Bereavement care guidelines used in health care facilities immediately following perinatal loss: a scoping review

OBJECTIVE

The objective of the scoping review was to explore the evidence and describe what is known about perinatal bereavement care guidelines provided within health care facilities prior to discharge. Additionally, the review sought to identify what is known about parents' mental health outcomes, and map these outcomes to the characteristics of the bereavement care guidelines.

INTRODUCTION

Perinatal loss poses a serious risk of emotional trauma and mental health sequelae. Conflicting evidence for international bereavement care guidelines and inconsistent implementation, a lack of experimental studies, and older syntheses with a limited focus or population made synthesis complex. Therefore, a scoping review was undertaken to determine the breadth and depth of the existing literature on this topic.

INCLUSION CRITERIA

Sources pertaining to bereavement care guidelines used in health care facilities immediately after perinatal loss (miscarriage, stillbirth, or neonatal death) and parents' mental health outcomes were included. Sources pertaining to family members other than parents, perinatal loss occurring outside of a health care facility, and physical care guidelines were excluded.

METHODS

The review was conducted using JBI methodology for scoping reviews. The team considered quantitative and qualitative studies, practice guidelines, case reports, expert opinions, systematic reviews, professional organization websites, and gray literature. CINAHL (EBSCOhost), PsycINFO (EBSCOhost), SocINDEX (EBSCOhost), Cochrane Library, JBI Evidence-based Practice Database (Ovid), Embase, PubMed (NLM), ProQuest Dissertations and Theses A&I (ProQuest), Web of Science Core Collection, and Epistemonikos were the major databases searched. OpenGrey, Google Scholar, and organizational websites were also searched. The earliest empirical study publication found (1976) served as the starting date limit. After pilot-testing the screening process, data were extracted, collated, and presented in narrative form as well as in tables and figures. The search was first conducted in September and October 2021, and an updated search was performed on February 9, 2023.

RESULTS

The results provide a broad view of bereavement care guidelines to support grieving parents' mental health. The included sources (n = 195) were comprised of 28 syntheses, 96 primary studies, and 71 literature review/text and opinion. From the studies that specified the number of participants, 33,834 participants were included. Key characteristics of bereavement care guidelines were categorized as i) making meaning/memories, ii) good communication, iii) shared decision-making, iv) effective emotional and social support, and v) organizational response. Parents' reported mental health outcomes included both negative outcomes, such as depression, anxiety, anger, and helplessness, and positive outcomes, including coping, healing, recovery, and well-being.

CONCLUSIONS

Conceptually the characteristics of published guidelines are fairly consistent across settings, with cultural variations in specific components of the guidelines. Despite the exponential increase in research pertaining to bereavement care after perinatal loss, there is a gap in research pertaining to certain characteristics of bereavement care guidelines accepted as best practice to support parents' mental health outcomes. This review provides support for future research given the trauma and mental health risks following perinatal loss. Policies ensuring consistent and appropriate implementation of bereavement care guidelines are essential to improve parents' mental health outcomes.

Short-Term Increases in NO2 and O3 Concentrations during Pregnancy and Stillbirth Risk in the U.S.: A Time-Stratified Case-Crossover Study

Associations between gaseous pollutant exposure and stillbirth have focused on exposures averaged over trimesters or gestation. We investigated the association between short-term increases in nitrogen dioxide (NO2) and ozone (O3) concentrations and stillbirth risk among a national sample of 116 788 Medicaid enrollees from 2000 to 2014. A time-stratified case-crossover design was used to estimate distributed (lag 0-lag 6) and cumulative lag effects, which were adjusted for PM2.5 concentration and temperature. Effect modification by race/ethnicity and proximity to hydraulic fracturing (fracking) wells was assessed. Short-term increases in the NO2 and O3 concentrations were not associated with stillbirth in the overall sample. Among American Indian individuals (n = 1694), a 10 ppb increase in NO2 concentrations was associated with increased stillbirth odds at lag 0 (5.66%, 95%CI: [0.57%, 11.01%], p = 0.03) and lag 1 (4.08%, 95%CI: [0.22%, 8.09%], p = 0.04) but not lag 0-6 (7.12%, 95%CI: [-9.83%, 27.27%], p = 0.43). Among participants living in zip codes within 15 km of active fracking wells (n = 9486), a 10 ppb increase in NO2 concentration was associated with increased stillbirth odds in single-day lags (2.42%, 95%CI: [0.37%, 4.52%], p = 0.02 for lag 0 and 1.83%, 95%CI: [0.25%, 3.43%], p = 0.03 for lag 1) but not the cumulative lag (lag 0-6) (4.62%, 95%CI: [-2.75%, 12.55%], p = 0.22). Odds ratios were close to the null in zip codes distant from fracking wells. Future studies should investigate the role of air pollutants emitted from fracking and potential racial disparities in the relationship between short-term increases in NO2 concentrations and stillbirth.

