also fulfilled criteria for a depressive episode. The relative risk of developing a depressive episode after spontaneous abortion was significantly higher than in females with a viable pregnancy (RR = 2.19, 95 % CI, 1.05 to 4.56). After adjustment for age and period of amenorrhoea, the difference was not significant. Prevalence of complicated grief was 54.74 % (95 % CI, 46.3-63.18).

CONCLUSION

The relative risk of developing a depressive episode after spontaneous abortion was not significantly higher compared to pregnant women after taking into account age and period of amenorrhoea (POA). Almost half the women developed complicated grief after spontaneous abortion. Of these, a significant proportion also had features of depressive disorder.

Pregnancy continuation and organizational religious activity following prenatal diagnosis of a lethal fetal defect are associated with improved psychological outcome

OBJECTIVE

The aim of the article is to examine the psychological impact, specifically symptoms of grief, post-traumatic stress and depression, in women and men who either terminated or continued a pregnancy following prenatal diagnosis of a lethal fetal defect.

METHOD

This project investigated a diagnostically homogeneous group composed of 158 women and 109 men who lost a pregnancy to anencephaly, a lethal neural tube defect. Participants completed the Perinatal Grief Scale, Impact of Event Scale - Revised and Beck Depression Inventory-II, which measure symptoms of grief, post-traumatic stress and depression, respectively. Demographics, religiosity and pregnancy choices were also collected. Gender-specific analysis of variance was performed for instrument total scores and subscales.

RESULTS

Women who terminated reported significantly more despair (p = 0.02), avoidance (p = 0.008) and depression (p = 0.04) than women who continued the pregnancy. Organizational religious activity was associated with a reduction in grief (Perinatal Grief Scale subscales) in both women (p = 0.02, p = 0.04 and p = 0.03) and men (p = 0.047).

CONCLUSION

There appears to be a psychological benefit to women to continue the pregnancy following a lethal fetal diagnosis. Following a lethal fetal diagnosis, the risks and benefits, including psychological effects, of termination and continuation of pregnancy should be discussed in detail with an effort to be as nondirective as possible.

Mindfulness-based Intervention for Perinatal Grief after Stillbirth in Rural India

We explored the concept of using a Mindfulness-based intervention to reduce perinatal grief among Indian women. Data were collected using mixed methods to explore concept acceptability, receptivity, modality, and feasibility of the intervention. The intervention was piloted and evaluated with measures of perinatal grief, psychosocial wellbeing, religious coping, perceived social provision of support, and mindfulness. The intervention was well received and effective in teaching skills to help women deal with high levels of grief and subsequent mental health challenges. To overcome attendance barriers modification is necessary. Partnership with a local nursing school is critical to enhance sustainability of the intervention.

Perinatal bereavement: a principle-based concept analysis

AIM

To report an analysis of the concept of perinatal bereavement.

BACKGROUND

The concept of perinatal bereavement emerged in the scientific literature during the 1970s. Perinatal bereavement is a practice-based concept, although it is not well-defined in the scientific literature and is often intermingled with the concepts of mourning and grief.

DESIGN

Concept Analysis.

DATA SOURCES

Using the term 'perinatal bereavement' and limits of only English and human, Pub Med and CINAHL were searched to yield 278 available references dating from 1974-2011. Articles specific to the experience of perinatal bereavement were reviewed. The final data set was 143 articles.

REVIEW METHODS

The methods of principle-based concept analysis were used. Results reveal conceptual components (antecedents, attributes and outcomes) which are delineated to create a theoretical definition of perinatal bereavement.

RESULTS

The concept is epistemologically immature, with few explicit definitions to describe the phenomenon. Inconsistency in conceptual meaning threatens the construct validity of measurement tools for perinatal bereavement and contributes to incongruent theoretical definitions. This has implications for both nursing science (how the concept is studied and theoretically integrated) and clinical practice (timing and delivery of support interventions).

CONCLUSIONS

Perinatal bereavement is a multifaceted global phenomenon that follows perinatal loss. Lack of conceptual clarity and lack of a clearly articulated conceptual definition impede the synthesis and translation of research findings into practice. A theoretical definition of perinatal bereavement is offered as a platform for researchers to advance the concept through research and theory development.

