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

Short Term Coping-Behaviors and Postpartum Health in a Population-Based Study of Women with a Live Birth, Stillbirth, or Neonatal Death

OBJECTIVE

Responding to the National Institutes of Health Working Group's call for research on the psychological impact of stillbirth, we compared coping-related behaviors by outcome of an index birth (surviving live birth or perinatal loss - stillbirth or neonatal death) and, among individuals with loss, characterized coping strategies and their association with depressive symptoms 6-36 months postpartum.

METHODS

We used data from the Stillbirth Collaborative Research Network follow-up study (2006-2008) of 285 individuals who experienced a stillbirth, 691 a livebirth, and 49 a neonatal death. We conducted a thematic analysis of coping strategies individuals recommended following their loss. We fit logistic regression models, accounting for sampling and inverse probability of follow-up weights to estimate associations between pregnancy outcomes and coping-related behaviors and, separately, coping strategies and probable depression (Edinburgh Postnatal Depression Scale > 12) for those with loss.

RESULTS

Compared to those with a surviving live birth and adjusting for pre-pregnancy drinking and smoking, history of stillbirth, and age, individuals who experienced a loss were more likely to report increased drinking or smoking in the two months postpartum (adjusted OR: 2.7, 95% CI = 1.4-5.4). Those who smoked or drank more had greater odds of probable depression at 6 to 36 months postpartum (adjusted OR 6.4, 95% CI = 2.5-16.4). Among those with loss, recommended coping strategies commonly included communication, support groups, memorializing the loss, and spirituality.

DISCUSSION

Access to a variety of evidence-based and culturally-appropriate positive coping strategies may help individuals experiencing perinatal loss avoid adverse health consequences.

Spanish adaptation of the Stillbirth Stigma Scale (SSS)

The death of a baby in the perinatal period is considered a disenfranchized grief that can be a source of significant symptoms of guilt, shame, and stigma. There is a lack of validated instruments for assessing the stigma associated with perinatal grief. The aim of this study was to examine the psychometric properties (factor structure, reliability, and validity) of the Spanish version of the Stillbirth Stigma Scale (SSS) in parents who have experienced a perinatal loss. A total of 291 participants (mostly mothers) completed an online questionnaire that included the SSS and other measures. The best-fitting factor structure was a second-order model with four dimensions and adequate reliability values. In terms of validity, we found statistically significant relationships between the SSS scores and the variables of self-esteem, complicated grief, event centrality, depression, and anxiety. In conclusion, the Spanish adaptation of the SSS is deemed to have adequate psychometric properties.

Culturally sensitive neonatal palliative care: a critical review

Although there are known disparities in neonatal and perinatal deaths across cultural groups, less is known about how cultural diversity impacts neonatal palliative care. This article critically reviews available literature and sets out key questions that need to be addressed to enhance neonatal palliative care provision for culturally diverse families. We begin by critically reviewing the challenges to recording, categorizing and understanding data which need to be addressed to enable a true reflection of the health disparities in neonatal mortality. We then consider whose voices frame the current neonatal palliative care agenda, and, importantly, whose perspectives are missing; what this means in terms of limiting current understanding and how the inclusion of diverse perspectives can potentially help address current inequities in service provision. Utilizing these insights, we make recommendations towards setting a research agenda, including key areas for future enquiry and methodological and practice-based considerations.

Clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancies: a systematic review

OBJECTIVE

This review aimed to identify guidelines with recommendations applicable to the antenatal management of dichorionic diamniotic twin pregnancies within high-income countries, appraise their methodological quality, and discuss the similarities and variability across guidelines.

METHOD

A systematic literature review of electronic databases was performed. Manual searches of guideline repositories and websites of professional organisations were performed to identify additional guidelines. The protocol for this systematic review was registered on PROSPERO (CRD42021248586, 25 June 2021). AGREE II and AGREE-REX tools were applied to assess the quality of eligible guidelines. A narrative and thematic synthesis described and compared the guidelines and their recommendations.

RESULTS

Twenty-four guidelines were included, from which 483 recommendations were identified across 4 international organisations and 12 countries. Guidelines addressed eight themes and recommendations were classified accordingly: chorionicity and dating (103 recommendations), fetal growth (105 recommendations), termination of pregnancy (12 recommendations), fetal death (13 recommendations), fetal anomalies (65 recommendations), antenatal care (65 recommendations), preterm labour (56 recommendations) and birth (54 recommendations). Guidelines showed significant variability in recommendations, with conflicting recommendations regarding non-invasive preterm testing, definitions surrounding selective fetal growth restriction, screening for preterm labour and the timing of birth. Guidelines lacked a focus on standard antenatal management of DCDA twins, management of discordant fetal anomaly and single fetal demise.

