When a baby dies after 24 weeks gestation, it is defined as stillbirth (Tommy's, 2019) and, according to the Office for National Statistics (ONS, 2018), 3 200 babies are stillborn in the UK every year. Although declining, the rate of stillbirth in the UK remains among the highest in Europe (Draper et al, 2017). Initiatives such as ‘Saving Babies' Lives’ (O'Connor, 2016) and ‘Each Baby Counts’ (The Royal College of Obstetricians and Gynaecologists, 2017) set national targets to reduce the number of stillborn babies in the UK. In order to achieve these targets, health interventions that directly reduce risk factors must be introduced, including those aimed at reducing the deprivation gap in stillbirths that still exists in the UK (Best et al, 2019).
Following a stillbirth, parents are left struggling with an overwhelming grief that is both complex and misunderstood by others (Kohner and Henley, 2001). Although nothing can be done to remove a parent's grief, receiving good care is central to the grieving process, making the situation more manageable and benefitting short- and long-term, physical and mental health outcomes (Sands, 2016). This article will use psychological and sociological theories to examine grief following a stillbirth and how these findings relate to midwifery practice.
Psychological theory and research
When examining grief, psychologists have recognised common stages that many people experience (Kubler-Ross, 1970; Bowlby, 1980), while acknowledging the emotional complexity of the process and that there is no ‘typical response’ to death (Kubler-Ross and Kessler, 2005). John Bowlby (1980) discussed grief in four stages: numbing, yearning and searching, disorganisation and despair, and reorganisation. Bowlby stated that although bonds between parents and unborn babies have a relatively short time to grow, the overall pattern remains similar.
In line with Bowlby's theory, after being told that their baby had died, parents commonly report denial and confusion, often leading to feelings of distance and disconnect between themselves and the situation (Downe et al, 2013). Nuzum et al's (2018) qualitative study exploring the impact of stillbirth on bereaved parents also reported confusion as a common theme, and that some women experienced this as an ‘out-of-body experience’. Unlike death in other circumstances, feelings of confusion are often exasperated by the sudden change from expectation to loss, and the emotional response is complex due to a lack of memories to mourn (Scott, 2011). It is important that midwives support memory making to help parents come to terms with their loss (Downe et al, 2013).
On the disorganisation and despair phase, Bowlby (1980) stated that mourning can proceed better, and the psychological impact is reduced, when parents maintain a supportive relationship. Congruent with this theory, research has shown that women who perceived family support were less likely to suffer from depression and anxiety (Cacciatore, 2009). Nevertheless, stillbirth often impacts negatively on parental relationships (Campbell-Jackson and Horsch, 2014). Although some parents report improved closeness (Cacciatore, 2013), the majority of relationships struggle as communication begins to breakdown, with blame often directed at one another (Human et al, 2014).
Bowlby (1980) described the phase of reorganisation as a process of realisation, and not merely letting go of the deceased. The effects of stillbirth are profound and long-lasting (Cacciatore and Bushfield, 2008) and although in general the severity of symptoms diminishes over time (Clement, 1998), the psychological effects remain for a lifetime. Mothers often maintain a strong desire to stay connected to their baby through commemorating anniversaries and conversations with family and friends (Cacciatore, 2013).
Sociological theory and research
As a proponent of the work of George Herbert Mead, Herbert Blumer (1986) coined the term ‘symbolic interactionism’ based on the premise that ‘human beings act toward things on the basis of the meanings that the thing has for them’. Therefore, using a symbolic interactionist theory to examine stillbirth, the severity of a mother's grief can be better understood as it recognises the meaning she placed on her unborn baby (Deery et al, 2015).
When a woman falls pregnant, she begins to construct a personhood for her baby, and subsequently motherhood, and the future they will share (Layne, 2000). Feeling kicks and hearing the heartbeat at antenatal appointments adds to her baby's ‘realness’ and contributes further to her becoming a mother. Parents of stillborn babies expressed the importance of acknowledging, treating and consequently grieving their baby the same as every other child (Nuzum et al, 2018).
Using symbolic interactionism to understand the meaning given to a baby while in utero, it is clear why the grief experienced by parents is so acute. However, societal views differ in that once the baby has died, their value has somehow diminished, which in turn devalues the parents' grief (Frøen et al, 2011). Unlike the mother and father who have already given meaning to the baby, for the rest of society there is no physical evidence of the baby's existence, with the effect that society expects the emotional response to be less than the death of a child in another circumstance.