Effect of adverse perinatal outcomes on postpartum maternal mental health in low-income and middle-income countries: a protocol for systematic review

INTRODUCTION

More than three-fourths of adverse perinatal outcomes (preterm, small for gestational age, low birth weight, congenital anomalies, stillbirth and neonatal death) occur in low-income and middle-income countries. These adverse perinatal outcomes can have both short-term and long-term consequences on maternal mental health. Even though there are few empirical studies on the effect of perinatal loss on maternal mental illness, comprehensive information on the impact of adverse perinatal outcomes in resource-limited settings is scarce. Therefore, we aim to systematically review and synthesise evidence on the effect of adverse perinatal outcomes on maternal mental health.

METHODS AND ANALYSIS

The primary outcome of our review will be postpartum maternal mental illness (anxiety, depression, post-traumatic stress disorder and postpartum psychosis) following adverse perinatal outcomes. All peer-reviewed primary studies published in English will be retrieved from databases: PubMed, MEDLINE, CINAHL Ultimate (EBSCO), PsycINFO, Embase, Scopus and Global Health through the three main searching terms-adverse perinatal outcomes, maternal mental illness and settings, with a variant of subject headings and keywords. We will follow the Joanna Briggs Institute critical appraisal checklist to assess the quality of the studies we are including. The review findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. Estimate-based meta-analysis will be performed. We will assess heterogeneity between studies using the I2 statistics and publication bias will be checked using funnel plots and Egger's test. A subgroup analysis will be conducted to explore potential sources of heterogeneity (if available). Finally, the certainty of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Since this systematic review does not involve human participants, ethical approval is not required. The review will be submitted for publication in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023405980.

Carrying Death: A Qualitative Study of Women's Bodily Perceptions After Their Baby Died in Utero

When a child dies in utero death becomes an integrated part of the mothers living body and this complex experience places a heavy existential and bodily burden on a woman experiencing stillbirth. This study uses a phenomenological approach with focus groups and individual interviews and data is discussed within a theoretical existential framework. Interviews of six women who experienced stillbirth within a range of 5 years were performed in Denmark. The participants experienced the dissonance of carrying death in their living body, expressed heightened existential considerations, a sense of transgression and of feeling trapped in an unbearable situation, and an experience of both dislocation from their body and an extreme bodily awareness. The study generates new knowledge and understanding of the how stillbirth is experienced as incomprehensible and as a violent bodily invasion of death with deep existential impact.

Religious Experience as a Predictor of the Meaning in Life and Life Satisfaction in the Lives of Polish Women after a Stillbirth

Many researchers have demonstrated the relationship of religiosity with dimensions of mental health such as searching for meaning in life, the presence of meaning in life, and life satisfaction. Hence, this study attempts to link such aspects of religiosity with the experience of the presence and/or absence of God with the search for and presence of meaning in life and satisfaction with life among a group of Polish women who have experienced a stillbirth in the past five years. The study included 64 women who lost a baby through stillbirth after the 22nd week of gestation. All the women were born into Christian families and declared themselves to be Christians and actively practicing their faith. Women's ages ranged from 29 to 47 years. The research results showed that the experience of God's presence and absence have a positive and significant relationship with the search for meaning in life and the presence of meaning in life, as well as with the satisfaction with life in the lives of women after stillbirth. The strongest relationship was between the presence of meaning in life and life satisfaction (r = .72; p < .01), God's presence and life satisfaction (r = .66; p < .01), as well as the presence of meaning in life and the search for meaning in life (r = .57; p < .01). The structural equation model showed that the experience of God's presence and God's absence have a significant, direct impact on the search for meaning in life and the presence of meaning in life, and the satisfaction with life. These also have an indirect impact on the satisfaction with life in the lives of women who have lost a child to stillbirth.

