Interpretations of stillbirth

Understanding the spirituality of parents following stillbirth: A qualitative meta-synthesis

This meta-synthesis aims to synthesize qualitative evidence from primary studies to better understand the experience of the spirituality of parents and its relationship to adapting following stillbirth. Five electronic databases were systematically searched and the quality of 21 eligible studies was critically appraised. A thematic synthesis revealed two analytical themes: (1) Spiritual suffering following stillbirth; (2) Moving through spirituality to adapt to the loss, each encompassing four descriptive themes. The findings can inform a more culturally and spiritually sensitive approach to care, taking into account the parents' beliefs, folk customs, religion, values, and spiritual needs.

A mixed methods sequential explanatory study of the psychosocial factors that impact on midwives' confidence to provide bereavement support to parents who have experienced a perinatal loss

BACKGROUND

Perinatal bereavement is traumatic for many parents. Not only is the experience itself emotionally painful, the impact on their lives is made more difficult if midwives are unable to provide appropriate care to the parents.

AIM OF THE STUDY

To explore within an Irish context, the psychosocial factors that impact on midwives' confidence to provide bereavement support to parents who have experienced a perinatal loss.

DESIGN

A mixed methods sequential explanatory design was used to complete this two-phased study from August 2013 to July 2014. Ethical approval was granted from Ethics Committees of three maternity hospitals and a University in Ireland. The recruitment process for the survey occurred in August 2013 and July 2014 for the focus groups.

METHODS

A series of univariate and multivariate analysis were used to analyze the quantitative data using IBM Statistical Package for the Social Sciences (SPSS; version 20). The qualitative data were analyzed using qualitative content analysis. Steps were taken to ensure data validity and reliability.

RESULTS

The overall meta-inference of this study is that the majority of the midwives did not have adequate levels of confidence to provide bereavement support to grieving parents. The psychosocial factors that impact on midwives' confidence were identified as the midwives' awareness of the needs of bereaved parents, their own inner strength and the organizational support they received at their place of work.

CONCLUSION

Improving midwives' bereavement support knowledge and skills is essential for promoting their confidence. Midwives also need adequate emotional and practical support from their organizations.

The meaning of rituals after a stillbirth: A qualitative study of mothers with a stillborn baby

AIMS AND OBJECTIVES

To explore the meaning of rituals that women and their families perform after a stillbirth.

BACKGROUND

A cultural taboo in Taiwan prohibits discussing death; thus, parents of stillborn babies have no established public mourning or burial ceremonies to perform for their stillborn children. Stillbirths are often treated as if they had never happened.

DESIGN

Qualitative descriptive study.

METHODS

In-depth interviews, which were transcribed and content analysed, were conducted with a purposive sample of 16 women discharged from two teaching hospitals in Taiwan after they had a stillbirth.

RESULTS

Families engaged in rituals for two underlying reasons: to benefit the deceased child and the immediate family. The meanings of the rituals for the child are presented through three themes: (i) sending the baby's spirit to a safe place, (ii) protecting it from suffering and (iii) preparing it for a better reincarnation. The meanings of rituals for the families are presented through four themes: (i) releasing parental guilt by doing their best for the deceased child, (ii) cutting bonds with the child, (iii) avoiding additional misfortune should they mishandle the funeral and (iv) praying for a successful subsequent pregnancy.

CONCLUSIONS

Death-related rituals are highly culturally diverse. This study fills a gap about Asian cultures. Participating in rituals permits a mother to do something for her deceased child, helps relieve her guilt and lets her cope with the stillbirth. Rituals after a stillbirth can help a woman recover from grieving and allow her to hope for a successful subsequent pregnancy.

RELEVANCE TO CLINICAL PRACTICE

Health professionals should discuss with bereaved parents what rituals they would like to perform and then respect their decisions. A continuum of care and support that exists from the prenatal diagnosis through the stillbirth and beyond is recommended for parents and families during this difficult time.

The Experience of Cancer Stigma in Taiwan: A Qualitative Study of Female Cancer Patients

BACKGROUND

Cancer is the leading cause of death in Taiwan. Because the causes of cancer are often difficult to identify, a diagnosis of cancer is occasionally attributed to karma and the concept of stigma. These feelings lead to a life predicament, and stigma influences these perceptions.

OBJECTIVE

This study intended to understand how stigma is formed in the disease-related experiences of women with cancer.

METHODS

Ten participants were interviewed at the time of a confirmed diagnosis of advanced cancer and completed cancer treatment with regular follow-up after treatment, and all subjects underwent 2-3 interviews. The number of interviews conducted was determined by data saturation. A content analysis method was used.

