Main Work

CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Motherhood and indeed the birth of a child call for celebration in every family. It is the desire
of every matured female to get married and make babies. Unfortunately, the joy of a couple
and indeed a family is cut short with any occurrence of perinatal loss. According to world
health organization (WHO, 2019), perinatal death can be defined as the death of a baby
between 22weeks of gestation or the death that occur when the baby’s weight is 500 g and it
could also occur 7 days after birth. According to World Health Organization (WHO, 2014)
stillbirth can be defined as the birth of a baby with no signs of life at or after 24 weeks of
gestation and is a global problem. In 2015, 2.6 million stillbirths occurred which equates over
700 deaths per day, 98% were concentrated in low- and middle-income countries and 60%
occurred in rural areas, mirroring the distribution of maternal death (WHO, 2019).
Starrs (2014) observed that women who had experienced stillbirth had a high risk of divorce,
so, a supportive therapy should be provided. Kerstin et al. (2011) opined that a behavioral
therapeutic assessment should be adopted to prevent negative side effect of the perinatal loss,
which mighty result to complicated grief. A good plan of adjustment to meet the needs of the
mothers who in one way or the other experienced pregnancy loss, which could be
miscarriage, top fetal anomalies or still birth, should be adopted. The occurrence of perinatal
loss is often sudden and unexpected but when it occurs grief follows. Grief after pregnancy
loss is one of the most profound events a family can endure.

There are several negative impacts that follow grieving after pregnancy loss, which includes
the physical and emotional heat that affects the mother, father, or relations. In addition,
finding the right resources for each person is essential to help navigate this challenging time.
Perinatal loss and grief are recognized as traumatic life events, that can take a longer period
(weeks to months) before recovering from the physical shock. To recover emotionally, may
equally take a longer period. In this case the “right way” to move on after perinatal loss, is to
find a suitable support and care that will work best for parents with the help of their health
care providers following perinatal loss. The occurrence of perinatal loss is one of the most
profound events a family can endure because the family were hoping to receive a baby at the
end of the pregnancy, despite all that is done to support a healthy pregnancy, all the plans
have changed and result to perinatal loss which is unfair and heartbreaking. The next option
is to grief, by allowing the parents and everyone involved to grieve before providing the
essential support required to avert complications. There are many resources available to help,
to Prevent complications is to find a professional care provider who understands these
immense feelings of sadness, loss, and emptiness who is ready to support you at this
period. Perinatal loss occurs in three different forms depending on the stage of pregnancy
and the cause of the perinatal loss. There are three types of perinatal loss are: Miscarriage.
This is the unintended ending of a pregnancy before 20 weeks of gestation and it is the most
common type of perinatal loss. Intrauterine Fetal Demise (IUFD), or early stillbirth, this is
the type of fetal death that occur between 20 and 27 weeks of gestation. A late or term
stillbirth. This is fetal death that occurred between 28 weeks gestation and delivery. Perinatal
loss occurs in women of all races, ethnicities, ages, and income levels. In the United States,
there are about 24,000 cases of perinatal loss annually. The most common sign of a problem
is vaginal bleeding. Bleeding or spotting, cramping in your lower abdomen and severe belly
pain should be reported immediately to your health care provider.
1.2 Statement of the Problem
Perinatal loss is a very devastating experience for parents especially following stillbirth.
Some parents especially the mother will continue to experience these for over four years.
Burden et al. (2016) in a recent systematic review estimates that over 4 million women
globally are living with depression following stillbirth and some reduce their working hours
after stillbirth; the bereaved parents returning to work exhibit only 63% of their usual input
of production after 6 months of stillbirth; and some misbehave due to this condition.
Erlandson et al. (2011) and Farrow et al. (2013) noted that some leave their marriages due to
constant perinatal loss, as some culture believe that too much perinatal loss is a spiritual
curse. Stillbirth has been neglected by the global health agenda until recently. The direct
economic and psycho-social costs of stillbirth are immense. Almost all parents report
multiple negative psychological effects following loss of their babies. The experience of
perinatal loss, requires midwives’ support to enhance psychological health of the clients with
this encounter.
Grief is a normal process and it is a healthy response to a loss. Parents experience feelings of
inferior, void, guilt, irritability, and an overwhelming sorrow, fear of a new pregnancy, rage,
Skeptics and apathy when this loss occur. About 20% of mothers suffer some psychological
disorder like depression or anxiety within one year after perinatal loss. These experiences can
result in mental disorders which can affect further pregnancies and relationship with their
spouses. A further review of happenings around the world in connection with perinatal losses
in Nigeria has prompted the researcher who is a midwife to carry out this study. This interest
is further stimulated by the encounter the researcher had with some midwives following the
experience of stillbirth during her first pregnancy, for the fact that midwives are at the
forefront in care of pregnant women from the antenatal period to the time of birth of the baby
an expert care should be adopt to avert the advance effect that might arise following perinatal
loss. Based on these the researcher decided to evaluate the midwives’ supportive attitude
towards parents following perinatal loss; considering the fact that this is a necessity, the
negative consequences of such experiences should be avoided.
1.3 Aim and Objectives
This study aims at ascertaining the midwives’ supportive attitude towards parents following
perinatal loss in two selected hospitals in Aba Abia State.
The specific objectives for the study are to:
i. Determine midwives’ support attitude towards parents following intraparum loss.
ii. Determine midwives’ support attitude towards parents following immediate post-
natal loss.
iii. Determine midwives’ support attitude towards parents through the following
postnatal period.
iv. Determine influence of midwives’ support attitude on parents’ reaction following
perinatal losses.
1.4 Research Questions and Hypotheses
i. What are support attitude towards parents following intrapartum loss experience?
ii. What are the supportive attitudes of midwives to parents following immediate
postnatal loss experience?
iii. What is the midwives’ support attitude towards parents through the following
postnatal period?
iv. What is the influence of midwives’ support attitude on parents’ reaction to perinatal
loss?
1.4.1 Hypotheses
The hypotheses to be analyzed in this study are:
i. There is no significant difference between midwives’ supportive attitude to parents
following intrapartum and postnatal loss.
ii. There is no significant association between midwives’ support attitude and parental
reaction to perinatal losses.
1.5 Significance of the Study
Perinatal loss has caused a devastating event in the lives of some parents and families who
have experienced perinatal losses. It is estimated that approximately one in five parents who
have experienced this ugly event will suffer intense and prolonged grief following the death
of the fetus or baby before birth, grief and depressive symptoms related to pregnancy loss can
last up to 10 years (Kokou-kpolou et al., 2018). Perinatal death has been identified as a risk
or contributory factors that wreck marriages. This is because many women who had stillbirth
in their first pregnancy is at risk of experiencing secondary infertility which can last for
years and this may cause the woman to face some challenges from their spouses or the family
member too, based on my findings in this study.

Findings from this study may therefore be beneficial to the parents experiencing perinatal
losses, the midwives who are vested with the responsibility of caring for women during these
encounters, the three tiers of government who are expected to ensure the availability of
healthcare facilities to the citizenry and the general public who are the consumers of health
care services by motivating the government to ensure that adequate facilities are put in place
to enhance proper care of the bereaved parents .Equipped with this knowledge, they will be
able to design plan in care that will be supportive and promote grieving process healing to
prevent depression.
For parents with perinatal loss experience, findings may be needed for healthcare availability
to parents to ensure prevention of perinatal losses. This is because perinatal losses may occur
due to inadequate healthcare resources to manage emergency situations. Secondly, the
findings may enhance the knowledge of parents towards perinatal loss and also enlighten
them on how to avert its occurrence by embracing early antenatal, proper nutrition and
treatment of minor diseases. This study may help women and men in the society to become
aware of perinatal losses. This in turn will help relations and victims of this encounter, to
develop a positive attitude that will be supportive rather than devastating. In addition,
findings may guide against future occurrence of perinatal losses. It will also enlighten the
public on the importance of supportive care from the spouses and family members to the
parents experiencing perinatal losses.

1.6 Scope of Study
This study is delimited to midwives who have rendered care to parents who have encountered
perinatal loss either miscarriage, stillbirths or death of a baby either a day, few days or weeks
after delivery.
1.7 Operational Definition of Items
Supportive Attitude: It is a way of assisting the bereaved parents to adapt to their present
condition. In this study what is measured is the support midwives give to parents who have
lost their baby while still pregnant, during labour or after the child is born. It involves the
midwives’ encouraging words and behavior aimed at comforting the parents.
Parents: In this study, parents refer to the father and the mother (spouses) that lost their baby
or fetus.
Loss: This refers to the death of the baby during pregnancy, labour or at birth of after
childbirth.
Midwives’ support attitude: this is a kind of charismatic care and empathy rendered by
midwives to the bereaved parents following perinatal loss.
Perinatal loss: fetal or neonatal death (22 weeks of gestation to 7 days of birth)
Reaction to perinatal loss: The feelings of parents towards death of baby during pregnancy,
labour and delivery.

CHAPTER TWO
LITERATURE REVIEW
A related literature of evaluation of midwives’ supportive attitude towards parents following
perinatal losses was reviewed under the following headings: Conceptual review, Theoretical
review, Empirical review, Summary of literature reviewed.
2.1 Conceptual Review
Midwives’ supportive attitude in care
Understandably, when a family experienced infant death most the focus of care is always on
the grieving parents. However, those who are involved in the care of the woman and infant
may also feel grief and distress. The feelings of midwives involved in the care of bereaved
parents are often ignored or inadequately dealt with, resulting in long-lasting ramifications,
especially for those who are in training or who have no previous experience of this aspect of
maternity care (Puia et al., 2013). When asked to comment on the quality of care they
received from nurse-midwives, women referred to both positive and negative episodes in
terms of physical and psychological aspects of care.
Physical aspects of care received Intrapartum
Women's interpretation of the quality of care received depended in part on the kind of
physical or medical care received. For instance, one woman was asked what the reaction of
the nurse-midwife was after the death of her newborn: According to me I think she took good
care of me as her patient. During labour, I was well attended to up to the time I had a
stillbirth, and after giving birth to a dead baby, she cleaned me up, pushed me on the
wheelchair and laid me on the bed, and I felt that the nurse had really cared for me (Interview
18). The respondent had a positive perception of care due to a nurse-midwife performing
basic (cleaning the patient) nursing tasks. On the other hand, several women described
feelings of abandonment or not being supported by nurse-midwives during labour and at the
time of their loss. If only she was close to me at the time, I was calling for her, I am sure my
child could have been alive now but she went away when the baby was about to come out.
Principles required when rendering bereavement care following perinatal loss
The key ideas include:
When a patient dies the care does not end but the care continues with the bereaved parent
Bereavement care should begin as soon as death is expected
Sensitive communication from an early stage with the dying patient and with close relatives
which is accepting of the fact that death happens can ease the transition into grief
Spiritual, religious and cultural needs should be identified and met both before death and
after death
Close liaison between departments of Spiritual Care and staff involved with the dying and
deceased is important
Those who sit with dying patients should be offered information about what to expect
Dignity and respect should be always shown to the deceased, and those who have been
bereaved
Clear guidance on last offices and protocols around death need to be provided by each Board
but must be flexible enough to meet the needs of the deceased and those who have been
bereaved.
Accurate information should be given at all times, and should include all choices which are
open to the dying patient or those who have been bereaved
All staff who may have contact with the dying or deceased patient should have received
training at the appropriate level
All staff involved in discussions around issues such as post mortem examinations, organ and
tissue donation, certification of death should be fully trained for the purpose and regularly
updated on changes to protocols and legislation
Relatives and friends of the deceased should be given a clear point of contact should they
wish to speak to someone before or after a death Shaping
Principles for Staff Support
• Management should recognize an obligation to support staff both through their
involvement in the death of a patient and support of people who have been bereaved
or when experiencing a personal loss
• A supportive culture needs to be created within each organization to facilitate staff
coping with bereavement especially in traumatic situations
• Time allowed for debriefing should become the norm
• Links with Spiritual Care departments should be increased