CONCLUSIONS

Specific guidance for dichorionic diamniotic twins is overall indistinct and access to guidance regarding the antenatal management of these pregnancies is currently difficult. Management of discordant fetal anomaly or single fetal demise needs greater consideration.

Experiences of Maternity Healthcare Professionals Returning to Work Following a Personal Perinatal Loss: A Scoping Review of the Literature

BACKGROUND

In Australia, midwives care closely for women during pregnancy and birth and the immediate postnatal period. This scoping review aimed to explore the experiences of female maternity healthcare professionals when they return to work following a personal pregnancy loss or neonatal death.Methodology: A scoping review was carried out on published and unpublished research and grey literature looking at how maternity healthcare professionals who have had a personal perinatal loss experience working in a maternity setting following the loss. A search of the literature was performed between October and December 2018, with no set limitations. A search for relevant references from included papers was also carried out. The literature was analysed thematically. The types of perinatal loss were defined as per Australian guidelines.

RESULTS

10 articles were included in this scoping review. Four themes emerged from the literature and these were: 1) Impact of being asked, "have you got children?"; 2) Impact on professional practice; 3) Impact of pre-existing professional knowledge; 4) Importance of collegial support on return to work.

CONCLUSIONS

Return to work in a maternity setting following a personal perinatal loss is emotionally challenging and requires a range of supports. Further research is needed in this area.

Being a Parent: Findings from a Grounded Theory of Memory-Making in Neonatal End-of-Life Care

PURPOSE

Neonatal palliative care guidelines increasingly recommend that parents be encouraged to provide care for their dying baby and to spend time with the before and after death. However, little is currently known about how parents perceive such memory-making interventions. This study explored the significance of memory-making for bereaved parents and the impact of memory-making on parents' experience of neonatal end-of-life care.

DESIGN AND METHODS

We conducted extended interviews with 18 parents who had experienced neonatal loss. Corbin and Strauss' grounded theory method was used throughout sampling, data collection and data analysis. A constant comparative approach was utilised throughout each stage of the data collection/data analysis process, resulting in the development of a grounded theory titled "Affirmed Parenthood".

RESULTS

The core category of "Affirmed parenthood" was underpinned by three primary categories: 'Creating Evidence', 'Needing Guidance' and 'Being a parent'. Opportunities to parent the baby by having contact with them, engaging with them, and providing care were central to parent's experiences of memory-making in the context of neonatal bereavement.

CONCLUSIONS

'Being a Parent' provided important affirmation of the baby's identity and importance, and affirmed the role of the parents. 'Being a Parent' was a critical element of memory-making and had a significant impact on parents' experience of loss.

PRACTICE IMPLICATIONS

Parents should be supported to have unrestricted contact with their baby, to engage with them, and to provide care throughout the baby's brief life and after their baby's death.

Development and evaluation of TEARDROP - a perinatal bereavement care training programme for healthcare professionals

Appropriate perinatal bereavement care can benefit bereaved parents and reduce further distress. Poor training can impact healthcare professionals (HCPs) at a personal and professional-level. HCPs have reported poor preparation to care for bereaved parents. High-quality perinatal bereavement care training is essential. This study describes the TEARDROP workshop for perinatal bereavement care training, an evaluation of its pilot and first workshop, and the teaching methods applied. The TEARDROP workshop was created in line with the Irish National Bereavement Standards, and based on the SCORPIO model of teaching, offering a participant-centred teaching. Both pilot session and workshop were held in a tertiary maternity hospital. Paper-based anonymous questionnaires were used to evaluate these sessions. Overall, participants were highly satisfied with the workshop. The level of information and quality of teaching in the pilot and workshop scored very high. Most participants stated not being adequately prepared to communicate or care for bereaved parents. The pre-workshop evaluation showed that only 8% of participants received prior training on discussing post-mortems with bereaved parents. Participants (100%) would recommend the workshop be available nationally and would recommend it to a colleague. To our knowledge this is one of few participant-centred perinatal bereavement care training for maternity staff in Ireland. The workshop has been well received and results highlighted the relevance and importance of the TEARDROP programme for HCPs. Adequate training for all maternity staff is essential and TEARDROP has the potential to impact on the quality of bereavement care provided in Irish maternity units.