Symbolic interactionists view language as a series of symbols, as human beings give meaning to symbols and communicate this meaning through language (Aksan et al, 2009). Health professionals often refer to stillbirth as ‘pregnancy loss’ or to the baby as a fetus, further devaluing the baby and consequently the mother's emotions (Cacciatore, 2010; Frøen et al, 2011). Such differing perceptions and misunderstanding leaves mothers feeling unsupported in their grief and socially isolated, which in turn, exacerbate the symptoms of loss (Cacciatore et al, 2009). Thoughtless exchanges such as ‘you can have another baby’ and ‘at least you know you can get pregnant’ further demonstrate the incongruence between bereaved mothers and the rest of society, and contribute further to social isolation (Deery et al, 2015).
Implications for practice
Since starting this this article, the NHS has released a second version of the ‘Saving Babies’ Lives Care Bundle' (2019), detailing achievements since the release of version one, and issues identified after the first evaluation. The evaluation reported an 18% reduction in stillbirths, but admitted that, although we are on track to meet targets, there remains too many instances of avoidable death. Smoking cessation, assessing risk and raising awareness of fetal movements were all identified as vital areas of care which require improvement, as was implementing continuity models of care, which research suggests can reduce fetal-loss by approximately 16% (Sandall et al, 2016).
Despite these improvements, further reports show a direct correlation between low-income areas within the UK and higher rates of stillbirth (Draper et al, 2018). Research states that stillbirth is 68% more likely to occur in the most deprived areas of the country, naming congenital anomalies as the leading contributor to the deprivation gap (Best et al, 2019). Such findings identify areas in which health provision must be improved in order to achieve government targets and eradicate socioeconomic disparities.
Although reducing stillbirths must remain a priority, continuing to develop bereavement care is of equal importance as the psychological and sociological implications are so great. The 2014 ‘Listening to Parents’ report (Redshaw et al, 2014) examined parents' experience of maternity care following a stillbirth and reported that staff behaviour was ‘a crucial aspect of care that affected their experience’. Therefore, every midwife should receive support and training, enabling them to deliver effective care (Sands, 2016), including communication training, given the adverse consequences of using the insensitive language outlined in this essay. Unfortunately, however, bereavement care training is not currently mandatory in the UK (Sands, 2016).
Midwives need to facilitate memory making and understand the importance of having quality photographs and meaningful mementos (Downe et al, 2013). Being able to share such memories moving forward is associated with fewer cases of post-traumatic stress disorder (Crawley et al, 2013) and are almost always reported to be of significant value to women (Cacciatore, 2007). However, not all women will feel the same way, therefore memory making should be sensitively discussed and not enforced.
Midwives should support couples to start the grieving process together so as to continue on a trajectory of togetherness as they grieve. To facilitate this, it is recommended that all maternity units have dedicated bereavement rooms where couples can be together at all times, and away from other labouring women and babies (Redshaw et al, 2014). During the last audit of bereavement care in the UK (Sands, 2016), only 63% of trusts had dedicated bereavement rooms.
Most women who have had a previous stillbirth conceive again within one year (Bakhbakhi et al, 2017), and, in comparison to women who have never had a stillbirth, are at increased risk of reoccurrence, anxiety and depression (Wojcieszek et al, 2018). It can therefore be assumed that these women would benefit from special care in future pregnancies, including increased psychological support. A recent survey of parents who had experienced stillbirth examined how much additional care they received in subsequent pregnancies (Wojcieszek et al, 2018). The survey reported that additional ultrasound scans and antenatal visits, were provided for 67% and 70% of parents, respectively. Psychosocial care provision, however, was much lower, with only 10% receiving additional bereavement counselling.
The Stillbirth and Neonatal Death (Sands) charity are currently piloting the National Bereavement Care Pathway across England. However, their interim report highlighted inconsistencies countrywide, and that a lack of resources and staff training, and poor facilities, were all barriers to delivering appropriate care (Donaldson, 2018).
Conclusions
The psychological and sociological impacts of stillbirth are both devastating and complex (Murphy and Cacciatore, 2017) but can be better understood using psychological and sociological perspectives to examine the multiple aspects of grief. By delivering care that embodies all aspects, healthcare professionals will be equipped with the necessary skills to give bereaved parents the best chance of achieving optimum long-term wellbeing (Downe et al, 2013).