Exploring the impact of healthcare workers communication with women who have experienced stillbirth in Malawi,Tanzania and Zambia. A grounded theory study

BackgroundCommunication and interaction with healthcare workers at the time of stillbirth remain in parents’ long-term memories and impact on emotional and psychological well-being. Cultural attitudes and norms influence how stillbirth is acknowledged and discussed in society. There is limited evidence on how women from sub-Saharan Africa became aware of the death of their babies. This research explored how women perceived the approach adopted by healthcare workers when the news of their stillbirth was disclosed to them.MethodsGrounded theory study. Women (n = 33) who had birthed a stillborn baby in the preceding 12 months were purposively sampled and participated in in-depth interviews (9 in Zambia, 16 in Tanzania and 8 in Malawi). Informed consent was gained from all participants. Data were analysed via a coding process using constant comparative analysis.FindingsWomen sacrificed individualized and personal grieving strategies to conform and behave according to what was expected within their community. An overarching theme of cultural conformity overrides personal grief incorporated four sub-themes: perceiving something was wrong, the unexpected outcome, experience contrasting emotions, bonding with the baby.Discussion and conclusionsMost participants embarked on a negative ‘emotion work’ to adapt and suppress emotions and grief due to cultural expectations. Inability to voice the trauma of losing a baby may lead to perinatal mental health issues and needs addressing. Maternity healthcare workers should encourage women to express their feelings and grief. Appropriate training in perinatal bereavement care including good communication, appropriate attitudes and provision of meaningful information to grieving women is recommended.     

Clinical practice guidelines for perinatal bereavement care — An overview

BackgroundHigh quality perinatal bereavement care is critical for women and families following stillbirth or newborn death. It is a challenging area of practice and a difficult area for guideline development due to a sparse and disparate evidence base.AimWe present an overview of the newly updated Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Excellence guideline for perinatal bereavement care. The guideline aims to provide clear guidance for maternity health care providers and their services to support the provision of care that meets the needs of bereaved parents.DiscussionThe Guideline for Respectful and Supportive Perinatal Bereavement Care is underpinned by a review of current research combined with extensive stakeholder consultation that included parents and their organisations and clinicians from a variety of disciplines. The Guideline contains 49 recommendations that reflect five fundamental goals of care: good communication; shared decision-making; recognition of parenthood; effective support; and organisational response.ConclusionBest available research, parents’ lived experiences and maternity care providers’ insights have contributed to a set of implementable recommendations that address the needs of bereaved parents.     

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

ProblemThe 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.BackgroundPerinatal death invariably brings intense grief which significantly impacts women, and requires adequate bereavement care to limit negative outcomes in the short and long-term.AimTo develop deeper understanding of women’s experience of care and support following perinatal death in high burden settings.MethodsSix 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.FindingsEight 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.DiscussionThere is insufficient care and support for women following perinatal death in high burden settings.ConclusionsFurther 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.     

A phenomenological exploration of parenting after birth trauma: Mothers perceptions of the first year

ProblemWhile perinatal mental health issues are considered to have an impact on a mother’s parenting capacity, there is limited research exploring mothers’ perceptions of their relationship with their child following traumatic birth experiences and how these might affect their parenting capacity.BackgroundBirth trauma is a well-recognised phenomenon which may result in ongoing physical and perinatal mental health difficulties for women. This may impact on their attachment to their children, their parenting capabilities, and their self-identity as mothers.AimsTo explore maternal self-perceptions of bonding with their infants and parenting experiences following birth trauma.MethodsIn-depth interviews with ten mothers were undertaken using an Interpretative Phenomenological Analysis methodology.FindingsWomen who experienced birth trauma often described disconnection to their infants and lacking confidence in their parental decision making. Many perceived themselves as being ‘not good enough’ mothers. For some women the trauma resulted in memory gaps of the immediate post-partum period which they found distressing, or physical recovery was so overwhelming that it impacted their capabilities to parent the way they had imagined they would. Some women developed health anxiety which resulted in an isolating experience of early parenthood.ConclusionsWomen who have suffered birth trauma may be at risk of increased fear and anxiety around their child’s health and their parenting abilities. Some women may experience this as feeling a lower emotional attachment to their infant. Women who experience birth trauma should be offered support during early parenting. Mother-Infant relationships often improve after the first year.     

