The relationship of attachment theory and perinatal loss

[Fetal death: Expert consensus from the College of French Gynecologists and Obstetricians]

Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient's wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it's the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.

Maintaining Parental Roles During Neonatal End-of-Life Care: A Review of the Literature

Parents who are experiencing neonatal death need support in promoting and maintaining their parental role. This includes parenting their infant during end-of-life. Bedside nurses should partner with parents to help them maintain the parent-infant relationship by establishing effective communication, building trust, and promoting the parental role. By doing so, parents will utilize these experiences to process their grief through meaning-making.

The needs of women experiencing perinatal loss: A qualitative systematic review and meta-synthesis

PROBLEM

There have been some studies on the needs of women experiencing perinatal loss in various socio-cultural contexts, but there is no research that systematically and comprehensively synthesizes these needs.

BACKGROUND

Perinatal loss has profound psychosocial effects. The misconceptions and prejudices existing in the public, the lack of satisfactory clinical care, and the available social support may all increase the negative impact.

AIM

To synthesize evidence for the needs of women experiencing perinatal loss, attempt to explain the findings, and provide insights into the application of evidence.

METHODS

Published papers were searched in seven electronic databases until 26 March 2022. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the methodological quality of the included studies. Through meta-aggregation, the data was extracted, rated, and synthesized, resulting in new categories and findings. The credibility and dependability of the synthesized evidence were evaluated by ConQual.

FINDINGS

Thirteen studies that fulfilled the inclusion criteria and quality assessment were included in the meta-synthesis. Five synthesized findings were identified, covering information needs, emotional needs, social needs, clinical care needs, as well as spiritual and religious needs.

CONCLUSION

Women's perinatal bereavement needs were individualized and diverse. There is a necessity to understand, identify, and respond to their needs in a sensitive and personalized way. Families, communities, healthcare institutions, and society form a coordinated whole and provide accessible resources to improve recovery from perinatal loss and a satisfactory outcome in the subsequent pregnancy.

Exploring the impact of healthcare workers communication with women who have experienced stillbirth in Malawi, Tanzania and Zambia. A grounded theory study

BACKGROUND

Communication and interaction with healthcare workers at the time of stillbirth remain in parents' long-term memories and impact on emotional and psychological well-being. Cultural attitudes and norms influence how stillbirth is acknowledged and discussed in society. There is limited evidence on how women from sub-Saharan Africa became aware of the death of their babies. This research explored how women perceived the approach adopted by healthcare workers when the news of their stillbirth was disclosed to them.

METHODS

Grounded theory study. Women (n = 33) who had birthed a stillborn baby in the preceding 12 months were purposively sampled and participated in in-depth interviews (9 in Zambia, 16 in Tanzania and 8 in Malawi). Informed consent was gained from all participants. Data were analysed via a coding process using constant comparative analysis.

FINDINGS

Women sacrificed individualized and personal grieving strategies to conform and behave according to what was expected within their community. An overarching theme of cultural conformity overrides personal grief incorporated four sub-themes: perceiving something was wrong, the unexpected outcome, experience contrasting emotions, bonding with the baby.

DISCUSSION AND CONCLUSIONS

Most participants embarked on a negative 'emotion work' to adapt and suppress emotions and grief due to cultural expectations. Inability to voice the trauma of losing a baby may lead to perinatal mental health issues and needs addressing. Maternity healthcare workers should encourage women to express their feelings and grief. Appropriate training in perinatal bereavement care including good communication, appropriate attitudes and provision of meaningful information to grieving women is recommended.

Clinical practice guidelines for perinatal bereavement care: A systematic quality appraisal using AGREE II instrument

PURPOSE

This study aimed to evaluate and analyze the methodological quality of the published clinical practice guidelines (CPGs) for perinatal bereavement care and provide a reference for implementing best clinical practices.

METHODS

We performed a systematic and comprehensive search in five electronic databases (PubMed, The Cochrane Library, Web of Science, CNKI, Wan Fang Database), eight guideline databases, and six websites of professional organizations from March 2021 to June 2021. Four researchers used the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to appraise the selected CPGs independently. The inter-rater reliability of AGREE II domains was calculated using the intraclass correlation coefficient with 95% CI.