Fathers' Relational Experiences of Stillbirth: Pre-natal Attachment, Loss and Continuing Bonds Through Use of Objects

This study aimed to investigate fathers' lived experiences of stillbirth through the lens of continuing bonds and use of objects. Semi-structured interviews were conducted with six fathers who had experienced stillbirth from 20 weeks gestation. Interpretative phenomenological analysis revealed five themes: loss and continued bonds in a mother-mediated dynamic, objects as manifestations of relational and meaningful memories, exerting existence and continued connection to others, continued bond through physical presence and evolving expressions of love and fatherhood. Findings offer a novel understanding of the relationship between objects and continued bonds, where objects are seen to facilitate this bond through varying means, including physical manifestation of the deceased and representation of the father-infant relationship. The study places importance on fathers' involvement in creating objects permeated with meaning and memories, and of validating fathers' experiences of loss rather than considering these men merely as partners of a mother who lost their own baby.

Association of antenatal anxiety disorders with antenatal comorbidities and adverse pregnancy outcomes among clinic attendees at a tertiary-care hospital in Sri Lanka

Purpose

Evidence on the association between antenatal anxiety disorders (AADs) and adverse pregnancy outcomes with detection of AADs using the gold-standard is scarce despite being vital to make decisions on interventions. We aimed to determine this association in women attending tertiary-care antenatal clinics in Sri Lanka.

Material and methods

Presence/absence of AADs in a systematic random sample of 221 antenatal women attending routine antenatal clinics of a teaching hospital who participated in a questionnaire-validation study were confirmed by a psychiatrist. These women were followed up until the end of pregnancy. Information on antenatal comorbidities, adverse pregnancy outcomes was extracted from health records. The association between AADs with antenatal comorbidities and adverse pregnancy outcomes were reported using adjusted odds ratios (ORs) and 95%confidence intervals (CIs) generated from logistic regression models.

Results

Mean (±SD) age of the women was 30 (±5.8) years. AADs were diagnosed in 81 (37%) women. Compared to women without AADs, those who had AADs were more at risk of pregnancy-induced hypertension (OR 6.1; 95% CI 1.2-31.9), gestational diabetes mellitus (OR 12.6; 95% CI 1.5-107.2), preterm labour (OR 4.3; 95% CI 1.4-13.0), prolonged labour (OR 19.0; 95% CI 7.1-51.1), lower segment caesarean section (OR 4.7; 95% CI 2.5-8.7) and low birthweight (OR 11.2; 95% CI 4.8-26.3). All miscarriages, stillbirths and assisted labour occurred exclusively in those with AADs.

Conclusions

AADs are strongly associated with several adverse pregnancy outcomes. Causal pathways and effect of interventions for AADs must be explored in future research.

The association between history of prenatal loss and maternal psychological state in a subsequent pregnancy: an ecological momentary assessment (EMA) study

BACKGROUND

Prenatal loss which occurs in approximately 20% of pregnancies represents a well-established risk factor for anxiety and affective disorders. In the current study, we examined whether a history of prenatal loss is associated with a subsequent pregnancy with maternal psychological state using ecological momentary assessment (EMA)-based measures of pregnancy-specific distress and mood in everyday life.

METHOD

This study was conducted in a cohort of N = 155 healthy pregnant women, of which N = 40 had a history of prenatal loss. An EMA protocol was used in early and late pregnancy to collect repeated measures of maternal stress and mood, on average eight times per day over a consecutive 4-day period. The association between a history of prenatal loss and psychological state was estimated using linear mixed models.

RESULTS

Compared to women who had not experienced a prior prenatal loss, women with a history of prenatal loss reported higher levels of pregnancy-specific distress in early as well as late pregnancy and also were more nervous and tired. Furthermore, in the comparison group pregnancy-specific distress decreased and mood improved from early to late pregnancy, whereas these changes across pregnancy were not evident in women in the prenatal loss group.