Responding to catastrophe: A case study of learning from perinatal death in midwifery practice

Problem/BackgroundPerinatal death has far reaching emotional effects for all involved in this devastating event. The opportunity for learning as a result of this catastrophe, however, remains unexplored.AimTo explore midwives’ experiences of caring through, and learning from, perinatal death, to better inform the effective planning and delivery of education that optimises both midwifery and self-care.MethodsA naturalistic interpretive multiple case study design. Seventeen midwives, located in Australia, participated in an online group activity hosted as a blog, followed by telephonic focus groups and in-depth email interviews.FindingsThematic data analysis revealed seven major themes: Grappling with the reality of perinatal death; Struggling with personal and professional heartache; Seeking the space to grieve as a professional; Being with the woman and her family; Finding a new purpose; Strengthened through support; and Developing the courage to care.DiscussionThe initial turmoil and impact of loss reflected the catastrophic nature of perinatal death. Midwives uncovered a journey to acceptance and learning, realising a determination to enhance expertise and discovering value in experiential knowledge. Insecurity regarding competence and confidence to manage perinatal death and bereavement care was highlighted. However, sharing their stories revealed professional fulfilment, personal strength, and solidarity amongst midwives who have endured similar experiences.ConclusionA coordinated approach to support and the dissemination of experiential knowledge and learning could be developed within an online model of narrative sharing and discussion. Debriefing, support and sharing of expertise in this way may foster engagement within and beyond the workplace.     

“If you don’t ask … you don’t tell”: Refugee women’s perspectives on perinatal mental health screening

ProblemNational guidelines recommending mental health screening in pregnancy have not been implemented well in routine maternity care. Women of refugee background are likely to have experienced traumatic events and resettlement stressors, yet are not often identified with mental health issues in the perinatal period.BackgroundGlobally, perinatal mental health conditions affect up to 20% of women. Many difficulties in accessing mental health care in pregnancy exist for women of refugee background including stigma, and cultural and language barriers. Technology can provide an efficient and effective method to overcome some of these barriers.AimTo determine if a digital perinatal mental health screening program is feasible and acceptable for women of refugee background.MethodsThis qualitative evaluation study used focus group and semi-structured telephone interviews with refugee and migrant women from four communities. Interpreters were used with women who spoke little or no English. Data were analysed using both an inductive and deductive approach to thematic analysis.FindingsUnder the three key themes: ‘Women’s experiences of perinatal mental health screening in pregnancy’; ‘Barriers and enablers to accessing ongoing mental health care’ and ‘Improvements to the program: the development of audio versions’, women found the program feasible and acceptable.DiscussionScreening using a mobile device offered women more privacy and opened up discussions with midwives on emotional health. Improvements in service coordination and access to further mental health management for women is required.ConclusionPerinatal mental health screening is an acceptable and feasible option for women of refugee background. Integrated models of care, case management, and patient navigators are options for improvements in uptake of referral and treatment services.     