RESULTS

We included a total of 8 CPGs. The mean scores of six domains ranged from the lowest score of 46.61% (editorial independence) to the highest score of 87.85% (clarity of presentation). Subgroup analysis showed no statistical difference. Each domain achieved "good" and "very good" intraclass reliability. Two CPGs were deemed as grade A (strongly recommended), five were rated as grade B (recommended with modifications), and one was evaluated as grade C (not recommended).

CONCLUSIONS

Healthcare professionals in obstetrics and neonatology play an important role in helping bereaved parents and families to cope with perinatal loss. High-quality CPGs for perinatal bereavement care can serve as useful resources to improve the quality and outcomes of clinical practice. More efforts should be made to disseminate the best practices for perinatal bereavement care. When implementing GCPs in countries or regions with different backgrounds, professional translations, strict validations, and cultural adaptations should be taken into account.

Effects of maternal psychological distress and perception of COVID-19 on prenatal attachment in a large sample of Italian pregnant women

BACKGROUND

Evidence concerning the impact of COVID-19-related stress exposure on prenatal attachment in pregnant women is unknown. In this study we sought to assess the effect of psychological distress and risk perception of COVID-19 on prenatal attachment in a Italian sample of pregnant women.

METHODS

1179 pregnant women completed an anonymous online survey and self-report questionnaires measuring socio-demographic and obstetric characteristics, psychological distress (STAI Form Y-1-2 and BDI-II), prenatal attachment (PAI) and risk perception of COVID-19. Data were collected from March 2020 to April 2020 referring to the national lockdown period.

RESULTS

After adjusting for the socio-demographic and obstetric factors in the multivariable analysis, we found out the state anxiety was shown to be a significant predictor (p < 0001) of prenatal attachment. Moreover, the COVID-19-risk perception positively moderate the relationship between trait anxiety and prenatal attachment (p=0008), indicating that when COVID-19-risk perception is high, the effects of trait anxiety on prenatal attachment is attenuated. The synergistic effect between STAI Form Y-1 and COVID-19-risk perception index on PAI is partially mediated by STAI Form Y-2 score.

CONCLUSIONS

Findings from this study showed that state anxiety related to COVID-19 outbreak in pregnant women may affect the prenatal attachment process of the expectant mother negatively. However, an adequate and functional perception of COVID-19 could enhance prenatal attachment. These results underline the importance of monitoring the prenatal attachment process and the mother's mental health during pandemics, to safeguard maternal and infant mental health.

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.

The grief ritual of extracting and donating human milk after perinatal loss

Perinatal loss is a major life crisis involving multiple losses, including the loss of future hopes and dreams, of being pregnant, and of self-esteem, to name a few. In the present study I focus on mothers who experienced perinatal loss and chose to extract and donate their human milk to nonprofit milk banks. Through an analysis of 88 women's personal testimonials, collected between 2017 and 2019, I uncover the ritualistic attributes of the extraction and donation process. The bereaved mothers in this study experienced ambiguous loss, comprising the combination of the physical absence and psychological presence of their baby. The process of extracting and donating their milk constitutes a grief ritual, allowing mothers to maintain and reconstruct the continuing bonds with their babies. The present study extends current understandings of organ donation in times of loss, highlighting the unique nature and consequences of the milk donation process through its conceptualization as a grief ritual.

Rural Perinatal Loss: A Needs Assessment

The purpose of this research was to ascertain the availability and depth of services of bereavement care for mothers who live rurally. The specific focus is on those who experienced early losses including pregnancy, stillbirth, neonatal, and young children who were born with fetal anomalies or neonatal disease that resulted in death. The convenience (nonprobability) sample originated from a population of mothers who lived in rural east central Minnesota. Participants were interviewed in a 60-minute interval. All data were coded confidential. Common themes, incidence of resources, or lack of bereavement resources for the participants' lived experiences were considered using a descriptive phenomenological approach. Our appreciation of the continuing bond between mother and child compels us to believe that there is an ethical obligation to reduce and remove these barriers and inequalities in bereavement support services for those who live rurally and have experienced perinatal and infant loss. Results of this study indicate the need for further study and establishment of bereavement resources in rural outreach for perinatal and early childhood loss.

Experiences of interactive ultrasound examination among women at risk of preterm birth: a qualitative study

BACKGROUND

Pregnant women who are at risk of preterm birth are often stressed, anxious and depressed because of worries and fears related to the health of the unborn baby, their own health and uncertainty about the future. Only a few studies have assessed the types of psychological support that would relieve these stress symptoms among women with high-risk pregnancies. The aim of this study was to describe 1) how women at risk of preterm birth experienced an interactive 3/4-dimensional (3/4D) ultrasound examination, and 2) their need for psychological support during the antenatal period.

