The role of midwives in cases of stillbirth and perinatal death.
The role of the midwife is to provide support, care, advice and education to pregnant women across the continuum of pregnancy, labour, birth and the postnatal period. For the most part, definitions like this of midwifery conjure up images of joy and happiness not tears and heartache. Words such as death and dying are not usually synonymous with midwifery. Throughout their careers though midwives will be faced with the challenges of caring for women and their families who are experiencing miscarriage; or who find themselves giving birth to a baby that has died or who is not expected to survive once born. Despite the advances in prenatal and neonatal care over the past decade or so, pregnancy and infant loss still affects thousands of families across the country each year. Across Australia, approximately 9.3 per 1000 births each year result in perinatal death (this includes fetal and neonatal deaths)1 and an estimated one in six diagnosed pregnancies results in miscarriage.2 Often there will be a midwife at the forefront to provide physical, emotional and spiritual care to these women and their families, guiding them through this unexpected journey.
It may be in the emergency department, supporting a woman having a miscarriage at ten weeks gestation; in the birth unit, caring for a woman birthing a stillborn baby at 38 weeks gestation; or on the ward with a baby who requires palliative care – wherever it may be, midwives who are experienced at providing bereavement care can assist during these traumatic times and have a very important role to play in the journey of this woman, her baby and her family. However, the skills that midwives require to deliver effective bereavement care do not come as second nature to most of us. For the majority of midwives, caring for women and their families experiencing pregnancy or infant loss can be a very challenging and stressful experience. The ramifications of providing inadequate care and support for women and their families during such life events can potentially lead to maternal mental health problems3 and can also impact on the mental health of all family members involved.4
When I reflect on my own nursing and midwifery training, I cannot recall exploring bereavement care in any great detail. This is reflected in studies that claim that the education that is provided to student midwives does not adequately prepare them to deliver effective bereavement care.3 So, how do midwives develop skills
to provide effective bereavement care? Often in maternity units there are midwives who have a particular interest in bereavement care who are a fantastic resource to student midwives and other midwifery colleagues. It important to have opportunities to observe experienced midwives and other healthcare providers at work with women and families experiencing pregnancy or infant loss, as this can be a valuable learning tool. Talking to colleagues experienced in providing clinical facilitation and opportunities for staff to debrief with colleagues, review cases and reflect on one’s own clinical practice is very beneficial and should be encouraged. Self-directed learning, such as reading articles and attending courses about perinatal loss and bereavement care, can also be valuable in developing skills in this area.
It is important clinicians have an understanding of the grieving process3 and acknowledge that individuals experience and display grief in different ways. This, in turn, assists midwives to tailor care to meet the needs of the individual. While having an understanding of the various grief models that exist is beneficial, parental grief is something that can only be fully understood by the parents experiencing it and often there is no end to this grief process. While parents will never get over the loss of a child, there are certainly strategies and supports that midwives can use and access to assist parents in the early stages to find some happiness and peace among all the sadness and trauma. Midwives require empathy to support women and their families throughout this process and an understanding of bereaved parents and the needs that they have. In some cases, midwives rely on their own personal experiences to achieve the level of empathy and understanding that is required, turning their own personal experience to positive use.
Good communication skills are essential for the midwife to provide high-quality bereavement care. Clear and open communication between the midwife, the woman and her family is paramount. This ensures the care provided to the woman and her family meets their needs, and is what is expected and anticipated by the woman and her family on a physical, emotional and spiritual level. It is important the woman and her family feel they are supported to make decisions that reflect their own wishes, morals and their cultural and religious beliefs, without feeling pressured to conform to what a particular clinician feels is the right thing to do. Allowing parents to be involved in the decision-making following pregnancy or infant loss can assist in helping parents feel a sense of control over the situation and help to give them a sense of purpose and meaning.
Being a good communicator also means being a good listener. Women and their families need opportunities to debrief with the staff involved in their care and midwives are in a perfect position to be able to do just this. Parents need be given the opportunity to talk and express their thoughts and feelings and to have reassurance that what they are thinking and feeling is perfectly normal and to know that help is available for them for the moments that they find themselves struggling with their thoughts and emotions. Often bereaved parents will feel more comfortable talking to a midwife about their experience owing to the relationship that has developed between them during this journey together.
In caring for women and their families who are experiencing or who have experienced pregnancy or infant loss, midwives have the opportunity to turn a devastating situation into a positive experience for the woman and her family. At the time, it may be difficult for the woman and family to acknowledge any positivity surrounding the loss of a baby as parents often find themselves confused as to why this is happening to them. However, it is important parents are supported to find a positive meaning in their experience of perinatal loss as some research suggests failure to do this can result in parents remaining ‘angry, emotionally distressed and unable to function normally for any period of time’.4 As with any birth journey, often the care, compassion and support that a midwife can provide throughout this experience will stay with the woman and her family forever and can result in positive lifelong memories of the experience.
A large part of the midwife’s role following the birth of a baby who has died is assisting in creating tangible memories and mementos for the family and this can be seen as a skill in itself. The making and sharing of memories following a stillbirth are associated with better maternal mental health outcomes and it is recognised that mothers value creating memories of their babies and most mothers wished they had more memories.4 The ritual of creating memories and mementos for the family is not only beneficial for the woman and her family, but can also be very rewarding and beneficial for the midwife. This process can give the midwife a sense of purpose in a situation that can be very confronting, especially for the less experienced. As a midwife, it is reassuring to know that these rituals can have a positive effect on maternal mental health and that this ritual does make a positive difference in the lives of women and their families. Some of the rituals midwives undertake to assist in creating memories include taking footprints and locks of hair, taking photographs of the baby with his/her parents and assisting the new parents to bath and dress their baby. Memory boxes are often used in which to store these treasured memories and mementos.
While preparing to write this article, I came across the following quote from Ronald Reagan, proclaiming October as Pregnancy and Infant Loss Awareness Month in 1988: ‘When a child loses a parent, they are called an orphan. When a spouse loses a partner, they are called a widow or widower. When parents lose their child, there isn’t a word to describe them.’5
I’d like to think that as healthcare providers and as a society we can, together, recognise that a parent is still a parent regardless of whether a baby has lived or died. I feel very strongly that as health professionals we have a responsibility to acknowledge this for the women and their families that we care for and assist parents in acknowledging this important life event. As a midwife, congratulating the family on the birth of their baby can be an extremely powerful and positive statement to make. For some families, this acknowledgement of the birth of their baby from the midwife and other healthcare professionals will be the only time that they hear the word ‘congratulations’ during the days, weeks and months following the birth and loss of their baby. Many family members and friends simply don’t know what to say or feel uncomfortable talking to the bereaved parents about their baby and their experience.
There is a lot in the literature on the impact stillbirth and perinatal loss has on women and their families, but very little on the impact that caring for these families has on the midwifery and medical staff. Stillbirth and perinatal loss has a profound effect on the woman and her family, but these moments in a midwifery and medical career can also dramatically impact our own emotional welfare. Often we are so busy and consumed with concern for the women and their families under our care, we neglect to care for ourselves. Regardless of the level of bereavement training or experience a midwife might have, training and experience often does not provide a defence for the midwife against the emotional distress that may be experienced when caring for women and their families who are experiencing pregnancy or infant loss.
On a finishing note, it is important to remember that providing effective bereavement care to women and their families should not be done in isolation from other health professionals. Our obstetrics and gynaecology colleagues and allied health workers, such as social workers, have an equally important role to play and a collaborative approach to bereavement care will ultimately result in the best care for the woman and her family. This collaborative approach will also ensure better support for the clinicians caring for the woman and her family.