Preparedness for the death of an elderly family member: A possible protective factor for pre-loss grief in informal caregivers

BACKGROUND

Pre-loss grief (PLG) has been identified as a robust risk factor for Prolonged Grief Disorder, which will be added to the DSM 5-TR. Therefore, identifying treatment targets to reduce PLG is warranted. "Preparedness" has been found to strongly predict PLG. The work is nascent and a consensus has not been reached about how best to assess for preparedness, and no reliable measure of this construct exists. Before examining the relationship between preparedness and PLG, an in depth understanding of how family members define preparedness is warranted.

OBJECTIVES

The purpose of this study was to develop a preliminary theoretical framework of preparedness for the loss.

METHODS

This was achieved through prospective semi-structured interviews with family members of Stage 4 Cancer (N = 16) and Advanced Dementia (N = 24) patients.

RESULTS

The overarching theme related to preparedness for the loss was the need to reduce uncertainty, both before the person passes away (i.e., present certainty) and after the person passes away (i.e., future certainty). Factors associated with the need to establish certainty in the present included, religiosity and spirituality, good relationship quality with the person with the life limiting illness, having access to support, good communication with person with life limiting illness, and acceptance of the impending death. Certainty for the future included, knowing what to expect due to past experience of loss, having plans for life without the person, and social support.

CONCLUSION

This study provides a preliminary framework of preparedness for family members of individuals with life limiting illness.

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.

The psychological implications of a subsequent pregnancy outcome in couples with a history of miscarriage

OBJECTIVES

The present study expands upon reproductive research by examining perinatal grief in couples following a miscarriage and throughout a subsequent pregnancy. The aim of the study was to address the question of whether the outcome of a successful live birth mitigates the negative impact of a previous miscarriage.

METHOD

Participants were recruited through 20 general practice surgeries that provided antenatal care in the United Kingdom. The study comprised 128 couples; 64 couples who experienced two consecutive miscarriages, and 64 couples who experienced a live birth following a miscarriage. Participants completed the Perinatal Grief Scale across four Time points (T1: Six weeks following the first pregnancy outcome; T2: Six weeks following the second pregnancy outcome; T3: Six months following the second pregnancy outcome and T4: Twelve months following the second pregnancy outcome).

RESULTS

The primary findings of the study demonstrated a significant mitigation effect with a decrease in perinatal grief over time. As predicted, couples who experienced a second miscarriage reported elevated perinatal grief; compared to couples who went on to have a successful live birth.

CONCLUSION

The present study's findings contribute to our knowledge of the long-term implications of miscarriage and its influence on psychological health in terms of perinatal grief.

Creating Evidence: Findings from a Grounded Theory of Memory-Making in Neonatal Bereavement Care in Australia

PURPOSE

Perinatal and neonatal palliative care guidelines recommend the provision of photographs and other mementos as an element of care for parents bereaved by neonatal loss. However, little is known about parents' perceptions of such bereavement interventions. This study explored the significance of memory-making for bereaved parents and the impact of memory-making on parents' experience of loss following neonatal loss.

DESIGN AND METHODS

We conducted semi-structured interviews with 18 bereaved parents. A grounded theory approach informed by Corbin and Strauss was used to underpin data sampling, data collection and data analysis. A constant comparative approach was used to engage in open, axial and selective coding to distil parents' stories into categories supporting a core concept.

RESULTS

"Creating evidence" emerged as a key theme in the grounded theory of memory-making in bereavement care for parents following neonatal loss. Creating evidence involved taking photographs, creating mementos, as well as involving friends and family during the baby's time in the Neonatal Unit.

CONCLUSIONS

Creating evidence affirmed the life of the baby and the role of the parents. Creating evidence was a significant element of memory-making that had a positive impact on parents' experience of bereavement.

PRACTICE IMPLICATIONS

Parents should be supported to create evidence of their baby's life, through taking photos, creating mementos, and involving others in their baby's care. Such interventions provide affirmation of the baby's life and of the individual's role as a parent.

The Grief of Parents After the Death of a Young Child

Research demonstrates that severe forms of grief and grief-related pathology exist in the general population. Less attention, however, has been paid to the grief of parents following the death of a young, dependent child. In this review, we summarize a search of Pubmed, PsycINFO and Web of Science from 1995 to 2017, using the terms 'parental complicated grief', 'parental traumatic grief', and 'parent Prolonged Grief Disorder', specifically addressing parental grief and identified risk factors for complicated or prolonged grief. Forty-two studies met criteria and indicate a significant burden of complicated or prolonged grief in parents of children dying from virtually any cause. It appears that the empiric literature is undermined by great variability, including the composition of samples, the causes of death studied, the psychometric measures used, and post-loss intervals. We conclude that the uniform severity of grief experiences following the death of a young child is potentially a distinct subtype of grief, deserving of attention in its own right in future research and diagnostic formulations.