The effect of COVID-19 lockdowns on women's perinatal mental health: a systematic review

BackgroundRisk factors for poor maternal perinatal mental health include a previous mental health diagnosis, reduced access to perinatal services, economic concerns and decreased levels of social support. Adverse maternal perinatal mental health can negatively influence the psychological wellbeing of infants. The outbreak of the COVID-19 pandemic presented an additional stressor. While literature on the impact of COVID-19 on perinatal mental health exists, no systematic review has focused specifically on maternal perinatal mental health during periods of COVID-19 lockdown.AimsThis systematic review explores how periods of COVID-19 lockdown impacted women’s perinatal mental health.MethodsSearches of CINAHL, PsycARTICLES, PsycINFO, PubMed, Scopus and Web of Science were conducted for literature from 1st January 2020–25th May 2021. Quantitative, peer-reviewed, cross-sectional studies published in English with perinatal women as participants, and data collected during a period of lockdown, were included. Data was assessed for quality and narratively synthesized.FindingsSixteen articles from nine countries met the inclusion criteria. COVID-19 lockdowns negatively impacted perinatal mental health. Risk factors for negative perinatal mental health noted in previous literature were confirmed. In addition, resilience, educational attainment, trimester, and ethnicity were identified as other variables which may influence mental health during perinatal periods experienced during lockdown. Understanding nuance in experience and harnessing intra and interpersonal support could advance options for intervention.ConclusionDeveloping resources for perinatal women that integrate informal sources of support may aid them when normal routine is challenged, and may mediate potential long-term impacts of poor perinatal maternal health on infants.     

The BLOSSoM study: Burnout after perinatal LOSS in Midwifery. Results of a nation-wide investigation in Italy

BackgroundRespectful care of bereaved parents after stillbirth plays a pivotal role in enabling the grieving process and reducing the traumatic impact of this life-changing event. Unfortunately, professionals and midwives, in particular, are often emotionally unprepared and frequently left alone when dealing with these stressful events.AimThe BLOSSoM (Burnout after perinatal LOSS in Midwifery) study aims to address the levels of professional burnout in Italian midwives and evaluate the psychological impact of bereavement care on professionals.MethodsWeb-based cross-sectional study, including socio-demographic questionnaire, survey on the knowledge of guidelines for stillbirth management and two psychometric tests: Maslach Burnout Inventory (MBI) and Impact of Event Scale - Revised (IES-R).FindingsOf 445 female midwives, mean age 35.1 (SD 9.9), working years 11.2 (SD 10.2), 149 (33.4%) reported specific training on stillbirth and 420 (94.6%) highlighted the need for further training and support. Medium to high levels of burnout (Emotional Exhaustion) were present in 65 midwives (15.9%) with a high prevalence of Reduced Personal Accomplishment (292, 64.2%). ‘Communicating the diagnosis of death’ was considered the hardest task, followed by ‘assisting the meeting with the baby’; 109 midwives (24.5%) reported high IES-R scores (>30), suggesting symptoms of PTSD related to stillbirth events; a good level of knowledge of guidelines favoured Personal Accomplishment (OR 0.3 [0.1 – 0.6]). The number of stillbirths assisted by midwives was not associated with burnout levels.ConclusionMidwives are particularly at risk of developing professional burnout, as early as after five years of work, with a significant association with the psychological impact exerted by stressful events (stillbirth).     

Qualitative insights into women's personal experiences of perinatal depression and anxiety

Background and aimSymptoms of perinatal depression and anxiety are usually described and understood from a nosological perspective. This research sought to gain insight into women's lived experience of postnatal depression and anxiety, the factors that contribute to these symptoms and the context in which they develop.MethodFace to face and telephone interviews were conducted with 28 women from metropolitan and rural areas across Australia, who had experienced postnatal depression and/or anxiety within the last five years. Analysis was conducted from a grounded theory perspective.FindingsParticular symptoms of anxiety and depression develop in the context of the numerous changes inherent to the transition to motherhood and contribute to a common experience of frustration and loss. Symptoms were also associated with feelings of dissatisfaction with the pregnancy and motherhood experience.ConclusionsThe findings provide useful insights into women's experiences of mental health symptoms during the perinatal period, how these symptoms present and the factors involved in their development and maintenance. The need to consider women's perspectives to develop resources and health promotions strategies, as well as within the context of relationships with health professionals is highlighted. The study emphasizes the need for greater, more accurate information surrounding perinatal depression and the need to increase the profile and awareness of anxiety disorders.     