• A resource list of where to access support should be available for managers and staff
alike
• Particular consideration should be given for staff in areas where they are exposed to
death and dying on a regular basis or following particularly traumatic death.
Psychological care rendered to bereaved parents by midwives following immediate
post-natal loss.
Some midwives said words of comfort to the bereaved parents and the bereaved women
found it encouraging: She reassured the bereaved parents and encourages them to be strong
and avoid too much worry too much because it might be Gods planned; He gives and takes
away so God will give the one that be alive.
However, substandard psychological aspects of care were reported as well. Several bereaved
parents noticed that some midwives lacked warmth and sensitivity and they felt that they
were caring. They reported that the nurses did not show any empathy by saying words of
encouragement or counseling them following their stillbirth or neonatal death.
Several bereaved parents wanted the midwife’s attention soon after experiencing perinatal
loss and they were disappointed when they were not adequately attended to.
They were helpless and confused, when their child died, they were just crying and walking
round the hospital area.
Some women broke down and were hospitalized at the time of their infant's death, and they
wanted encouragement and attention from the midwives at that crucial time.
In the extract below, the respondent points to the absence of a nurse
After delivery the midwives did not come to my bed to attend to me and know how am doing
but a different person in a green uniform came to attend to me.
I notice that staffs wearing green uniform are cleaners who are often called upon by
midwives to assist them carry the baby to the postnatal unit after delivery. Bereaved parents
viewed the attitude of midwives positively following perinatal loss based on how they
explained to them the possible cause of stillbirth or the child's death. However, twelve
women said that the midwives did not offer any explanation based on the possible caused
their perinatal loss, such as suffocation,
A few bereaved parents expressed difficulty evaluating care rendered to them by midwives,
they mentioned that the midwives knew better and stands the chance of serving them well, it
is the role of the midwives to create a good personal relationship with women during
pregnancy, birth and postpartum. Midwives play an essential role in providing emotional
support to women and families following perinatal loss (Wall bank). However, some
midwives may attempt to protect themselves emotionally from the burden of perinatal loss
through maladaptive coping styles, such as self-blame, disengagement, and denial (Wall
bank). Studies have shown that student midwives may be left to deal with negative feelings
by themselves, and may be given very little opportunity to work through and acknowledge
the grief they may be experiencing (Wallbank & Robertson, 2013).
A phenomenological study, using diaries and interview data, indicated that student midwives
were not confident in their ability to communicate properly with grieving parents. For
example, students reported being so overcome with emotion that they were unable to support
parents. Often, students believed that they needed support as much as the affected family.
Student midwives' experience of caring for bereaved families resulted in feelings of distress,
guilt and anxiety regarding their competence to offer appropriate care.
Palliative Care following Perinatal Loss
Perinatal palliative care (PNPC) is an emerging field within the area of perinatal loss which
aims to provide care for dying babies and their parents. For some couples it can provide an
alternate option to TOP for fetal abnormalities. To date, no empirical studies have
determined the best model for perinatal palliative care, however, a small number of clinical
studies have identified key components to be: early engagement, continuity of antenatal care,
a family‐centered approach to care, and multi‐disciplinary team involvement, including a
bereavement specialist centre that provides a perinatal hospice or palliative care service
report up to 87% uptake (Balaguer et al., 2012).
Supporting parents in end‐of‐life decision‐making when a baby is dying or when
continuation of care is futile, includes clear, compassionate communication, physical and
emotional care, collaborative decision making and follow‐up care. Active parental
involvement in discussions and decisions about withholding or withdrawing care has not
been found to aggravate or prolong parental grief or increase the incidence of grief
pathology. A model of shared decision‐making based on the discussion of mutual ‘goals of
care’ gives equal weight to the family and the medical team and often reduces the potential
for conflict.
Effective neonatal pain and symptom management, discussing options for parental
involvement in the baby’s dying, preparation for the death and guided decision‐making are
important aspects of palliative care. Common challenges to providing comprehensive end‐of‐
life care include care‐giver comfort, consistency of care, cultural and legal barriers, and lack
of adequate staff training. There are several negative impacts that follow grieving after
pregnancy loss, which includes the physical and emotional heat that affects the mother,
father, or relations. In addition, finding the right resources for each person is essential to help
navigate this challenging time. Perinatal loss and grief are recognized as traumatic life
events, that can take a longer period (weeks to months) before recovering from the physical
shock. To recover emotionally, may equally take a longer period. In this case the “right way”
to move on after perinatal loss, is to find a suitable support and care that will work best for
parents with the help of their health care providers following perinatal loss. The occurrence
of perinatal loss is one of the most profound events a family can endure because the family
were hoping to receive a baby at the end of the pregnancy, despite all that is done to support
a healthy pregnancy, all the plans have changed and result to perinatal loss which is unfair
and heartbreaking. The next option is to grief, by allowing the parents and everyone
involved to grieve before providing the essential support required to avert complications.
There are many resources available to help, to Prevent complications is to find a professional
care provider who understands these immense feelings of sadness, loss, and emptiness who is
ready to support you at this period. Perinatal loss occurs in three different forms depending
on the stage of pregnancy and the cause of the perinatal loss. There are three types of
perinatal loss are: Miscarriage. This is the unintended ending of a pregnancy before 20 weeks
of gestation and it is the most common type of perinatal loss. Intrauterine Fetal
Demise (IUFD), or early stillbirth, this is the type of fetal death that occur between 20 and 27
weeks of gestation. A late or term stillbirth. This is fetal death that occurred between 28
weeks gestation and delivery. Perinatal loss occurs in women of all races, ethnicities, ages,
and income levels. In the United States, there are about 24,000 cases of perinatal loss
annually. The most common sign of a problem is vaginal bleeding. Bleeding or spotting,
cramping in your lower abdomen and severe belly pain should be reported immediately to
your health care provider.
Birthing options after the diagnosis of fetal death
Following the diagnosis of an intrauterine fetal death (IUFD), most women opt for delivery
of the baby within 48 hours. The timing of delivery depends on a variety of factors and
management should be individualized, however, postponing the birth too long may increase
maternal psychological distress and anxiety. One study found that women who postponed
delivery for more than 24 hours, had a fivefold increased risk of long‐term anxiety related
symptoms
Mode of birth is largely dependent on fetal gestational age and maternal clinical history, with
consideration of the couple’s personal preference. Induction or augmentation of labour and
natural vaginal birth has the lowest medical risk for women. Caesarean section should be
reserved for women when clinically indicated. Although couples with a diagnosis of IUFD
commonly consider a caesarean section as their initial preferred mode of birth, women with
no clinical indication for this procedure should be encouraged to consider a normal labour
due to the known increased risks associated with previous caesarean section in a subsequent
pregnancy (Flenady et al., 2014). Reassurance should be given to the parents that pain relief
and physical and emotional support during labour and birth will be provided (O’Neil et al.,
2013). There are several negative impacts that follow grieving after pregnancy loss, which
includes the physical and emotional heat that affects the mother, father, or relations. In
addition, finding the right resources for each person is essential to help navigate this
challenging time. Perinatal loss and grief are recognized as traumatic life events, that can
take a longer period (weeks to months) before recovering from the physical shock. To
recover emotionally, may equally take a longer period. In this case the “right way” to move
on after perinatal loss, is to find a suitable support and care that will work best for parents
with the help of their health care providers following perinatal loss. The occurrence of
perinatal loss is one of the most profound events a family can endure because the family were
hoping to receive a baby at the end of the pregnancy, despite all that is done to support a
healthy pregnancy, all the plans have changed and result to perinatal loss which is unfair and
heartbreaking. The next option is to grief, by allowing the parents and everyone involved to
grieve before providing the essential support required to avert complications. There are many
resources available to help, to Prevent complications is to find a professional care provider
who understands these immense feelings of sadness, loss, and emptiness who is ready to
support you at this period. Perinatal loss occurs in three different forms depending on the
stage of pregnancy and the cause of the perinatal loss. There are three types of perinatal
loss are: Miscarriage. This is the unintended ending of a pregnancy before 20 weeks of
gestation and it is the most common type of perinatal loss. Intrauterine Fetal Demise (IUFD),
or early stillbirth, this is the type of fetal death that occur between 20 and 27 weeks of
gestation. A late or term stillbirth. This is fetal death that occurred between 28 weeks
gestation and delivery. Perinatal loss occurs in women of all races, ethnicities, ages, and
income levels. In the United States, there are about 24,000 cases of perinatal loss annually.
The most common sign of a problem is vaginal bleeding. Bleeding or spotting, cramping in
your lower abdomen and severe belly pain should be reported immediately to your health
care provider.
Encouragement of pain relief and sedation in care of bereaved parents
A systematic review on hospital care after perinatal death found that pain relief is often
inadequate. Yet, sedation is often over‐prescribed after perinatal loss. A large anonymous
national survey of obstetricians in the United States revealed that 48.5% supported the
prescription of sedatives for a grieving mother in acute bereavement care, despite the lack of
evidence for its benefit in the improvement of sleep or grief. Furthermore, a significant body
of evidence exists about the potential addictive nature of this group of medications. It is
strongly recommended that pharmacological management of grief should only be considered
in the presence of an established psychological disorder for which medication is indicated.
Currently, best practice guidelines recommend that all parents should be offered a choice
about whether or not they want to see and hold their stillborn baby, and that parents should
be supported throughout this process. However, the evidence around the benefit of holding
and seeing remains somewhat controversial, providing no simple directions to guide staff and
parents. There are several negative impacts that follow grieving after pregnancy loss, which
includes the physical and emotional heat that affects the mother, father, or relations. In
care provider.
A controversial study in the UK of mothers with a subsequent pregnancy following a
stillbirth found that seeing and holding a stillborn baby was associated with worse maternal
psychological outcomes. Mothers who saw their stillborn baby were more likely to
experience anxiety in the third trimester of a subsequent pregnancy. By one year postpartum,
anxiety had resolved but PTSD symptoms were higher compared with women who had not
seen their baby. Women who held their stillborn baby were more likely to experience
symptoms of PTSD in the third trimester of a subsequent pregnancy and one year after
delivery, but this was not the case for depression or anxiety. Follow‐up of the mothers at
seven years indicated that higher rates of PTSD symptomatology persisted over time. The
study by Hughes and colleagues has been heavily criticized by both bereaved parents and
researchers who feel that the translation of the study results to all women should be made
with caution due to issues with cohort representation, small sample size and the lack of detail
provided around how women were presented with (the option of seeing or holding) their
stillborn baby. In a study on late stillbirths (greater than 28 weeks gestation), nearly all
mothers who held their stillbirth baby found the experience valuable. Mothers who felt they
had not received enough support from hospital staff to hold their baby were four times more
likely to have not held their stillborn baby when compared with mothers who felt supported.
The importance of perceived staff supports and attitudes in influencing parental decision‐
making about seeing and holding a deceased baby is well documented Anecdotal evidence
suggests that bereaved parents have much appreciated the experience of seeing and holding
their stillborn baby. Women who experienced a stillbirth in the past have repeatedly come
forward in more recent years, expressing their distress about not being allowed to see or hold
their stillborn baby at the time and not knowing what happened to their babies' bodies.
Despite a lack of empirical evidence, research and opinion papers published on this topic
generally agree that holding and seeing a stillborn baby is valuable for most, but not all
women, and that staff should hence be mindful and sensitive to the individual needs and
wishes of each family. There are several negative impacts that follow grieving after
pregnancy loss, which includes the physical and emotional heat that affects the mother,
father, or relations. In addition, finding the right resources for each person is essential to help
navigate this challenging time. Perinatal loss and grief are recognized as traumatic life
events, that can take a longer period (weeks to months) before recovering from the physical
shock. To recover emotionally, may equally take a longer period. In this case the “right way”
to move on after perinatal loss, is to find a suitable support and care that will work best for
parents with the help of their health care providers following perinatal loss. The occurrence
of perinatal loss is one of the most profound events a family can endure because the family
were hoping to receive a baby at the end of the pregnancy, despite all that is done to support
a healthy pregnancy, all the plans have changed and result to perinatal loss which is unfair
and heartbreaking. The next option is to grief, by allowing the parents and everyone
involved to grieve before providing the essential support required to avert complications.
There are many resources available to help, to Prevent complications is to find a professional
care provider who understands these immense feelings of sadness, loss, and emptiness who is
ready to support you at this period. Perinatal loss occurs in three different forms depending
on the stage of pregnancy and the cause of the perinatal loss. There are three types of
perinatal loss are: Miscarriage. This is the unintended ending of a pregnancy before 20 weeks
of gestation and it is the most common type of perinatal loss. Intrauterine Fetal
Demise (IUFD), or early stillbirth, this is the type of fetal death that occur between 20 and 27
weeks of gestation. A late or term stillbirth. This is fetal death that occurred between 28
weeks gestation and delivery. Perinatal loss occurs in women of all races, ethnicities, ages,
and income levels. In the United States, there are about 24,000 cases of perinatal loss
annually. The most common sign of a problem is vaginal bleeding. Bleeding or spotting,
cramping in your lower abdomen and severe belly pain should be reported immediately to
your health care provider.
Encouraging Memory creation by midwives when caring for bereaved parents care.
Activities that support parents in developing a bond with their baby help create a sense of
identity of the child Clinical guidelines support activities such as bathing and dressing the
baby, talking to the baby and using the baby's name, engaging in religious or naming
ceremonies, introducing the baby to extended family, and capturing interactions in
photographs and movies. For many parents, it is the experience of parenting, not mementos,
which is the most valuable in the creation of a bond.
There is general consensus that bereaved parents should be offered items of memorabilia
such as photos, hand/footprints and special clothing or blankets when a baby dies. The
collecting of such items does not appear to lead to adverse grief outcomes and not having
such items has been linked to increased anxiety in mothers of stillborn babies. A meta‐
analysis of hospital care for parents after a perinatal loss found that parents overwhelmingly
appreciated having photos and memorabilia of their deceased baby, and frequently expressed
regret if these were not provided by the hospital. Fathers reported that tokens of
remembrance were invaluable, and were appreciative of staff collecting them, even if they
were decline. There are several negative impacts that follow grieving after pregnancy loss,
which includes the physical and emotional heat that affects the mother, father, or relations. In
care provider.
Social support to bereaved parents
The social environment of the griever has been identified as a significant factor in grief
outcomes, and the role of social support in parental grief has been well documented
(Umphrey, 2011). Qualitative studies demonstrate a correlation between support (from
doctors, nurses and families) and lower levels of anxiety and depression in mothers following
a stillbirth, with family support reported as most significant. Support from partners, family
and those outside the family has been shown to reduce maternal distress in the long‐term (15
months), though not in the short‐term. The role of support groups in perinatal loss is less
clear. A few qualitative studies report a range of important benefits, particularly for women.
Despite the potential value for some mothers however, without well‐designed studies to
measure both qualitative and quantitative outcomes, support groups may not be
recommended for all grieving mothers. There are several negative impacts that follow
grieving after pregnancy loss, which includes the physical and emotional heat that affects the
mother, father, or relations. In addition, finding the right resources for each person is
essential to help navigate this challenging time. Perinatal loss and grief are recognized as
traumatic life events, that can take a longer period (weeks to months) before recovering from
the physical shock. To recover emotionally, may equally take a longer period. In this case the
“right way” to move on after perinatal loss, is to find a suitable support and care that will
work best for parents with the help of their health care providers following perinatal loss.
The occurrence of perinatal loss is one of the most profound events a family can endure
because the family were hoping to receive a baby at the end of the pregnancy, despite all that
is done to support a healthy pregnancy, all the plans have changed and result to perinatal loss
which is unfair and heartbreaking. The next option is to grief, by allowing the parents and
everyone involved to grieve before providing the essential support required to avert
complications. There are many resources available to help, to Prevent complications is to
find a professional care provider who understands these immense feelings of sadness, loss,
and emptiness who is ready to support you at this period. Perinatal loss occurs in three
different forms depending on the stage of pregnancy and the cause of the perinatal loss.
There are three types of perinatal loss are: Miscarriage. This is the unintended ending of a
pregnancy before 20 weeks of gestation and it is the most common type of perinatal loss.
Intrauterine Fetal Demise (IUFD), or early stillbirth, this is the type of fetal death that occur
between 20 and 27 weeks of gestation. A late or term stillbirth. This is fetal death that
occurred between 28 weeks gestation and delivery. Perinatal loss occurs in women of all
races, ethnicities, ages, and income levels. In the United States, there are about 24,000 cases
of perinatal loss annually. The most common sign of a problem is vaginal bleeding. Bleeding
or spotting, cramping in your lower abdomen and severe belly pain should be reported
immediately to your health care provider.
Midwives encourage culturally sensitive care when caring for bereaved parents
The importance of recognizing the cultural perspective of loss and grief is well supported in
the adult loss and grief literature (Butler & Niemeyer, 2012). However, only limited attempts
have been made to explore the cultural context of perinatal loss. Seminars in Fetal and
Neonatal Medicine published a series of discussion papers on cultural perspectives of care in
fetal and neonatal medicine. They conclude the importance of sensitive cultural approaches
and encourage further research in this area of perinatal care. Others caution imposing a
‘Western grief culture’ which values engagement with death and grief onto other cultures.
Staff's knowledge and understanding of key religious and cultural rituals can greatly facilitate
difficult discussions and decision‐making around the time of death of a baby. There are
several negative impacts that follow grieving after pregnancy loss, which includes the
physical and emotional heat that affects the mother, father, or relations. In addition, finding
the right resources for each person is essential to help navigate this challenging time.
Counselling and psychotherapy for parents following perinatal loss
No robust studies have been undertaken in the area of perinatal loss to determine the effect of
grief counselling or psychotherapy on parental grief. A recent systematic review of 61
controlled outcome studies of grief counselling in the general bereaved population over the
last three decades found only small observed advantages in treated clients compared to
untreated controls, effects which are lost over time. Authors conclude that universally applied
bereavement interventions do not achieve measurable benefit when compared with ‘no
treatment’ groups, and the majority of grievers experiencing ‘normal’ grief will adapt to their
loss or respond resiliently. This is in contrast to high‐risk groups such as parents who have
lessor grievers with significant symptomatology, such as those with complicated grief or
clinical depression, who do receive benefit. The task for primary clinicians in the area of
parental bereavement will be to identify parents who are at increased risk of pathological
grief, and who would benefit from referral to mental health services. There are several
negative impacts that follow grieving after pregnancy loss, which includes the physical and
emotional heat that affects the mother, father, or relations. In addition, finding the right
resources for each person is essential to help navigate this challenging time. Perinatal loss
and grief are recognized as traumatic life events, that can take a longer period (weeks to
months) before recovering from the physical shock. To recover emotionally, may equally
take a longer period. In this case the “right way” to move on after perinatal loss, is to find a
suitable support and care that will work best for parents with the help of their health care
providers following perinatal loss. The occurrence of perinatal loss is one of the most
There is no doubt that compassionate, sensitive care is invaluable for bereaved parents and
families. The importance of appropriate psychosocial support for all women and families
globally was recently highlighted in a comprehensive international stillbirth series published