Complicated grief after perinatal loss

The loss of an infant through stillbirth, miscarriage, or neonatal death is recognized as a traumatic life event. Predictors of development of complicated grief after prenatal loss include lack of social support, pre-existing relationship difficulties, or absence of surviving children, as well as ambivalent attitudes or heightened perception of the reality of the pregnancy. Risk of complicated grief was found to be especially high after termination of a pregnancy due to fetal abnormality. Studies have revealed that men and women show different patterns of grief, potentially exacerbating decline in a relationship. Although it is clear that prenatal loss has a large psychological impact, it is concluded that there is a substantial lack of randomized controlled studies in this field of research,

Grief and Women: Stillbirth in the Social Context of India

INTRODUCTION

Few in Western society would argue the potentially devastating impact of stillbirth related grief; but in many developing countries where stillbirth remains the highest in the world, perinatal grief is barely recognized as an issue. The purpose of this study was to explore how poor, rural central Indian women perceive and cope with stillbirths.

METHODS

Seventeen key informant interviews and two focus groups (N = 33) with local health care providers, family members, and women who experienced stillbirth were conducted over a 1-month period in 2011 and then systematically coded for emerging themes using grounded theory methods to explore how women experienced stillbirth.

RESULTS

Although usually never talked about and not recognized as an issue, perinatal grief emerged as a significant shared experience by all. The perceptions of stillbirth-related grief emerged in three major themes and bear evidence of gender and power issues and indicate that local social norms negatively factor heavily into their perinatal grief experiences.

DISCUSSION

The findings in this richly textured study add to the limited literature regarding rural, central Indian women's experiences with stillbirth and factors influencing their resulting perinatal grief. In light of the void of recognition of this phenomenon in Indian society, a better understanding of the context in which poor Indian women experience perinatal grief will be a first step toward developing much needed culturally rooted interventions to positively impact the women's abilities to better cope with stillbirth in the context of their realities.

Social and cultural factors associated with perinatal grief in Chhattisgarh, India

Stillbirth is a globally significant public health problem with many medical causes. There are also indirect causal pathways including social and cultural factors which are particularly salient in India's traditional society. The purpose of this study was to explore women's perceptions of stillbirth and to determine how issues of gender and power, social support, coping efforts, and religious beliefs influence perinatal grief outcomes among poor women in rural Chhattisgarh, India. Structured interviews were done face-to-face in 21 randomly selected villages among women of reproductive age (N=355) who had experienced stillbirth (n=178) and compared to those who had not (n=177), in the Christian Hospital, Mungeli catchment area. Perinatal grief was significantly higher among women with a history of stillbirth. Greater perinatal grief was associated with lack of support, maternal agreement with social norms, and younger maternal age. These predictors must be understood in light of an additional finding-distorted sex ratios, which reflect gender discrimination in the context of Indian society. The findings of this study will allow the development of a culturally appropriate health education program which should be designed to increase social support and address social norms, thereby reducing psychological distress to prevent complicated perinatal grief. Perinatal grief is a significant social burden which impacts the health women.

Grief and Women: Stillbirth in the Social Context of India

INTRODUCTION: Few in Western society would argue the potentially devastating impact of stillbirth related grief; but in many developing countries where stillbirth remains the highest in the world, perinatal grief is barely recognized as an issue. The purpose of this study was to explore how poor, rural central Indian women perceive and cope with stillbirths.

METHODS: Seventeen key informant interviews and two focus groups (N = 33) with local health care providers, family members, and women who experienced stillbirth were conducted over a 1-month period in 2011 and then systematically coded for emerging themes using grounded theory methods to explore how women experienced stillbirth.

RESULTS: Although usually never talked about and not recognized as an issue, perinatal grief emerged as a significant shared experience by all. The perceptions of stillbirth-related grief emerged in three major themes and bear evidence of gender and power issues and indicate that local social norms negatively factor heavily into their perinatal grief experiences.

