Mothers’ attitudes towards perinatal autopsy after stillbirth

Life and Death Sometimes Coincide, and Pastoral Response is Crucial to the Brokenhearted

Perinatal loss may remain unexplained, despite current technology, modern preventive care measures, and advanced diagnostic procedures. Culturally sensitive and competent discussions should be prioritized in medicine, but religious and spiritual feelings are often marginalized. Here we highlight our reflections on the importance of the spiritual and theological responses to parents grieving stillbirth. Chaplains are critical for the wellbeing of both families and physicians.

Holding a baby after stillbirth: the impact of fetal congenital and structural abnormalities

OBJECTIVE

Stillbirth can result in numerous adverse psychosocial sequelae. Recommendations vary with regard to holding the baby after a stillbirth. Few studies have addressed the impact of fetal abnormalities on these outcomes.

STUDY DESIGN

Analyses of singleton stillbirths within the Stillbirth Collaborative Research Network were conducted. Patient and stillbirth characteristics were compared between those who did and did not hold their baby. Results from psychometric surveys were compared between cases with and without visible fetal anomalies.

RESULT

There were no significant differences between those who held and those who did not hold in any patient or stillborn characteristics. Visible fetal abnormalities were not associated with adverse psychological outcomes.

CONCLUSION

Fetal abnormalities, including congenital and post-demise changes, do not differ between those who held and did not hold their baby after stillbirth. This suggests that patients should not be discouraged from holding their stillborn infant in the presence of visible abnormalities.

Stillbirth aftercare in a tertiary obstetric center - parents' experiences

OBJECTIVES

This study aimed to assess parents' satisfaction with received care and support when experiencing stillbirth.

METHODS

This was a questionnaire survey conducted at Helsinki University Hospital, Helsinki, Finland during 2016-2020. Separate questionnaires were sent to mothers and partners who had experienced an antepartum singleton stillbirth at or after 22 gestational weeks during 2016-2019. The questionnaire covered five major topics: stillbirth diagnosis, delivery, information on postmortem examinations, aftercare at the ward, and follow-up appointment.

RESULTS

One hundred nineteen letters were sent and 57 (47.9%) of the mothers and 46 (38.7%) of their partners responded. Both mothers and their partners felt well supported during delivery. They were also satisfied with the time holding their newborn. Partners reported even higher satisfaction in this aspect with a significant within-dyad difference (p=0.049). Parents were generally pleased with the support at the ward. However, both groups were less satisfied with social worker counseling (mothers 53.7%, partners 61.0%). The majority felt that the follow-up visit was helpful. Nonetheless, a remarkable proportion felt that the follow-up visit increased their anxiousness (25.9%, 14.0%, p=0.018). Partners rated their mood higher than mothers (p=0.001). Open feedback revealed that the support received after discharge from hospital was often insufficient.

CONCLUSIONS

Our study showed that the parents who experience stillbirth in our institution receive mostly adequate care and support during their hospital stay. However, there is room for further training of healthcare professionals and other professionals contributing in stillbirth aftercare.

"Why didn't we do it"? Reproductive loss and the problem of post-mortem consent

Informed consent has been a much debated topic within the social sciences. It often forms a central feature of discussions on research in medical settings and in social research methods more broadly. While sympathetic to its' underlying principles of autonomy and choice, social scientists have tended to argue that these are seldom enacted in research or clinical practice. Rather, such principles are often circumscribed by wider social structures and by a culture of medical dominance. Drawing on data from a qualitative study on perinatal post-mortem, this paper explores informed consent in the emotionally charged clinical arena of perinatal pathology. Our in-depth analysis will provide fresh insight into post-mortem decision-making in the sensitive arena of baby loss. Our findings show how parents often found it difficult to give consent for post-mortem, and also for professionals to take consent from parents. It was also not uncommon for parents to experience regret over non-consent later on. One of our key findings, however, related to the sense of emotional and diagnostic closure often afforded by post-mortem when consent had been given. We conclude by arguing that, although we cannot resolve the tension between the principles of consent and their enactment in practice, we can develop a reflexive approach with which to navigate the process. In doing so, the paper contributes to wider sociological discussions on the meaning and use of informed consent in various settings beyond medical contexts.

Minimally invasive autopsy for fetuses and children based on a combination of post-mortem MRI and endoscopic examination: a feasibility study

BACKGROUND

Less invasive perinatal and paediatric autopsy methods, such as imaging alongside targeted endoscopy and organ biopsy, may address declining consent rates for traditional autopsy, but their acceptability and accuracy are not known.