in the Lancet in 2011. Yet, what continues to pose difficulties for those attempting to provide
perinatal bereavement support is exactly what it is that comprises 'best practice', particularly
in relation to psychosocial care. We undertook this review to identify evidence from high
quality randomized controlled trials, looking at optimal approaches for supporting parents
and families experiencing perinatal death. There are several negative impacts that follow
grieving after pregnancy loss, which includes the physical and emotional heat that affects the
mother, father, or relations. In addition, finding the right resources for each person is
essential to help navigate this challenging time. Perinatal loss and grief are recognized as
traumatic life events, that can take a longer period (weeks to months) before recovering from
the physical shock. To recover emotionally, may equally take a longer period. In this case the
“right way” to move on after perinatal loss, is to find a suitable support and care that will
work best for parents with the help of their health care providers following perinatal loss.
The occurrence of perinatal loss is one of the most profound events a family can endure
because the family were hoping to receive a baby at the end of the pregnancy, despite all that
is done to support a healthy pregnancy, all the plans have changed and result to perinatal loss
which is unfair and heartbreaking. The next option is to grief, by allowing the parents and
everyone involved to grieve before providing the essential support required to avert
complications. There are many resources available to help, to Prevent complications is to
find a professional care provider who understands these immense feelings of sadness, loss,
and emptiness who is ready to support you at this period. Perinatal loss occurs in three
different forms depending on the stage of pregnancy and the cause of the perinatal loss.
There are three types of perinatal loss are: Miscarriage. This is the unintended ending of a
pregnancy before 20 weeks of gestation and it is the most common type of perinatal loss.
Intrauterine Fetal Demise (IUFD), or early stillbirth, this is the type of fetal death that occur
between 20 and 27 weeks of gestation. A late or term stillbirth. This is fetal death that
occurred between 28 weeks gestation and delivery. Perinatal loss occurs in women of all
races, ethnicities, ages, and income levels. In the United States, there are about 24,000 cases
of perinatal loss annually. The most common sign of a problem is vaginal bleeding. Bleeding
or spotting, cramping in your lower abdomen and severe belly pain should be reported
immediately to your health care provider.
Types of interventions used to provide psychological wellbeing for bereaved parents
It refers to any type of intervention provided by professional or non‐professional individuals
or groups which is aimed at improving the psychological well‐being of parents and families
after perinatal death. These may include any form of:
 general supportive hospital interventions aimed at supporting parents around the
time of their baby's death. This may include parent information provision after a
stillbirth diagnosis or diagnosis of fetal abnormality, photographs and other
memorabilia, holding and naming the baby, offering dignified funeral rites or
disposal arrangements for stillbirths, and hospital follow‐up visits;
 specific religious, spiritual and/or cultural supports;
 interventions labelled as bereavement counselling;
 specialized psychotherapy, counselling, or assessment, either single or multiple
sessions or therapeutic episodes;

 interventions for women with a previous perinatal death in the subsequent
pregnancy;
 community and online support groups.
Component of Midwives Supportive Attitude of Care
The roles of midwives to a bereaved parents following subsequent postnatal loss
It is the duty of the midwives to help the family start a normal grief reaction by letting the
family members know that a grieving process is a normal reaction or feeling one who lost a
child will react and the midwives should meet their needs at the moment by reassuring them
that in no distant time, they will conceive and bear one that will stay with them. Midwives
should assess when the parents are in their mourning process and then adjust and encourage
them with words of encouragement
Bereavement counselling should be a part of the midwives’ training because of a situation
like this. It will enhance and restore hope to the bereaved. In this situation the best beneficial
aspect of this grieving process is that the midwives should offer a non-judgmental deep sense
care and also involve them in their care to encourage them.
Midwives provide care that will help the mother recognize that she has given birth despite
that she is no longer with her baby, Myles (2014) in the case of perinatal loo midwives
should be able to assist mother to regain control over the loss.
 Bereaved parents value compassionate relationship with midwives.
 Self-awareness and connecting emotionally with parents are care components in
creating a safe relational space.
 Compassionate relationships are deeply influenced by effective communication and
quality information.
 Quality bereavement care and quality initiatives are more likely to be effective and
sustainable when delivered within a compassionate relationship
Follow Up Care to bereaved parents
 Ensure women are aware that they will pass lochia after birth and are aware of the
normal and abnormal lochia and when to report to the midwife or seek for medical
aid.
 Inform women about options on how to manage lactation including pharmacological
and non-pharmacological methods.
 Provide counseling and support parents following their bereavement.
The Reactions of Parents Following Perinatal Loss
All the women, grief over their loss because said they were looking forward to having their
baby at the end of the pregnancy but it turned to be a sad new to them and their families.
Women described how they felt when they miscarried or loss their neonates.
I was filled with sorrow because I was expecting something good, I was eagerly waiting, and
I was also happy that I would have a baby. I was heart-broken…I become depressed
especially when I see other peoples' children, but I try to encourage myself to think that it
happens. perinatal loss is a traumatic experience because it thwarts expectations; the hoped
for, planned for, and anticipated child were not seen or nurtured.
Some women related their emotional distress to the work involved in a pregnancy, and also
view the work as having been in vain: I was depressed because I labored in vain, I felt very
sorry and bad for myself because it was as if I had worked and labored for nothing. Women'
explanations of the possible causes of perinatal loss Some women attributed their baby's
death to external factors, which includes blaming other people for the loss. While some
women suspected that their husbands were promiscuous and that their behavior had
significantly contributed to their perinatal loss. I think I had a miscarriage because of the
sexually transmitted infection my husband passed on to me. According to local
interpretations, affairs can lead to pregnancy problems including miscarriages or stillbirths.
One participant attributed the loss to a relative with evil intensions who she suspected
bewitched her: Someone who is my mother's relation did not want me to give a normal birth;
she wanted me to die during delivery More common was attribution of loss to medical
procedures, and blaming health practitioners for the death while some mentioned a medical
procedure of inserting tubes into their babies' noses during oxygen therapy as having
contributed to their neonates' deaths, some women blamed it on the nurses' negligence, and in
the words of one: I think it is the nurse's negligence because if she had attended to me a way
could have been found to save my baby, either through an operation or widen the way for the
baby to come out as it was done for my second born Perinatal death has been identified as a
risk factor for relationship break‐down Gold and colleagues found that stillbirth increased the
risk of parental separation by 40% (adjusted Hazard Ratio (aHR) 1.40; 95% confidence
interval (CI) 1.10 to 1.79). Similarly, Starrs (2014) found that women who had experienced
stillbirth had a significantly increased risk of divorce post‐loss (Odds ratio (OR) 1.70; P <
0.05), Another study found that for couples with a previous stillbirth, the risk of relationship
breakdown was fourfold compared with couples with no history of stillbirth (OR 4.3; 95% CI
1.6 to 12.0). However, this study did not control for important relationship factors, which
may partly explain the larger effect of stillbirth on the risk of relationship breakdown (Starrs,
2014).
Perceived partner support after the death of a loved one is well known to be a significant
protective factor against lasting grief and distress). Couples who share and communicate
their grief report less severe grief reactions and greater partner satisfaction. This suggests that
congruent grieving within couples leads to better relationship outcomes and conversely, that
incongruent grief could result in relationship problems. A small, unique study investigated
this concept and found that emotional exchange between parents was reflected by concordant
grieving in which levels of suffering, depression and anxiety as well as processes of post‐
traumatic growth were shared by parents. In contrast, parents with disconcordant grief were
also disconcordant in suffering, depression and anxiety and did not share post‐traumatic
growth. Separate, independent experiences of grief, suffering and post‐traumatic growth are
likely to negatively impact relationship dynamics and satisfaction and may even result in
separation). Based on the concept of grief concordance, it is not surprising that despite
intensified relationship stress, some couples indicate that their loss has “brought them closer
together” increasing the relationship cohesion).
Negative psychological symptoms after the bereavement: bereaved parents demonstrated
high rates of anxiety, depression, social phobia, suicidal ideation and post-traumatic stress
disorder. Some parents, particularly fathers, also reported increased substance misuse. Some
mothers reported a complex change in perception of their own body after stillbirth, many
citing their body’s “failure” and their embarrassment about their postpartum body shape in
the absence of a baby.

Disenfranchised grief: parents felt that their grief was not legitimized and that their identity
as parents was not acknowledged by society.
Feelings of regret about decisions made in the immediate aftermath of stillbirth: many
parents who had not spent time with or held their stillborn baby expressed regrets about their
decisions. Others reported conflicting emotions about their decisions surrounding
postmortem consent and highlighted the significant influence of healthcare providers in these
decisions.
Relationship difficulties: many bereaved couples reported separation or divorce following
stillbirth, often citing discordant grieving patterns between the mother and father of the baby
as the source of the difficulties. In some cases, this was associated with anger, infidelity and
domestic violence. Conversely, some couples stated that their shared experience of loss had
brought them closer.
Altered social behavior: some bereaved parents demonstrated avoidance of activities that
could bring them into contact with babies, children or anything that they associated with their
own loss, leading to social isolation.
Stigmatization, rejection and abuse: this was reported by women in the majority of LMIC
represented in the study. Women frequently described being blamed for the death of the
baby, with the stillbirth sometimes being portrayed as divine or supernatural retribution for
sins or crimes committed by the mother. Some were abandoned by their partner, physically
abused, forced to return to work immediately after the birth or ostracized by the entire
community.
Employment and financial problems: particularly in fathers in LMIC, the costs incurred
through hospital care and funeral expenses led to financial instability, debt and exacerbation
of family tensions. On their return to work, bereaved mothers were more likely to take
extended sick leave than those with live children, and some reported feeling isolated and
unwanted.
Therapeutic activities: some bereaved parents altered their activities as part of a coping
strategy following stillbirth, including voluntary social isolation and altered interest in
religious and sexual activity. Physical exercise and increased engagement with social media,
which was regarded as a forum that facilitated free discussion of parents’ experiences, were
generally viewed as beneficial.
Effect on subsequent pregnancies: many parents experienced persistent psychosocial
problems during subsequent pregnancies, including intense anxiety, panic attacks, constant
fear of recurrent stillbirth and inability to participate in antenatal classes. Some parents also
reported chronic pain, chronic fatigue and withdrawal from or distrust of healthcare services
in their subsequent pregnancies.
The review identified several factors that negatively influenced parents’ psychological state
following stillbirth, including delay in induction of labor after the stillbirth was diagnosed;
not seeing or holding the stillborn baby; ambiguity of burial arrangements; insensitive
treatment by healthcare providers; and lack of a good social and family support network.
Counseling, psychological treatment and sensitive support from staff involved in
bereavement care were reported as positive factors.

Negative psychological effect on Fathers after perinatal loss: When a baby dies, mothers
generally report more severe and enduring grief than fathers. However, the more active
parenting role of today's fathers is likely to impact on grief intensity. Increased prenatal
attachment associated with modern obstetric practices, such as prenatal diagnostic
procedures, assisted reproduction and graphic ultrasound imaging, has been reported to
increase the intensity of mothers' grief. It is therefore reasonable to expect that fathers too
may experience more intense grief with increasing attachment.
Research indicates both similar and distinctly different grief responses in mothers and fathers
after perinatal death. A review of the effects of perinatal death on fathers identified common
themes in paternal and maternal grief such as shock, anger, emptiness, helplessness and
loneliness. Feelings of guilt were frequently reported by mothers but were rarely reported by
men. Although findings on maternal and paternal responses to perinatal death are relatively
consistent across studies and provide useful information, studies tend to lack statistical power
and design quality. Hence, well‐designed studies which take a more systematic approach to
identifying affective and behavioral responses that are specific to mothers and fathers are
needed.
Perinatal Loss
Perinatal loss also termed perinatal mortality is the number of fetus that died in-utero that
occur in the first week of life (WHO, 2019). Others include miscarriage or abortion and
neonatal deaths that occur up to 28 days after birth. Meredith et al. (2017), more than 6.3
million cases of perinatal losses occur globally annually based on estimation, majority of
deaths which occur in low- and middle-income countries (Ibrahim et al., 2016). Peudal et al.
(2018), this occurrence is placing a big burden on health systems and conditions of some
families globally. Clossicks (2016) and Kalu et al. (2018) opined that prenatally, bereaved
mothers and fathers react differently to their losses and mothers are believed to be highly on
increased risk of severe grief after experiencing perinatal loss than fathers. Starrs (2015)
noted that about 2.7 million babies died through stillbirth globally.
In some countries like Asia, death is viewed as a taboo and their behavior towards
bereavement are strongly influenced by the principles of Confucianism and Buddhism which
teach the importance of deaths especially among men, the principle states that men are not to
cry or experience negative emotion outside their family or homes, with this the bereaved
person always feels ashamed to show the importance of formal training to deal with their
perinatal bereavement care. Midwives are told to care for the bereaved parents and their
families that are affected by these bad or tragic events, which are stressful. The midwives are
expected to interact and relate with these families in a supportive manner whether they feel
adequately prepared or not. It is also the responsibility of the midwives to talk to the
bereaved through a key person could be an older or elderly person or a respectable person in
their community or in the bereaved family with this approach, a positive outcome will be
achieved.
Some hospitals have developed perinatal bereavement support groups in which staff educate,
teach, counsel and support bereaved parents. The duty or role of this group formed is to
provide adequate support and care to bereaved couples which will facilitate or provide quick
recovery as they go through the process of grief. Meanwhile, study has revealed that hospital-
based bereavement support services focus mainly on sorrow and harm reduction for bereaved
families.
Types of Perinatal Losses
There are three types of perinatal losses.
1. Miscarriage
2. Intrauterine fetal death
3. stillbirth
The Causes of Perinatal Losses
There are various causes of perinatal losses. This can be grouped as antenatal, intra-natal and
postnatal causes.
Trauma during pregnancy accounts for 30.5% perinatal loss.
 Low birth weight result to 23.9% perinatal losses.
 -Hemorrhage which could be antepartum or postpartum leads to 13.7% of perinatal
losses.
 Toxemia in pregnancy count for 10.3% perinatal loss.
 Congenital malformation causes 4.3% perinatal losses while the unknown causes results
to 10% perinatal and immediate child delivery losses. Caring for women facing
bereavement often takes a significant toll on the psychological wellbeing of midwives
and it can also cause stress and anxiety for midwives caring for bereaved parents
according to the experiences reported by the midwives (Wallbank & Robertson, 2013).
The feeling of midwives who is involved in the care of bereaved parents are often
ignored or inadequately dealt with, which result in hay lasting problems (Puia et al.,
2013). Midwives are to form close relationship with woman during pregnancy, birth and
postpartum, as a result this, it plays a significant role in providing emotional support to
woman and families following perinatal loss (Wallbank & Robertson, 2013). It is well
recognized in the literature that the quality of the relationship between the midwife and
the woman is central to the quality of care provided during pregnancy, childbirth and the
postnatal period (Downe et al., 2014). Within this unique relationship with their midwife,
women highlight the importance of an emotional connection, trust, presence, empathy
and being valued as a unique person (Froen et al., 2013). Sadly, not all pregnancies result
in the birth of a live baby. However, the presence of quality relational care, which is
embedded in maternity care, remains particularly crucial when caring for parents who
experience a perinatal death.
The essence of compassionate relational care after perinatal loss
Compassionate relationships are core elements in creating a safe relational space for the
provision of quality clinical and perinatal bereavement care. Bereaved parents' journeys
through the maternity services may be greatly influenced, either positively or negatively, by
the quality of the relationships that emerge between them and each health professional they
encounter. Froen et al. (2016) describe compassion as ‘a skilled interpersonal and relational
process’. Embracing a relational approach to bereavement care requires a compassionate
relationship to develop between the individual worlds of the caring midwife and the wounded
parents. This unique relationship is epitomized by kindness, openness, trust, dignity, mutual
respect, collaborative care, sensitive and honest communication, consistent and accurate
information, guidance, and support (Annamma, 2016). The unwavering presence of this
relationship creates a unique shared, relational space where the bereaved parents and the
midwife emotionally connect and collaborate. Within this space, the midwife relates with
sensitivity, is open to meet with the parents' experience in a meaningful way, and is
emotionally present with them in supporting and bearing witness to their unique grieving
journey.
Self-reflection: To create and share in this unique relational space with bereaved parents and
their families, the midwife must embark on a journey of continuous self-reflection. Each
midwife's unique life story, attitudes, values, experiences and commitment will influence his
or her behaviors, either negatively or positively. Ultimately, it will shape the quality of
relationships with bereaved families and colleagues and the quality of care provided. Self-
reflection enables midwives to explore their emotions and experiences. It highlights the
individual's strengths and limitations, and the insight gained may necessitate that the midwife
adapts his or her attitudes and behaviours in order to enhance the quality of the approach in
relating to bereaved parents. Following a baby's death, the midwife's approach in relating to
bereaved parents remains deeply etched in parents' memories. Midwives who are self-aware
are empowered to create a relational space where parents experience a sense of belonging, a
genuine acknowledgement of the magnitude of their baby's death and their overwhelming
grief, together with a compassionate response to their needs and preferences. In the midst of
the parents' profound grief, possessing positive memories of the relationships that were
created with midwives and the care that was provided enables them to store those meaningful
memories, provides comfort, and ultimately shapes their onward grieving journey (Downe et
al., 2013). For parents who experience early miscarriage, the focus of care is often on
physical needs, with less emphasis on the relational aspect of care. Midwives should be
constantly mindful of creating positive relationships with parents, by acknowledging their
miscarriage, communicating sensitively and effectively, providing support, quality