Prolonged grief disorder in Chinese Shidu parents who have lost their only child

Background: China has the largest population of '"loss-of-only-child' parents, that are also known as Shidu parents in Chinese society; however, little is known about their unresolved grief. Objective: This is the first study to examine the grief symptoms, prevalence, comorbidity and potential predictors of prolonged grief disorder (PGD) in such parents, taking into consideration that the new PGD diagnostic criteria ICD-11 will soon be implemented in China. Methods: 149 Shidu parents completed assessments of PGD (PG-13), PTSD (PCL-C), depression (CES-D) and general psychiatric morbidity (GHQ-12) via in-person interviews. Results: Of the 149 Shidu parents, 22.2% met the PGD criteria, with a mean of 7.59 years post-loss, and 62.4% experienced daily longing or yearning. Regression analysis indicated that fewer years since loss, subjective perception of poor economic situation, female gender and more hospital visits were prominent risk factors for the development of PGD. Older age of the parents at the time of child loss was also associated with PGD. Parents with PGD had higher comorbidity of PTSD or depression compared with those without PGD. Conclusions: There is a high prevalence of PGD and a high rate of comorbidity between PGD and PTSD or depression in Shidu parents in China, which highlights the need of timely developing effective assessments and interventions to prevent PGD in this population, particularly in female, recently bereaved, low-income and aged parents who lost their only child.

Italian translation and validation of the Perinatal Grief Scale

AIMS

The short version of the Perinatal Grief Scale (PGS) has 33 items of Likert type whose answers vary from 1 (strongly agree) to 5 (strongly disagree), and is used to assess the grief after perinatal loss and to identify women at major need of specific support. This is the first attempt to validate an Italian version of PGS.

MATERIALS AND METHODS

The English version of PGS by Potvin et al. was translated into Italian by a professional mother tongue English translator. The survey was administered at 3 different times (translated Italian version; original English version after 10 days; and same Italian version after other 10 days) to 16 Italian/English bilingual women who had experienced a perinatal loss. The reproducibility among the three administrations and concordance were assessed using Cronbach's alpha and Cohen's kappa, respectively.

RESULTS

Considering the PGS, median score ranged from 74.5 (58.5-94.5) to 78 (64-95), with no significant difference among the three questionnaire administrations (p = 0.616). No significant difference emerged among the three administered questionnaires for subscales (p = 0.095, 0.410 and 0.410 for 'active grief' AG, 'difficulty in coping' DC and 'despair' D scores, respectively). Concordance varied from good to very good among all questionnaire administrations.

CONCLUSIONS

This Italian version of the PGS can be used by clinicians to assess Italian women's responses to stillbirth and perinatal loss, as well as by researchers for research purposes.

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.

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.

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.

Persistent depressive and grief symptoms for up to 10 years following perinatal loss: Involvement of negative cognitions

BACKGROUND

Perinatal loss is known to be associated with a heightened risk of mental health complications. However, the psychological mechanisms underlying the perinatal grief process are less well documented. We hypothesized that negative cognitions are associated with post-perinatal loss symptomatology, and vary according to whether the death occurs before or after birth.

METHODS

We adopted a cross-sectional design to assess demographics, variables related to the death, five types of negative cognitions (about the self, world, life, future, and self-blame), prolonged grief, and depressive symptoms. The sample included 98 perinatally bereaved mothers with a mean age of 33.9 years.

RESULTS

When we controlled for demographics and variables related to the death, hierarchical linear regression showed that maladaptive cognitions about life, the future and the world were associated with prolonged grief symptoms, whereas only maladaptive cognitions about the world were associated with depressive symptoms. Significant interaction effects confirmed that cognitions about the world were associated with increased depressive symptoms when the death occurred after the birth, and cognitions about life when it occurred before the birth.

LIMITATIONS

The cross-sectional design precluded causal conclusions. However, the sample size was relatively representative and limited to perinatally bereaved mothers.

CONCLUSIONS

Different negative cognitions are involved in persistent depressive versus grief symptoms following perinatal loss, and vary depending on the type of loss. These results will serve to enhance perinatal grief interventions.

Life after loss: Parent bereavement and coping experiences after infant death in the neonatal intensive care unit

The death of an infant in the neonatal intensive care unit (NICU) is a profound and unexpected loss for parents that results in a complex process of coping with bereavement. A descriptive qualitative approach was used to explore parent bereavement and coping experiences after infant death in the NICU. The dual process model of coping with bereavement was used as a conceptual framework to help understand how parents cope with grief after infant death. Living with infant death was a process that resulted in major life changes and a process of oscillating among various coping strategies.