OBJECTIVES

The aims of this study were to provide empirical data on the acceptability and likely uptake for different types of autopsy among key stakeholders (study 1); and to analyse existing autopsy data sources to provide estimates of the potential efficacy of less invasive autopsy (LIA) and its projected utility in clinical practice (study 2).

REVIEW METHODS

Study 1: this was a mixed-methods study. Parents were involved in research design and interpretation of findings. Substudy 1: a cross-sectional survey of 859 parents who had experienced miscarriage, termination of pregnancy for fetal anomaly, stillbirth, infant or child death, and interviews with 20 responders. Substudy 2: interviews with 25 health professionals and four coroners. Substudy 3: interviews with 16 religious leaders and eight focus groups, with 76 members of the Muslim and Jewish community. Study 2: a retrospective analysis of national data in addition to detailed information from an existing in-house autopsy database of > 5000 clinical cases that had undergone standard autopsy to determine the proportion of cases by clinical indication group for which tissue sampling of specific internal organs significantly contributed to the diagnosis.

RESULTS

Substudy 1: 91% of participants indicated that they would consent to some form of LIA, 54% would consent to standard autopsy, 74% to minimally invasive autopsy (MIA) and 77% to non-invasive autopsy (NIA). Substudy 2: participants viewed LIA as a positive development, but had concerns around the limitations of the technology and de-skilling the workforce. Cost implications, skills and training requirements were identified as implementation challenges. Substudy 3: religious leaders agreed that NIA was religiously permissible, but MIA was considered less acceptable. Community members indicated that they might consent to NIA if the body could be returned for burial within 24 hours. Study 2: in 5-10% of cases of sudden unexplained death in childhood and sudden unexplained death in infants, the final cause of death is determined by routine histological sampling of macroscopically normal organs, predominantly the heart and lungs, and in this group routine histological sampling therefore remains an important aspect of investigation. In contrast, routine histological examination of macroscopically normal organs rarely (< 0.5%) provides the cause of death in fetal cases, making LIA and NIA approaches potentially highly applicable.

LIMITATIONS

A key limitation of the empirical research is that it is hypothetical. Further research is required to determine actual uptake. Furthermore, because of the retrospective nature of the autopsy data set, findings regarding the likely contribution of organ sampling to final diagnosis are based on extrapolation of findings from historical autopsies, and prospective data collection is required to validate the conclusions.

CONCLUSIONS

LIA is viable and acceptable (except for unexplained deaths), and likely to increase uptake. Further health economic, performance and implementation studies are required to determine the optimal service configuration required to offer this as routine clinical care.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Impact of bereavement care and pregnancy loss services on families: Findings and recommendations from Irish inquiry reports

BACKGROUND

Pregnancy loss and the death of their baby can be overwhelming for families, especially when the loss is unexpected. The standard of bereavement care families receive around the time of pregnancy or early infant loss can have a significant impact on their psychological recovery. At times external inquiries are carried out to identify issues in the maternity care provided and make recommendations to improve its' standard.

OBJECTIVE

This study aims to describe the impact of bereavement care provided to families around the time of pregnancy and/or early infant loss as stated in ten published inquiry reports related to Irish maternity services.

METHODS

Using thematic analysis, issues with care encountered by bereaved parents as outlined in the reports were identified. These focussed around five main themes (communication, healthcare staff skills, maternity unit environment, post-mortem/coronial process, local incident reviews).

FINDINGS

Bereavement care, as described by families in the ten reports, was not consistently individualised or respectful, resulting in additional feelings of anger and upset. Problems with clear communication of complex issues, in a manner that is understandable to bereaved families, were identified in several reports. Recommendations from the inquiry reports included that experienced and skilled staff should always be available to provide immediate support to bereaved families as appropriate, and assist families in understanding and processing information around the time of their loss.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Consistent, individualised bereavement care facilitates a seamless transition for bereaved families from diagnosis through the hospital stay to discharge and follow-up, allowing them to focus on their baby, their bereavement and their family's wellbeing. The process of consent for a perinatal post-mortem and associated concerns have evolved over the timeframe of the ten inquiries. We reflect further on this and the impacts of the other issues highlighted, as well as discussing possible improvements to address them as described in the scientific literature.

"The communication and support from the health professional is incredibly important": A qualitative study exploring the processes and practices that support parental decision-making about postmortem examination

Background

Consent rates for postmortem (PM) examination in the perinatal and paediatric setting have dropped significantly in the United Kingdom, the United States, and the Western Europe. We explored the factors that act as facilitators or barriers to consent and identified processes and practices that support parental decision‐making.

