Grief and Women: Stillbirth in the Social Context of India

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

Women's experiences of care and support following perinatal death in high burden countries: A metasynthesis

PROBLEM

The experiences of women in low and middle-income countries following perinatal death remains difficult and challenging, thereby increasing their susceptibility to negative psychological impact particularly with insufficient bereavement care and support.

BACKGROUND

Perinatal death invariably brings intense grief which significantly impacts women, and requires adequate bereavement care to limit negative outcomes in the short and long-term.

AIM

To develop deeper understanding of women's experience of care and support following perinatal death in high burden settings.

METHODS

Six electronic databases were searched with relevant terms established using the SPIDER tool, supplemented by hand search of reference lists. Studies were independently screened for inclusion by all authors. Meta-ethnography (Noblit and Hare,1988) was used to synthesise existing qualitative studies.

FINDINGS

Eight studies conducted in Sub-Saharan African and South Asian countries namely South Africa, Uganda, Ghana, Kenya, India and Malawi were included, and three main themes were identified; mothers' reaction to their baby's death, care and support after perinatal death, and coping strategies in the absence of care and support. Perinatal death was not appropriately acknowledged therefore care and support was inadequate and, in some cases, non-existent. Consequently, mothers resorted to adopting coping strategies as they were unable to express their grief.

DISCUSSION

There is insufficient care and support for women following perinatal death in high burden settings.

CONCLUSIONS

Further research is required into the care and support being given by healthcare professionals and families in high burden settings, thereby ultimately aiding the development of guidance on perinatal bereavement care.

Factors Predicting Mental Health Among Women in Low-Income Communities of a Changing Society: A Mixed-Methods Study

Purpose

To explore women's mental health in India's rapidly changing society.

Participants and Methods

A convenience sample of low-income women (N = 286) in a medium-sized city in South-India participated in a mixed-methods, exploratory study in 2022. Institutional Review Board (IRB) approval was received from Loma Linda University in the US, and Christian Medical College-Vellore in India, in accordance with the declaration of Helsinki, prior to data collection. All study materials were forward and back translated for Tamil, the local language. Phase 1(n = 25) involved audio recorded key-informant interviews and focus groups. Verbatim transcripts were inductively coded, and emerging themes identified. Phase 2 (n = 261) entailed a quantitative survey including demographics, health history, and validated scales measuring mental health symptoms, coping strategies, social support, living situation, and life satisfaction. Data collectors were gender and language matched, research trained, community health nurses.

Results

Qualitative themes included: 1) benefits of living in the city, 2) double duty for women doing household work and paid work, 3) challenges of living in the urban environment, 4) advantages of living in the village, 5) struggles associated with village life. Quantitative results: the average Hopkins Symptoms Checklist (HSCL) score of 1.82 (SD = 0.70) exceeded the 1.65 cut-off score for anxiety and depression symptomology. Among participants with elevated HSCL scores (n = 129) the average was markedly elevated (M = 2.39, SD = 0.56). These women were more likely to rely on wishful thinking, religious coping, and reported more post-migration living difficulties, less social support, and less satisfaction with life. Regression analysis further explored variables associated with participant HSCL scores.

Conclusion

In this sample of low-income urban-dwelling women depression and anxiety symptomology was elevated. Given the limited mental health workforce and cultural stigmatization of mental health issues, further attention is required.

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

Background

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

Methods

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

Results

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

Conclusions

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

Perinatal Grief Among Poor Rural and Urban Women in Central India

PURPOSE

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

PARTICIPANTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Women and Infertility in a Pronatalist Culture: Mental Health in the Slums of Mumbai

Background

Infertility is a global problem, with high prevalence in India. As a pronatalist society, infertility is particularly problematic in India, causing stigma, shame, and blame especially for women. Infertility consequences for women include discrimination, social exclusion, and abandonment, putting them at high risk for mental health distress. Furthermore, mental health is highly stigmatized and specialized care is largely unavailable. Despite the cultural importance of childbearing, research on infertility distress and resulting mental health sequelae is lacking, particularly among low-income women. The purpose of this study is to assess mental health, using validated scales, among Mumbai slum-dwelling women with a history of infertility.

Methods

We conducted a mixed-method, cross-sectional study. A focus group discussion with community health workers (n = 7) informed the development of a comprehensive survey. The survey consisted of validated scales whenever possible, in addition to questions pertaining to women’s sociodemographic and reproductive history. After rigorous forward and back translation, the surveys were conducted as face-to-face structured interviews due to low literacy levels and the research naiveté of our respondents. Interviews were conducted by culturally, linguistically, gender-matched, trained research assistants.

Results

Mumbai slum-dwelling women of reproductive age suffering from infertility (N = 74) participated. Most (85%) women and their husbands (66%) reported previous infertility testing. Participants had elevated mental health distress (anxiety and depression symptomology) largely explained by general health, length of marriage, and coping strategy employed.

Conclusion

Women facing the double stigma of mental health and infertility need innovative programs to address their challenges.

A qualitative study of childbirth fear and preparation among primigravid women: The blind spot of antenatal care in Lilongwe, Malawi

Objectives

This study aimed to explore childbirth fear and childbirth preparation among primigravid women in the late pregnancy from 36 to 40 weeks gestation.

Methods

We purposively recruited 18 primigravid women into in-depth interviews, 21 birth companions, and 13 health workers into focus group discussions. Participants were recruited from two community hospitals’ maternity waiting homes in Lilongwe, Malawi. Semi-structured interview guides were used to collect data that were analyzed using content analysis. NVivo11 computer software was used to organize the data.

Results

The four categories developed were: “ambivalent pregnancy feelings” , “dependence on traditional childbirth counseling” ,“inadequate prenatal childbirth instruction” and “inconsistent roles of a birth companion” . The findings suggest that primigravid women who were mainly exposed to traditional childbirth mentoring rather than professional care providers, experienced childbirth fear, and lacked proper psychosocial childbirth preparation.

Conclusions

Childbirth fear among primigravid women emanate from personal; family; ineffective traditional counseling; and inadequate antenatal childbirth instruction. Birth companions may increase childbirth stress. However, our findings highlight birth companions as readily available psychosocial support resources among primigravid women. We recommend that professional childbirth instruction during antenatal care should be strengthened to surpass traditional childbirth counseling. Appropriateness and effectiveness of birth companions need to be carefully assessed.

Parents' and healthcare professionals' experiences of care after stillbirth in low- and middle-income countries: a systematic review and meta-summary

BACKGROUND

Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement.

OBJECTIVE

To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs.

SEARCH STRATEGY

Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL.

SELECTION CRITERIA

Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs.

DATA COLLECTION AND ANALYSIS

Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES).

MAIN RESULTS

In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth.

CONCLUSIONS

Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately.

TWEETABLE ABSTRACT

Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs.