Bereavement Care Provided by Nurses and Midwives after Perinatal Loss: A Systematic Scoping Review

Abstract

Background: Each year, 2.6 million stillbirths occur globally, according to the World Health Organization (2014). Over 80% of the basic care needed by women after a perinatal loss can be provided by educated midwives. The role of midwives and nurses in delivering bereavement care is crucial, yet there is a need to explore further this aspect of care, particularly in low- and middle-income countries.

Objective: This review aims to investigate the bereavement care provided by midwives and nurses after perinatal loss, focusing on the impact of this care on patient satisfaction, well-being, and emotional support.

Methods: A systematic scoping review was conducted in February 2018. Four electronic databases—Google Scholar, PubMed, ProQuest, and Science Direct—were searched using the following strategy: “Patient satisfaction” AND “well-being” AND “emotional support” AND “midwives” AND “Nurses” AND (“miscarriage” OR “Stillbirth”). From the 168 articles initially identified, 12 articles were selected that specifically addressed bereavement care provided by midwives and nurses to parents following perinatal loss.

Results: The review revealed that midwives and nurses play a significant role in providing essential support and therapeutic communication to parents experiencing perinatal loss. This support can help expedite the grieving process and result in positive, long-lasting effects for the parents of stillborn babies. However, the review also highlighted a significant gap in interventional studies on bereavement care in low- and middle-income countries.

Conclusion: The findings emphasize the critical role of midwives and nurses in delivering bereavement care, suggesting that more interventional studies are needed, particularly in low-resource settings. Enhancing the support provided by healthcare professionals in these regions could improve outcomes for bereaved parents globally.

Keywords: Bereavement care, parents, nurses, midwives, perinatal loss.

BACKGROUND

What already known

Bereavement care is important in speeding up the grieving process. Perinatal death greatly impacts the psychological well-being of mothers and nurses in prenatal units.

What this paper adds

This paper will help to identify the need for bereavement care for perinatal loss from the perspective of parents. This will recognize strategies required to provide bereavement care. This paper will emphasize the importance of training sessions for nurses and midwives related to bereavement care.

INTRODUCTION

There is often a great deal of hope associated with being pregnant. Pregnancy and childbirth are deeply personal experiences. Every woman appreciates the wonder of conception and childbirth [1]. Perinatal refers to the time leading to and immediately following

childbirth, particularly the five months beforehand. A state of sorrow, despair, and grieving following the death of a loved one is known as bereavement [2]. Perinatal bereavement refers to the death of the mother or the child. Consequently, parental connection, kinship, and memory-making are all taken away by pregnancy loss, whether it occurs through miscarriage, stillbirth, or neonatal death. It is quite hard to mourn a child loss, whom somebody has shared a lifetime of memories [3].

The World Health Organization (2014) estimates that there are 2.6 million stillbirths worldwide [4, 5]. According to the ICN [6] and State of the World’s Midwifery Report (SoWMy) (2014), midwives who have received an education are capable of providing more than 80% of the basic care that women require after perinatal loss [7]. Supporting the families to express their emotional pain and entire bereavement care responsibilities are all parts of the nurse’s role in facilitating bereavement care. The nurses must have an in-depth understanding of a client’s situation, its significance, as well as how it distresses their capacity to move on if they are to be effective [8]. Knowing how to comfort clients and their families even when there is no longer hope of having children requires knowledge and compassion when working with clients experiencing a loss [3].

Aim

This scoping review aims to investigate the bereavement care provided by midwives and nurses after perinatal loss in the global context.

METHODS

Design

A Systematic scoping review was the best method for our study given the understudied nature of emotional support on perinatal loss and the type of review question [9]. Based on an operational framework suggested by Arskey and O’Malley, this scoping review was carried out in early 2018. The five steps are as follows: (a) define the research question (described above), (b) identify relevant studies, (c) choose the study, (d) chart the data, and (e) compile, summarise, and report the findings. As it offers direction on scoping reviews and encourages the quality and rigor of the study, the Preferred Reporting Items for Systematic Reviews was used for the Scoping Reviews (PRISMA-ScR) checklist [10].

Identification of Research Question

What is the existing literature related to the bereavement care provided by nurses and midwives after a perinatal loss globally?