Methods

A qualitative study conducted with bereaved parents, parent advocates, and health care professionals in the United Kingdom. Analysis was conducted on 439 free‐tect comments within a cross‐sectional survey, interviews with a subset of 20 survey respondents and 25 health professionals, and a focus group with five parent advocates.

Results

Three broad parental decision‐making groups were identified: 1, “Not open to postmortem examination”; 2, “Consent regardless of concerns”; and 3, “Initially undecided.” Decisional drivers that were particularly important for this “undecided” group were “the initial approach,” “adjustment and deliberation,” “detailed discussion about the procedure,” and “formal consent.” The way in which these were managed by health care staff significantly impacted whether those parents' consented to PM, particularly for those who are ambivalent about the procedure.

Conclusions

We propose a set of recommendations to improve the way PM counselling and consent is managed. Adopting such measures is likely to lead to improved family experience and more consistent and high‐quality discussion regarding PM.

What's already known about this topic?

There has been a significant decline in uptake of paediatric post mortem, despite evidence that it provides clinically useful data in between 22% and 76% of cases.

What does this study add?

This study identifies key actions by health care staff that are highly influential in whether or not parents' consent to the postmortem procedure. Recommendations for practice are also provided.

Autopsy rates in Iceland

A clinical as well as forensic autopsy is a uniform medical investigation of the deceased, which mainly serves to verify the plausibility of information on the cause, mode and mechanism of death provided by the police and/or medical personnel. Despite its importance in the context of a conclusive assessment of a person's medical history and in detecting any criminal correlation or malpractice, a significant decline in autopsies is evident in Iceland. This article gives an overview on autopsy rates in Iceland and compares the situation with European countries.

An audit of healthcare professionals' knowledge regarding perinatal autopsy

BACKGROUND

Perinatal autopsy is one the most valuable investigations to ascertain the cause of death (Nijkamp et al., Seminars in Fetal & Neonatal Medicine. 22:167-175, 2017; Korteweg et al., AJOG 53, e1-12, 2012; Late Interuterine Death and Stillbirth' RCOG Green-top Guideline No.55, 2015). Discussions about perinatal autopsy can be difficult for parents and healthcare professionals. Perinatal staff need a good level of knowledge and understanding regarding perinatal autopsy in order to discuss the procedure with parents. This study aims to investigate healthcare professionals' knowledge regarding perinatal autopsy.

METHODS

An audit conducted in a large teaching hospital using a questionnaire was developed and distributed to healthcare professionals in the hospital.

RESULTS

Seventy healthcare professionals participated in the audit. Of those surveyed, 64% (n = 45) have discussed perinatal autopsy with a mother and the majority of healthcare professionals (67%) found this difficult. Self-reported levels of understanding were found to be low with just 10% reporting 'excellent understanding'.

CONCLUSIONS

The results of this audit highlight the need for further education among all healthcare professionals working with bereaved families.

Understanding mothers' decision-making needs for autopsy consent after stillbirth: Framework analysis of a large survey

BACKGROUND

Experiencing stillbirth is devastating and leaves parents searching for causes. Autopsy is the gold standard for investigation, but deciding to consent to this procedure is very difficult for parents. Decision support in the form of clear, consistent, and parent-centered information is likely to be helpful. The aims of this study were to understand the influences on parents' decisions about autopsy after stillbirth and to identify attributes of effective decision support that align with parents' needs.

METHODS

Framework analysis using the Decision Drivers Model was used to analyze responses from 460 Australian and New Zealand (ANZ) mothers who took part in a multi-country online survey of parents' experiences of stillbirth. The main outcomes examined were factors influencing mothers' decisions to consent to autopsy after stillbirth.

RESULTS

Free-text responses from 454 ANZ mothers referenced autopsy, yielding 1221 data segments for analysis. The data confirmed the difficult decision autopsy consent entails. Mothers had a strong need for answers coupled with a strong need to protect their baby. Four "decision drivers" were confirmed: preparedness for the decision; parental responsibility; possible consequences; and role of health professionals. Each had the capacity to influence decisions for or against autopsy. Also prominent were the "aftermath" of the decision: receiving the results; and decisional regret or uncertainty.

CONCLUSIONS

The influences on decisions about autopsy are diverse and unpredictable. Effective decision support requires a consistent and structured approach that is built on understanding of parents' needs.

Late stillbirth post mortem examination in New Zealand: Maternal decision-making

BACKGROUND

For parents who experience stillbirth, knowing the cause of their baby's death is important. A post mortem examination is the gold standard investigation, but little is known about what may influence parents' decisions to accept or decline.

AIM

We aimed to identify factors influencing maternal decision-making about post mortem examination after late stillbirth.