CONCLUSION

Our findings suggest that prenatal loss in a prior pregnancy is associated with a subsequent pregnancy with significantly higher stress and impaired mood levels in everyday life across gestation. These findings have important implications for designing EMA-based ambulatory, personalized interventions to reduce stress during pregnancy in this high-risk group.

Comparing posttraumatic growth in mothers after stillbirth or early miscarriage

The possibility of posttraumatic growth in the aftermath of pregnancy loss has received limited attention to date. This study investigated posttraumatic growth in mothers following stillbirth compared to early miscarriage. It was hypothesised that mothers following stillbirth will demonstrate more posttraumatic growth, challenge to assumptive beliefs, and disclosure than mothers following early miscarriage. The study also sought to understand how theoretically-derived variables of the Model of Growth in Grief (challenge to assumptive beliefs and disclosure) explained unique variance in posttraumatic growth when key factors were controlled for. One-hundred and twenty women who had experienced a stillbirth (N = 57) or early miscarriage (N = 63) within the last two to six years completed validated questionnaires in an online survey relating to posttraumatic growth and key variables relevant to emotional adjustment post-bereavement. Participants who had experienced a stillbirth demonstrated significantly higher levels of posttraumatic growth, posttraumatic stress symptoms, perinatal grief, disclosure, challenge to assumptive beliefs and rumination than participants who had experienced an early miscarriage (Cohen’s d ranged .38-.94). In a hierarchical stepwise regression analysis, challenge to assumptive beliefs alone predicted 17.5% of the variance in posttraumatic growth. Intrusive and deliberate rumination predicted an additional 5.5% of variance, with urge to talk, reluctance to talk, and actual self-disclosure predicting a further 15.3%. A final model including these variables explained 47.9% of the variance in posttraumatic growth. Interventions targeting challenge to assumptive beliefs, disclosure, and rumination are likely to be clinically useful to promote psychological adjustment in mothers who have experienced stillbirth and early miscarriage.

Perinatal bereavement care during COVID-19 in Australian maternity settings

OBJECTIVES

Perinatal bereavement care is a complex area of practice. The COVID-19 pandemic led to reconfiguration of maternity and perinatal bereavement care services. This study explores Australian health care providers' perspectives of the impact of COVID-19 on the provision of respectful and supportive care following stillbirth or neonatal death.

METHODS

Members of a perinatal bereavement care network were consulted at the commencement of the pandemic in Australia using an online feedback form. Respondents provided ratings and free-text comments on the impact of COVID-19 on implementation of 49 recommendations contained in the Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Clinical Practice Guideline for Respectful and Supportive Perinatal Bereavement Care.

RESULTS

Responses were received from 35 health care providers who provided perinatal bereavement care in clinical settings or through support organisations in Australia. Major impacts of COVID-19 were reported for 8 of 49 guideline recommendations. Impacts included reduced: support for mothers due to visitor restrictions; availability of cultural and spiritual support and interpreters; involvement of support people in decision-making; options for memory-making and commemorative rituals; and staff training and supervision. Adaptations to minimise impacts included virtual consultations, online staff training, use of cold cots, and increased staff support for memory-making.

CONCLUSIONS

Health care providers encounter substantial challenges as they strive to implement best practice perinatal bereavement care in pandemic conditions. Some practice adaptations developed during the COVID-19 pandemic could benefit parents; however, evaluation of their effectiveness and acceptability is needed.

Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review

BACKGROUND

This systematic review aimed to provide an updated summary of studies investigating depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) in parents after stillbirth (from 20 weeks gestational age until birth).

METHODS

A literature search was conducted in the databases Web of Science and PsychINFO. Main inclusion criteria were 1) peer-reviewed, quantitative, English-language articles published from 1980; (2) studies investigating depression, anxiety, PTSD, or OCD among parents following stillbirth; and (3) studies defining stillbirth as equal to or after 20 weeks of gestation.