Identification of Studies for Inclusion

In February 2018, the following four electronic databases were searched: Google Scholar, PubMed, ProQuest, and Science Direct by using the search strategy (Fig. 1). “Patient satisfaction” AND “emotional support” AND (“midwives” OR “Nurses”) AND (“Prenatal bereavement” OR “miscarriage” OR “Stillbirth”)

The filter applied for searching articles was full text, 10 years of publication from 2009 to February 2018, and English language. The grey literature was also searched but not found any relevant article. The Medical Subject

Heading was combined with other terms in Pubmed. For complete search strategies for each database, see the supplemental file Appendix. The search included quantitative, qualitative, mixed method studies and also the reviews done previously. Additionally, the reference lists of accepted studies were carefully examined. The search process was carried out independently by two reviewers MA & MZ.

Study Selection

Studies were reviewed and chosen after the initial search in two steps: screening of the title and abstract and screening of the entire text. The study selection process involved two authors (MZ, MA). Every potential article had the words “include”, “exclude”, or “unclear” next to it. Once the full text of the studies marked as “include” or “unclear” had been obtained, two authors individually studied them wholly to determine whether to include the studies. A third author was consulted to settle any dispute (MM). Based on the stringent eligibility criteria, studies were chosen. Following were the inclusion requirements for this review: 1) Research done on nurses, midwives, or parents with perinatal loss. 2) Original studies and reviews focusing the bereavement care after perinatal loss 3) studies on nurses’ experiences and patients’ satisfaction and well-being in emotional support and counseling; 4) Both quantitative or qualitative studies or reviews were included because the scope of these studies was very wide. The following were the exclusion requirements: duplicate publications, news or study protocols, and non-English studies were excluded from this review.

Data Collection and Management

The first author (MM) carefully read and evaluated each identified article, and another member (MZ) of the research team double-checked his or her work. The following information was extracted using a standard table: country, primary author, publication year, study’s methodology, subjects, sample size, and findings. Both qualitative and quantitative data were extracted using this process, which provided enough in-depth information for the pertinent data to be integrated [11].

Gathering, Summarizing, and Reporting the Findings The summarization and evaluation of the main study verdicts were made possible by descriptive tables on

separate sheets concerning the previous study [12].

The authors found it easy to compare the findings of the included studies and to pinpoint common threads. The data synthesis employed a narrative strategy. Members of the research (MA, MZ, MM) team contributed to discussion and revision throughout, helping to validate the creation and description of themes.

RESULTS

Characteristics of Included Studies

The key features of each study included are outlined in Table 1. Twelve articles were found to focus on how

Table 1: Summary findings of the selected studies.

nurses and midwives should provide support to improve patient satisfaction and well-being and the bereavement experiences of parents with perinatal loss. There were two reviews and among primary studies, two were conducted in the United States and China, one each in Australia, Spain, Singapore, Malawi, India, and Ireland.

Study Design

The vast majority of studies (n=6) employed qualitative study designs. Of the rest, one was review (n=2), four were quantitative study design (n=4) and mixed method study (n=1) was also included in the review.

Study Participants

Twelve studies were reviewed to examine experiences with perinatal bereavement care. These studies focused on two primary areas:

Healthcare Providers: Six studies explored the experiences of nurses and midwives in providing perinatal bereavement care.

Parents: Six studies examined parental experiences with perinatal loss. Two studies included experiences from both mothers and fathers, while four studies

focused solely on mothers’ experiences. The sample sizes across these studies varied considerably, ranging from 18 to 573 participants.

Content

The contents of emotional support and counseling were intricate and primarily comprised a grouping of the three core elements listed below: (1) the grieving phases and the info that parents wanted (2) effective and compassionate verbal skills assistance with moral and ethical choices and (3) self-care and psychological support for nurses and midwives.

Main Findings

Miscarriage may be considered a relatively minor and common complication because physical recovery is typically uneventful and uncomplicated. However, the emotional aftermath of miscarriage is frequently very distressing and can include guilt and depression for both the woman and her family [21]. Midwives and Nurses need more training in providing bereavement care, in addition to better communication among team members and hospital support. The results may be used to enhance nurses’ and midwives’ support, the

Table 2: Coding tree of data.

provision of sympathetic and empathetic bereavement care in prenatal and postnatal settings, and the inclusion of mandatory training in the curriculum content for midwifery and nursing schooling [22]. Refer to Table 2 for themes and codes generated from data synthesis.

