IMR Press / CEOG / Volume 49 / Issue 10 / DOI: 10.31083/j.ceog4910218
Open Access Editorial
Breaking the Silence around Stillbirth by Improving Caregivers' Skills, Education, and Support
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1 Egeria Medical Center, 20122 Milano, Italy
*Correspondence: laura.avagliano@unimi.it (Laura Avagliano)
Academic Editor: Michael H. Dahan
Clin. Exp. Obstet. Gynecol. 2022, 49(10), 218; https://doi.org/10.31083/j.ceog4910218
Submitted: 29 June 2022 | Revised: 24 July 2022 | Accepted: 27 July 2022 | Published: 21 September 2022
(This article belongs to the Special Issue Stillbirth: Improving Knowledge, Understanding, and Patient Care)
Copyright: © 2022 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license.

The silence is one of the hardest impacting aspects that surrounds stillbirth [1]: the absence of any sound in the hospital room, the absence of a baby’s crying, the absence of any word from caregivers and parents, nobody talking, a cold environment, just silence. Why? Sometimes an embarrassed silence is a common practice because standing beside bereaving parents is stressful for many caregivers [2]. Despite the known difficulties [3, 4], caregivers should remember that they play an important role in supporting parents’ needs, offering respectful care [2, 5], avoiding personal assumption about the “normal” intensity of grief (for example related with the gestational age at death or the presence of previous live children at home) [2].

Recently, the pandemic aggravated an already difficult challenge. Caregivers should learn from the crises of the pandemic, trying to improve the care in case of any other health crises, including stillbirth [6].

“I found out my baby’s heart had stopped beating on April 2020, when I was 35 weeks pregnant. It happened during the pandemic, and I was alone in that moment and the next day, when I gave birth. It was my second pregnancy, and I could not believe that I was experiencing a stillbirth. … I will always remember the moment when I saw his little body, hoping to hear him crying, that a miracle would bring him back to me; instead, it was me and my beautiful and perfect lifeless baby alone in the silence of the room”. (Mother of stillborn baby boy).

1. Formal Education of Caregivers

A critical point is the education of caregivers around stillbirth [2]. Caregivers should be trained to support all the wide range of the intense grief response, including sadness, guilt, anger, blame [7]. The PSANZ guidelines highlighted the importance of including fellows in education about stillbirth care [2]. The way of breaking bad news impacts immediately and lasting, with potential long-term consequences [8]. Parents remember all details about the place and words used to break the bad news [8], as well as the timeframe between the observation of the diagnosis and the real communication of them. Delays in receiving information are worrying and distressing for parents [8]. Caregivers should be trained for timely, honest, sensitive verbal communication, also remembering the importance of the non-verbal communication. Learning-by-doing may not be an appropriate strategy in this field.

“It was Christmas Eve; I was a young Ob&Gyn resident with a probe in my hand and a still heart below it. I was alone in the room. The mother kept looking me in the eyes, searching for comfort. But I had none to offer. I looked her back in the eyes, told her I was having trouble finding the heartbeat, but I was no expert in the job and for this reason I was going to call the consultant. He came and certified that the baby’s heart had stopped. He said, “I am sorry”. Then he went out of the room and never returned. Should I have talked about the heart beating or not? Did I make a mistake in anticipating my diagnosis to the mother along with showing her all my insecurity? Should I have just showed her the baby’s still heart in the monitor? Was that the right thing to do?” (Young Medical Doctor).

One of the most important actions of the caregivers includes supporting parents in the decision about seeing and holding the baby. Preparing parents to meet their baby requires skilled and sensitive communication abilities [2]. Caregivers should be mindful that the decision of meeting the baby requires more than a one-off conversation. Initially parents may be uncertain and fearful. Calling the baby by name, speaking sensitively about the baby, using the same tenderness and respect given to any other baby could help parents to take their own decision [2].