Stillbirth in Australia 5: Making respectful care after stillbirth a reality: The quest for parent-centred care

Stillbirth is a tragedy that can leave parents feeling powerless and vulnerable. Respectful and supportive bereavement care is essential to reducing adverse psychosocial impact. Initiatives of the Australian Centre of Research Excellence in Stillbirth are designed to improve care after stillbirth. At their heart are the voices of perinatally bereaved parents and support organisations and shared decision making between parents and health care providers. Priorities in future perinatal bereavement care research include ensuring appropriate care for population groups who experience higher rates of stillbirth and addressing implementation challenges to best practice in respectful and supportive bereavement care within our health systems.     

Implementing innovative evidence-based perinatal mental health screening for women of refugee background

ProblemNational guidelines recommend repeated screening for depression and anxiety for all women in the perinatal period. Routine screening in pregnancy is limited due to service, community and individual barriers.BackgroundPerinatal depression and perinatal anxiety affect up to 20% of all women. Women of refugee background are at even greater risk for perinatal mental health conditions due to refugee experiences and resettlement stressors.AimTo evaluate the acceptability and feasibility of a perinatal mental health screening program for women of refugee background from the perspective of health professionals.MethodsA mixed methods design guided by the Normalization Process Theory was used. Data were collected at a dedicated refugee antenatal clinic in the south-eastern suburbs of Melbourne, Australia. An online survey (n = 38), focus groups (n = 2; 13 participants) and semi-structured interviews (n = 8; 11 participants) with health professionals were conducted.FindingsUnder the four constructs of the Normalization Process Theory, health professionals reported improvements in identifying and referring women with mental health issues, more open and in-depth conversations with women about mental health and valued using an evidenced-based measure. Key issues included professional development, language barriers and time constraints.DiscussionImplementing a perinatal mental health screening program has been positively received. Strategies for sustainability include professional development and the addition of audio versions of the measures.ConclusionThis perinatal mental health screening program is acceptable and a feasible option for health professionals. Health professionals value providing more holistic care and have more open discussion with women about mental health.     

Experiences of and visions for collaboration between midwives and nurses in Nova Scotia

ProblemIn jurisdictions where midwifery and nursing are autonomous and separate health care professions, little is known about how they collaborate during the delivery of perinatal health care services.BackgroundMidwifery became a regulated profession in the province of Nova Scotia, Canada in 2009. Since regulation, midwives and nurses have worked together at three models sites for the delivery of midwifery services and perinatal care.QuestionHow do midwives and nurses collaborate during the provision of birthing care in Nova Scotia, Canada?MethodsThis was an instrumental case study guided by feminist poststructuralism. Individual interviews of 17 participants were audio-recorded and transcribed verbatim. Twenty-five documents were reviewed, and field notes were gathered. Feminist poststructuralist discourse analysis was used.FindingsMidwives and nurses collaborated well together. Participants described how positive collaborative experiences could influence a new way for midwives and nurses to work together. In this paper we present the theme Moving forward: A Modern Model for Nurses and Midwives working together, and its sub-themes of 1)’The birthing culture has changed’ and 2) ‘Allies and advocates’.DiscussionWithin the global context of strengthening midwifery and nursing, this study illustrated the potential for developing formal, collaborative perinatal models of care led by midwife and nurse teams to address inequities in perinatal health care services.ConclusionMidwives and nurses need more opportunities to collaborate and to build professional relationships. Establishing a midwife-led and nurse supported model of care may transform existing perinatal health care values, beliefs, and practices.     