Theme. The Critical Role of Professionals after Stillbirth

Childbirth has a significant adverse influence on mothers’ emotional health. This extends to a higher danger of anxiety and depression in the early postnatal period when related to women who gave birth to a live child [23]. Interventions are required to raise awareness and help nurses in a sensitive healthcare system become more attuned to the emotional needs of the mothers [24]. The mother is most likely to experience long-term benefits from active management, which includes a mindful presence, responsiveness, support, and a staff willing to facilitate, reducing the negative immediate and long-term risks of traumatic grief.

The way that nurses/midwives and grieving parents interact with one another is crucial to how well families can deal with loss. The best possible compassionate care should be provided to both parents who have a stillbirth [23]. Parents in the United Kingdom believed that communication with hospital staff was crucial to their ability to cope with the death of their baby. This belief was supported by a provisional analysis of data from 21 interviews with families across the country. Parents who formed dependable relationships with medical professionals, such as doctors, nurses, midwives, and counselors, described the difference that these professionals can make [25].

Theme. Priorities for Enhancing Clinical Care and Bereavement Support

To provide bereavement support, not only nurses and midwives need proper training and education but also enough time and resources to provide both emotional and psychological care [25]. Family support, and physical, emotional, cultural, and psychosocial care, need to be included in this “Compassionate Care” training program. Work-life balance and several exercises that can enhance self-care may be covered in the module. The outcomes of research by Jennings

[26] suggest that even though this training program has a specialized perinatal loss unit, nurses still require specialized and continuous learning, abilities, and support to manage the emotionally challenging role of compassion for women and families undergoing perinatal loss [25]. The probability of midwives having an optimistic attitude towards perinatal bereavement care was statistically significantly higher when they held spiritual beliefs and had more favorable attitudes toward the significance of hospital guidelines and exercises for bereavement care [3]. Additionally, addressing nurses’ educational and training needs will help them provide quality bereavement care [13]. Hence, special training will be provided to the Nurses and Midwives that may facilitate the parents time to time counseling by following the defined manual.

Theme. Impact of Perinatal Loss on Nurses and Midwives

Perinatal loss families received excellent care but nurses and midwives were particularly vulnerable to the stress brought on by that care. After losses, nurses should be given formal and informal opportunities to reflect with

their peers. They should also be encouraged to regularly engage in self-care activities [14]. Hence, regular measures ensure the emotional and psychological health of nurses and midwives facing recurrent deaths.

Theme. Strategies and Planning for Providing Support

With the right support and empathy, families have a better chance of coping with such an unbearable loss and need not suffer in silence [27]. In this process, nonverbal communication and silence management become crucial. Studies suggested that the “Bereavement Midwife” be acknowledged as key in the healthcare team in the support and aftercare of these couples because they understood the significance of adequate support and subsequent follow-up [15]. Because of the psychological reaction to loss, Nurses and Midwives need to provide adequate educational support during the grieving process. Besides this, environmental considerations such as the right amount of physical space and enough family time also need to be considered [17].

Giving student nurses and midwives supportive educational and clinical bereavement experiences and recognizing their integral role at the time of stillbirth would be ingrained from the beginning of their training, which would better prepare them for becoming graduate practitioners [28]. Midwife care and participation during this period have the potential to change the parent experience. For parents, practical tasks like planning the funeral can also serve as a useful diversion from the intense grief of the loss [16]. Additionally, the bereavement team’s sensitive communication and compassionate care are insufficient in many settings. The entire hospital must adopt a considerate and encouraging attitude toward perinatal loss patients.

Theme. Support to the Father

While fathers may be reluctant to express a need for care, care providers can still help by understanding the father’s feelings and helping him adopt healthy behaviors and attitudes towards the expected child. Fathers can also play an active role by helping the spouse by providing due support. Nurses and Midwives need to treat the father as a grieving father rather than a routine medical case [21]. Consequently, fathers should also be involved in care and support sessions provided by nurses/midwives. Referrals to nearby parental support networks should be made by providers as they might help normalize parents’ feelings.