information and choices, and engaging them in decision-making Studies suggest that the
presence of a compassionate relationship eases the woman's grief following miscarriage and
has a positive influence on how she negotiates her grieving journey.
Creating a safe relational space: When parents receive the news that their baby has died or
is dying, it is usually unexpected and often results in significant shock, profound grief, fear,
and uncertainty. In an instant, their lives have totally changed. The safe relational space that
is created becomes a crucial stable and healing sanctuary in sustaining or ‘holding’ bereaved
parents as they are bombarded with unexpected, unfamiliar and unwelcome feelings.
Creating and maintaining a safe relational space is greatly influenced by the midwife's
attitude and behavior, along with his or her willingness and capacity to be emotionally
present with parents.
Midwives become emotionally present in the bereaved parents' world when they intentionally
allow themselves to be guided, not by care plans or pathways, but by their inherent
humanness and compassion. In revealing these valued qualities, midwives are empowered to
be openhearted, mindful, gentle, respectful and supportive of parents in their overwhelming
sadness and vulnerability. They are also in harmony with and focused on the parents' unique
needs, preferences and concerns. The midwife's emotional presence offers the parents a
human connection to guide them to some sense of stability amid the temporary chaos they
are experiencing. Initially, parents require a safe relational space to enable them to grasp the
enormity of the news they have just received; subsequently, they need a safe space to be
present with their baby, their families and friends, to tell their story, share their grief and
begin their journey of processing the thoughts and emotions that emerge. It is within this
space that midwives will deliver consistent, high-quality and safe clinical care, together with
sensitive and collaborative bereavement care. Bereavement care initiatives—for example,
care plans or guidelines, which are necessary components in the provision of quality perinatal
bereavement care—will only be truly effective when delivered in the presence of a
compassionate relationship; if delivered in isolation, they are merely viewed as tasks that
must be completed. The significance of emotional presence is highlighted in a study
conducted by Kelly and Trinidad (2012), where bereaved parents reported that during their
entire journey in the maternity services, the most profound aspect of care occurred when staff
assigned time to sit, emotionally connect and be fully present with the parents in their
grief. Lawn et al. (2016) reported in their study that parents valued staff who validated their
experience by relating with humanness, listened to their story, supported their wishes, and
acknowledged and respected the worth of their baby's life and the significance of their baby's
death. In connecting emotionally and being fully present with vulnerable parents, the
midwife assumes the role of a true advocate and remains a constant companion as parents
meet with the numerous difficult decisions and challenges ahead, such as induction of labour,
labour itself and the birth of their baby. The midwife's consistent openness, compassionate
presence and empathetic attitude and behavior will enable this safe relational space to be
maintained with the bereaved family. The process of creating and maintaining compassionate
relationships with parents involves vital strands of care being woven together.
The process of creating and maintaining compassionate relationships is a continuous journey
of self-reflection by the midwife it involves the following: Creating a safe relational space;
emotional connection with parents; empathetic attitudes and behaviors, Establishing quality
relationships between colleagues and among other health-care teams, Maintaining effective
communication with and between parents, colleagues and multidisciplinary teams in the
hospital and the community, Providing quality information that flows smoothly between the
bereaved family and all health-care teams, and Quality relationships between colleagues and
teams.
Quality relational care is dependent on a network of relationships. It embraces the
establishment of quality relationships between colleagues, and within and between
multidisciplinary teams in the hospital and the community. The presence of quality
relationships ensures effective communication between teams, encourages collaboration and
transparency, nurtures mutual respect and support.
Effective Communication when Caring for Bereaved Parents
Communicating effectively is also fundamental in maintaining relational care, as the quality
of the relationship established between health-care providers and bereaved parents is
inevitably linked to the quality of communication that flows between them. Effective
communication actively includes parents in all aspects of their own and their baby's care; it
should be a continuous process and evident throughout their care. It is particularly crucial in
conveying bad news, acknowledging and validating parents' thoughts and emotions,
identifying their needs, preferences and concerns, obtaining and sharing information with and
between parents, colleagues and teams, offering choices, collaborating in decision-making,
obtaining informed consent, and for safe practice.
In the midst of their grief, parents may find it difficult to hear and/or understand the
information that is being conveyed to them; therefore, the midwife should sit with them and
communicate in a calm, caring tone of voice. Information should be delivered slowly, in
small chunks, and the midwife should check frequently to elicit the parents' understanding.
Be prepared to repeat information and use supportive written information. If appropriate, it
may be worth considering the use of diagrams to aid understanding, and avoid using medical
terminology. The midwife's body language should convey openness and kindness, attitudes
should be caring and respectful, and behaviors gentle and compassionate during every
episode of communication. Actively listen to the parents' story, use a caring touch if
appropriate and respect cultural, spiritual and religious values. The use of open-ended
questions—for example, ‘What are your feelings about labour/birth?’—will enable parents to
express their thoughts and feelings and encourage them to engage in the communication
process.
When their baby dies, parents are likely to desperately search for answers, information,
reassurance, guidance and support. Questions they have may include: Why did our baby die?
What tests will be done? Should we tell our other children? Communicating quality
information sensitively and honestly creates trust and realistic expectations, and offers
parents some sense of control. This is essential in offering parents’ choice and empowering
them in decision-making concerning their own and their baby's care. Insensitive,
inconsistent, incorrect and outdated information tends to add to parents' distress, so the
midwife must ensure that the information he or she delivers is sensitive, accurate, current,
consistent, timely, relevant, concise, clear and complete. To enable parents to reach informed
decisions, it is imperative that they are allowed sufficient time to process the information
they receive; to ask questions, consider options, change their minds or clarify any lingering
concerns e.g., in relation to burial arrangements or postmortem examination. Quality

information should flow smoothly between health professionals and the bereaved family, and
between colleagues and health-care teams in the hospital, across hospitals and into the
community setting. Evidence of both effective and poor communication processes between
health professionals and bereaved parents is evident in the literature. In a study by Downe et
al. (2013) some bereaved women recounted practices and attitudes that they perceived as
helpful, such as staff being conscientious and compassionate in every episode of
communication, while other women experienced care that was devoid of an emotional
connection and communication and reported that information was insensitive, insufficient
and inconsistent. A study by Radesta et al. (2014) showed that effective listening,
acknowledgement of the parents' concerns, and collaborative decision-making were deemed
‘essential aspects of care by bereaved parents but were sometimes absent, which led to
concerns being dismissed.
The reciprocal influence of providing relational care
Because a baby's death is viewed as particularly heartbreaking, bearing witness to the
parents’ profound grief can have a considerable emotional impact on health professionals.
There is evidence to suggest that the presence of meaningful relationships not only provides
support for parents but also has a positive reciprocal influence in supporting health
professionals to cope with their own grief (Avelin et al., 2011). Relational care has the
potential to be both enriching and fulfilling for the midwife. The most satisfying aspects of
care reported by midwives were being allowed time to establish a meaningful relationship
with parents and knowing they had positively influenced the parents' grieving journey. Other
studies have found that, although midwives experienced caring for bereaved families as
challenging, they genuinely valued the emotional connection they shared with parents.
Effect of Bereaved Care On Midwives
A daily challenge for all health professionals is to deliver and sustain compassionate
relational care. The hospital culture in relation to perinatal bereavement care is greatly
influenced by existing practices, attitudes, behaviors, values and priorities. It is essential that
organizations and hospital systems support and nurture midwives, along with other health
professionals, to create an environment where an open, consistent and compassionate
hospital culture is visible and relational care is valued and encouraged. The presence of such
a culture will help to ensure bereaved families' needs become the central focus of care. The
process of creating and maintaining compassionate relationships with parents involves vital
strands of care being gently woven together to embrace and comfort bereaved parents and
positively shape their grieving journey. Evidence strongly suggests that bereaved parents
value meaningful relationships with their midwife. These perceptions greatly influence their
assessment of the quality of the overall care they receive. Midwives have an integral role in
initiating and maintaining compassionate relational care. At the heart of relational care is the
creation of a shared relational space where the midwife communicates to parents a readiness
to emotionally connect and collaborate with them as they begin their journey of coping with
the enormity of their baby's death. The absence of an emotional connection leads to missed
opportunities to explore the parents' needs, their overwhelming sadness, their genuine fears
and profound vulnerability.There is evidence that the presence of meaningful relationships
not only provides support for parents but also has a reciprocal influence in supporting health
professionals to cope with their own grief (Ben-Ezra, et al., 2014).

Insensitive care that is devoid of a connection or relationship between the midwife and
bereaved parents can create an impediment in the family's grieving journey. Negative intense
emotions associated with insensitive care often persist unabated and dominate a space in the
parent's mind, which rightfully should be a space to grieve and remember their baby. A
commitment by midwives to create and maintain a compassionate, safe relational space with
parents, will not abolish the profound anguish that the parents experience, but it may temper
their grief and create positive memories that will become part of their deceased baby's
narrative and flow forward with them on their grieving journey.
What is Miscarriage or Abortion?
Miscarriage or abortion can be defined as the loss of a baby or fetus before the 20th week
of pregnancy. The medical term for a miscarriage is spontaneous abortion. Research has
shown that as many as 50% of all pregnancies end in abortion; it occurs most often before a
woman misses a menstrual period or even notice that they’re pregnant. About 15%-25% of
recognized pregnancies always end in a miscarriage or abortion (Blackmore et al., 2011).
More than 80% of abortions happen within the first trimester of pregnancy. Abortions are
less likely to occur after 20 weeks. When abortion occur within 20 weeks; it is called late
miscarriages.
Types Abortions
There are different types of Abortions:

Threatened Abortion: In the type of abortion there is bleeding and the pregnancy is
threatened, but the cervix hasn’t dilated. The pregnancy will likely progress to term without
any problems.
Inevitable Abortion: This type of abortion bleeding and cramping is present, cervix is
dilated. Abortion is likely.
Incomplete Abortion: This type of abortion that occur and there is some retain product of
conception in the uterus.
Complete Abortion: when this type of abortion occur all the product of conception will
flush out there will be no ruminant in the uterus. This type usually occurs before the 12th
week of the pregnancy.
Missed Abortion: This type the embryo dies or was never formed, but the product of
conception is seen in the uterus. Recurrent miscarriage or Abortion. This is the type of
abortion that occur when three or more pregnancies is been loss in a row during the first
trimester. This type of abortion only affects about 1% of couples trying to have a baby.
Causes Abortion and Risk Factors Associated to It
Most Abortion occur due to the unborn baby has fatal genetic problems.
Other problems that can increase the risk of miscarriage include:
 Infection
 Medical conditions like a mother that has diabetic induced, or thyroid disease
 Hormonal imbalance
 Immune system responses

 Physical problems in the mother
 Uterine abnormalities
 Smoking
 alcoholic mother
 Mother Using over the counter drugs
 Exposure to radiation or toxic substances
A woman that has a higher risk of abortion are:
1. Are over age 35
2. Have certain diseases, such as diabetes or thyroid problems
3. Fibroid
4. Have had three or more abortions
Cervical insufficiency: This occurs due the weakness of the cervix. It means that the cervix
cannot hold the pregnancy to term. This type usually happens in the second trimester of the
pregnancy.
Some of the symptoms that occur due to cervical insufficiency are.
 Feeling of sudden pressure
 Breakage of water
Escape of tissue from the baby and placenta could occur without much pain. Doctors usually
treat an insufficient cervix with a "circling" stitch in the next pregnancy, usually around 12
weeks. The stitch holds your cervix closed and the pregnancy will be intact until term and the
doctor removes it for delivery to occur. If you have not experienced abortion before but it
was observed that you have cervical insufficiency, the stitch is use to prevent it from
occurring.
Prevention of Abortion
Most abortion occur because there’s a problem with the pregnancy. The following can help
prevent abortion: Treat any symptom or illness, it can improve your chances for a successful
pregnancy. One step you can take is to get as healthy as you can before you try to have a
baby:
Do regular exercise.
 Eat a healthy, well-balanced and adequate diet.
 Maintain a healthy weight.
 Avoid infections.
 Don’t smoke, drink alcohol, or take illegal drugs.
 Cut back on caffeine.
Treatments of Abortion
At least 85% of women who have miscarriages have subsequent normal pregnancies and
births. Having a miscarriage does not necessarily mean you have a fertility problem. On the
other hand, about 1-2% of women may have repeated miscarriages (three or more). Some
researchers believe this is related to an autoimmune response.