“I never thought that one day I would share a personal experience like this, painful but at the same time important, an experience that changed my life and my way of being. I will never forget the gaze of the fellow during the ultrasound scan at the 37th week. I asked her if everything was ok, and she wrongly and lying answered in a lost voice “yes”, while she was trying the consultant’s gaze to give her a sign. A sign that I understood immediately… from those moment I was hit by a wave that overwhelmed me. However, I decided to trust and entrust myself to caregivers. I trusted and entrusted myself to the Doctor who supported and prepared me to see my son at birth when instinctively I would have done the opposite. I trusted and entrusted myself… And now, some years later, I can say that I did the right thing”. (Mother of stillborn baby boy).

Caregivers should remember that many parents who declined the opportunity to meet the baby, later experienced regret [9]. Seeing and holding the baby is a positive experience for many parents [10], however, it is important to support and facilitate parents to take their own decisions without any imposition [2].

According to the PSANZ guidelines [2], a multidisciplinary care team should be planned to warrant an approach based on open dialogue, for facilitating parents’ decisions about all the aspects of stillbirth care. The multi-specialist team should include Obstetricians, Midwives, bereavement Counselors, Psychologists, and social workers. Moreover, the team should involve members known to the family where appropriate, warranting spiritual, religious, or cultural support services, avoiding cultural stereotypes [2]. When appropriated, an accredited interpreter should engage to avoid cultural or linguistic barriers [2].

2. Support for Caregivers’ Experience

Personal experiences of caregivers may affect the quality of care given to bereaved parents, due to grief and loss in their own lives [2].

“I return to work after my third miscarriage. And I go back to the delivery room. The wounds are still fresh, I am in mourning, but no one understands it…. I meet her. She is in mourning as well, but maybe she doesn’t realize it yet. She is more dazed than sad, I understand her. I sustain her through the labor. She tells me about the waiting for the first child, the ready bedroom, the clothes, and the empty cradle. She doesn’t know where to put everything, and how she fears going home where everything speaks to her about the baby. I don’t talk about me, but she felt that I share her grief in empathic way; she is looking for me and does not want any other colleague. I struggle, but I stay with her”. (Senior midwife).

Supporting bereaved parents could increase the vulnerability of caregivers [2]. Institutional responses should support caregivers to improve their coping with stillbirth. Caregivers may experience sadness, helplessness, feelings of guilt, and distress facing with bereaved parents [11]. The ACOG stated that “It is ok not to be ok” after stillbirth [12]. Caregivers should have facilitated access to good information about effective self-care [12]. Informal and formal debriefing and sharing of experiences with colleagues and mentoring could be helpful for improving resilience [4]. On the contrary, the lack of Institutional support contributes to improve a feeling of traumatic work experience [4], increasing the risk of burn-out [2]. Shared reflection on the emotional implications could be used as a resource in education and practice [11], leading in turn to an improvement of the quality of care.

“When I was a young midwife, I thought that there was no space for negative emotions, I used to hide the sad and grief; I rarely shared negative emotion with my colleagues because I thought that these emotions were professionally inappropriate.

Now, many years later, I know that I was wrong; I’m not afraid of being sad anymore.

So here I am, with a woman who’s dealing with grief in her personal way. I feel her grief. We talk through our eyes; I catch her eyes and follow her. I keep looking at her, showing that there’s nothing to me that matters more than her at this moment. I keep looking at her warranting she can find my eyes, whenever she needs them. I keep looking at her to keep ever our connection.

I’m aware that I will be surrounded and whelmed by strong emotions. But I’m also aware that I have the courage to stand by her, to support and take care of whom can’t be left alone, never alone. I strongly want to be with her, providing my best care” (Chief midwife).

In conclusion, an improvement of the education, skills and support of caregivers is useful for improving all aspects of sensitive care around stillbirth.

Author Contributions

LA design, literature search, extraction and writing.

Ethics Approval and Consent to Participate

Not applicable.

Acknowledgment

The author is deeply grateful to parents and clinicians for their support and inspiration.

Funding

This research received no external funding.

Conflict of Interest

The authors declare no conflict of interest. LA is serving as one of the Editorial Board members and Guest editors of this journal. We declare that LA had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to MHD.

Publisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Publisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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