Assistance to families affected by stillbirth: an international position statement on contact with the child
Italian version edited by Claudia Ravaldi and Alfredo Vannacci of the document Warland J, Davis DL, et al (2011) Caring for Families Experiencing Stillbirth: A unified position statement on contact with the baby. An international collaboration.
Authors: Joanne Cacciatore, Jillian Cassidy, Line Christoffersen, Liz Conway, Mairie Cregan, Vicki Culling, Deborah Davis, Pat Flynn, Sue Hale, Suzanne Helzer, Sherokee Ilse, Cathi Lammert, Rana Limbo, Joann O’Leary, Suzanne Pullen, Ingela Rådestad, Claudia Ravaldi, Janne Teigen, Alfredo Vannacci, Jane Warland
Stillbirth is recognized to be one of the most traumatic experiences in a parent’s life and can be associated with long-term psychosocial changes. For the parents this could be the first ever experience of death; they are generally confused and frightened about what lies ahead and unsure of what is still possible to do.
Seeing and holding a live newborn after birth is a normal parental care response. Seeing and holding a stillborn baby is also a normal response, and there is much evidence to point to this experience as welcome and desirable for parents. Parents benefit greatly from personalized support and guidance to accompany them as they make their decisions regarding this option, how long to stay with their child, and also when and how to spend this time.
Prior to the 1970s, common practice in hospitals was to discourage or prohibit parents from seeing their child dead. Towards the end of the 1970s, however, perinatal health practitioners began to pay more attention to parents’ requests regarding contact with their dead child, and the first scientific papers that led to a change in clinical practice began to be published 1 -3 . Over the next 30 years, bereaved families in most Western countries were therefore encouraged to come into contact with the dead child.
Since 2002, after the publication of a study on possible adverse outcomes in some of the parents holding their stillborn babies, 4 this practice has been questioned. This small study has limited support for families in some countries, to the point where some hospitals have stopped encouraging and supporting parents in contact with stillbirths. This change in stillbirth management is highly controversial, as there is no evidence that discouraging or prohibiting parents from seeing their baby is long-term positive for their psychological well-being.
Many studies and guidelines published both before and during 20025-24 have in fact shown how parents can receive a great benefit in spending time with their child, having the opportunity to live an experience of recognition and contact with the child in which they can acquire precious memories for mourning. Conversely, when parents do not see or hold their babies, they very often regret this missed opportunity over time. Furthermore, in many cultures there are socially recognized habits and rituals related to holding and caring for the body of a deceased loved one, of any age. These traditions help the bereaved person recognize the reality of death, greet the deceased, and begin to process the loss. 25-30
Parents normally see and hold their babies alive after birth. It is therefore quite unnatural to assume that parents do not benefit or do not wish to see their child stillborn. Whether and when to spend time with the dead child is a very personal decision and it is important to ensure that parents receive the support and information they need to make truly informed and aware choices.
As international referents of organizations and associations dealing with support and care in perinatal bereavement, we recommend the following points to institutions, companies and professionals working with families affected by stillbirth. These recommendations are based on: a) empirical studies, b) narrative experiences and testimonies of families, c) interdisciplinary clinical practice of professionals of different areas and skills e d) the awareness and reflection work of the parents’ associations.
1. Provide a standard of care that reflects the parents’ natural desire to see and hold the baby after birth. This means always avoiding closed-ended questions like “Do you want to see it?” Parents usually answer no to these kinds of questions, even though these do not often mean “not now”, and not “now and never”.
2. After the bad news is broken: Begin to build a sensitive and welcoming relationship with parents. It is important to understand their needs by establishing a dialogue based on open questions, related to their experience, their child, and care. It is important to remember that parents will be shocked and will not be able to hear or say many things at such times. Explain in a simple way the different possible options and present them to the parents both verbally and in writing. During this time, if parents express uncertainty or reluctance to see or hold the baby, one can try to gently explore their fears and concerns, including those related to the baby’s appearance. It is necessary to reassure them that the staff will be with them during the meeting with the child.
3. During labor and birth : If the parents have not expressed any fear of contact with the baby, it is advisable to proceed in a natural and respectful way as you do with any parent who wishes to see and hold their long-awaited baby. .
4. After the birth : Offer kind, participatory support when parents meet the baby. Most parents feel emotionally overwhelmed and this can affect their ability to make the best decisions for them, consider the long-term consequences of what they will or won’t do, or make decisions on their own. If necessary, actualize the contact with the child by sharing with the parents how important and meaningful it was for other parents to greet their children and put aside some memories. Helping parents by cradling and speaking kindly to the baby first can be a powerful demonstration for parents on how to spend time with the baby.
5. If parents refuse to see or spend time with the child, respect and fully support this will. Continue to talk in a sensitive way about the child and their experience. Explain to them that they can change their minds at any time up until the burial or cremation. However, it is important to inform parents that the hospital can collect memories of the child for them. The family can choose to take the memories home immediately, or leave them in the hospital for later collection.