If the miscarriage is complete and your uterus is empty, you probably would not need further
treatment. Sometimes all the tissue does not come out. If that happens, your doctor might do
a dilation and curettage (D&C) the procedure is carried out by dilating the cervix and
remove all the left over in the uterus and medications like oxytocin can be used to move the
remaining retain products in the uterus. This may be a better option if you want to avoid
surgery. In a stillbirth, indication of labor can be use to induce labour and delivered the dead
baby. There is what is called incompetent cervix which occurs when the cervix is dilated but
the pregnancy is still intact ,Your doctor might do a procedure to close it called cerclage , if
the reason for the abortion is Rh negative, a blood product called Rh immune globulin
(Rhogam) can be given to prevents it from occurring because This prevents you from
developing antibodies that could harm your baby or any future pregnancies. You can get
pregnant after a miscarriage. At least 85% of women who have one go on to have normal
pregnancies and births. Having a miscarriage doesn’t mean you have a fertility problem. On
the other hand, about 1%-2% of women may have had repeated miscarriages up to (three or
more). If you have had two miscarriages in a row, you should stop trying to conceive, use a
form of birth control, and ask your doctor to do tests to find out the cause of the miscarriages.
Midwives’ Supportive Attitude When Trying To Conceive After an Abortion
Besides the physical effects, you may also feel a range of emotions, from sadness and guilt
to grief and worry about future pregnancies. Talk to people in your life who are supportive
like your partner, a friend, or family member. One can also talk to a professional mental
health counselor. Pregnancy loss support groups may also be a valuable resource to you and
your partner. Ask the doctor for more information about these resources. And remember that
everyone heals at a different pace and in different ways. Discuss the timing of one’s next
pregnancy with your midwife and doctor. Some experts say you should wait a certain amount
of time (from one menstrual cycle to 3 months) before you try again. To prevent another
miscarriage, the doctor may suggest treatment with progesterone, a hormone that helps the
embryo implant and supports early pregnancy in your uterus. Taking time to heal both
physically and emotionally after a miscarriage is important. Above all, don't blame
yourself. Counseling is available to help you handle your loss.
The causes of perinatal loss
The following are the major causes of perinatal loss: -
 Trauma during pregnancy count for 30.5% perinatal loss.
 Low birth weight result to 23.9% perinatal losses.
 Hemorrhage which could be antepartum or postpartum leads to 13.7% of perinatal
losses.
 Toxemia in pregnancy count for 10.3% perinatal loss.
 Congenital malformation causes 4.3% perinatal losses while the unknown causes
results to 10% perinatal and immediate child delivery losses.
Caring for women facing bereavement often takes a significant toll on the psychological
wellbeing of midwives and it can also cause stress and anxiety for midwives caring for
bereaved parents according to the experiences reported by the midwives (Wallbank &
Robertson, 2013). The feeling of midwives who is involved in the care of bereaved parents
are often ignored or inadequately dealt with, which result in hay lasting problems (Puia et al.,
2013). Midwives are to form close relationship with woman during pregnancy, birth and
postpartum, as a result this, it plays a significant role in providing emotional support to
woman and families following perinatal loss (Wallbank and Robertson, 2013).
Grief Reactions after pregnancy loss
Grief is a natural non pathological phenomenon; it can result to complicated grief where
symptoms are more disruptive, pervasive in long-lasting than in a normal grief response. It is
a deeply personal process which include temporary impairment of day-to-day function,
retreat from social activities, intrusive thought, and feeling of bad and numbness which can
continue for a long period of time. This is especially likely if the death has occurred in
sudden, violent, or traumatic way. Kerstin et al. (2011) revealed that in normal grieving,
negative grief indicators such as disbelief, yearning, and anger and depression peak within
approximately 6 months of loss. Lee (2012) found a similar grief process in a study that
looked specifically at bereaved parents after pregnancy loss. Adjustment after bereavement
has been empirically shown to occur through a sequence of stages in a longitudinal study of
bereaved individuals. In Lee (2012), grief scores were initially relatively high and declined
most steeply over the first year. In 2 years follow up their evaluation of the grief process
showed an interesting result. Whilst 41% of participants showed a normal decline of grief
scores, the remaining 59% showed different pattern of pervasive presence or delayed
resolution of grief, but self-blame may prolong grief.

2.2 Theoretical Framework
Ronald Lippitt theory on Change in Attitude was used to underpin the study. The theory has
its constructs divided into phases.
Phase 1: Developing a need for change; diagnosing the problem
 The creation of problem awareness and a strong feeling in the client for a
need for change.
 Recognizing the existence of any communication blockages between client
and practitioner
 The creation of at least some confidence within the client that their situation
can move to a more desirable state and tackling defeatist beliefs
 The client has to be helped to believe that external help or the practitioner’s
help is relevant and available and linked to that working with the client to
resolve resistance to help from outside/by the practitioner – the client may
see this is a failing on their part for not being able to resolve change to a
positive outcome themselves for instance. There could also be cultural or
social foundations for resistance we need to be aware of.
Phase 2: Change relationship; assessing motivation and capacity for care
This phase may reveal or generate problems for the client:
 in communicating their need for help with change in a way that the
practitioner understands and accepts or
 by the client needing to assess the validity of the practitioner’s assessment
and ability to help

Lippitt argues that one of the crucial features of this phase is the way that the client starts to
think about working relationship with the practitioner, the first impression they have of the
practitioner. Reassuring the client and using a friendly and open way of communicating with
them that is not authoritative is important. This includes the client’s attitude towards and
opinion of career guidance/counselling and your position within the organization if your
work is within a school environment for instance. Building trust is important in this phase.
Moreover, the client may not be sure about the process and may expect relatively ‘quick and
easy solutions’ offered by the practitioner. We need to help the client create realistic
expectations.
Phase 3: Clarification; diagnosing the client system’s problem.
 In this phase, the client often needs to cope with a broader and more
involved diagnosis of the problem and the consequential change, according
to Lippitt. As a result, the client may come to think that their problem is too
complex to be resolved and change may not happen or may be too difficult.
 Another client response Lippitt identified is of the client becoming hostile
and uncooperative, closing down communication with the practitioner or
denying the working relationship information to work with.
Lippitt argues that it usually comes down to helping the client strike a balance between
helpless dependency on ‘outside help’ and defeatism or hostile rejection of ‘the diagnoses.
Phase 4: Establishing alternative routes.

The client starts translating ‘the diagnoses into possible routes forward. Alternative routes
forward are discussed between client and practitioner.
 Motivation is important in choosing alternative solutions and making a
decision as to which one would be best. Commitment requires an emotional
and material/practical investment and the client will make assessments as to
the resources that are required, which will affect motivation positively or
negatively (feeling overwhelmed for instance).
 There is a realization that old habits and practices will need to be given up.
This may result in a tendency in the client to retract back to known habits
and practices or this may cause anxiety or fear of failure.
Phase 5: Transforming intentions into actual efforts to change.
So far, success is measured by the extent to which plans and intentions are translated into
actual action for change or achievements. Lippitt doesn’t seem to have a lot to say about this
phase that is of use to us in a career context other than that the practitioner may not be able to
see the efforts for change in the environment the client has to apply them.
Getting feedback on the consequences (or effects) of the change process may be difficult, he
also argues, which may cause the client to discontinue their efforts to implement or continue
implementing the changes agreed upon. I feel this is far less likely in the working
relationships we work within and with the clients we support.
Phase 6: Stabilizing change.

Lippitt rightly claims that one critical factor in the stabilization of change is that of the spread
or ‘non-spread’ of the changes to ‘neighboring systems or subsystems’, which can be
translated to whether the changes are integrated within the client’s framework of habits and
whether their surroundings support maintaining the change. Here, if we stick to Lippitt’s
work, he does not have a lot to say about the individual client and the one-to-one working
relationship we have with them. His work is more focused on organizational change.
Phase 7: Terminal relationship
Lippitt claims that the client’s dependency on the practitioner is a major issue when
terminating the relationship. I agree that this may be an issue in counselling and other
relationships where there has been an intense and longer-term working relationship between
the client and the practitioner, this may be a real issue. I can’t speak for anyone else but in
my practice, most of the time the working relationship is short in nature. This is in no small
part because of how career guidance is perceived and funded in England, promoting short
term interventions with a focus on (if some agents had their way) employability and the
economy at large, rather than longer term career management.
Another issue at the end of our working relationship is the question of whether the client has
integrated the techniques and behaviors to implement and sustain change enough to ensure
their long-term viability. At the end of the working relationship, we need to make sure that
we fully understand how far and how well change behaviors and thinking has been
integrated within the client’s natural thinking and behavior. We also need to act if this is not
the case, postponing the point of termination of the working relationship.
Application of the theory
Lippitt’s theory of change is based on the concept of an external agent creating change
through careful planning. The Nursing Informatics explains that in nursing the care team
becomes the external agent affecting change through designing and implementing care plans
for patients. The Canadian Journal of Nursing Informatics also describes seven stages of
Lippitt’s theory of change in detail, and at each stage, the nursing team and its actions are
central to the overall outcome for the patient.
The first-stage process is diagnosing the problem, carried out by a senior midwife, and the
results are then passed on to the affected bereaved parents. Motivation is then assessed, both
in terms of the midwives. The midwives aim to discover whether there is any opposition to
their understanding of the way forward to render care to this client, this is the second stage.
The third stage involves checking that the front-line staff, which is the midwives, who
actually affect the change by given adequate care to the bereaved parents, are able to do so,
and the supportive care they rendered were able to effectively created the desired change
required. The plan is then put in writing, and the roles of everyone involved are clearly
defined. The process is monitored to ensure it is working; in the case of midwives, this stage
involves the bereaved parent’s health improving. The final stage of the process involves
terminating the relationship once the desi red change has been affected.
2.3 Empirical Review
Starrs (2014) opined that Normal parental grief reactions immediately following perinatal
death have been well documented. Profound sadness, depressed mood, irritability,
preoccupation, anxiety, anorexia and insomnia are all considered to be part of a normal grief
response. Symptoms of acute grief typically subside with time and for most people the
intensity has significantly reduced by six to 12 months post‐loss, Symptoms of acute grief
typically subside with time and for most people the intensity has significantly reduced by six
to 12 months post‐loss. When midwives are caring for women with a perinatal loss, the
support they receive when caring for women and the impact this experience might have on
them as midwives of the future. There is limited research exploring student midwives'
experiences in dealing with bereavement and the availability of training and support to help
develop the skills needed to be most effective.
Downe et al. (2012) provided parents with information, enabling them to be actively
involved in decision making of their care and it is also a way of relieving anxiety, and
assisting parents to gain control and become active participants in decision making
concerning their care. Some 52 studies conducted, 40 articles related to parents’ experiences
and 14 healthcare workers which had experienced stillbirth care. The study was carried out
using questionnaire, interview and focus group studies and it was analyzed using qualitative
methods and statistics, the size varied from 1 to 2631 participants, the parent’s studies were
conducted across eight countries while the staff studies over five countries. It was also
observed that behaviours and actions of staff can create a memorable impact on parents
during perinatal grief and continuity of care is important to parents at this period while
midwives should support parents to express their concern.

Kelly and Trinidad (2012) emotional support and acknowledging the birth and death of a
baby is an important part of bereavement cares which makes midwives feel that is important
to support parents’ emotional reactions and grief responses, at this period while midwives
should support parents to express their concern.
Gravensteen et al. (2012) noted that student midwives may be left to deal with negative
feelings by themselves, and may be given very little opportunity to work through and
acknowledge the grief they may be experiencing. A phenomenological study, using diaries
and interview data, indicated that student midwives were not confident in their ability to
communicate properly with grieving parents. For example, students reported being so
overcome with emotion that they were unable to support parents. Often, students believed
that they needed support as much as the affected family. Student midwives' experience of
caring for bereaved families resulted in feelings of distress, guilt and anxiety regarding their
competence to offer appropriate care. The student midwives' experience of bereavement care
was strongly related to training and to the support they received from senior staff in the
clinical area. However, the study also indicated that many students received only minimal
training in caring for parents following bereavement, with a limited focus on personal
coping.
Lee (2012) opined that grief recovery on perinatal death' has been reported to last up to five
to 18 years. When midwives are caring for women with a perinatal loss, the support they
receive when caring for women and the impact this experience might have on them as
midwives of the future. There is limited research exploring student midwives' experiences in
dealing with bereavement and the availability of training and support to help develop the
skills needed to be most effective. Normal parental grief reactions immediately following
perinatal death have been well documented and resemble those in other bereavement
situations (e.g., after the death of a spouse). Profound sadness, depressed mood, irritability,
preoccupation, anxiety and changes in eating and in sleeping patterns are all considered to be
part of a normal grief response). Pathological responses to bereavement include
bereavement‐related major depression, post‐traumatic stress disorder (PTSD) and
complicated grief and it is not uncommon that these conditions co ‐occur in bereaved
individuals. Pathological grief responses are more likely to occur in patients with a pre‐
existing mental health diagnosis. Although the majority of bereaved parents will experience
normal grief, bereaved parents have been repeatedly identified to be at increased risk of
complicated Persisting and significant grief‐related problems may be more prevalent in a
subset of parents.
Puia et al. (2013) stated that continuity of care is important for staff to make out time and
stay with parents to enhance relationships and build rapport found that recently bereaved
mothers who had a termination of pregnancy (TOP) for fetal abnormalities, were
significantly more likely than controls to suffer from a range of psychiatric disorders for up
to 14 months after their loss). In this cohort, acute stress disorders such as PTSD, were
mostly resolved at 14 months post‐loss, while anxiety and affective disorders were the most
common diagnoses at the 14‐month point. Post‐traumatic stress has also been reported in the
subsequent pregnancy following perinatal death. Although a clinical diagnosis of PTSD was
not made, one study) reported that 20% of women fulfilled the criteria of PTSD during a
pregnancy following stillbirth, compared with the general PTSD population incidence of 5%
to 10%). One year postpartum, however (i.e., following the birth of a healthy baby), both
current and lifetime PTSD rates in these women had decreased to around 5%, similar to
population levels. At seven‐year follow‐up, there were no longer significant differences in -
summary) were used to extract findings and calculate frequency effect sizes (FES%) for each
theme, a measure of the prevalence of that finding in the included studies. Researchers’ areas
of interest may influence reporting of findings in the literature and result in higher FES
PTSD and major depression between bereaved mothers and controls. Four thousand four
hundred eighty-eight abstracts were identified; 52 studies were eligible for inclusion.
Synthesis and quantitative aggregation (meta sizes, such as; support memory making (53 %)
and fathers have different needs (18 %). Other parental findings were more unexpected;
Parents want increased public awareness (20 %) and for stillbirth care to be prioritized (5 %).
Parental findings highlighted lessons for staff; prepare parents for vaginal
birth (23 %), discuss concerns (13 %), give options & time (20 %), privacy not
abandonment (30 %), tailored post-mortem discussions (20 %) and post-natal
information (30 %). Parental and staff findings were often related; behaviours and actions of
staff have a memorable impact on parents (53 %) whilst staff described emotional,
knowledge and system-based barriers to providing effective care (100 %). Parents reported
distress being caused by midwives hiding behind ‘doing’ and ritualizing guidelines whilst
staff described distancing themselves from parents and focusing on tasks as coping strategies.
Parents and staff both identified the need for improved training (parents 25 % & staff
57 %); continuity of care (parents 15 % & staff 36 %); supportive systems &
structures (parents 50 %); and clear care pathways (parents 5 %). Parents’ and healthcare
workers’ experiences of stillbirth can inform training, improve the provision of care and
highlight areas for future research. Bereavement care is one of the psychosocial cares all the
midwives should possess as a responsibility for a quality care to be achieved.