DISCUSSION

This scoping review adds to the body of literature by compiling a substantial body of global studies on the subject of nursing and midwifery perinatal bereavement care. According to the data, midwives, and nurses provide a wide range of obstetrical services, including miscarriage and stillbirth. We discovered very little about the education and training of healthcare providers

about perinatal loss bereavement care. While Hewitt (2015) has taken some steps in recognizing the need for competencies for abortion, more studies are required to assess the extent to which abortion content is taught in numerous undergraduate nursing and midwifery curricula [29]. The context of practice, the nurse or midwife’s competence and confidence, the public’s health needs, and the health service’s policy requirements all have an impact on the scope of practice of nurses and midwives [30]. It has been evident that nurses and midwives working in obstetric care services, within the scope of their practice may offer perinatal loss bereavement care all over the world [31]. It’s critical to keep in mind that historically, [32] stillbirths have been disenfranchised losses without societal acknowledgment. This can have significant psychological effects on the mother, so it’s important to actively recognize her motherhood and the value of the baby as soon as possible [27].

Consistent evidence suggested that properly trained nurses and midwives could provide perinatal loss bereavement care more independently and within nurse-led care models. A framework that includes decentralized service delivery, high-quality integrated services, bereavement care, emotional support, and counseling is required. It addresses additional pertinent issues for the health of women and is affordable for both women and health systems [33].

Implications for Future Research

Additionally, this paper makes recommendations for future regulations, nursing strategies, policies, and guidelines for involving nurses and midwives in providing proper bereavement care to both parents. Little evidence has been found on the father’s involvement in bereavement care. Furthermore, most of the studies have been conducted in high-income countries which stresses the need for research on bereavement care for perinatal loss in low and middle-income countries. Future studies should focus on nurse-led care models, comprehensive care nursing practice, and psychosocial intervention in bereavement care. More rigorous studies on Nurse-led psycho-social intervention or therapies for families who have experienced stillbirth or perinatal loss.

Relevance for the Clinical Practice

Nurses and midwives currently provide women seeking perinatal bereavement care with special technical and emotional support. Governments and regulatory bodies could broaden the scope of practice to provide safe care by making bereavement care clinics in community settings. Hospital staff members may be reminded to be sensitive by the use of a unique ID or bereavement sticker on the main page of the portable patient folder. The Nursing and midwifery profession is instrumental in promoting better treatment for both parents of stillbirth children. However, we must make investments in the profession in terms of support, guidance, and education for this fulfilling but demanding aspect of the job.

STRENGTHS AND LIMITATIONS

This is the first review of its kind focusing on literary evidence on bereavement care provided by nurses and midwives after perinatal loss, miscarriage, or stillbirth on patient satisfaction. A constraint of this scoping review is that most studies were done in high-income countries. Restricted studies have been conducted in Low- and middle-income countries. It maps the body of knowledge related to bereavement care on prenatal loss identifies the breadth and depth of research and highlights the areas for future research. We reviewed 12 articles and 4 databases, as more than 10 studies and two different databases when combined, improve the reliability of the results [34]. Furthermore, because the scoping review compiled findings from various research topics, study populations, methods, and findings, generalizable conclusions should not be drawn from the study. Because our search strategy was English-only, some articles may have been overlooked. Our limitation is the potential for unintended selection bias caused by the exclusion of those missing studies that are not available in the above-mentioned databases.

CONCLUSION

By showing families genuine kindness and sensitivity, adequate support and therapeutic communication can be established by nurses and midwives, which may aid the grieving process and have long-lasting positive effects on the stillbirth parents’ well-being. To do this, nurses and midwives should receive regular training, and the entire hospital management system may be involved. Caretakers must also help fathers by understanding their feelings and supporting them as they work through the grieving process and adopt healthy attitudes toward the expected child.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS

We would like to express our sincere gratitude to Dr. Rafat Jan and Dr. Robina Barolia for their guidance and encouragement in pursuing this review. Their insights were instrumental in sparking my interest in this important topic.

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