In following these recommendations, one must always be aware that suffering the death of a child is a traumatic grieving experience and a real shock. It is important to remember that parents need some time to manage emotions, make better decisions, and take the opportunity to connect with their child. Each parent’s personal values, cultural traditions and religious beliefs can influence the amount of time spent with the child or even in some cases exclude contact with the child after death. It is therefore very important to offer support that is sensitive, unhurried, serene, respectful, and recognizes cultural differences.
It would be ideal for these recommendations to be implemented by specially trained staff with prior experience in caring for bereaved parents and for inexperienced staff to be followed and trained in the field. It is also recommended that those directly involved in care participate in staff meetings and resource development to offer support to families, build relationships and discuss different options in an open and helpful way. Finally, it is recommended that well-defined protocols, guidelines and evidence-based intervention strategies to support bereaved parents are available in each clinic, hospital or birth center, and that the administration implement all necessary strategies for bereavement. their realization.
- Giles PF. Reactions of women to perinatal death. Aust NZJ Obstet Gynaecol. 1970; 10 (4): 207-210.
- Kennell JH, Slyter H, Klaus MH. The mourning response of parents to the death of a newborn infant. N Engl J Med. 1970; 283 (7): 344-349.
- Lewis E. Mourning by the family after a stillbirth or neonatal death. Arch Dis Child. 1979; 54 (4): 303-306.
- Hughes P, Turton P, Hopper E, Evans CD. Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study. Lancet. 2002; 360 (9327): 114-118.
- Lovell A. Some questions of identity: late miscarriage, stillbirth and perinatal loss. Soc Sci Med. 1983; 17 (11): 755-761.
- Rådestad I, Steineck G, Nordin C, Sjögren B. Psychological complications after stillbirth – influence of memories and immediate management: population based study. BMJ. 1996; 312 (7045): 1505-1508.
- Trulsson O, Rådestad I. The silent child – mothers’ experiences before, during, and after stillbirth. Birth. 2004; 31 (3): 189-195.
- Cacciatore J, Rådestad I, Frederik Frøen J. Effects of contact with stillborn babies on maternal anxiety and depression. Birth. 2008; 35 (4): 313-320.
- Barr P, Cacciatore J. Problematic emotions and maternal grief. Omega (Westport). 2007; 56 (4): 331-348.
- Hunter J. Stillbirth: patient-centered psychosocial care. Clin Obstet Gynecol. 2010; 53 (3): 691-699.
- Hunter J. The unique experiences of women and their families after the death of a baby. Soc Work Health Care. 2010; 49 (2): 134-148.
- Wijngaards-de Meij L, Stroebe M, Stroebe W, et al. The impact of circumstances surrounding the death of a child on parents’ grief. Death Stud. 2008; 32 (3): 237-252.
- Hunter J. The silent birth: a feminist perspective. Soc Work. 2009; 54 (1): 91-95.
- Rådestad I, Christoffersen L. Helping a woman meet her stillborn baby while it is soft and warm. British Journal of Midwifery. 2008; 19 (9): 588-591.
- Schott J, Henley A, Kohner N. Pregnancy Loss and the Death of a Baby: Guidelines for Professionals. 3rd ed. Sands UK / Bosun-Publications; 2007.
- Flenady V, Wilson T. Support for mothers, fathers and families after perinatal death. Cochrane Database Syst Rev. 2008; (1): CD000452. doi: 10.1002 / 14651858.CD000452.pub2.
- Pregnancy Loss and Infant Death Alliance. Practice Guidelines: Offering the Baby to Bereaved Parents. 2008. link . Accessed May 4, 2011.
- Primeau MR, Lamb JM. When a baby dies: rights of the baby and parents. J Obstet Gynecol Neonatal Nurs. 1995; 24 (3): 206-208.
- Rådestad I, Surkan PJ, Steineck G, Cnattingius S, Onelov E, Dickman PW. Long-term outcomes for mothers who have or have not held their stillborn baby. Midwifery. 2009; 25 (4): 422-429.
- Limbo R, Kobler K. The tie that binds: relationships in perinatal bereavement. MCN Am J Matern Child Nurs. 2010; 35 (6): 316-321; quiz 321-323.
- Gold KJ, Dalton VK, Schwenk TL. Hospital care for parents after perinatal death. Obstet Gynecol. 2007; 109 (5): 1156-1166.
- Brabin PJ. To see or not to see: that is the question. Challenging good-practice bereavement care after a baby is stillborn: the case in Australia. Grief Matters: Australian Journal of Grief and Bereavement. 2004; 7 (2): 28-33.
- Christoffersen L. Parents experience and the use of the Norwegian public health service previous to, during and after stillbirth: a pilot project. 2009 [ link to English abstract , Paper in Norwegian] Accessed May 4 2011.
- Davis DL. Reflections on the Lancet Stillbirth Study. The Forum: Newsletter of the American Association of Death Education and Counseling. 2004; 30 (2): 4-5.