METHODS

This qualitative study was conducted at one university hospital in Finland in 2017. Women with a singleton pregnancy of 26-32 gestational weeks (gwks) were included in the study. The interactive 3/4D ultrasound included a joint observation of the baby, based on the mother's wishes, with an obstetrician and psychologist. After the examination, the experiences were explored with a semi-structured interview. The data was analyzed using inductive thematic analysis.

RESULTS

The women enjoyed the fact that the staff were focused on her fetus and genuinely present during the session and also enabled the women to actively participate. Watching the baby and her/his activities made the baby more concrete and relieved their concerns. The need for additional psychological support varied individually.

CONCLUSIONS

Interactive ultrasound examination is an interesting way to awaken mental images, increase attachment, and reduce stress. The results imply that an interactive way of jointly looking at the fetus supports pregnant women at risk of preterm birth and may be useful in clinical practice.

I lost my baby today: Embodied writing and learning in organizations

This article focuses on miscarriage and the sharing of intimate experiences as an example of alternative writing that can be used to challenge and resist dominant masculine discourse in academia. It steps back from patriarchal forms of writing organizations and contributes in three ways: in terms of methodology through the use of multi-voice autoethnography that embraces evocative language; with regard to the subject matter, by sharing a narrative that focuses on the bodily and dirty in day-to-day organizing; and in style, by going beyond traditional structures to foster personal, fragile and reflexive narratives that can enhance the understanding of lived experiences in organizations. More specifically, the first author’s autoethnographic account of perinatal loss in the context of contemporary academia is used as an example of resistance to patriarchal norms of organizing.

The loss of self: The effect of miscarriage, stillbirth, and child death on maternal self-esteem

A child's death augments how grieving parents view the world, the family, and the self. Using a representative sample of women ages 25-45 who have ever given birth, we assessed whether miscarriage, stillbirth, and child death impact self-esteem and whether this loss is moderated by maternal identity. We found that stillbirth and child death, but not miscarriage, negatively impacted self-esteem. For those who experienced a loss, the impact on self-esteem was moderated by maternal identity. Women who experienced a stillbirth were the only group who had significantly lower self-esteem after controlling for background characteristics and maternal identity variables.

Teaching attachment behaviors to pregnant women: a randomized controlled trial of effects on infant mental health from birth to the age of three months

BACKGROUND

Maternal-fetal attachment, which forms as soon as pregnancy starts, is essential to an infant's mental development.

OBJECTIVE

This study aimed to explore the effect of teaching attachment behaviors to pregnant women on infant mental health from birth to 3 months of age.

DESIGN

Randomized controlled trial.

SETTING

Hafiz Hospital, Shiraz University of Medical Sciences, Iran, from February to November 2014.

PATIENTS AND METHODS

The participants were randomly divided into an intervention and a control group at 28-34 weeks gestation. The participants in the intervention group attended six educational sessions each lasting for 60-90 minutes. After delivery, the infants of mothers in each group were compared in terms of mental health indexes (total mean scores and scores derived from a checklist of questions for infant mental health with results categorized as low, average and high). Maternal anxiety levels were also recorded at birth and at 3 months.

MAIN OUTCOME MEASURE(S)

Infant mental health index.

RESULTS

In 190 pregnant women (96 in the intervention group and 94 in the control group), the total mean (SD) scores for infant mental health at birth were 16.66 (1.51) in the intervention group and 16.07 (1.74) in the control group (P=.013). At 3 months, the total mental health scores infants were 31.05 (1.88) in the intervention group and 30.25 (2.10) in the control group (P=.007). Differences in checklist scores between the groups at 3 months were not statistically significant, except for crying intensity at 3 months (P=.021). Women in the control group had higher anxiety levels at 3 months (P=.01).

CONCLUSION

Teaching attachment skills to mothers increased the attachment between the mothers and their infants, and consequently, improved infant mental health. Thus, teaching attachment skills should be incorporated into routine prenatal care.

LIMITATIONS

Use of phone calls by the researcher to assess mental health.