METHODS

In the New Zealand Multicentre Stillbirth Study, 169 women with singleton pregnancies, no known abnormality at recruitment, and late stillbirth (≥28weeks gestation), from seven health regions were interviewed within six weeks of birth. The purpose of this paper was to explore factors related to post mortem examination decision-making and the reasons for declining. We asked women if they would make the same decision again.

RESULTS

Maternal decision to decline a post mortem (70/169, 41.4%) was more common among women of Māori (adjusted odds ratio (aOR) 4.99 95% confidence interval (CI) 1.70-14.64) and Pacific (aOR 3.94 95% CI 1.47-10.54) ethnicity compared to European, and parity two or more (aOR 2.95 95% CI 1.14-7.62) compared to primiparous. The main reason for declining was that women 'did not want baby to be cut'. Ten percent (7/70) who declined said they would not make this decision again. No woman who consented regretted her decision.

CONCLUSION

Ethnic differences observed in women's post mortem decision-making should be further explored in future studies. Providing information of the effect of post mortem on the baby's body and the possible emotional benefits of a post mortem may assist women faced with this decision in the future.

Bereaved mothers' attitudes regarding autopsy of their stillborn baby

Background

Here we present additional information from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigated.

Objective

To explore bereaved mothers' attitudes toward obtaining an autopsy on their stillborn baby, and the future implications of consenting or non-consenting to autopsy in retrospect.

Methods

Demographic data was obtained by a questionnaire. A largely qualitative mixed-methods approach was used to meet the aims of the study, using an exploratory and descriptive research design to provide a detailed description of maternal attitudes. A semi-structured questionnaire based on information from literature and reflections on practice was administered during individual interviews.

Results

We interviewed 25 women who had had a recent stillbirth. The time interval between the time of consenting to autopsy and completing this study ranged from 6 to 18 months. Most participants reported that autopsy results provided peace of mind and helped alleviate their feelings of blame. Participants who were unable to comprehend the results reported negative reactions to receiving autopsy results. The majority of participants were of the opinion that they benefited from consenting to autopsy.

Conclusion

Autopsy and the disclosure of its results generally contribute positively to coping following stillbirth.

Parents' experience of perinatal post-mortem following stillbirth: A mixed methods study

Objectives

To analyse quantitative and qualitative data, to describe the experience of parents in relation to post-mortem following stillbirth, looking at offer and uptake of post-mortem, information-giving, the type of post-mortem carried out, receiving the results and any sociodemographic differences in care practices in relation to post-mortem.

Design

Secondary analysis of a postal survey which included both open and closed questions allowing for a mixed methods study design.

Population

Random sample of women who experienced a stillbirth in 2013.

Methods

A sample of women who experienced a stillbirth in 2013 were selected by staff at the Office for National Statistics and sent a letter and information leaflet about the study followed by a postal questionnaire. The questionnaire included questions about pregnancy, labour and birth, the postnatal period, the time at which the baby died, and also asked about the post-mortem process.

Results

Completed questionnaires were received from 477 women. Overall, 95% of women were asked for consent to a post-mortem, almost half prior to birth, and half by a consultant. The majority of women received written information and felt sufficiently informed, and agreed to a full post-mortem. A third of women had to wait longer than 12 weeks for the post-mortem result and this was the most common theme in the free text comments. Women also commented on the manner of being asked for consent, and wrote about issues related to communication and support. There were significant differences between sociodemographic groups in many of these factors.

Conclusions

The inconsistencies in offer and consent to post-mortem following stillbirth suggest inequality in this area. The amount of time that many parents have to wait for post-mortem results is unacceptable and should be prioritised for improvement.

Factors affecting uptake of postmortem examination in the prenatal, perinatal and paediatric setting

Background

Postmortem examination is the single most useful investigation in providing information to parents about why their baby or child died. Despite this, uptake remains well below the recommended 75%.

Objective

To address the question ‘what are the barriers and motivators to perinatal, prenatal and paediatric PM examination?’

Search strategy

Key databases including Pubmed and CINAHL; Cochrane library, websites of relevant patient organisations, hand search of key journals, first and last authors and references.

Selection criteria

Peer‐reviewed qualitative, quantitative or mixed methods research examining factors affecting uptake or decline of perinatal or paediatric postmortem examination.

Data collection and analysis

Narrative synthesis; findings were compared across studies to examine interrelations.

Main results

Seven major themes describing barriers to postmortem uptake were identified: dislike of invasiveness, practicalities of the procedure, organ retention issues, protective parenting, communication and understanding, religion and culture and professional or organisational barriers. Six major themes related to factors which facilitated parental consent were identified: desire for information, contributing to research, coping and well‐being, respectful care, minimally invasive options, and policy and practice. There were a number of themes in the literature that reflected best practice.