- Beder J. Mourning the unfound: how we can help. Fam Soc. 2002; 83 (4): 400-404.
- Boss P. Ambiguous loss: learning to live with unresolved grief. Cambridge, Massachusetts: Harvard University Press; 1999.
- Worden JW. Grief counseling and grief therapy: a handbook for the mental health practitioner. New York: Springer Pub; 2008.
- Cooke MW, Cooke HM, Glucksman EE. Management of sudden bereavement in the accident and emergency department. BMJ. 1992; 304 (6836): 1207-1209.
- Chapple A, Ziebland S. Viewing the body after bereavement due to a traumatic death: qualitative study in the UK. BMJ. 2010; 340: c2032.
- Paul R. Viewing the body and grief complications: the role of visual confirmation in grief reconciliation. In: Cox GR, Bendiksen R, Stevenson RG, eds. Complicated grieving and bereavement: understanding and treating people experiencing loss. Amityville, New York: Baywood; 2002.
Acknowledgments: This position statement was initiated by Sherokee Ilse and the Parent Advisory Committee (PAC) of the International Stillbirth Alliance (ISA), and was developed by a group of bereaved parents, health professionals, international academics and other experts from the perinatal bereavement area, coordinated by Jane Warland and Deborah L. Davis. The authors thank Cathy Fischer, Managing editor / writer, Department of Medical Research, Gundersen Lutheran Medical Foundation, Inc., USA, for editorial reviews.
Copyright © 2011 This Position Paper may be reproduced in its entirety without alteration. The suggested reference is: Warland J, Davis DL, et al (2011) Caring for Families Experiencing Stillbirth: A unified position statement on contact with the baby. An international collaboration.
List of authors in alphabetical order
Joanne Cacciatore, PhD, MSW
Assistant Professor, Arizona State University
Founder, MISS Foundation International, USA
Bereaved parent, Parent advocate
Co-founder, Umamanita, Spain
Line Christoffersen, PhD
Bereaved parent, Parent advocate
Associate Professor, Oslo School of Management, Norway
Bereaved parent, Parent advocate
Mairie Cregan, MIITD, MSW
Bereaved parent, Lecturer University College Cork, Feileacain, Ireland
Vicki Culling, PhD, MSW
Bereaved parent, Co-chair, PAC / ISA & ISA Board
Sands New Zealand
Deborah Davis, PhD
Psychologist; Writer, Empty Cradle, Broken Heart
Pat Flynn, PhD
Bereaved parent, Parent advocate; CEO, 1st Breath; Treasurer ISA Board; USA
Bereaved parent, Parent advocate
Group Development Manager, Sands, UK
Suzanne Helzer, RNC-OB, LCCE
Bereavement Services / RTS Program Coordinator
Banner Desert Medical Center, Mesa, AZ, USA
Bereaved parent / Advocate; Int’l speaker; Author, Empty Arms
Babies Remembered Co-chair PAC / ISA, ISPID Board, USA
Cathi Lammert, RN
Bereaved parent; President, PLIDA; Executive Director,
Share Pregnancy & Infant Loss Support, Inc., USA
Rana Limbo, PhD, RN
Director, Bereavement Services
Gundersen Lutheran Medical Foundation, Inc., USA
Joann O’Leary, PhD, MPH, MS
Parent / Infant Specialist; Field Faculty, Center for Early Education and Development, University of Minnesota, USA
Bereaved parent, Parent advocate, Communication educator
PAC / ISA, Doctoral student, Arizona State University, USA
Ingela Rådestad, RN, RM, PhD
Professor, Sophiahemmet University College
President, Swedish National Infant Foundation, Sweden
Claudia Ravaldi, MD, MSc
Bereaved parent, Psychiatrist Psychotherapist, ISA Board and PAC member, Founder & President, CiaoLapo Charity for Perinatal Grief Support, Italy
Janne Teigen, RN, RM
Bereaved parent, Parent advocate, Author, Midwife,
Hospital of Telemark, Norway
Alfredo Vannacci, MD, PhD
Bereaved parent, ISA PAC member, Founder and Vice-President, CiaoLapo Charity for Perinatal Grief Support, Italy
Jane Warland, RN, RM, PhD
Bereaved parent, Midwife, Author, Faculty (Nursing and Midwifery)
University of South Australia, Australia
Organizations that support this position statement
1st Breath (USA)
Babies Remembered (USA)
Bereavement Services (USA)
CiaoLapo Onlus (ITALY)
Feileacain (SANDAI) (IRELAND)
International Society for the study and prevention of Perinatal and Infant Death (ISPID)
Norwegian SIDS and Stillbirth Society
Pregnancy Loss and Infant Death Alliance (International)
Sands (New Zealand)
Share Pregnancy & Infant Loss Support, Inc. (USA)
Star Legacy Foundation (USA)
Swedish National Infant Foundation
The MISS Foundation International (USA)