Parents' evaluation of support in Australian hospitals following stillbirth

The present study evaluated the level of support and satisfaction among parents of stillborn babies in Australian hospitals. One-hundred and eighty-nine mothers and fathers completed an online survey designed by the researcher based on the guidelines designed by the Perinatal Society of Australia and New Zealand. Support was inconsistent with guidelines implemented on average only 55% of the time. Areas of support regarding creating memories, birth options and autopsy were most problematic. A significant positive correlation was found between support and satisfaction and there is indication that there has been some increase in support and satisfaction over time. There has been a significant increase in both support and satisfaction since the release of the guidelines in 2009. Creating memories was regarded by parents as the most influential to their grief. It is recommended that health professionals review guidelines and seek feedback from parents as to how they can improve the support they provide.

The Understanding Bereavement Evaluation Tool (UBET) for midwives: factor structure and clinical research applications

BACKGROUND

The NMSF (2009) survey reported that bereavement midwife care was inadequate in a number of UK NHS Trusts. Using a small grant from the Scottish government, 3 experienced midwifery lecturers designed an interactive workbook called "Shaping bereavement care for midwives in clinical practice" for the purpose of improving delivery of bereavement education to student midwives. An instrument called the Understanding Bereavement Evaluation Tool (UBET) was designed to measure effectiveness of the workbook at equipping students with essential knowledge.

AIM

To assess validity and reliability of the UBET at measuring midwives' self-perceptions of knowledge surrounding delivery of bereavement care to childbearing women, partners and families who have experienced childbirth related bereavement.

METHOD

An evaluative audit using the UBET was undertaken to explore student midwives' (n=179) self perceived knowledge levels before and after the workbook intervention. Validity tests have shown that the UBET, (6-item version), could be considered a psychometrically robust instrument for assessing students' knowledge gain. PCA identified that the UBET comprised two sub-scales (theoretical knowledge base - Q 1, 2 & 3 and psychosocial elements of care delivery - Q 4, 5 & 6).

DISCUSSION

Data has shown that the easy to administer and short 6-item UBET is a valid and reliable tool for educators to measure success at delivering education using the "Shaping bereavement care for midwives in clinical practice" work book.

Support for mothers, fathers and families after perinatal death

BACKGROUND

Provision of an empathetic, sensitive, caring environment and strategies to support mothers, fathers and their families experiencing perinatal death are now an accepted part of maternity services in many countries. Interventions such as psychological support or counselling, or both, have been suggested to improve outcomes for parents and families after perinatal death.

OBJECTIVES

To assess the effect of any form of intervention (i.e. medical, nursing, midwifery, social work, psychology, counselling or community-based) on parents and families who experience perinatal death.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and article bibliographies.

SELECTION CRITERIA

Randomised trials of any form of support aimed at encouraging acceptance of loss, bereavement counselling, or specialised psychotherapy or counselling for mothers, fathers and families experiencing perinatal death.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of trials.

MAIN RESULTS

No trials were included.

AUTHORS' CONCLUSIONS

Primary healthcare interventions and a strong family and social support network are invaluable to parents and families around the time a baby dies. However, due to the lack of high-quality randomised trials conducted in this area, the true benefits of currently existing interventions aimed at providing support for mothers, fathers and families experiencing perinatal death is unclear. Further, the currently available evidence around the potential detrimental effects of some interventions (e.g. seeing and holding a deceased baby) remains inconclusive at this point in time. However, some well-designed descriptive studies have shown that, under the right circumstances and guided by compassionate, sensitive, experienced staff, parents' experiences of seeing and holding their deceased baby is often very positive. The sensitive nature of this topic and small sample sizes, make it difficult to develop rigorous clinical trials. Hence, other research designs may further inform practice in this area. Where justified, methodologically rigorous trials are needed. However, methodologically rigorous trials should be considered comparing different approaches to support.

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.

A Survey Comparing the Attitudes Toward Perinatal Bereavement Care of Nurses From Three Asian Cities

Caring for parents whose infant has died is extremely demanding, difficult, and stressful. In some situations, nurses may experience personal failure, feel helpless, and need to distance themselves from bereaved parents because they are unable to deal with the enormity of the parental feelings of loss. The aim of the study was to describe and compare attitudes toward perinatal bereavement care across a sample of nurses working in five obstetrics and gynecology settings from three Asian cities, as well as the factors associated with these attitudes. A survey was conducted, and 573 nurses were recruited from 2006 to 2007. The data were collected using the perinatal bereavement attitudes scale, which involves an 11-item self-report questionnaire. Nurses’ attitudes were mainly positive, but differed across cities, with the attitude of Jinan nurses being significantly more positive than nurses from the other two cities, and the attitude of Hong Kong nurses being significantly the lowest. Positive attitudes were associated with position, and nurses who were well informed of hospital policy and received training for bereavement care were statistically significantly more likely to have a positive attitude toward perinatal bereavement care. Although nurses’ attitudes to prenatal bereavement care differ significantly across the three Asian cities, they are generally similar. The differences observed could be related to the wider social, cultural, and organizational circumstances of nursing practice.