Wallbank & Robertson (2013) stated that the mean knowledge score was 6.31 out of 10. Of
all participants, 47% recently cared for couples with miscarriage, and the majority (97%)
indicated a key role for midwives’ supportive attitude of care to those couples. Lack of time,
incapability and fear of being overwhelmed by their own feelings were identified as main
barriers for psychosocial support. Knowledge was more often evaluated as adequate when
miscarriage was included in the midwifery education (31% vs. 17.3%, χ 2 = 12.965, df = 1,
p<0.001). Midwives trained for the topic ‘miscarriage’ more often valued their role in
miscarriage care (98.8% vs. 94.1%, χ 2 = 11.002, df = 1, p = 0.001). They considered
themselves being more capable to provide adequate psychosocial support when feeling
sufficiently trained in communicative skills (77.7% vs. 33.8%, χ 2 = 96.574, df = 1, p<0.001).
The majority (72.4%) indicated a lack of knowledge regarding miscarriage. Almost 89%
expressed a need for extra training. Previous studies indicate that health professionals often
develop coping strategies to manage emotionally challenging situations at work, particularly
when coping with death and bereavement. Studies have shown that student midwives may
be left to deal with feelings by themselves, and may be given very little—if any—
opportunity to work through and acknowledge the grief they may be experiencing. They
included the whole medical staff; the remaining ones focused only on some healthcare
professionals, in most cases midwives and/or nurses. The literature analysis showed a slight
change over time in studies’ both aims and criteria. Older studies were mostly descriptive
and concerned the experiences of healthcare professionals, without addressing policies aimed
at preventing and/or mitigating the trauma: the need for a vocational training on perinatal loss
was the only notable exception. Since the 2000s, articles often acknowledged healthcare
professionals’ need for support and sharing painful experience.

Farrow et al. (2013) conducted a qualitative study Obstetricians (N=335) Ad hoc
questionnaire about emotional responses 53.7% of obstetricians reported grief, 17.2% self-
doubt, 16.9% depression, and 16.4% self-blame. Older age, solo practice, higher volume
practices, and higher proportion of Medicaid patients are found to be associated with
psychological impact.
Kain (2013) conducted a qualitative study on Nurses (N=24) Focus groups about nurses’
beliefs, perceptions, and experiences Grief and distress, sadness, and dilemmas. Needs for
maintaining treatment boundaries (familiarity and trust) within the nurse patient
relationships, for acknowledging nurses’ grief and sadness in order to alleviate many of the
dilemmas.included the whole medical staff; the remaining ones focused only on some
healthcare professionals, in most cases midwives and/or nurses. The literature analysis
showed a slight change over time in studies’ both aims and criteria. Older studies were
mostly descriptive and concerned the experiences of healthcare professionals, without
addressing policies aimed at preventing and/or mitigating the trauma: the need for a
vocational training on perinatal loss was the only notable exception. Since the 2000s, articles
often acknowledged healthcare professionals’ need for support and sharing painful
experience. In perinatal loss, a randomized controlled investigation which effects of support
following perinatal loss was done. The experimental group, comprising 25 bereaved mothers
received ideal supportive midwifery care was done together with counseling.
Flenady et al. (2014) examined the midwives view caring for bereaved parents as rewarding
because it helps midwives to provide support and give information required to care for the
bereaved parents. Systematic review and meta-summary of 144 studies from 25 countries,
including 129 from high-income countries (HIC) and 15 from low- and middle-income
countries (LMIC). Quantitative, qualitative and mixed-methods studies that investigated at
least one potential psychosocial effect of stillbirth on bereaved parents or extended families
were eligible for inclusion. 23 key themes were identified and frequency effect size (FES)
was calculated for each, as a measure of prevalence in the included literature.
Redesta et al. (2014) stated that staff action and attitudes have a huge influence on parents’
decision-making and ability to cope with the ugly event. behaviours and actions of midwives
have a memorable impact on parents, about 53% whist staff described emotional, knowledge
and system-based barriers that prevents from providing 100% effective care. Midwives
described distancing themselves from parents and focus on the tasks as coping strategies.
About 25% of parents and 57% staff identified the need for improved training on bereaved
care. The narrative review on support after a perinatal death highlighted the need for further
high‐quality research in this area. Over time, an abundance of studies has been conducted in
the area of perinatal loss, leading to the development of clinical practice guidelines and the
widespread development and implementation of a range of support interventions. Common
interventions described in the literature include a wide range of medical and psychosocial
interventions, provided in both the antenatal and postnatal period. According to Mckenna &
Rolls who opined that midwives find caring for bereaved families stressful and emotionally
challenging, with many experiencing difficulties with this area of practice, feeling
unprepared due to a lack of support and training. Their psychological involvement in
perinatal loss is a largely overlooked, subject by healthcare systems, scientific research and
prevention policies. A systematic scientific review has been carried out about emotional
experiences, attributed meanings and needs conveyed by healthcare professionals in relation
to perinatal loss. We identified 213 studies between 1985 and 2015, 20 of which were
included in the present study for qualitative analysis. Our results point out the need for a
targeted vocational training in perinatal loss, enabling healthcare professionals to achieve a
proper management of their own internal states.
Ben-Ezra et al. (2014) observed higher levels of PTSD, depressive and psychosomatic
symptoms in nurses exposed to perinatal loss. Age and workload might have an influence on
healthcare professionals’ psychological response: some authors observed a direct correlation
between vulnerability to stress, age, and multiple experiences of perinatal loss Ben-Ezra et al
(2014) According to WHO, “Perinatal mortality rate (PMR) can be defined as the number of
late fetal deaths which occur within 28 week of gestation or more, including early neonatal
deaths which may occur (1st week) in a given year per 1000 live births in that same year.
Gandino et al. (2014) reported that 73 parental bereaving, instilling a sense of self-efficacy
and self-assurance. Some authors reported symptoms of burnout syndrome, characterized by
irritability and psychosomatic disorders. Salutogenic model in maternity care, Salutogenic
theory suggests the role of professionals involved in health promotion is to provide options
that enable people to make sound choices about their health while increasing awareness of
determinants of health and enabling choices to be expended. Through a process of problem-
solving, identification of both internal and external resources for resistance and of a
collective sense of coherence (comprehensibility, manageability and meaningfulness),
salutogenic theory promotes and enhances positive states in an individual's health. This
respectful and comprehensive care should include the newborn and not end with death;
dignified maternal and newborn care matters to grieving parents the provision of care for
families when a child is stillborn is vitally important to prevent short and long-term negative
outcome Current care for bereaved parents after a baby dies is inconsistent and parents are
more likely to develop prolonged psychological problems if professional support is not given
Bereaved parents have been identified as a high-risk group for complicated grief with up to
25 % suffering severe symptoms years after the death of their baby . The support received by
the mother following the death of her child was the single most important factor in predicting
the nature of the grief process that she would experience. Midwives find caring for bereaved
families stressful and emotionally challenging, with many experiencing difficulties in this
area of practice feeling unprepared due to a lack of essential experience support and training
While women and their families interpret the experience of stillbirth as the birth and death of
a baby and a major family tragedy, hospital staff appear to view it as a clinical problem. This
mismatch of focusing on ‘clinical’ rather than ‘personal’ care appeared to cause distress to
parents. Despite the impact stillbirth has on both parents and staff, it remains an area in
which most obstetricians and midwives receive little or no training and 31 % of those who
received training said it was inadequate. A survey of over 2000 UK staff found that one third
of respondents reported unsatisfactory training to counsel parents about investigations after
stillbirth.
Flenady et al. (2014) conducted a study in compliance with PRISMA—Preferred Reporting
Items for Systematic Reviews and Meta-Analyses—guidelines for search, systematization,
and report of systematic reviews. with a combination of the following keywords: (1)
stillbirth, perinatal loss, perinatal grief, perinatal death, with (2) staff distress, physician grief,
obstetrician, healthcare professionals, burnout, . The eligibility of each article was
independently assessed by two authors. Progressive exclusion was performed starting from
the title, then the abstract and finally the full text. Including criteria for articles eligibility
were as follows: (1) publication within the given time interval (1985–2015), (2) publication
in English, (3) publication in peer-reviewed journals, and (4) focus on healthcare
professionals’ inner experience. We opted for publications in English, rather than in our own
mother tongue, due to the vast amount of international literature available. Our choice was
additionally motivated by the general lack of Italian studies pertaining to our focus and our
goal to conduct a deep, comprehensive analysis. With regard to criterion 4, we chose to
include only papers pertaining to the effects of perinatal loss exposure on healthcare
professionals, in terms of mental states, personal experiences, attribution of meanings and
emotional impact. Database searches resulted in a total of 31,666 articles, 627 of which were
in compliance with the eligibility criteria, based on title and abstract evaluation. Duplicate
removal resulted in a total of 213 articles. 193 were excluded based on full text evaluation
(Figure 1) for compliance with criterion 4. In fact, they were focused on parental bereaving,
specific customs or support groups for couples who suffered a perinatal loss (22); they
assessed the quality and quantity of care delivered by healthcare professionals to the parents
and their own fulfillment in terms of care’s effectiveness and general well-being (12); they
analyzed the features of decision making related to preterm birth, focusing on parents’ and
healthcare professionals’ responsibilities inside neonatal intensive care units (13); they
assessed the effectiveness of different therapies employed in neonatal end-of-life care,
including palliative ones (13); they investigated disorders, diseases, and infections pre- and
post-partum and available treatments (28); they focused on entirely different subjects (e.g.
risk factors for perinatal loss, infant health practices, infertility, preterm birth, impact of
newborn infants on the family system, disorders and risk factors in adolescence) and were
too heterogeneous to be grouped in macro-categories (104); and finally one article was
withdrawn from publication, because of major overlaps with previous publications from the
same authors (1). The remaining 20 articles have undergone qualitative analysis—see Figure
1 for the PRISMA flow diagram. Data analysis Duplicate removal resulted in a total of 213
articles. Full-text analysis was conducted independently by two judges in order to identify
works relevant to our focus. Any discrepancy regarding the inclusion/exclusions of papers
was discussed. When an agreement could not be reached, a third judge was consulted. Meta-
analysis based on the 20 identified studies was deemed unsuitable, given the high
methodological variability, the type and size of samples employed, and the instruments used.
Results Qualitative analysis was carried out considering aims, methodologies employed, and
results. Detailed information for each article is displayed in Two articles concerned
theoretical considerations, while 18 were original experimental studies regarding healthcare
professionals. Sampling for each study was performed from nurses (9),
obstetricians/physicians (5), nurses/midwives (2), and 68 Journal of Health Psychology 24(1)
every healthcare professional involved in perinatal loss (2). A total of 10 focused on the
psychological impact of perinatal loss, 5 centered on the attitudes toward perinatal loss, and 3
investigated needs and coping strategies connected to perinatal loss. Samples employed in
the 18 experimental studies varied greatly in terms of size, from a minimum of 8 to a
maximum of 804 subjects Summary of included studies. Methodology Sample Measures
Impact, needs, coping, anxiety and lack of experience, knowledge, communication skills,
needs for increased knowledge and support for a sensitive care of bereaved parents.
Blackmore et al (2016) examined women grief a lot after miscarriage and more than half of
the women grief after pregnancy loss and it has been reported that excessive grief eliciting
causes psychological distress while most women manifested anxiety and depression and the
benefits of social support by midwives are widely reported as a healing element for women
after pregnancy loss and death of a child. Parents with perinatal loss needs
psychotherapeutically oriented care and counseling, in a bereaved mother the support may
last for just one month or more. Achieving balance between compassionate, According to
WHO, “Perinatal mortality rate (PMR) can be defined as the number of late fetal deaths
which occur within 28 week of gestation or more, including early neonatal deaths which may
occur (1st week) in a given year per 1000 live births in that same year opined, Conversely,
inadequate care might exacerbate an already difficult grief thereby hindering the parents’
process of healing. An estimated 2.6million third trimester stillbirths occurred worldwide in
2015, of which 98 percent occurred in low-income and middle-income countries Lawn et al.
(2016). Parents usually experience shock, frustration, rage, feelings of emptiness and
loneliness, possibly leading to short- an Introduction Miscarriage, stillbirth or neonatal death
occurring a few days after delivery is an extremely complex and painful event, which
strongly impacts expecting parents, as well as neonatal/ gynecological units’ routine. The
heterogeneity of definitions and classifications of perinatal loss in each legislation system
makes it difficult to analyze and compare different countries. Epidemiological data show
how common perinatal loss still is: since the new millennium, the rate of miscarriages and
stillbirths has been diminishing much slower than both maternal and child (aged 5 or less)
mortality rates
Lawn et al. (2016) noted that 2.7 million babies were stillborn in 2015 worldwide. In the UK,
3286 babies were stillborn in 2013 approximately 10 bereaved families every day. The
experiences of bereaved parents were recognized in a series of papers in the Lancet as key to
bringing about change. The 2011 series identified stillbirth as one of the “most shamefully
neglected” areas of public health and recommended improving interactions between families
and frontline caregivers and made a play for increased investment in relevant research. The
series emphasized that the enduring economic, psychological and social costs of stillbirth
which need to be addressed, not only by prevention of still birth, but also by improvements
in care for bereaved families. Midwives find caring for bereaved families stressful and
emotionally challenging, with many experiencing difficulties in this area of practice feeling
unprepared due to a lack of essential experience support and training While women and their
families interpret the experience of stillbirth as the birth and death of a baby and a major
family tragedy, hospital staff appear to view it as a clinical problem. This mismatch of
focusing on ‘clinical’ rather than ‘personal’ care appeared to cause distress to parents

Despite the impact stillbirth has on both parents and staff, it remains an area in which most
obstetricians and midwives receive little or no training and 31 % of those who received
training said it was inadequate. A survey of over 2000 UK staff found that one third of
respondents reported unsatisfactory training to counsel parents about investigations after
stillbirth the Cochrane Collaboration published a systematic review of the support available
for parents and their families following perinatal death of the three trials identified for
potential inclusion in the review all were excluded because of the high loss-to-follow-up rate.
Therefore, no judgment could be made on the advantages or disadvantages of certain
behaviors or management currently used in bereavement care. As a result, the review authors
recommended other study designs should be used to inform practice. No previous research
has systematically analyzed the available evidence on parents’ views on the experience of
going through a stillbirth, or key healthcare workers experiences of caring for couples
dealing with a stillbirth. This systematic review aimed to assess the current available
evidence, extract findings and highlight key themes that may help to guide midwifery and
medical management, training of key healthcare workers and development of support
services dealing with bereaved parents in the future. Bereavement care, as described by
families in the ten reports, was not consistently individualized or respectful, resulting in
additional feelings of anger and upset. Problems with clear communication of complex
issues, in a manner that is understandable to bereaved families, were identified in several
reports. Recommendations from the inquiry reports included that experienced and skilled
staff should always be available to provide immediate support to bereaved families as
appropriate, and assist families in understanding and processing information Conclusions and
implications for practice are consistent, individualized bereavement care facilitates a
seamless transition for bereaved families from diagnosis through the hospital stay to
discharge and follow-up, allowing them to focus on their baby, their bereavement and their
family's wellbeing. The process of consent for a perinatal post-mortem and associated
concerns has evolved over the timeframe of the ten inquiries. We reflect further on this and
the impacts of the other issues highlighted, as well as discussing possible improvements to
address them as described in the scientific literature. A systematic scientific review has been
carried out about emotional experiences, attributed meanings and needs conveyed by
healthcare professionals in relation to perinatal loss.
2.4 Summary of Literature Review
The WHO (2019) perinatal death can be defined as the death of a baby between 22weeks of
gestation to 7 days after birth.. Perinatal loss includes the period when a mother experiences
abortion or miscarriage, an ectopic pregnancy, a stillbirth or the death of a child few weeks
after birth. The midwives’ supportive attitude is the way by which the midwives rendered
help to reduce stress in a mother who is a victim of perinatal loss. supporting her will make
her feel accepted and respected, while reassuring her shows sign of care and it will make her
and the family to communicate freely and share their experiences and feelings. In this period
of grief, the midwives should support the bereaved parents by encouraging and teaching them
on how to cope with their present condition by doing this negative effect that might arise will
be prevented and also the occurrence of depression which might lead to mental illness due to
perinatal loss will be averted. Majority of the reviewed empirical studies were conducted
outside Africa, therefore presents a knowledge gap to be filled by this study.

