Professional approach to the care of women who have suffered a perinatal loss

To understand the experience, training, and needs of midwives in their approach to perinatal grief. A descriptive cross-sectional study was carried out using an online questionnaire with 26 questions related to institutional management and individual clinical practices in the care of a perinatal loss was developed by a team of midwives from the Hospital "La Mancha-Centro" of Alcazar de San Juan (Ciudad Real). Strobe checklist was followed. A total of 267 midwives participated. A total of 92.1% (246) of the centers had specific protocols for action, but each professional applied their own criteria. The presence of a perinatal psychology team was nonexistent according to 88% (235) of those surveyed. Regarding their training and professional experience, 16.5% (44) of the midwives had never received training. Only 4.1% (11) of the midwives felt very prepared to care for women with a perinatal loss. Among the factors associated with greater application of recommended practices in the face of perinatal death by midwives were being a woman, having prior training on care during perinatal death, and a greater perception of preparation (p < 0.05). The perception of lack of preparation on the part of midwives in the accompaniment of these families was high.

The Disenfranchisement of Perinatal Grief: How Silence, Silencing and Self-Censorship Complicate Bereavement (a Mixed Methods Study)

Based on an ethnographic and mixed-methods research design, the article explores the social and interactive processes of disenfranchisement of perinatal grief through the mechanisms of silence, silencing and self-censorship in encounters between bereaved women and the social milieu. The analysis finds that disenfranchisement results from the constriction of the social space of bereavement along various lines of discourse, cultural values, practice and materiality, that include: the passing of time (expectations of a quick 'recovery'); competing discourses of loss (simplistic-dominant vs. complex-subordinate meaning-making); the biometrics of pregnancy (lower gestational age being equated with less intense grief); gendered ideas of reproduction and feeling rules; asymmetries in social power; social spheres (hospital, home, community, support groups); socio-materialities and performance/ritual; and structural aspects of social and familial organization (gender, age, intergenerational and kin v. non-kin relations). These processes are intimately linked to the complication of grief by undermining support, meaning-making and continuing bonds.

The psychological impact of Early Pregnancy Loss in Portugal: incidence and the effect on psychological morbidity

Introduction

Worldwide, up to a quarter of all recognized pregnancies result in Early Pregnancy Loss (EPL), also known as miscarriage. For many women, this is a traumatic experience that leads to persistent negative mental health responses. The most common morbidity reported in studies from different countries is complicated grief, usually comorbid with depression, anxiety, and Post-Traumatic Stress Disorder (PTSD). To our best knowledge, no studies characterizing the psychological impact of EPL have been made in Portugal.

Methods

An online survey was conducted to evaluate clinical symptoms of perinatal grief, anxiety, depression, and PTSD in women who suffered a spontaneous loss within 20  weeks of gestation. Out of 1,015 women who answered this survey, 873 were considered eligible, and subsequently distributed in 7 groups according to the time passed between their loss and their participation in the study.

Results

The proportion of women showing symptoms of all comorbidities was greater in those whose loss had happened within a month, and there was a significant gradual decrease over time in scores and proportions of clinical perinatal grief and PTSD. In terms of depression symptoms, scores dropped significantly in the group whose loss occurred 13-24  months before their participation but proportions oscillated without great changes in the other groups. Regarding anxiety, there were small oscillations, but there was no significant decrease of symptoms over time.

Discussion

Overall, despite a general drop in scores for most morbidities over time, substantial proportions of women showed persistent symptoms of clinical morbidities 3  years or more after the loss. Therefore, it is essential to promote monitoring of possible complicated responses to the event, to provide appropriate and timely intervention to those women in need.

Paternal Experiences of Perinatal Loss-A Scoping Review

BACKGROUND

Perinatal grief is one of the most complex and devastating types of mourning for both mothers and fathers; however, there is still little research on the psychological impact on men who experience it. Therefore, the objective of this study was to summarize and synthetize the existing literature on the way men's grief is experienced.