Validation of the Perinatal Grief Scale for use in Chinese women who have experienced recent reproductive loss

The primary objective of this research was to validate the short version of the Perinatal Grief Scale (SVPGS) in the Chinese population. The Chinese SVPGS was administered to a sample of Chinese women who had experienced recent reproductive loss (N = 314). The results of the confirmatory factor analysis rejected the original 3-factor model delineated by Potvin (1989). A follow-up exploratory factor analysis suggested an alternative 3-factor model, consisting of a 12-item Sense of Worthlessness subscale, a 7-item Social Detachment subscale, and a 7-item Painful Recollection subscale. Further analysis showed that both the original and Chinese SVPGS demonstrated good internal consistency. Cronbach's alpha equaled .86, .83, .90, and .95, respectively, for the three subscales of Active Grief, Difficulty Coping, and Despair, and the total original SVPGS, and .85, .93, .91, and .95, respectively, for the new subscales of Sense of Worthlessness, Social Detachment, and Painful Recollection, and the total Chinese SVPGS. Both versions demonstrated satisfactory correlations with the participants' psychological distress and spousal emotional support. The authors suggest that both versions are useful in measuring the responses of Chinese women to reproductive loss; the original SVPGS should be used for cross-cultural studies, whereas the Chinese SVPGS should be used for local studies.

Investigating factors associated with nurses' attitudes towards perinatal bereavement care: a study in Shandong and Hong Kong

AIMS

To explore nurses' attitudes towards perinatal bereavement care and to identify factors associated with these attitudes.

BACKGROUND

It is likely that the attitude of nursing staff can influence recovery from a pregnancy loss and that nurses with positive attitudes to bereavement care can help bereaved parents to cope during their grieving period.

DESIGN

Survey.

METHOD

Data were collected through a structured questionnaire; 657 nurses were recruited from Obstetrics and Gynaecology units in Hong Kong and Shandong during 2006. Outcome measures included attitudes towards perinatal bereavement care, importance of hospital policy and training support for bereavement care.

RESULTS

The majority of nurses in this study had a positive attitude to bereavement care. Results show that only 21.6% (n = 141) of the nurses surveyed had bereavement-related training. In contrast, about 89.8% (n = 300) believed they needed to be equipped with relevant knowledge, skills and understanding in the care and support of bereaved parents and more than 88.5% (n = 592) would share their experiences with their colleagues and seek support when feeling under stress. A regression model showed that age, past experience in handling grieving parents, recent ranking and nurses' perceived attitudes to hospital policy and training provided for bereavement care were the factors associated with nurses' attitudes to perinatal bereavement care.

CONCLUSIONS

Nurses in both cities emphasised their need for increased knowledge and experience, improved communication skills and greater support from team members and the hospital for perinatal bereavement care.

RELEVANCE TO CLINICAL PRACTICE

These findings may be used by nursing educators to educate their students on issues related to delivery of sensitive bereavement care in perinatal settings and to enhance nursing school curricula.

Negotiating the transition: caring for women through the experience of early miscarriage

AIM

To explore women's experiences of having an early miscarriage in a hospital gynaecological unit.

BACKGROUND

Miscarriage is a global health issue affecting significant numbers of women and is usually considered a distressing experience. This distress is often interpreted as being characteristic of grief. Nurses and other health professionals in hospital and community settings are therefore expected to provide appropriate care to meet the physical and emotional needs of the woman.

DESIGN

A qualitative, ethnographic study of a hospital gynaecological unit in the UK.

METHODS

The primary method was 20 months of part-time participant observation. Data were also collected through documentary analysis of key documents in the setting and formal interviews. These were with eight women who had an early miscarriage and 16 health professionals (nurses, doctors, ultrasonographers) working in the unit.