RESULTS

Thirteen quantitative, peer-reviewed articles were eligible for inclusion. Selected articles investigated depression, anxiety, and PTSD, while no studies on OCD met our inclusion criteria. The majority of studies investigated women, while only two studies included men. The results indicated heightened short- and long-term levels of depression, anxiety, and PTSD in parents after stillbirth compared to those of parents with live birth. Studies investigating predictors found that social support, marital status, negative appraisals, and variables related to care and management after stillbirth affected levels of symptoms.

CONCLUSIONS

Parents who experience stillbirth have a considerably higher risk of reporting symptoms of depression, anxiety, and PTSD compared with parents with live births. More longitudinal studies are needed to increase our knowledge of how symptoms develop over time, and more research on fathers, transgender, non-binary and gender fluid individuals is needed. Research on the association between stillbirth and OCD is also warranted. Knowledge of the severity of anxiety, depression, and PTSD after stillbirth, and predictors associated with symptom severity could provide healthcare professionals with valuable information on how to provide beneficial postpartum care.

Bereavement care immediately after perinatal loss in health care facilities: a scoping review protocol

OBJECTIVE

This scoping review will summarize what is known about formal and informal perinatal bereavement care guidelines used in health care facilities before discharge, and map the mental health outcomes of parents against characteristics of the guidelines.

INTRODUCTION

Conflicting evidence for bereavement care guidelines, the lack of randomized controlled trials and experimental studies, and older synthesized information with a limited focus or population make synthesis complex. A scoping review will facilitate the process of determining the breadth and depth of the literature.

INCLUSION CRITERIA

Sources pertaining to bereavement care guidelines used in health care facilities immediately after perinatal loss (miscarriage, stillbirth, or neonatal death) and measuring parents' mental health outcomes will be included. Sources relating to family members other than parents, perinatal loss occurring outside of a health care facility, and physical care guidelines will be excluded.

METHODS

The proposed review will be conducted using JBI methodology for scoping reviews. The team will consider quantitative and qualitative studies, practice guidelines, case reports, expert opinions, systematic reviews, professional organization websites, and gray literature. Major databases to be searched will include CINAHL (EBSCO), PsycINFO (EBSCO), SocINDEX (EBSCO), Cochrane, Embase, MEDLINE (PubMed), and Web of Science. The earliest empirical study found (1976) will serve as the starting date limit. After pilot testing the two-step screening process (titles and abstracts, then full-text articles), data will be extracted, collated, and presented in narrative form as well as in tables and diagrams. The results will provide facilities with a broad view of bereavement care to support grieving parents' mental health.

The brain oxytocin and corticotropin-releasing factor systems in grieving mothers: What we know and what we need to learn

The bond between a mother and her child is the strongest bond in nature. Consequently, the loss of a child is one of the most stressful and traumatic life events that causes Prolonged Grief Disorder in up to 94 % of bereaved parents. While both parents are affected, mothers are of higher risk to develop mental health complications; yet, very little research has been done to understand the impact of the loss of a child, stillbirth and pregnancy loss on key neurobiological systems. The emotional impact of losing a child, e.g., Prolonged Grief Disorder, is likely accompanied by dysregulations in neural systems important for mental health. Among those are the neuropeptides contributing to attachment and stress processing. In this review, we present evidence for the involvement of the brain oxytocin (OXT) and corticotropin-releasing factor (CRF) systems, which both play a role in maternal behavior and the stress response, in the neurobiology of grief in mothers from a behavioral and molecular point of view. We will draw conclusions from reviewing relevant animal and human studies. However, the paucity of research on the tragic end to an integral bond in a female's life calls for the need and responsibility to conduct further studies on mothers experiencing the loss of a child both in the clinic and in appropriate animal models.

Men's grief following pregnancy loss and neonatal loss: a systematic review and emerging theoretical model

BACKGROUND

Emotional distress following pregnancy loss and neonatal loss is common, with enduring grief occurring for many parents. However, little is known about men's grief, since the majority of existing literature and subsequent bereavement care guidelines have focused on women. To develop a comprehensive understanding of men's grief, this systematic review sought to summarise and appraise the literature focusing on men's grief following pregnancy loss and neonatal loss.