Conclusion

Findings highlight the need for better health professional education and the fact some concerns may be mitigated if less invasive methods of postmortem were routinely available. New consent packages and codes of practice may have a positive impact on perception of examination after death. The landscape is changing; further research is necessary to assess the impact on postmortem uptake rates.

Tweetable abstract

Systematic review to explore the barriers and motivators to perinatal, prenatal and paediatric postmortem examination.

Systematic review to explore the barriers and motivators to perinatal, prenatal and paediatric postmortem examination.

Parental decision making around perinatal autopsy: a qualitative investigation

BACKGROUND

Decades of decline in uptake rates of perinatal autopsies has limited investigation into the causes and risk factors for stillbirth.

AIMS

This study aimed to qualitatively explore perinatal autopsy decision-making processes in parents who experienced antepartum and intrapartum stillbirths.

MATERIAL AND METHODS

A qualitative semi-structured interview format was utilized. The line of questioning centred on how parents came to decide on consenting or declining to have a perinatal autopsy undertaken. Interpretative phenomenological analysis was employed as the analytic strategy. Purposive sampling was used to recruit 10 parents who either consented or declined autopsy from a large tertiary maternity hospital in Cork Ireland, where there were 30 stillbirths in 2011.

RESULTS

Findings revealed four superordinate themes influencing parents' decision-making which varied with type of stillbirth experienced. Those parents who experienced antepartum stillbirths were more likely to consent; thus, knowing that the child was stillborn prior to delivery rather than on the day of delivery was associated with consent. In fact, these parents had more time for meaning-making; those consenting wanted to rule out self-blame and were fearful about future pregnancies. Parents who declined autopsy wanted to protect their infant from further harm. Interestingly, parents' knowledge and understanding of the autopsy itself were acquired primarily from public discourse.

CONCLUSION

Parents' decision-making regarding autopsy is profoundly affected by their emotional response to stillbirth; clinicians and other health professionals may play a key role, especially if they can address parental concerns regarding the invasiveness of the autopsy procedure.

You Don't Leave Your Baby—Mother's Experiences after a Stillbirth

When a baby has died during pregnancy, the first encounter between mother and child occurs when the baby is already dead. Despair, emptiness, and grief characterize the encounter, which is also a gradual farewell to the child and the planned future for the family. This study describes mothers' experiences of the farewell of their stillborn baby at discharge from hospital. Twenty-three mothers from different parts of Sweden, who suffered stillbirth, were interviewed. Semi-structured questions were used and the replies were analyzed using content analysis. The mothers describe the separation from the child when leaving hospital as unnatural and that the separation ruins the motherhood they felt during pregnancy. Five categories were identified: unnatural to leave the baby; going home empty-handed; access to the child; security and insecurity in the separation; to let go. The overarching theme that we recognized from these responses we have formulated as: You don't leave your baby. Leaving the baby at the hospital goes against the biological instinct to care for and protect the offspring. Routines for a dignified goodbye including designating a deputy guardian into whose arms the mother can place the baby can help to facilitate the separation. The possibility of leaving the baby in the arms of someone known to the parents should be an option for parents who choose to take farewell of the child at the hospital. The place and time for the farewell should be decided on by the parents, taking the baby home for a personal farewell could be an alternative.

Sharing experiences to improve bereavement support and clinical care after stillbirth: report of the 7th annual meeting of the International Stillbirth Alliance

Stillbirth remains a global health challenge which is greatly affected by social and economic inequality, particularly the availability and quality of maternity care. The International Stillbirth Alliance (ISA) exists to raise awareness of stillbirth and to promote global collaboration in the prevention of stillbirth and provision of appropriate care for parents whose baby is stillborn. The focus of this ISA conference was to share experiences to improve bereavement support and clinical care. These issues, relevant throughout the globe, are not discrete but closely interrelated, with both similarities and differences depending on the specific country and cultural context. Counting stillbirths and understanding the causes of stillbirth are essential not only for providing optimal care and support to parents whose babies die, but also for reducing the future burden of stillbirth. This summary highlights novel work from obstetricians, midwives, psychologists, parents and peer support organizations that was presented at the ISA meeting. It covers topics including the bereavement process, peer support for parents, support and training for staff, evidence for clinical care, and the need for accurate data on stillbirths and perinatal audits. Representatives from the maternity services of the region presented their outcome data and shared their experiences of clinical and bereavement care. Data and developments in practice within stillbirth and bereavement care must be widely disseminated and acted upon by those responsible for maternity care provision, both to prevent stillbirths and to provide high-quality care when they do occur.