RESULTS

Three clear phases emerged in the women's experience of miscarriage and hospital admission; first signs and confirmation, losing the baby and the aftermath. These were interpreted as being components of a process of transition. The hospital admission emerged as vital in these early phases in which the importance of nurses and other health professionals providing sensitive, engaged care to meet the emotional and physical needs of the woman was identified.

CONCLUSIONS

The hospital setting emerged as highly influential in shaping the care that was given to women and influencing their experiences. Transition models were felt to be more appropriate than grief and bereavement models in guiding the psychological care given to women.

RELEVANCE TO CLINICAL PRACTICE

The experience of hospital admission and the actions of nurses and other health professionals is influential in how women negotiate the transition through miscarriage.

The dying neonate: family-centered end-of-life care

There is a need in the NICU for an end-of-life care guideline that nurses can follow when working with dying infants and their families. Maintaining intravenous access to relieve the infant's pain, communicating sensitively to the family, and creating precious, everlasting memories are goals that should be part of every dying infant's care. The nurse's ability to partner with the family in caring for the infant is integral to helping the family take the first steps in their grief journey. Evidence-based literature provides NICU nurses with the knowledge that they are the facilitators of end-of-life care for dying infants. New mothers and fathers are not aware of the caring parental tasks they can perform for their dying baby. They look to and depend on their infant's nurses to encourage them. The guideline included here provides nurses with a tool for ensuring that families have the opportunity to create memories that will not only help them with their immediate pain, but also comfort them for a lifetime.

Support for mothers, fathers and families after perinatal death

BACKGROUND

Provision of an empathetic caring environment, and strategies to enable the mother, father and family to accept the reality of perinatal death, are now an accepted part of standard nursing and social support in most of the developed world. Provision of interventions such as psychological support or counselling, or both, has been suggested to improve outcomes for families after a perinatal death.

OBJECTIVES

The objective of this review was to assess the effects of the provision of any form of medical, nursing, social or psychological support or counselling, or both, to mother, father and families after perinatal death.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 October 2007) and reference lists of articles.

SELECTION CRITERIA

Randomised trials of any form of general support aimed at encouraging acceptance of loss, specific bereavement counselling, or specialised psychological support/counselling including psychotherapy for mother, father and families experiencing perinatal death.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of trials; a third person subsequently assessed the quality of the identified trials as a part of this review update.

MAIN RESULTS

No trials were included.

AUTHORS' CONCLUSIONS

There is currently insufficient information available from randomised trials to indicate whether there is or is not a benefit from interventions which aim to provide psychological support or counselling for mothers, fathers or families after perinatal death. Methodologically rigorous trials are needed.

Stepping back to gain perspective: pregnancy loss history, depression, and parenting capacity in the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B)

Previous empirical studies of pregnancy loss have predominantly focused on complex grief response and emergent problems associated with future parenting in self-selected samples of bereaved women. This article presents findings from a retrospective secondary data analysis conducted with a racially and ethnically diverse sample of currently parenting women in the United States (N = 10,688) that examined the relationships among pregnancy loss history, current maternal depressive symptoms, and mother-infant interaction with the enrolled child. Study findings underscore a racial-ethnic disparity in pregnancy loss history for African American women, whereas current maternal depressive symptoms remain fairly constant across racial-ethnic groups. Multiple loss history is associated with a slight elevation in overall symptoms of depression, but there is no relationship between pregnancy loss history and current mother-infant interaction in the study sample. An important limitation in this study is that the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) data does not allow for inferences specific to the type of loss, gestational age of fetus, time since loss, or whether the loss was spontaneous or induced. However, study findings highlight areas of incongruity between clinical and population-based research that deserve further investigation. Ultimately, the findings from this population-based research contribute to a wider perspective regarding maternal response to reproductive loss that can inform future research and targeted bereavement support.

Psychological morbidity following miscarriage

Emerging evidence has suggested that miscarriage could be associated with significant and possibly enduring psychological consequences. As many as 50% of miscarrying women suffer some form of psychological morbidity in the weeks and months after loss. About 40% of miscarrying women were found to be suffering from symptoms of grief shortly after miscarriage, and pathological grief can follow. Elevated anxiety and depressive symptoms are common, and major depressive disorder has been reported in 10-50% after miscarriage. Psychological symptoms could persist for 6 months to 1 year after miscarriage. The underlying risk factors predisposing a miscarrying woman to psychological morbidity include a history of psychiatric illness, childlessness, lack of social support or poor marital adjustment, prior pregnancy loss, and ambivalence toward the fetus. In addition, care-givers should be aware of the possible moderating effect of clinical practices such as surgical treatment and ultrasound findings on the psychological impact on a miscarrying woman. Unlike in postpartum depression, simple and effective screening measures of psychological morbidity in the context of miscarriage have not been well established. While studies have highlighted that psychological follow-up was highly desired by miscarrying women, and that psychological intervention was potentially beneficial, there is a substantial lack of randomized controlled intervention studies in this area.