METHODS

A systematic review was undertaken with searches completed across four databases (PubMed, PsycINFO, Embase, and CINAHL). These were guided by two research questions: 1) what are men's experiences of grief following pregnancy/neonatal loss; and 2) what are the predictors of men's grief following pregnancy/neonatal loss? Eligible articles were qualitative, quantitative or mixed methods empirical studies including primary data on men's grief, published between 1998 and October 2018. Eligibility for loss type included miscarriage or stillbirth (by any definition), termination of pregnancy for nonviable foetal anomaly, and neonatal death up to 28 days after a live birth.

RESULTS

A final sample of 46 articles were identified, including 26 qualitative, 19 quantitative, and one mixed methods paper. Findings indicate that men's grief experiences are highly varied, and current grief measures may not capture all of the complexities of grief for men. Qualitative studies identified that in comparison to women, men may face different challenges including expectations to support female partners, and a lack of social recognition for their grief and subsequent needs. Men may face double-disenfranchised grief in relation to the pregnancy/neonatal loss experience.

CONCLUSION

There is a need to increase the accessibility of support services for men following pregnancy/neonatal loss, and to provide recognition and validation of their experiences of grief. Cohort studies are required among varied groups of bereaved men to confirm grief-predictor relationships, and to refine an emerging socio-ecological model of men's grief.

TRIALS REGISTRATION

PROSPERO registration number: CRD42018103981.

Pain without reward: A phenomenological exploration of stillbirth for couples and their hospital encounter

Stillbirth constitutes a unique form of grief related to the death of an unborn child. This study explores the experiences of eight couples who lost a child to stillbirth, from the time they suspected something was wrong to their release from the hospital and beyond. Couples were interviewed conjointly and data were analyzed qualitatively using a phenomenological approach. Analysis revealed themes of positive and negative encounters with hospital staff, grief and loss, relationships with spouse and family, and long-term impacts. Implications for clinicians are discussed, including gender differences in the grief process for fathers and mothers.

From “Silent Birth” to Voices Heard: Volunteering, Meaning, and Posttraumatic Growth After Stillbirth

Volunteerism after stillbirth has not been adequately explored despite recent advances in research on volunteering after trauma and the voluminous research on posttraumatic growth (PTG). Previous research on PTG, “altruism born of suffering,” and constructivist theories of grief, meaning, and social narrative provide applicable frameworks. Parents ( N = 191) in the present study were assessed for self-reported growth factors with the Posttraumatic Growth Inventory (PTGI) scale and gave narrative reports describing the importance of volunteering for them after their baby's death. Parents who volunteered after their baby's death self-reported significantly higher mean scores on the PGTI than parents who did not volunteer. Qualitative analysis with parents who volunteered only after their baby's death ( n = 39) discovered salient categories that confirm and connect theoretically similar explorations from prior research, and also illuminate new directions for research. Clinical implications and caveats are presented.

Cognitive predictors and risk factors of PTSD following stillbirth: a short-term longitudinal study

This short-term longitudinal study investigated cognitive predictors and risk factors of posttraumatic stress disorder (PTSD) in mothers following stillbirth. After a stillbirth at ≥ 24 weeks gestational age, 65 women completed structured clinical interviews and questionnaires assessing PTSD symptoms, cognitive predictors (appraisals, dysfunctional strategies), and risk factors (perceived social support, trauma history, obstetric history) at 3 and 6 months. PTSD symptoms decreased between 3 and 6 months (Cohen's d ranged .34-.52). Regression analyses also revealed a specific positive relationship between Rumination and concurrent frequency of PTSD symptoms (β = .45). Negative Self-View and Negative World-View related positively and Self-Blame related negatively to concurrent number of PTSD symptoms (β = .48, .44, -.45, respectively). Suppression and Distraction predicted a decrease and Numbing predicted an increase in time-lagged number of PTSD symptoms (β = -.33, -.28, .30, respectively). Risk factors for PTSD symptoms were younger age (β = -.25), lower income (β = -.29), fewer previous pregnancies (β = -.31), and poorer perceived social support (β = -.26). Interventions addressing negative appraisals, dysfunctional strategies, and social support are recommended for mothers with PTSD following stillbirth. Knowledge of cognitive predictors and risk factors of PTSD may inform the development of a screening instrument.

"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.