DISCUSSION: The findings in this richly textured study add to the limited literature regarding rural, central Indian women’s experiences with stillbirth and factors influencing their resulting perinatal grief. In light of the void of recognition of this phenomenon in Indian society, a better understanding of the context in which poor Indian women experience perinatal grief will be a first step toward developing much needed culturally rooted interventions to positively impact the women’s abilities to better cope with stillbirth in the context of their realities.

Death and bereavement in a paediatric intensive care unit: Parental perceptions of staff support

OBJECTIVES

To determine which staff behaviours and interventions were helpful to a family who had a child die in the intensive care unit (ICU) and which behaviours could be improved.

METHODS

Families whose child died six to 18 months earlier were invited to participate. Families whose child's death involved a coroner's inquiry were excluded. Family members were interviewed by a grief counselor, and completed the Grief Experience Inventory Profile and an empirically designed questionnaire.

RESULTS

No family refused to participate. All family members (13 families, 24 individuals) reported that they wanted, were offered and had: time to be alone with their child, time to hold the child, chances to discuss their feelings, and an opportunity to cry and express their emotions openly. Tangible mementos of the child were appreciated. Support provided by nursing staff was rated as excellent. Some physicians appeared to be abrupt, cold and unfeeling. Hospital social workers and chaplains, when available, were appreciated. Parents valued access to private space and holding their child, but these options needed to be suggested, as they did not know to ask for them. Some families wanted more information about funeral arrangements; most wanted more timely information about autopsy results and feedback on organ donations. Follow-up contact from the hospital about four weeks after the death was valued. Families saw the study as an opportunity to provide feedback that may help others.

CONCLUSIONS

Many acute bereavement interventions need to be initiated by staff because families do not know to request them. Physicians do not always meet individual family's needs for support. Contact initiated by staff following a death is appreciated.

Meta-analysis to obtain a scale of psychological reaction after perinatal loss: focus on miscarriage

Pregnancy has different meanings to different women depending upon their circumstances. A number of qualitative studies have described the experience of miscarriage by women who had desired to carry their pregnancy to full term. The aim of this meta-analysis was to identify a scale of psychological reaction to miscarriage. Meta-analysis is a quantitative approach for reviewing articles from scientific journals through statistical analysis of findings from individual studies. In this review, a meta-analytic method was used to identify and analyze psychological reactions in women who have suffered a miscarriage. Different reactions to stress associated with the period following miscarriage were identified. The depression reaction had the highest average, weighted, unbiased estimate of effect (d₊ = 0.99) and was frequently associated with the experience of perinatal loss. Psychiatric morbidity was found after miscarriage in 27% of cases by a diagnostic interview ten days after miscarriage. The grief reaction had a medium d₊ of 0.56 in the studies included. However, grief after miscarriage differed from other types of grief after perinatal loss because the parents had no focus for their grief. The guilt is greater after miscarriage than after other types of perinatal loss. Measurement of the stress reaction and anxiety reaction seems to be difficult in the included studies, as evidenced by a low d₊ (0.17 and 0.16, respectively). It has been recommended that grief after perinatal loss be measured by an adapted instrument called the Perinatal Grief Scale Short Version.

Continuity and change in mothers' narratives of perinatal hospice

OBJECTIVES

(1) To broadly explore the experiences of women who chose to continue pregnancies affected by lethal fetal diagnoses and (2) to develop knowledge useful to nurses and other healthcare professionals who provide perinatal hospice (PH) care.

DESIGN

Qualitative descriptive study using narrative analysis.

PARTICIPANTS

Fifteen women who learned during their pregnancies of a lethal fetal diagnosis and chose to continue the affected pregnancies.

METHOD

Participants' stories of their PH experiences were recorded in face-to-face interviews. A qualitative approach using narrative analysis was used to identify themes and develop suggestions for care.

RESULTS

The element of time was prevalent in mothers' stories. Some aspects of mothers' experiences continued, particularly feelings of love and connection to their babies. Mothers also reported evolving changes in their thoughts and feelings. Personal changes such as increased compassion, faith, and strength were frequently mentioned. Mothers described transient phases of highs and lows. Drawing personal meanings or life lessons was the main way mothers connected their experiences to their present lives.