CHAPTER THREE
METHODOLOGY
This chapter discussed the research methods under the following subheadings, Research
design, Study area, Population of the study, Sample and Sampling Techniques, Source of
Data, Method of Data Collection/Instrumentation, Validity and Reliability of Instruments,
Method of Data Analysis, and Ethical approval.
3.1 Research Design
Descriptive survey was used for the study. The descriptive survey allows for the use of
questionnaire and checklist to collect data without any manipulation or alteration. It is
suitable for study of midwives who cared for parents who have experienced perinatal losses
in one way or the other. The descriptive survey research design allows the study of a group of
people by using few people as a representative of the entire group to analyzed data.
3.2 Study Area
The study area is Aba, the commercial nerve center of Abia State, in south-eastern region of
Nigeria. Aba metropolis is made up of five local Governments namely; Aba south, Aba north,
Osisioma, Ugwunagbo and Obingwa. In 2016, the estimated population of Aba was
2,534,265. The two hospitals used for this research study are General Hospital and Cottage
Hospital all located in Aba.
3.3 Population of the Study
The study population is all the midwives that are working in prenatal, intrapartum and post-
natal units of the two selected hospitals and all midwives who are present in the prenatal,
intrapartum and post-natal units of selected hospitals. The number of the midwives are 95
which is the study population

3.3.1 Inclusion Criterion
1. Midwives working in antenatal, prenatal, intranatal and postnatal unit including
parents in the antenatal, prenatal, intranatal and postnatal unit of the selected
hospitals.
3.3.2 Exclusion Criteria
1. Nurses working in other wards of the hospital.
2. Parents admitted in others wards of the two selected hospitals.
3.4 Sample Size and Sampling Techniques
Sample size
The census sample size of 95 was used which comprises of midwives practicing in antenatal,
prenatal, intrapartum and postnatal units. The sample for the study involved midwives from
Cottage Hospital (n = 28) and Abia State Teaching Hospital (n = 67).
Sampling Techniques
Multi-stage sampling technique was adopted, giving each hospital equal chance of being
selected. In determining the sample size several stages or steps was adopted in collection
At first stage: at this stage the researcher wrote list of government hospitals in Aba, Abia
State for easy selection of the two suitable hospitals used for the study.
At second stage: simple random sampling through a balloting was used to select the two
hospitals used from the city. The names of the government hospitals in Aba was written and
presented to some individuals to pick for easy and objective selection of the two hospitals
used for the study.

At third stage: census sampling was utilized in selecting midwives practicing in prenatal,
intrapartum and postnatal units from each of the hospitals that were selected for the study.
3.5 Method of Data Collection/Instrumentation
It is the researcher-designed structured questionnaire and the questionnaire was arranged in
sections (A-C) based on the topic and the researcher passed experienced on perinatal care,
helped the researcher to be able to structure the questions used to construct the questionnaire.
The researcher-structured questionnaire was used for data collection.
In order to get a concrete result, the researcher personally administer the instrument directly
to the on the wards and outpatient clinics. The researcher was able to collect duly completed
questionnaire on each day of administration on while the research assistant collected the
remaining ones at a later date. The data collection lasted for a period of three weeks all duly
completed questionnaires were assessed and those inappropriately completed was recorded as
invalid. The questionnaire used for data analyzes were stored and locked up in a cupboard for
two months after analyzing the date before discarding it, by burning for confidentiality.
3.6 Validity and Reliability of the Instrument
Validity: validity indicates whether a test actually measures what it set to measure (Ebong
et al., 2015) the instrument was validated by the researcher’s supervisor, and other experts in
the school of Public Health and Toxicological Research, Africa Centre of Excellence,
University of Port Harcourt. The observations of the supervisors and the experts was adopted
and incorporated in the final assembling and draft of the instruments. Explain face and
content validity
Reliability: The reliability of the instrument was established using the test-retest method.
The first 10 copies of the instruments were administered to a population with similar attribute
in the study population at two weeks interval was distributed to a smaller group of the study.
After an interval of 14 days, the same pilot respondents were allowed to give responses again
using the questionnaire. The two sets of data were analyzed using Pearson correlation. A
reliability index of 0.91 was obtained, therefore the instrument was considered reliable.
3.9. Method of Data Analysis
Data collective were coded in a spreadsheet. The coded data were analyzed using descriptive
statistics (bar charts, frequencies and percentages) and inferential statistics such as Chi
square for test the hypothesis at a 5% level of significance.
3.10 Ethical Approval
The ethical approval was sought and obtained from the University of Port Harcourt’s Ethics
and Research Committee and the two areas of study; General Hospital and Cottage Hospital
all in Aba were given approval for data collection. Prior to the commencement of data
collection, the purpose of the study was explained to all the midwives, working in those
selected units and assured them that it is strictly for academic purpose only, written and
verbal consents were obtained from participant and authority of the hospitals all the
necessary assurance given to the participant about the privacy and confidentiality of all
information obtained from them were adhered to the participant and also informed them that
they have the choice to continue with or withdraw from the study , no penalty or charge was
attached to the choices made. This study was only carried out upon due ethical clearance
from the relevant authorities and the study respondents. Explain privacy, anonymity and
confidentiality. How will the questionnaire be stored? When will it be discarded?

CHAPTER FOUR
RESULTS AND DISCUSSION OF FINDINGS
This chapter presented results data analyses and a discussion of the findings
4.1 Result Presentation
4.1.1 Socio-demographic characteristics
A total number of 95 questionnaires were issued out by the researcher to the respondents in
the two selected hospitals for the study.
Table 4.1: Socio-demographic profile of the respondents, N = 95
Categories F %
Gender/Sex
Male 41 43.2
Female 54 56.8
Age in years
18-25 22 23.2
26-33 28 29.5
34-41 32 33.7
42-49 13 13.7
Midwifery experience in years
1-10 31 32.6
11-20 33 34.7
21-30 21 22.1
31-40 10 10.5
Marital status
Married 43 45.3
Single 45 47.4
Divorce 7 7.4
Religion
Christianity 78 82.1
Islam 12 12.6
Others 5 5.3
f = frequency, % = percentage
Research Question 1: What are support attitude towards parents following intra-natal loss
experience?
Table 4.2: The supportive attitude of midwives to parents following intrapartum loss, N = 95
Options SA A U D SD
Midwives give parent time to 52.6% 22.1% 15.8% 5.2% 4.2%
grieve. 50 21 15 5 4
All those involve in the care of 55.8% 22.1% 13.7% 6.3% 3.2%
bereaved parent are informed 53 21 13 6 3
by midwives following intra-
natal loss
Midwives allow parent hold 50.5% 31.6% 10.5% 4.2% 3.2%

and touch the deceased child. 43 30 10 4 3
Midwives comfort parent with 68.4% 15.8% 10.5% 4.2% 3.2%

words of hope and 65 12 10 4 3
encouragement.
Midwives provide advice on 73.7% 10.5% 5.3% 5.3% 5.3%

how to go about laying the 70 10 5 5 5
child to rest.
SA = strongly agree, A = agree, U = undecided, D = disagree, SD = strongly disagree
Research Question 2: What are the supportive attitudes of midwives to parents following
immediate postnatal loss experience?

Options SA A U D SD
Midwives communicating with 69.4% 25.3% 3.3% 1.0% 1.0%
parent in a clear, sensitive and 66 24 3 1 1
honest manner.
Midwives can provide grief 52.6% 27.4% 10.5% 5.3% 4.2%

caring program to provide 50 26 10 5 4
psychological support to the
bereaved parent.
Increased workload prevents 74.8% 15.8% 5.3% 3.2% 1.0%

adequate midwives’ care. 71 15 5 3 1
Midwives blame one another 71.6% 15.8% 7.4% 3.2% 2.0%

following immediate post-natal 68 15 7 3 2
loss.
Shortage or inadequate 51.6% 32.6% 10.5% 3.2% 2.1%

manpower prevents rendering 49 31 10 3 2
supportive care following post-
natal care.
Table 4.3: The supportive attitude of midwives towards parents following immediate post-
natal loss, N = 95
Research Question 3: What is the midwives’ support attitude towards parents through the
following postnatal period?

Table 4.4: The supportive attitude of midwives to parents following subsequent postnatal
loss, N = 95
Options SA A U D SD
Increased workload prevents 68.4% 15.8% 10.5% 3.2% 2.1%
adequate supportive care of 65 15 10 3 2
midwives to parents care
Shortage or inadequate manpower 73.7% 10.4% 5.3% 5.3% 5.3%

prevents midwives rendering 70 10 5 5 5
optimum care to parent
Inadequate facility prevents 52.6% 22.1% 15.8% 5.3% 4.2%

adequate midwives care 50 21 15 5 4
Midwives counsel parent from 55.8% 22.1% 13.7% 6.3% 3.1%

experience guilty feeling 53 21 13 6 3
following postnatal loss.
Midwives experience difficulties 50.5% 31.6% 10.5% 4.2% 3.2%

in caring for parents following 48 30 10 4 3
perinatal loss.
Research Question 4: What is the influence of midwives’ support attitude on parents’
reaction to perinatal loss?

Figure 4.1 summarized midwives report on influence of midwives’ support attitude on
parents’ reaction to perinatal loss.
How much influence do you (Midwife) think

your supportive attitude had on the parents
coping following perinatal death?
70
60 58.9% (n = 56)
50
40
30
24.2% (n = 23)
20
14.7 (n = 14)
10
2.1% (n = 2)
0
Not at all Very little influence Some influence Very large influence
Figure 4.1: midwives report on influence of midwives’ support attitude on parents’ reaction
to perinatal loss, N = 95
4.2 Test of Hypotheses
4.2.1 Hypothesis 1: There is no significant difference between midwives’ supportive attitude
to parents following intrapartum and postnatal loss.
Table 4.5 tested the null hypotheses at a 5% level of significance using the Chi square
inferential statistical tool.
Table 4.5: Chi square test of goodness of fit between midwives’ supportive attitude to
parents following intrapartum and postnatal loss, N = 95
Chi
squar p
Intrapartum Postnatal df e value
Options SA A U D SD SA A U D SD 36 53.57 0.029
Midwives 66 24 3 1 1 53 21 13 6 3
communicating with
parent in a clear,
sensitive and honest
manner.
Midwives can provide 50 26 10 5 4 48 30 10 4 3

grief caring program to
provide psychological
support to the bereaved
parent
.
Increased workload 71 15 5 3 1 50 21 15 5 4
prevents adequate
midwives’ care.
Midwives blame one 68 15 7 3 2 65 15 10 3 2

another following
immediate post-natal
loss.
Shortage or inadequate 49 31 10 3 2 70 10 5 5 5
manpower prevents
rendering supportive
care following post-natal
care.
p value < 0.05 = significant, df = degree of freedom, SA = strongly agree, A = agree, U =
undecided, D = disagree, SD = strongly disagree,
4.2.2 Hypothesis 2: There is no significant association between midwives’ support attitude
and parental reaction to perinatal losses.
Table 4.6 tested the null hypotheses at a 5% level of significance using the Chi square
inferential statistical tool.
Table 4.6: Chi square test of association between midwives’ support attitude and parental
reaction to perinatal losses, N = 95
Midwives’ supportive attitude df Chi p
square value
Report on Consistent irregular Inconsistent 6 29.27 <0.001
influence on
parents coping
Not At All 0 0 2
Very Little 1 3 19
Some 26 5 25
Very Large 11 3 0
df = degree of freedom, p value < 0.05 = significant