METHODS

A search was carried out to examine three databases for articles published in the last four years; 56 articles were obtained, and 12 were retained for analysis.

RESULTS

Four common themes were found: the men's experience of grief, their role as fathers, the impact of the death, and their needs regarding grief and how to face it.

CONCLUSIONS

There is also a need for discussion of the importance of validating perinatal grief in men and studies that examine it without social gender stigmas in order to provide them with effective emotional support.

Women pregnant after previous perinatal loss: relationships between adult attachment, shame, and prenatal psychological outcomes

BACKGROUND

Insecure adult attachment, shame, self-blame, and isolation following perinatal loss place bereaved women at risk of adverse psychological outcomes, which can impact child and family outcomes. To date, no research has considered how these variables continue to influence women's psychological health in pregnancy subsequent to loss.

OBJECTIVE

This study explored associations between prenatal psychological adjustment (less grief and distress) and adult attachment, shame, and social connectedness, in women pregnant after loss.

METHOD

Twenty-nine pregnant Australian women accessing a Pregnancy After Loss Clinic (PALC) completed measures of attachment styles, shame, self-blame, social connectedness, perinatal grief, and psychological distress.

RESULTS

Four 2-step hierarchical multiple regression analyses revealed adult attachment (secure/avoidant/anxious; Step 1), shame, self-blame, and social connectedness (Step 2) explained 74% difficulty coping, 74% total grief, 65% despair, and 57% active grief. Avoidant attachment predicted more difficulty coping and higher levels of despair. Self-blame predicted more active grief, difficulty coping, and despair. Social connectedness predicted lower active grief, and significantly mediated relationships between perinatal grief and all three attachment patterns (secure/avoidant/anxious).

CONCLUSIONS

Although avoidant attachment and self-blame can heighten grief in pregnancy after loss, focusing on social connectedness may be a helpful way for prenatal clinicians to support pregnant women during their subsequent pregnancy - and in grief.

Are women diagnosed with early pregnancy loss at risk for anxiety, depression, and perinatal grief?

OBJECTIVES

To examine the effects of early pregnancy loss on emotions such as depression, grief, or a sense of hopelessness, while investigating different types of diagnoses, hospital stays, and treatments.

METHODS

A prospective cohort epidemiological study was carried out in Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey, between January and September 2019. The study included women diagnosed with early pregnancy loss classified into 3 groups: missed abortus, anembryonic pregnancy, and spontaneous abortion. The patients were screened via the Spielberger state-anxiety inventory (STAI-1) before initiating treatment. The Edinburgh postpartum depression scale (EPDS) and Perinatal Grief Scale (PGS) were also carried out in the first week of their hospital discharge.

RESULTS

The study was carried out with a total of 116 patients. The median gestational week of the patients was calculated at 9, their median hospital stay was 2 days, and their median dose of misoprostol was 800 mcg. The STAI-1 revealed that median values computed for women in all groups indicated moderate anxiety. The EDPS also demonstrated depression-positive median values for women in all 3 groups (EPDS>13). However, no statistically significant difference was noted in comparisons of the 3 groups apropos STAI-1, EPDS, and PGS.

CONCLUSION

Moderate anxiety, depressed mood, and perinatal grief were found in women diagnosed with early pregnancy loss, regardless of the type of abortion.

Are Mindfulness-Based Interventions as Effective as Cognitive Behavioral Therapy in Reducing Symptoms of Complicated Perinatal Grief? A Systematic Review

INTRODUCTION

Perinatal loss can be a devastating experience for parents that can result in complicated grief symptoms that include depression, anxiety, and posttraumatic stress. Perinatal bereavement care pathways have been developed internationally within health care services; however, there is an apparent lack of recommendations and guidance on grief-focused interventions specifically for complicated perinatal grief. Studies have analyzed the effectiveness of cognitive behavioral therapy (CBT) for perinatal grief, and more recent research has emerged on the use of mindfulness-based interventions (MBIs) for perinatal grief symptoms. The purpose of this study was to conduct a systematic review and present the effectiveness of CBT and MBIs for perinatal grief, to report patient experiences of the interventions, and to determine which intervention can be more effective in managing symptoms of complicated perinatal grief.