RESULTS

The stigma of cancer includes the concepts of "cancer equals death", including the feeling of death approaching and an awareness of disease severity. "Cancer equals menace to social life" suggests that social life is affected and includes other individuals' uncomfortable attitudes toward cancer (shame, sympathy, pity, suffering, and over-cautiousness) and external physical changes. "Cancer equals cancer-ridden life" includes being sensitive to the topics of death and calculating the number of remaining survival days.

CONCLUSIONS

The process from early diagnosis to the decision to receive treatment is complicated for patients with cancer. After the diagnosis is confirmed, the stigma of diagnosis significantly affects patients. Regarding social stereotypes, educating the public to resolve individuals' negative responses to cancer and further convey social and public information to women in society is necessary.

Stillbirths: economic and psychosocial consequences

Despite the frequency of stillbirths, the subsequent implications are overlooked and underappreciated. We present findings from comprehensive, systematic literature reviews, and new analyses of published and unpublished data, to establish the effect of stillbirth on parents, families, health-care providers, and societies worldwide. Data for direct costs of this event are sparse but suggest that a stillbirth needs more resources than a livebirth, both in the perinatal period and in additional surveillance during subsequent pregnancies. Indirect and intangible costs of stillbirth are extensive and are usually met by families alone. This issue is particularly onerous for those with few resources. Negative effects, particularly on parental mental health, might be moderated by empathic attitudes of care providers and tailored interventions. The value of the baby, as well as the associated costs for parents, families, care providers, communities, and society, should be considered to prevent stillbirths and reduce associated morbidity.

A Systematic Review of the Peer-Reviewed Literature on Self-Blame, Guilt, and Shame

This is the first systematic review of the evidence on the prevalence of self-blame, guilt, and shame in bereaved parents. A search of PsychINFO, MEDLINE, Embase, CINAHL, PubMed, and Science Direct resulted in 18 studies for the period 1975 to 2013 which the authors have appraised. Self-blame, guilt, and shame are common in bereaved parents, albeit to varying degrees, with differential relationships to sex, and diminishing over time. There is some evidence that guilt and shame predict more intense grief reactions and that self-blame predicts posttraumatic symptomology, anxiety, and depression in bereaved parents. Heterogeneity of the studies and numerous methodological concerns limit the synthesis and strength of the evidence and the generalizability of the findings. Self-blame, guilt, and shame are commonly experienced by bereaved parents. Awareness of these affective states may assist clinicians in the identification of bereaved parents who are at a higher risk of developing adverse psychological outcomes. Overall, self-blame, guilt, and shame have received very little attention in the bereavement research, leaving many unanswered questions. Implications for practice and recommendations for future research are discussed.

Taiwanese Women's Experiences of Lactation Suppression After Stillbirth

OBJECTIVE

To explore the experiences of lactation suppression (LS) among Taiwanese women who experienced stillbirth after 20-weeks gestation.

DESIGN

Qualitative research combining practitioner ethnography and the observ-view method (participant observation and unstructured interviews while caring for participants).

SETTING

Participants were recruited from a medical center in central Taiwan between June 2013 and November 2014.

PARTICIPANTS

Seven Taiwanese women who had stillbirths.

METHODS

Data were collected by the observ-view method. Recorded interviews were analyzed by content analysis.

RESULTS

Participants described three core experiences: deciding to use LS without careful deliberation; psychological pain is substantially stronger than physical pain; and not regretting their choice regarding method of LS.

CONCLUSION

Physical pain often remains unaddressed because of the greater psychological pain following fetal death. Therefore, LS should be an essential component of follow-up care as part of the discharge plan. Follow-up should be for at least 14 days. More research is needed on nonpharmacological LS to address cultural differences and personal beliefs about methods of LS.

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

Background

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

Method

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

Results

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

Conclusions

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

From seed to tree: developing community support for perinatally bereaved mothers

Despite burgeoning evidence on the positive effects of perinatal loss support groups, some communities still lack such services. Those wishing to begin a support group may find the task daunting, especially if there is little support for their efforts. In this article, the authors discuss the development of a pregnancy loss support group, which included a community assessment, launching a pilot program, and providing training for facilitators. Other practical considerations will also be reviewed, such as finding a location for the group and securing funding for advertising.