4.3 Discussion of Findings
For socio-demographic profile of the respondents, Table 4.1 revealed that Sex/gender
distribution of the respondents indicate that 41 males and 54 females representing 43.2% and
56.8% respectively, were involved in the study. The results show that females are more than
the male respondents. Age distribution of the respondents indicated that persons between the
ages of 18 to 25 years are 28 (23.2%), those between the ages of 26 to 33 years are 22
(29.5%). Again, the numbers of persons between the ages of 34 to 41 years are 32 (33.7%)
and those above 45 years of age are 13 (13.7%). The result indicates that those between the
ages of 26 to 33 had the highest number. For years of experience, the results indicate that
respondent (midwives) with between 1 to 10 years of working experience are 31 (32.6%),
those who have worked between 11 to 20 years are 33 (34.7%), while those between 21 to 30
years are 21 (22.1%). However, those who have worked between 31 to 40 years are 10
(10.5%) persons. The analysis indicate that majority of the respondents have adequate
experience in hospital settings. This means that they understand the work conditions of the
hospital and thus are suitable for the study. For marital status, the results indicate that
midwives who are married are 43 (45.3%), those that are single are 45 (47.4%), while those
that are divorced are 7 (7.4%). Thus, the analysis indicate that majority of the respondents are
single. For Religion status, the results indicate that midwives who are Christian are 78
(82.1%), those that are Muslims are 12 (12.6%), while those that are fall under the category
of others were 5 (5.3%). Thus, the analysis indicate that majority of the respondents are
Christians.
For midwives’ supportive attitude of midwives to parents following intrapartum loss, Table
4.1.2 showed that most of the respondents’ 52.6% (50) strongly agreed that midwives gives
parents time to grieve after perinatal loss.22.2% (21) agreed that midwives gives parents time
to grieve after perinatal loss . 15% (15) midwives indifference that midwives gives parents
time to grieve after perinatal loss.5.26% (5) midwives disagreed that midwives gives parents
time to grieve after perinatal loss.4.25% midwives strongly disagreed that midwives gives
parents time to grieve after perinatal loss.55.8% (53) midwives strongly agreed that all those
involved in care of the bereaved parents are informed by midwives following intra-natal
loss.22.1% (12) agreed that all those involved in care of the bereaved parents are informed by
midwives following intra-natal loss.13.7% (13) midwives are indifference the all those
involved in care of the bereaved parents are informed by midwives following intra-natal
loss.6.3% (6) midwives disagreed that all those involved in care of the bereaved parents are
informed by midwives following intra-natal loss.3.2% (3) midwives strongly disagreed. all
those involved in care of the bereaved parents are informed by midwives following intra-
natal loss. 50.5% (43) midwives agreed that midwives allow parents to hold and touch the
deceased child.51.2% (30) midwives. Strongly agreed that midwives allows parents to hold
and touch the deceased child.10.5% (10) midwives indifferent that midwives allows parents
to hold and touch the deceased child.4.4%(4)midwives disagreed that midwives allows
parents to hold and touch the deceased child. 3.2% (3) midwives strongly disagreed that
midwives allows parents to hold and touch the deceased child.68.4% (65 midwives) agreed
that midwives comfort parents with words of hope and encouragemen.15.8% (12) midwives
indifferent that midwives allows parents to hold and touch the deceased child. 10.5% (10)
midwives disagreed that midwives allows parents to hold and touch the deceased child .4.2%
(4) midwives disagreed that midwives allows parents to hold and touch the deceased child
316% (3)midwives strongly disagreed that midwives allows parents to hold and touch the
deceased child.73.7% (70) midwives strongly agreed that midwives provides advice on how
to go about laying the child to rest.10.5% (8) midwives agreed that midwives provides
advice on how to go about laying the child to rest. 5.3% (5) midwives indifferent that
midwives provides advice on how to go about laying the child to rest. 5.3% (5) midwives
disagreed’ agreed that midwives provides advice on how to go about laying the child to rest.
5.3% (5) midwives strongly; disagreed’ agreed that midwives provide advice on how to go
about laying the child to rest.
For midwives’ supportive attitude of towards parents following immediate post-natal losses,
Table 4.3 showed that most of the respondents, 69.5% (66) midwives strongly agreed that
they communicate with the bereaved parents duly. 25.3% (24) agreed that they
communicated with the bereaved, sensitive and honest manner. 3.2% (3) midwives
indifference that they did not communicate with the bereaved parents a clear sensitive and
honest manner. 1.0% (1) disagreed that they did not communicate with the bereaved parents
in a clear, sensitive and honest manner. 1.0% (1) strongly disagreed that they did not
communicate with the bereaved parents a clear, sensitive and honest manner. 52.6%, (50)
midwives strongly agreed that they can provide grief caring program to provide
psychological support to the bereaved parents. 27.3% (26) midwives agreed that they can
provide a grief caring program to bereaved parents to provide psychological support to the
bereaved parents. 10.5% (10) midwives indifference stated that they did not provide grief
caring program to provide psychological support to the bereaved parents. 5.3% (5) midwives
disagreed that they can provide grief caring program to provide psychological support to the
bereaved parents. 4.2% (4) midwives strongly disagreed that they can provide grief caring
program to provide psychological support to the bereaved parents.74.7% (71) strongly agreed
that increased workload prevents adequate midwives caret to the bereaved parents. 15.8%
(15) midwives agreed that increased workload prevents adequate midwives care to the
bereaved parents. 5.26% (5) midwives indifference that increased workload did not adequate
midwives care.3.16% (3) midwives disagreed that increased work load prevents adequate
midwives care.1.05% (1) midwife strongly disagreed that workload prevent adequate
midwife care to prevent adequate care. 71.5% (68) midwives strongly agreed and blame one
another following immediate postnatal loss.15.8% (15) midwives agreed and blame one
another following immediate postnatal loss. 7.4% (7) midwives indifferent and blame one
another following immediate postnatal loss. 3.2% (3).midwives disagreed and blame one
another following immediate postnatal loss. 2.1% (2) midwives strongly disagreed and
blame one another following immediate postnatal loss.
Table 4.4 summarized that most of the respondents’ 68.4% (65) midwives strongly agreed
that increased workload prevents adequate supportive care of midwives to parents care.
15.8% (15) midwives agreed that increased workload prevents adequate supportive care of
midwives to parents care. 10.5% (10) midwives indifferent that 7 increased workload
prevents adequate supportive care of midwives to parents care.3.2% (3) midwives disagreed
that increased workload prevents adequate supportive care of midwives to parents care. 2.1%
(2) midwives strongly disagreed that increased workload prevents adequate supportive care
of midwives to parents care. 73.7% (70) midwives strongly agreed that shortage or
inadequate manpower prevents midwives rendering optimum care to parent, 10.5% (10)
midwives agreed that shortage or inadequate manpower prevents midwives rendering

optimum care to parent. 5.3% (5) midwives indifferent stated that shortage or inadequate
manpower prevents midwives rendering optimum care to paren. 5.3% (5) midwives
disagreed that shortage or inadequate manpower prevents midwives rendering optimum care
to parent. 5.3% (5) midwives strongly disagreed shortage or inadequate manpower prevents
midwives rendering optimum care to parent. 52.6% (50) midwives strongly agreed tha
Inadequate facility prevents adequate midwives care. 22.1% (21) midwives agreed tha
Inadequate facility prevents adequate midwives care. 15.8% (15) midwives indifferent stated
that Inadequate facility prevents adequate midwives care. 5.26% (6) midwives disagreed that
Inadequate facility prevents adequate midwives care. 4.2% (4) midwives strongly disagreed
Inadequate facility prevents adequate midwives care. 55.8% (53) midwives strongly agreed
that midwives counsel parent from experience guilty feeling following postnatal loss. 22.1%
(21) midwives agreed that midwives counsel parent from experience guilty feeling following
postnatal loss, 13.7% (13) midwives indifferent stated that midwives counsel parent from
experience guilty feeling following postnatal loss, 6.3% (6) midwives disagreed that
midwives counsel parent from experience guilty feeling following postnatal loss, 3.2% (3)
midwives strongly disagreed that midwives counsel parent from experience guilty feeling
following postnatal loss and 50.5% (48) respondent strongly agreed that midwives
experience difficulties in caring for parents following perinatal loss.31.6% (30) respondent
agreed that and midwives experience difficulties in caring for parents following perinatal
loss. 10.53% (10) respondents indifferent stated that midwives experience difficulties in
caring for parents following perinatal loss. 4.21% (4) respondent disagreed that midwives
experience difficulties in caring for parents following perinatal loss. 3.16% (3) respondents
strongly agreed that midwives experience difficulties in caring for parents following perinatal
loss.
Figure 4.1 revealed that the majority of midwives think their supportive attitude had some
(58.9%) influence on parents coping after perinatal death. Additionally, for hypothesis one,
Table 4.5 revealed a significant difference in midwives’ supportive attitude in the
intrapartum and postnatal periods (p = 0.029). The null hypothesis was rejected, while the
alternative hypothesis was accepted and thus, implying that there is a significant effect of the
supportive attitude of midwives to parents following intranatal loss. This finding according to
Gardner (2016), perinatal death has been described as a life crisis for both parents and
professionals. Communication between nurses and parents may be ineffective because of the
reactions of each to the reality of death. Parents may withdraw from nurses as they
experience initial feelings of shock. Nurses may hesitate to interact with parents because of
feelings of inadequacy, helplessness, frustration, or lack of experience in caring for the
bereaved.
For Hypothesis two, Table 4.6 revealed a significant association between midwives’ support
attitude and parental reaction to perinatal losses (p = <0.001). The null hypothesis was
rejected, while the alternative hypothesis was accepted and thus, implying that there is a
significant effect of the supportive attitude of midwives to parents following immediate post-
natal loss. This finding was in support of Clossick (2016) who opined that Doctors and
midwife, by the nature of their occupation, encounter emotional and stressful work situations,
however midwives often suffer grief and fear when dealing with the loss of a baby, and may
find themselves unable to cope with their emotional distress. He reports that 40% of
miscarrying women in their study were predominantly or totally dissatisfied with the care
after miscarriage, and that dissatisfaction centered particularly on professional psychological
support rather than care in a medical/technical sense. There is a significant effect of the
supportive attitude of midwives to parents following subsequent postnatal loss. This finding
was in support of Kavanagh and Wheeler (2012) they opined that despite drastic reductions
in newborn and infant mortality in the past 20 years, infant death is still a reality in neonatal
intensive care units. They further articulate that mothers who had complications during
pregnancy are unprepared for the infant’s death and their own intense grief. Nurses who care
for these parents must understand the range and intensity of reactions that are unique to this
type of loss, death through pregnancy loss is a tragedy which touches nursing staff as well as
parents exposed to the intense emotions. The emotional needs of nurses have to be fully
acknowledged by recognizing the importance of managed emotion in the construction of
professional knowledge.
CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATIONS
This chapter presented the summary, conclusion, and recommendations in line with the
findings of this study.
5.1 Summary of Findings
Perinatal death is the demise of a baby between 22 weeks to 7 days after birth. The aim of
this study was to evaluate the midwives’ supportive attitude towards parents following
perinatal loss in two selected hospitals in Aba, Abia State. Descriptive analytical design was
adopted for this study on a multi-stage sample of 95 midwives practicing in the prenatal,
intrapartum and postnatal units of two public hospitals. A novel questionnaire designed by
the researcher was used for data collection. Collected data were analyzed using descriptive
and inferential statistics at a 5% level of significance with the aid of IBM-SPSS 21. Results
revealed that more than half of the respondents strongly agreed that midwives give parent
time to grieve and allow parent hold and touch the deceased child (52.6%), midwives
comfort parent with words of hope and encouragement, gives advice on how to go about
laying the child to rest (50.5%), and midwives counsel parents following loss (55.8%)
through intrapartum and postnatal periods. About 58.9% respondents reported that the
parents verbalized some enhancement in coping owing to the midwives’ supportive attitude.
There was significant difference in supportive attitude of midwives in the intrapartum and
postnatal periods (p = 0.029). There was significant association between midwives’
supportive attitude and antenatal, intrapartum, and postnatal coping (p = <0.001). In
conclusion, the midwives had just above average supportive attitude towards parents
following perinatal loss in the two public hospitals. The study recommends that strategies to
improve the clinical practice of supportive attitude in times of perinatal loss such as setting
up emotional care training centre for midwives.
5.2 Limitation
This study was limited by two major factors which includes the use of a non-standardized
questionnaire and the assessing parents coping reaction to perinatal loss from the midwives’
reported parents verbalization.
Firstly, the choice to utilize a researcher designed structured questionnaire limited this study
in the sense that the comparability of results across studies was difficult given that the
instruments in related studies measured diverse constructs.
Secondly, the choice to measure parents coping to perinatal loss from what the midwives
reported limits the conformability, trustworthiness, and dependability of the retrieved data.
The mentioned limitation would suggest that caution should be excercised when using the
conclusion of this study for generalization purposes outside the population for this study.
5.3 Conclusion
Pregnancy loss or death of a baby can be overwhelming for families, especially if the loss is
unexpected. The standard of bereavement care families receive around this time, can have a
significant impact on their short- and long-term psychological recovery. Midwives need to
ensure that facilities are equipped to provide consistent excellent individualized perinatal
bereavement care. However, offering emotional care following a perinatal loss is a key
aspect which needs to be considered taking into account the individualized circumstances of
the mourners. Midwives should focus their attention on the specific emotional grief care as
part of the holistic support provided to grieving parents. Cultural values, the number of
previous perinatal losses, specific grief in cases of multiple pregnancies, anxiety in
subsequent pregnancies following the loss, information given to the parents regarding
decision-making, contact with the deceased child are aspects that midwives should be take
into account during the emotional care of grieving families. What were the major findings,
use it for conclusion.
5.4 Recommendation s
Strategies to improve the clinical practice in this field should be implemented, such as
emotional care training for midwives and a variety of strategies for preparing and resolving
perinatal grief as a part of the support provided to grieving parents.
Despite its recognized relevance, research on emotional care after perinatal loss is only
beginning to surface, further understanding and research on the topic is necessary.
There is a need for more research into care provided following perinatal deaths in resource-
poor settings to increase the evidence-base for informed and improved care for women who
have miscarriages, stillbirths or whose baby dies soon after birth
5.5 Contribution to Knowledge
Based on the findings in this study, midwives should be encouraged and also be motivated to
do their best in caring for the perinatal bereaved parents. Government should put in place all
the required methods that will boast the knowledge of the midwives in caring for the
bereaved parents by conducting seminars, workshops and trainings for the fresh midwives
graduates in our various hospitals to enhance your knowledge on caring for bereaved parents.
Adequate facilities to improve care of the bereaved and prevent maternity and infant
mortality rate should be put in place to prevent all the negative effect that might arise from
perinatal loss.
Nursing and midwifery council of Nigeria should ensure that the care of the bereaved parents
should be included in the curriculum to enhance the ability of the students and fresh
graduates in care of the bereaved parents.
5.6 Implications for Midwifery Practice
Nursing and midwifery council of Nigeria should include perinatal bereavement care in
nursing and midwifery curriculum to help provide adequate experience in clinical practice for
future nurses and midwives.
Registered nurses and midwives with appropriate practicing skill should carryout perinatal
bereavement care as part of their regular practice in all their various hospital and also
appreciate the need for adequate referral when necessary.
Midwives are aware of perinatal loss, an extra training on care of bereaved parents following
perinatal loss is required.

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CHAPTER ONE

1.1 Background to the Study

loss is one of the most profound events a family can endure.

to Prevent complications is to find a professional care provider who understands these

pain should be reported immediately to your health care provider.

1.2 Statement of the Problem

negative consequences of such experiences should be avoided.

1.3 Aim and Objectives

perinatal loss in two selected hospitals in Aba Abia State.

The specific objectives for the study are to:

i. Determine midwives’ support attitude towards parents following intraparum loss.

iv. Determine influence of midwives’ support attitude on parents’ reaction following

1.4 Research Questions and Hypotheses

postnatal loss experience?

The hypotheses to be analyzed in this study are:

i. There is no significant difference between midwives’ supportive attitude to parents

following intrapartum and postnatal loss.

reaction to perinatal losses.

1.5 Significance of the Study

member too, based on my findings in this study.

due to inadequate healthcare resources to manage emergency situations. Secondly, the

parents experiencing perinatal losses.

1.7 Operational Definition of Items

midwives’ encouraging words and behavior aimed at comforting the parents.

midwives to the bereaved parents following perinatal loss.

labour and delivery.

A related literature of evaluation of midwives’ supportive attitude towards parents following

review, Empirical review, Summary of literature reviewed.

2.1 Conceptual Review

Midwives’ supportive attitude in care

terms of physical and psychological aspects of care.

Physical aspects of care received Intrapartum

Principles required when rendering bereavement care following perinatal loss

The key ideas include:

Bereavement care should begin as soon as death is expected

open to the dying patient or those who have been bereaved

training at the appropriate level

updated on changes to protocols and legislation

wish to speak to someone before or after a death Shaping

Principles for Staff Support

• Management should recognize an obligation to support staff both through their

or when experiencing a personal loss

• A supportive culture needs to be created within each organization to facilitate staff

coping with bereavement especially in traumatic situations

• Time allowed for debriefing should become the norm

• Links with Spiritual Care departments should be increased

death and dying on a regular basis or following particularly traumatic death.

Psychological care rendered to bereaved parents by midwives following immediate

away so God will give the one that be alive.

encouragement or counseling them following their stillbirth or neonatal death.

round the hospital area.

but a different person in a green uniform came to attend to me.

their perinatal loss, such as suffocation,

the grief they may be experiencing (Wallbank & Robertson, 2013).

guilt and anxiety regarding their competence to offer appropriate care.

Palliative Care following Perinatal Loss

a family‐centered approach to care, and multi‐disciplinary team involvement, including a

report up to 87% uptake (Balaguer et al., 2012).