METHODS

A systematic search was conducted of 5 academic databases: PsycINFO, CINAHL, MEDLINE, Social Science, and ASSIA. No limits on publication date, language, or geographic location were set because of the paucity of research published on this subject. Quality appraisal was conducted for each included study. Findings are reported in accordance with the PRISMA statement.

RESULTS

This systematic review identified 8 eligible studies with a total of 681 bereaved participants. The results were examined for effectiveness of CBT and MBIs for grief; effectiveness of CBT and MBIs for depression, anxiety, and posttraumatic stress; and participant experiences. Both interventions produced favorable reductions of perinatal grief symptoms, depression, and posttraumatic stress. However, a true comparison between the 2 interventions' effect on complicated perinatal grief symptoms could not be made because of the limited studies in this area and the heterogeneity of the included studies' methods and outcomes.

DISCUSSION

Both MBIs and CBT interventions can be effective in reducing symptoms of complicated perinatal grief. The findings of this review are heavily weighted in quantitative outcome measurements. More qualitative research and randomized controlled trials with larger sample sizes are needed in this area of perinatal bereavement care.

Grief and ruminative thought after perinatal loss among Turkish women: one-year cohort study

BACKGROUND

Among women who have suffered loss of pregnancy, the level of grief decreases gradually. Age, mental health status and childlessness are the factors known to mostly affect women's levels of grief.

OBJECTIVES

To assess the levels of grief among women who experienced perinatal loss and the changes in their ruminative thought styles over the first year after their loss.

DESIGN AND SETTING

One-year follow-up study carried out in a university hospital in Turkey.

METHODS

The study population included 70 women who experienced loss of pregnancy in the hospital. The sample size was calculated using G*Power V3.1. Data were collected at 48 hours, at the third month, at the sixth month and at one year after pregnancy loss, between June 2018 and June 2019. A personal information form, the Perinatal Grief Scale and the Ruminative Thought Style Questionnaire were used for data collection.

RESULTS

The women's highest levels of grief and ruminative thought style were in the first 48 hours. Their tendency towards grief and ruminative thought styles decreased over the repeated measurements during the follow-up. Women aged 20-29 years had the highest levels of grief at the third month after perinatal loss.

CONCLUSIONS

Nursing assessments regarding grief and ruminative thought style over the first 48 hours after perinatal loss should be integrated into nursing care for these women. Grief follow-up programs for these women can be developed through nursing research.

Perinatal Grief and Related Factors After Termination of Pregnancy for Fetal Anomaly: One-Year Follow-up Study

Introduction:

Many people grieve in a resilient manner, often having a sense of equilibrium restored within six months. The most devastating type of loss is usually considered to be the death of the child. For such a loss, bereavement may take a period of distressing years with signs and symptoms that are related to grief. There have been different phases identified in the grieving process, and this process encompasses various difficulties with different levels of psychological effects. Women with perinatal losses can suffer long periods of grief. The purpose of this study was to monitor the grief in women who had undergone a termination of pregnancy due to fetal anomaly.

Methods:

Forty-six women who applied to the Gynaecology Clinic of Istanbul University Cerrahpaşa Faculty of Medicine and who decided to terminate their pregnancy due to fetal anomaly were included in the study. The Perinatal Grief Scale (PGS), the Impact of Event Scale-Revised (IES-R), Beck Anxiety Inventory (BAI), the Edinburgh Postnatal Depression Scale (EPDS), the Multidimensional Relationship Questionnaire (MRQ) and the Adult Attachment Scale (AAS) were administered to the participants six weeks after termination. Participants’ grief signs were re-evaluated with the PGS at the sixth and 12th months.