The Psychological Impact of Stillbirth on Women: A Systematic Review

This systematic review explored the psychological impact of stillbirth (from 20 weeks gestation) on mothers. A search was conducted in the National Library for Health and Web of Science, Cochrane Review, and Google Scholar. A secondary search based on results from the preliminary search was undertaken. A systematic search identified 26 articles (8 qualitative, 18 quantitative studies), which met criteria and were reviewed according to guidelines. The findings revealed that stillbirth is a distressing experience that can result in high levels of psychological symptoms including anxiety, depression, distress, and negative well-being. Symptoms appear to be highest in the first few months post loss although there is evidence to suggest that for some, symptoms may persist up to 3 years. The long-lasting impact of stillbirth on women was echoed in the qualitative research. Risk factors for higher levels of anxious and depressive symptoms included higher parity at the time of loss and not being married. Social support in particular was identified to be beneficial for women post loss. Longitudinal studies utilizing designs which permit causality to be determined are required to explore the specific experience of stillbirth. Further exploration of risk and protective factors, cultural beliefs, and the impact on partner relationships is needed. Clinical implications of the findings are discussed in light of current guidance.

Taiwanese women's process of recovery from stillbirth: a qualitative descriptive study

The purpose of this qualitative descriptive study was to portray the recovery process of Taiwanese women after stillbirth. Data were generated through individual in-depth interviews with 21 women selected using purposeful sampling. Three stages in an emotional journey of recovery were suffering from silent grief, searching for a way out, and achieving peace of mind and mental stability. Throughout their journey, the women's overarching concern was where the deceased child had gone and whether it was well. Together these stages composed A pathway to peace of mind, a mental journey on which women struggled to spiritually connect with the lost baby and finally sought a personal pathway to emotional peace. Findings can inform healthcare providers in providing culturally sensitive care for Taiwanese women to facilitate healing after a stillbirth.

Memory keepers: a narrative study on siblings never known

Drawing on literature relevant to the impact of sibling death, the authors examined the invisible loss of siblings never known. This article presents findings of a phenomenological study of 15 adult siblings who "storied" the psychological presence and power of a deceased infant sibling never known but who acted as memory keepers for their unknown sibling. Transcriptions of the 15 interviews were analyzed usng NVivo software to support development of thematic categories. The initial 29 subthemes were collapsed into 3 overarching themes of personal loss/ unacknowledged loss, continuing bonds/memory keeping and sense-making. The participants' experiences reflect support for unaddressed and unacknowledged loss for the phenomenon of loss of an unknown sibling. The retrospective narratives echo their perceived roles as memory keepers of their unknown siblings. For many participants, the research process itself was the first recognition of a sense of loss.

Ascertaining causes of neonatal deaths using verbal autopsy: current methods and challenges

OBJECTIVE

'Verbal autopsy' (VA) is used to ascertain cause of death in countries where vital registration systems are lacking. Current VA methods for neonatal deaths vary widely and suffer from several limitations. We aimed to: (1) review current neonatal VA methods, (2) identify gaps and limitations, (3) illustrate some limitations using VA data and (4) identify new approaches in methodology and analysis.

STUDY DESIGN

Rolling techniques and database search terms were used to identify articles that described neonatal VA administration, validation and cause of death assignment.

RESULT

Current VA interviews include open and close-ended modules and are administered by trained interviewers. Causes of death are determined using physician review and/or computer algorithms for various neonatal causes of death. Challenges include lack of a standardized VA instrument and administration of methods, difficulty in identifying gold standards for validation studies, lack of validated algorithms for causes of death, poor existing algorithms, lack of standardized death classification terminology and the use of hierarchy to assign causes of death. Newer probabilistic methods of analysis such as Bayes Theorem or the Symptom Pattern method may improve accuracy for cause of death estimation and alleviate some of the challenges with traditional physician and algorithmic approaches, although additional research is needed.

CONCLUSION

Given the continued reliance on VA to determine cause of death in settings with inadequate registration systems, it is important to understand the gaps in current VA methods and explore how methods can be improved to accurately reflect neonatal disease burden in the global community.

Unearthing the Construct of Transgenerational Grief: The “Ghost” of the Sibling Never Known

A child's death profoundly affects family dynamics, stories, and even other siblings' perceived reasons for being. This influence is often sustained over time to affect not only the lost child's parents and siblings, but also future generations. Health care and mental health care workers frequently encounter such stories, but little is known about the actual phenomenon, which may be a form of disenfranchised grief. This conceptual article explores the construct of transgenerational grief as it pertains to adults' lifelong grief responses to a sibling whom they did not know, but whose “ghost” has been important in the family. The authors consider this construct within its historical family context, proposing that miscarriages and infant losses that a family experienced even a century ago may have resembled unresolved grief, due in part to brief, unresolved mourning. Bereavement theory, Bowenian family theory, and constructionist theory of grief are woven together to create speculative theoretical underpinnings to support transgenerational grief and its impact as uncovered in the authors' study of personal stories of sibling loss.