Knowing how to help: Grandmothers’ experiences of providing and receiving support following their child’s pregnancy loss

ProblemPregnancy loss is a distressing experience for parents, however no research has addressed grandmothers’ experiences of grief and support following a child’s pregnancy loss.BackgroundNo research has specifically addressed grandmothers’ experiences of support and bereavement care following pregnancy loss.AimThis study seeks to understand three key areas: (1) the support grandmothers provide to their child; (2) the support they received themselves following pregnancy loss, and; (3) supports desired by grandmothers. The study aims to contribute insights into actions midwives could take to support grandmothers following pregnancy loss.MethodsSemi-structured interviews were conducted with 14 grandmothers to understand their support experiences. Interviews were analysed using Braun and Clarke’s approach to thematic analysis.FindingsThemes related directly to the three research questions: one: providing support, comprising two themes — being strong, protecting their family and the challenges of knowing how to help. Two, receiving support, also comprised two themes — lack of professional support offered to grandmothers and informal support and self-support strategies. Three, desired support, comprised three themes — I had no idea: increasing knowledge of pregnancy loss, peer support helps: they know how it feels, and honouring our grandchildren, making meaning.DiscussionGrandmothers may give extensive support to their child following pregnancy loss but lack confidence and face challenges in doing so. Few formal supports are available to grandmothers themselves, with grandmothers relying on their social networks for their own support.ConclusionsGrandmothers need early access to information and guidance from midwives and hospital bereavement services, as well as ongoing peer support with flexible delivery options.     

Postpartum women’s experiences of social and healthcare professional support during the COVID-19 pandemic: A recurrent cross-sectional thematic analysis

ProblemDisrupted access to social and healthcare professional support during the COVID-19 pandemic have had an adverse effect on maternal mental health.BackgroundMotherhood is a key life transition which increases vulnerability to experience negative affect.AimExplore UK women’s postnatal experiences of social and healthcare professional support during the COVID-19 pandemic.MethodsSemi-structured interviews were conducted with 12 women, approximately 30 days after initial social distancing guidelines were imposed (T1), and a separate 12 women were interviewed approximately 30 days after the initial easing of social distancing restrictions (T2). Recurrent cross-sectional thematic analysis was conducted in NVivo 12.FindingsT1 themes were, ‘Motherhood has been an isolating experience’ (exacerbated loneliness due to diminished support accessibility) and ‘Everything is under lock and key’ (confusion, alienation, and anxiety regarding disrupted face-to-face healthcare checks). T2 themes were, ‘Disrupted healthcare professional support’ (feeling burdensome, abandoned, and frustrated by virtual healthcare) and ‘Easing restrictions are bittersweet’ (conflict between enhanced emotional wellbeing, and sadness regarding lost postnatal time).DiscussionRespondents at both timepoints were adversely affected by restricted access to informal (family and friends) and formal (healthcare professional) support, which were not sufficiently bridged virtually. Additionally, the prospect of attending face-to-face appointments was anxiety-provoking and perceived as being contradictory to social distancing guidance. Prohibition of family from maternity wards was also salient and distressing for T2, but not T1 respondents.ConclusionHealthcare professionals should encourage maternal help-seeking and provide timely access to mental health services. Improving access to informal and formal face-to-face support are essential in protecting maternal and infant wellbeing.     

Voices of the unheard: A qualitative survey exploring bereaved parents experiences of stillbirth stigma

BackgroundEvery year, 2.6 million babies are stillborn worldwide. Despite these figures, stillbirth remains a relatively ignored public health issue. The wider literature suggests that this is due to the stigma associated with stillbirth. The stigma of stillbirth is seen as possibly one of the greatest barriers in reducing stagnant stillbirth rates and supporting bereaved parents. However, empirical evidence on the extent, type, and experiences of stillbirth stigma remain scarce.AimThis study aimed to explore the stigma experiences of bereaved parents who have endured a stillbirth.MethodsAn online survey of closed and open-questions with 817 participants (n = 796 female; n = 17 male) was conducted in high-income countries.FindingsBased on self-perception, 38% of bereaved parents believed they had been stigmatised due to their stillbirth. Thematic data analysis revealed several themes consistent with Link and Phelan’s stigma theory- labelling, stereotyping, status loss and discrimination, separation, and power. One more theme outside of this theory- bereaved parents as agents of change was also discovered.ConclusionBereaved parents after stillbirth may experience stigma. Common experiences included feelings of shame, blame, devaluation of motherhood and discrimination. Bereaved parents also reported the silence of stillbirth occurred during their antenatal care with many health care providers not informing them about the possibility of stillbirth. Further research needs to be undertaken to explore further the extent and type of stigma felt by bereaved parents after stillbirth, and how stigma is impacting the health care professional disseminating and distributing resources to pregnant women.     