Interpretations of stillbirth

BACKGROUND

Continuity is a major concept in the father-son domain of the Han Chinese value system in Taiwan. Aspects of continuity may include structure, interactions and other facets of family; however, providing descendants is the keystone of women's reality in these families. In a culture in which death is seen as a taboo subject and the unborn child has not been recognized as a real baby, losing a long-expected child at the end of pregnancy becomes a great challenge to women who have experienced stillbirth.

AIM

The aim of this paper is to report a study exploring Taiwanese mothers' interpretations of stillbirth, and their unique sociocultural context.

METHOD

An interpretive ethnographic approach was used. Over a two and a half-year period, 20 women who had experienced such losses after at least 20 weeks of pregnancy were interviewed to find out how they interpreted their babies' deaths. Interview data were analysed thematically.

FINDINGS

The four major themes identified were: 'loss of control', 'broken dream', 'shattered self' and 'something wrong with me'. Interpretations of stillbirth among Taiwanese women indicate a strong sense of incompleteness and personal failure, triggering reactions in terms of not only maternal identity, but also female cultural roles. Many interviewees blamed themselves for the deaths of their unborn children, a viewpoint resulting in excessive guilt feelings.

CONCLUSION

Culturally bound taboos against talking about death, participating in death-related events, and expressing grief in public affect the adaptation and grieving processes of Taiwanese women who have had a stillbirth. Nurses should, therefore, make an effort to listen to the perspectives of such patients in order to assist them with coming to terms with their loss. As part of their education, nurses require information on cultural beliefs so that they can provide appropriate care to grieving mothers.

The role of caregivers after a stillbirth: views and experiences of parents

BACKGROUND

The clinical role of the caregiver to parents in the event of a stillbirth has yet to be defined. The aim of this paper was to focus on the caregivers' support as revealed by the parents' experiences.

METHOD

One or both parents of 31 stillborn infants (> or =28 weeks) were interviewed twice, for a total of 57 interviews. The data analysis was conducted using a qualitative approach.

RESULTS

Parents identified the caregivers' behavior and handling of the stillbirth as important. Findings showed that caregivers should support parents in moments of chaos and at other difficult times. The parents needed assistance in both facing and separating from the baby. The six "qualities" that summarized the findings were "support in chaos,""support in the meeting with and separation from the baby,""support in bereavement,""explanation of the stillbirth,""organization of the care," and "understanding the nature of grief." Findings indicate that the hospital is under an obligation to organize the care and make it possible for parents to see the same caregivers again, and to offer extra ultrasound investigations and checkups without unnecessary bureaucracy.

CONCLUSION

We suggest that the "qualities" identified by the study findings should be implemented in clinical care, and could facilitate active guidance and counseling for bereaved parents who have experienced a stillbirth.

A grief ignored: narratives of pregnancy loss from a male perspective

This paper, utilising a narrative approach, aims to describe the experiences of men whose partner had experienced pregnancy loss, based on data from Northern Ireland. The methodology was based upon observation within pregnancy loss self-help groups and in-depth interviews with 14 men who attended the groups. The study also included interviews with 32 midwives and nurses, with the intention of examining attitudes within the medical context towards bereaved fathers. The impact of pregnancy loss on male partners has been largely overlooked in academic research. When a baby dies before birth the loss can be devastating for fathers yet, very often, the world that surrounds them tends to discount their loss, and emotional support and cultural rituals that are normally available to other bereaved individuals are often absent for this group of men. Previous research has shown that men are expected to be emotionally strong in order to support their partner. The present study will show that the perception that men have only a supportive role in pregnancy loss is unjustified, as it ignores the actual life-world experiences of the men, and the meanings they attach to their loss, in what may be a very personal emotional tragedy for them where they have limited support available. The study uncovered several recurring themes including self-blame; loss of identity; and the need to appear strong and hide feelings of grief and anger. There is consideration of the need for hospital staff and the wider community to acknowledge the male partner's grief as being a valid response to the bereavement suffered.