Results:

There was no relationship between severity of grief symptoms and socio-demographic and clinical characteristics of the patients. The perinatal grief symptoms can decrease gradually from termination of pregnancy to six months and can persist for a period of six months up to a year. There was positive correlation between the scores of PGS and BAI, IES-R hyper-arousal. The mean score of PGS changed significantly from sixth week to sixth month and from sixth week to 12th months. IES-R hyper-arousal and MRQ relational satisfaction were found to be the predictors for PGS total score at the first year.

Conclusion:

The diagnosis of fetal anomaly and especially the termination of pregnancy itself may be traumatic and disruptive. In women with perinatal loss, grief may become persistent after the first six months. It would be helpful to examine how the women resolve this experience. Especially the anxiety and the hyper-arousal signs following the termination should not be ignored. Perinatal grief is a unique bereavement experience; specific interventions should be performed for detecting and treating severe perinatal grief.

[Nursing Experience Using Art Therapy With Parents Facing the Death of a Newborn]

When a newborn requires immediate hospitalization due to a potentially life-threatening situation, parents face a sudden and significant increase in stress. This situation and the potential loss of their child will bring great grief and loss to the parents, which may lead to conditions that foster dysfunctional family dynamics. This article describes the author's experience providing hospice care to a dying infant with a group B streptococcus infection in the neonatal intensive care unit. The author served as the primary care nurse from April 5th to July 6th, 2019. Data were collected during direct care provision, observations, and interactions with parents, while overall systemic assessments were used in analysis to establish that the health problems of the case were: (1) existing infection: related to group B streptococcus; (2) ineffective tissue perfusion: insufficient perfusion of multiple organs, including brain, heart, lung, and kidney, due to sepsis infection; and (3) caregiver grief: facing the death of a newborn. Nursing care provided to the patient included maintaining individualized physical functions and retaining physical integrity during the end-of-life period. The nursing care provided to the parents included the use of art therapy to encourage them to express their inner emotions through the writing of memoirs and diaries and their participation in companionship. This intervention was designed to help the parents transition from the grief of denying the collapse to the fact that their baby had died. As Taiwanese culture typically avoids discussions of death, the nursing experience described in this article may provide a reference for caring for similar patients. This article highlights the beauty of nursing through art therapy, demonstrates the achievement of whole-person and family-centered nursing, shows how the case was successfully helped through the crisis, and illustrates how normal family functions may be maintained.

Nursing Interventions to Facilitate the Grieving Process after Perinatal Death: A Systematic Review

Perinatal death is the death of a baby that occurs between the 22nd week of pregnancy (or when the baby weighs more than 500 g) and 7 days after birth. After perinatal death, parents experience the process of perinatal grief. Midwives and nurses can develop interventions to improve the perinatal grief process. The aim of this review was to determine the efficacy of nursing interventions to facilitate the process of grief as a result of perinatal death. A systematic review of the literature was carried out. Studies that met the selection criteria underwent a quality assessment using the Joanna Briggs Institute critical appraisal tool. Four articles were selected out of the 640 found. Two are quasi-experimental studies, and two are randomized controlled clinical studies. The interventions that were analyzed positively improve psychological self-concept and role functions, as well as mutual commitment, depression, post-traumatic stress and symptoms of grief. These interventions are effective if they are carried out both before perinatal loss and after it has occurred. The support of health professionals for affected parents, their participation in the loss, expressing feelings and emotions, using distraction methods, group sessions, social support, physical activity, and family education are some of the effective interventions.

Uncovering Prolonged Grief Reactions Subsequent to a Reproductive Loss: Implications for the Primary Care Provider

Introduction

There is a paucity of clinical guidelines for the routine assessment of maladaptive reproductive grief reactions in outpatient primary care and OB-GYN settings in the United States. Because of the disenfranchised nature of perinatal grief reactions, many clinicians may be apt to miss or dismiss a grief reaction that was not identified in the perinatal period. A significant number of those experiencing a reproductive loss exhibit signs of anxiety, depression, or post-traumatic stress disorder. Reproductive losses are typically screened for and recorded numerically as part of a woman’s well-visit intake, yet this process often fails to identify patients emotionally troubled by a prior pregnancy loss.