Social resources and Arab women’s perinatal mental health: A systematic review

Background

Women’s mental health in the perinatal period is understudied worldwide and in Arab countries especially.

‘There is trauma all round’: A qualitative study of health workers’ experiences of caring for parents after stillbirth in Kenya and Uganda

BackgroundStillbirth is a traumatic life-event for parents. Compassionate care from health workers supports grief and adjustment, alleviating psychological distress and minimising serious adverse health and social consequences. Bereavement support in facilities in LMICs, including in sub-Saharan Africa, often fails to meet parents’ needs. However, very few studies have explored health worker’s experiences in these settings.AimTo explore the lived experiences of midwives, doctors and others, caring for women after stillbirth in Kenya and Uganda.MethodsQualitative, guided by Heideggerian phenomenology. Sixty-one health workers, including nurse-midwives (N = 37), midwives (N = 12) and doctors (N = 10), working in five facilities in Kenya and Uganda, were interviewed. Data were analysed following Van Manen’s reflexive approach.ResultsThree main themes summarised participants’ experiences: ‘In the mud and you learn to swim in it’ reflected a perceived of lack of preparation; skills were gained through experience and often without adequate support. The emotional and psychological impacts including sadness, frustration, guilt and shame were summarised in ‘It’s bad, it’s a sad experience’. Deficiencies in organisational culture and support, which entrenched blame, fear and negative behaviours were encapsulated in Nobody asks ‘how are you doing?’.ConclusionHealth workers in Kenya and Uganda were deeply sensitive to the impacts of stillbirth for women and families, and often profoundly and personally affected. Care and psychological support were acknowledged as often inadequate. Interventions to support improved bereavement care in sub-Saharan Africa need to target increasing health worker knowledge and awareness and also embed supportive organisational cultures and processes.     

Honesty and comfort levels in mothers when screened for perinatal depression and anxiety

PurposeTo evaluate the degree of honesty and level of comfort reported by women when questioned about their emotional wellbeing during the perinatal period; to investigate if honesty and comfort are associated with perinatal depression or perinatal anxiety; and to examine the reasons why women may not always respond honestly.MethodsQualitative and quantitative data from 1597 women from the cross-sectional perinatal mental health substudy (part of the Australian Longitudinal Study on Women’s Health) were analysed using a mixed methods approach.ResultsWhen questioned by their health practitioner about their emotional wellbeing in the perinatal period, 20.7% of women indicated they had not always responded honestly. Reasons for not being honest reflected four main themes: normalizing of symptoms/coping; negative perceptions (self-and others); fear of adverse repercussions; and fear of involvement of health services (trust and confidentiality). The 38.9% of women who did not feel comfortable when questioned by their health practitioner about their emotional wellbeing were four times more likely to report perinatal depression (odds ratio = 4.09; 95% confidence interval = 2.55, 6.57) and nearly twice as likely to report perinatal anxiety (odds ratio = 1.90; 95% confidence interval = 1.24, 2.94) than other women.ConclusionsWomen who are most likely to need mental health care during the perinatal period are also those least likely to be honest about their mental health. A non-judgemental, open and reassuring approach by clinicians may help to reduce the stigma and fears contributing to lack of honest responses, and improve early diagnosis and treatment of mental health problems.