Interconceptional counseling after perinatal and infant loss

Historically, preconceptional health promotion has been recommended for all prospective parents to improve perinatal outcomes. Preconceptional health promotion and interconceptional counseling may be even more beneficial for parents who have had previous perinatal losses. Perinatal loss can be devastating, with long-term effects on subsequent pregnancies and children. A theoretical framework for interconceptional counseling after perinatal loss needs to be developed. Interconceptional counseling can give couples important information to improve outcomes, acknowledge fears and anxieties, evaluate genetic risks, facilitate grieving, and explore attachment and parenting issues.

Bereavement support for women and their families after stillbirth

OBJECTIVES

(1) To heighten awareness of the grieving process of the mother and her family experiencing the death of a baby; (2) to offer suggestions to health-care providers of the type of support that will achieve optimal grief resolution.

OPTIONS

Early, late, or no interventions for women and families who experienced stillbirths.

OUTCOME

Success of health-care providers in preventing, recognizing, and treating psychological problems in the bereaved parents and families, and also in helping these families to build meaningful experiences and positive memories from their loss.

EVIDENCE

English-language articles and their references on grief and bereavement after perinatal death, through a search of MEDLINE, the Cochrane Library, and publications of other national bodies including the Canadian Paediatric Society, and the American College of Obstetricians and Gynecologists.

Neonatal end-of-life care in Sweden: the views of Muslim women

OBJECTIVE

To explore Muslim women's views of neonatal end-of-life-care in Sweden.

METHODS

Interviews using a standardized questionnaire with open-ended questions about care before birth, directly after birth, and during and after the death of the infant. Content analysis was performed on the data.

PARTICIPANTS

Eleven immigrant women of Muslim background living in Sweden.

RESULTS

The categories identified were information both useful and threatening, priority of medical facts, maternal feelings, roles of significant others, predetermined lifetime, protection of the dying infant, staff's role, memories aggravate the grief, special tradition, life after death and belief in the future.

CONCLUSIONS

The women provided suggestions for improvement of care including being given sufficient information of and the need for culturally sensitive care. In providing care for Muslim women it is imperative that care take into account the woman's religion and ethnicity as well as individual preferences.

Both empowered and powerless: mothers' experiences of professional care when their newborn dies

BACKGROUND

The death of a newborn is a complex and tragic situation, the uncertain and stressful nature of which places emotional burdens on the parents. The aim of this study was to examine and illuminate mothers' experiences and perceptions of the care given to them at neonatal clinics while facing the threat and the reality of losing their baby.

METHOD

Interviews were performed, in the form of conversations, with 16 mothers approximately 2 years after the death of their newborns. The interviews were analyzed using a hermeneutic phenomenological method.

RESULTS

The primary themes identified were feeling empowered and feeling powerless. Three related themes to feeling empowered were a sense of nearness--supporting confidence; a sense of encouragement--supporting self-esteem; and a sense of empathy--supporting comfort. Three related themes to feeling powerless were a sense of distance--leading to strength or adjustment; a sense of violation--leading to helplessness and despondency; and a sense of disconnection--leading to insecurity and discouragement. All mothers felt both empowered and powerless. When experiencing empowering care, they had a feeling of encountering benevolence, with respect to their individual desires. Experiencing competent care without humane treatment madethemfeel powerless, and they were neither respected as a mother nor a person.

CONCLUSIONS

Feelings of empowerment emerged when the health care professionals not only saw the mother as an individual but also "saw through the mothers' eyes" and "felt with the mother's feelings". Feelings of powerlessness emerged when the similarity in the lifeworld (i.e., the world of lived experiences) differed, and the perspectives of the mothers and the health care professionals did not correspond.

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.

Predicting Outcomes after Pregnancy Loss: Results from Studies Using the Perinatal Grief Scale

There are widely diverse findings in the literature on the types of variables that best predict grief following a pregnancy loss. This article compares the results from twenty-two studies, carried out in four countries, which all used the Perinatal Grief Scale as their outcome measure. Results of the comparison support the value of the measure for such investigations and indicate strong commonalities among the findings. Specifically, lower grief scores are consistently related to male gender, older age, shorter pregnancy, passage of more time since the loss, mental health, good marital relationship and social support, and a subsequent pregnancy. Conclusions suggest the need for studies that include more diverse populations and evaluate the impact of attributions, coping, and interventions following a loss.