Materials and Methods

A summative content analysis of 164 recent website blogs from female participants who self-reported having experienced a miscarriage or abortion in their lifetime was conducted. The narratives were reviewed for details regarding the time span between the pregnancy loss and the composition of the blog post. The stories were analyzed for subsequent relationship problems and detrimental mental health conditions. Maladaptive reactions were contrasted for those that indicated a greater than 12 months’ time-lapse and those who had not.

Results

More than a third (39.6%) of the women reported in the narrative that at least one year or more had passed since experiencing the miscarriage or abortion. For those women, the median time span between the loss and composing the blog was 4 years with a range of 47 years. Mental health conditions attributed to the reproductive loss by those who reported longer bereavement times included subsequent relationship problems, substance misuse, depression, suicidal ideation, and PTSD. The percent of reported maladaptive issues was more than double (136.9% vs. 63.6%) for those who reported that a year or more had passed since the loss of the pregnancy.

Discussion

Grief reactions following the loss of a pregnancy may be prolonged or delayed for several months which can contribute to adverse biopsychosocial outcomes. Recognition and treatment of maladaptive grief reactions following a pregnancy loss are critical. Screening methods should be enhanced for clinicians in medical office settings to help identify and expedite the appropriate mental health assistance.

Perinatal Grief and Post-Traumatic Stress Disorder in Pregnancy after Perinatal Loss: A Longitudinal Study Protocol

Background: Pregnancies that follow perinatal loss are often associated with mental health disorders, which are not usually treated or even identified. Objectives: The main study aim is to identify the prevalence of symptoms of post-traumatic stress disorder and complicated perinatal grief at different stages of pregnancy following a prior gestational loss. Methods: This descriptive longitudinal study will be conducted with a twelve-month follow-up. The study variables addressed will include sociodemographic data (age, sex, education, marital status, employment status and obstetric history) together with clinical data on complicated perinatal grief and post-traumatic stress disorder scores. Results: The results obtained are expected to provide a new perspective on the healthcare approach to perinatal loss and subsequent pregnancy. Conclusions: We seek to optimise comprehensive healthcare in cases of pregnancy following previous perinatal loss and to evaluate options to minimise possible risks.

Qualitative Interpretive Metasynthesis of Parents' Experiences of Perinatal Loss

OBJECTIVE

To identify and synthesize common, experiential themes from qualitative studies of parents who experienced perinatal loss.

DATA SOURCES

We searched PubMed, CINAHL, and PsycINFO for qualitative articles about parents' experiences of perinatal loss.

STUDY SELECTION

We included research on parents' experiences of perinatal loss published in English in the last 10 years. We excluded articles on the perspectives or experiences of health care professionals or persons other than the biological parent who experienced the perinatal loss, systematic reviews, outcome studies, and gray literature.

DATA EXTRACTION

We used a priori inclusion and exclusion criteria and identified five articles in which perinatal loss was described from the parents' perspectives. We extracted thematic findings and supporting quotes from each article and documented them in a table for subsequent synthesis.

DATA SYNTHESIS

We used a qualitative metasynthesis and interpretive model to synthesize findings from the included studies. Findings were synthesized into one overarching theme, The Paradox of Perinatal Loss, and four subthemes: Complex Emotional Responses, Prenatal Bonding-Acknowledging Personhood, Interactions With Health Care Professionals, and Traversing the Social Sphere.

CONCLUSION

Our findings indicate that perinatal loss is often a transformative event during which parents experience multiple losses and intense, complex emotions. Interactions with health care professionals greatly affected the pregnancy experience, which places professionals in a unique position to positively influence parents' overall experiences. Therefore, it is important to develop protocols related to perinatal loss and ensure that staff are adequately trained and equipped to care for parents during this experience. Findings from this synthesis may also inform the future development of theory related to bereavement surrounding perinatal loss.