CONCLUSIONS

Mothers' descriptions of their experiences can enhance nurses' understanding of perinatal loss. Established care practices, such as birth planning and creating mementoes, were supported. Nurses can help mothers experiencing loss by elucidating and reflecting their personal meanings.

Women's well-being improves after missed miscarriage with more active support and application of Swanson's Caring Theory

PURPOSE

The purpose of this study was to provide better organization and more efficient use of resources within the health care system in order to identify women with nonviable pregnancy earlier in their gestation terms and also to identify those women who experience severe grief reaction after the miscarriage. The proposed solution is to offer an appointment with a gynecologist during regular office hours after consultation with the patient's midwife to women experiencing symptoms and who are concerned with the viability of their pregnancy. Unnecessary contact with the emergency room by the patients would be reduced as a result of this improvement in organization. The aim of the study was to give the women experiencing missed miscarriage an increased sense of well-being by applying Swanson's Caring Theory to their recovery, in addition to the better organization and more efficient use of resources.

METHOD

Both the original study from 2002 to 2003 and the later study from 2004 to 2005 applied Swanson's Caring Theory in the follow-up care management of the women, but only the later study was influenced by the changes made in the health care system. In the past, diagnosis of missed miscarriage was delayed because women experiencing minor symptoms were not highly prioritized in the health care system. More active support was introduced in order to get the proper information to the patient throughout the health care system. The size of the original study database was n = 43, compared with the later study database, which was n = 56. All of the women answered the Perinatal Grief Scale (PGS) questions twice, 1 month and 4 months after their diagnosis. Some additional questions about their circumstances unrelated to the PGS were also mailed to the women 4 months after their diagnosis.

RESULTS

As a result of the more active support, women felt that they received professional care when they needed it most. The patients were satisfied that they were treated as if they were suffering from normal grief. The group score above the limits for deep grief 4 months after diagnosis was significantly lowered. The chances of receiving their diagnosis at an appointment during office hours increased (odds ratio 3.38). Sick leave time of more than a week was reduced from 44% in the original study to 22% in the later study.

Applicability of general grief theory to Swedish women's experience after early miscarriage, with factor analysis of Bonanno's taxonomy, using the Perinatal Grief Scale

BACKGROUND

Grief is a normal phenomenon but showing great variation depending on cultural and personal features. Bonanno and Kaltman have nonetheless proposed five aspects of normal grief. The aim of this study was to investigate if women with miscarriage experience normal grief.

MATERIAL AND METHODS

Content analyses of 25 transcribed conversations with women 4 weeks after their early miscarriages were classified depending on the meaning-bearing units according to Bonanno and Kaltman's categories. In the factor analyses, these categories were compared with the Perinatal Grief Scale and women's age, number of children and number of miscarriages, and gestational weeks.

RESULTS

Women with miscarriage fulfill the criteria for having normal grief according to Bonanno and Kaltman. All of the 25 women had meaning-bearing units that were classified as cognitive disorganization, dysphoria, and health deficits, whereas disrupted social and occupational functioning and positive aspects of bereavement were represented in 22 of 25 women. From the factor analysis, there are no differences in the expression of the intensity of the grief, irrespective of whether or not the women were primiparous, younger, or had suffered a first miscarriage.

CONCLUSION

Women's experience of grief after miscarriage is similar to general grief after death. After her loss, the woman must have the possibility of expressing and working through her grief before she can finish her pregnancy emotionally. The care-giver must facilitate this process and accept that the intensity of the grief is not dependent on the woman's age, or her number of earlier miscarriages.

Attachment and meaning-making in perinatal bereavement

The study examined the psychological impact of perinatal bereavement on 108 women, from a dual attachment and meaning-making perspective, both descriptively and predictively. The study hypothesized that grief acuity is a function of both attachment security (operationalized by A. Antonovsky's 1979 Sense of Coherence [SOC] scale), and the ongoing search for meaning. Controlling for time post-loss, psychological distress and intrusive thoughts; sense of coherence and search for meaning significantly predicted current grief acuity. The findings supported the conceptualization of grief as an interpretive phenomenon, elicited by the loss of a primary attachment figure, thereby shattering core life purposes, and implicating the need to reinstate meaning.