Integrative Review of Emotional Care Following Perinatal Loss

Emotional care is an important part of the holistic labor and should be considered when providing care to people affected by perinatal losses. To synthesize the findings from recently published scientific evidence on the emotional care needed following perinatal loss, a search in PubMed, CINAHL, SCOPUS, and Web of Science was carried out in January 2020 yielding 22 studies which met the inclusion criteria and were analyzed following Whittemore and Knafl's (2005) methodology. One category on "offering emotional care" was identified: "Aspects influencing the psychosocial well-being of women after perinatal loss," comprising eight themes: risk of complicated grief, cultural values, perinatal losses in multiple pregnancies, experience of subsequent pregnancies, need of information, contact with the deceased baby, impact on relatives, and strategies for emotional care. In conclusion, the evidence highlights the need of specific emotional grief care.

The psychological implications of a subsequent pregnancy outcome in couples with a history of miscarriage

OBJECTIVES

The present study expands upon reproductive research by examining perinatal grief in couples following a miscarriage and throughout a subsequent pregnancy. The aim of the study was to address the question of whether the outcome of a successful live birth mitigates the negative impact of a previous miscarriage.

METHOD

Participants were recruited through 20 general practice surgeries that provided antenatal care in the United Kingdom. The study comprised 128 couples; 64 couples who experienced two consecutive miscarriages, and 64 couples who experienced a live birth following a miscarriage. Participants completed the Perinatal Grief Scale across four Time points (T1: Six weeks following the first pregnancy outcome; T2: Six weeks following the second pregnancy outcome; T3: Six months following the second pregnancy outcome and T4: Twelve months following the second pregnancy outcome).

RESULTS

The primary findings of the study demonstrated a significant mitigation effect with a decrease in perinatal grief over time. As predicted, couples who experienced a second miscarriage reported elevated perinatal grief; compared to couples who went on to have a successful live birth.

CONCLUSION

The present study's findings contribute to our knowledge of the long-term implications of miscarriage and its influence on psychological health in terms of perinatal grief.

Impact of Perinatal Death on the Social and Family Context of the Parents

BACKGROUND

Perinatal death (PD) is a painful experience, with physical, psychological and social consequences in families. Each year, there are 2.7 million perinatal deaths in the world and about 2000 in Spain. The aim of this study was to explore, describe and understand the impact of perinatal death on parents' social and family life.

METHODS

A qualitative study based on Gadamer's hermeneutic phenomenology was used. In-depth interviews were conducted with 13 mothers and eight fathers who had suffered a perinatal death. Inductive analysis was used to find themes based on the data.

RESULTS

Seven sub-themes emerged, and they were grouped into two main themes: 1) perinatal death affects family dynamics, and 2) the social environment of the parents is severely affected after perinatal death.

CONCLUSIONS

PD impacts the family dynamics of the parents and their family, social and work environments. Parents perceive that society trivializes their loss and disallows or delegitimizes their grief.

IMPLICATIONS

Social care, health and education providers should pay attention to all family members who have suffered a PD. The recognition of the loss within the social and family environment would help the families to cope with their grief.

'In the hospital there are no care guidelines': experiences and practices in perinatal loss in Spain

BACKGROUND AND OBJECTIVES

Healthcare professionals play an important role in supporting and attending to families that experience a perinatal loss. Previous research has identified the existence of obstacles that professionals may encounter during their practices. The main objective of the current research was to identify and examine the subjective experiences and practices of experienced professionals attending to perinatal loss in the hospital context in Spain.

DESIGN

Qualitative descriptive design.

SETTING

Three different hospitals in Spain.

PARTICIPANTS

Sixteen professionals were interviewed, including doctors, nurses, midwives, nursing assistants, a psychologist and a funeral home manager.

METHODS

Individual semi-structured interviews focusing on three areas were carried out: practices with the baby-foetus, practices with parents and interaction with the team. A thematic analysis was performed using the three main focuses of the semi-structured interview (deductive approach) and the codes that emerged from the data (inductive approach).

RESULTS

Regarding guideline-based care for the baby/foetus, participants made a distinction between the initial process of care for the baby and the decision-making process with parents. Where support for families was concerned, participants identified considerable variability in the practices used and lack of organisational and care guidelines, psychological support and follow-up. Finally, interactions with other team members were perceived as a source of support, although participants identified a significant lack of coordination.

CONCLUSION

Participants reported variability of practices in care for the baby and parents, lack of continuity-of-care guidelines and the importance of support from a coordinated healthcare team.

[Perinatal and intrauterine infant death: professional practices and their effects on healthcare personnel]

INTRODUCTION

The sorrow caused by perinatal loss is a phenomenon of pathological mourning, a burden for the parents, their environment and the medical personnel, yet, it is a less studied field.

AIM

(1) To present the applied practice in healthcare institutions, to compare the valid protocol with the effective help provided and to study how these events affect the helping personnel professionally and psychologically.

METHOD

In-depth interviews with the involved personnel (n = 8). The authors studied the practice of the given institution; existing and wanted theoretical and practical competencies; personal attitude and the experienced difficulties.

RESULTS

Acting well professionally is a specially demanding task, with few tools to use when communicating, when helping the parents cope with sorrow, or when coping with their own feelings, all these involving a risk for burn-out.

CONCLUSIONS

The results can serve to create trainings aimed at helping the patients with adequate support and improving coping strategies.

Grief and Women: Stillbirth in the Social Context of India

INTRODUCTION

Few in Western society would argue the potentially devastating impact of stillbirth related grief; but in many developing countries where stillbirth remains the highest in the world, perinatal grief is barely recognized as an issue. The purpose of this study was to explore how poor, rural central Indian women perceive and cope with stillbirths.

METHODS

Seventeen key informant interviews and two focus groups (N = 33) with local health care providers, family members, and women who experienced stillbirth were conducted over a 1-month period in 2011 and then systematically coded for emerging themes using grounded theory methods to explore how women experienced stillbirth.

RESULTS

Although usually never talked about and not recognized as an issue, perinatal grief emerged as a significant shared experience by all. The perceptions of stillbirth-related grief emerged in three major themes and bear evidence of gender and power issues and indicate that local social norms negatively factor heavily into their perinatal grief experiences.

DISCUSSION

The findings in this richly textured study add to the limited literature regarding rural, central Indian women's experiences with stillbirth and factors influencing their resulting perinatal grief. In light of the void of recognition of this phenomenon in Indian society, a better understanding of the context in which poor Indian women experience perinatal grief will be a first step toward developing much needed culturally rooted interventions to positively impact the women's abilities to better cope with stillbirth in the context of their realities.

Social and cultural factors associated with perinatal grief in Chhattisgarh, India

Stillbirth is a globally significant public health problem with many medical causes. There are also indirect causal pathways including social and cultural factors which are particularly salient in India's traditional society. The purpose of this study was to explore women's perceptions of stillbirth and to determine how issues of gender and power, social support, coping efforts, and religious beliefs influence perinatal grief outcomes among poor women in rural Chhattisgarh, India. Structured interviews were done face-to-face in 21 randomly selected villages among women of reproductive age (N=355) who had experienced stillbirth (n=178) and compared to those who had not (n=177), in the Christian Hospital, Mungeli catchment area. Perinatal grief was significantly higher among women with a history of stillbirth. Greater perinatal grief was associated with lack of support, maternal agreement with social norms, and younger maternal age. These predictors must be understood in light of an additional finding-distorted sex ratios, which reflect gender discrimination in the context of Indian society. The findings of this study will allow the development of a culturally appropriate health education program which should be designed to increase social support and address social norms, thereby reducing psychological distress to prevent complicated perinatal grief. Perinatal grief is a significant social burden which impacts the health women.