work

Midwifery Good practices in perinatal bereavement care in public maternity hospitals in Southern Spain –Manuscript Draft– Manuscript Number: YMIDW-D-22-00654 Article Type: Original Research Keywords: stillbirth; care providers; perinatal bereavement care; midwifes; guidelines Abstract: Objective To assess attitudes and practices of health care providers in the Granada province with respect to perinatal bereavement care, determine their degree of compliance with international standards, and identify potential differences in personal factors among those who better adapted to said recommendations. Design A local survey was conducted on 117 nurses and midwives from the five maternity hospitals in the province using the Lucina questionnaire developed to explore professionals’ emotions, opinions, and knowledge during perinatal loss care. Adaptation of practices to international recommendations was assessed by means of the CiaoLApo Stillbirth Support (CLASS) checklist. Sociodemographic data were gathered to determine their association with a higher degree of compliance with recommendations. Findings The response rate was 75.4%, the majority were female (88.9%), with a mean age of 40.9 (SD=1.4) and 17.4 (SD= 10.58) years of work experience. Midwives were the most represented (67.5%) and they reported having taken care of more cases of perinatal death (p=0.010) and having more specific training (p<0.001.) Out of them, 57.3% would recommend immediate birth, 26.5% would recommend the use of pharmacological sedation during birth, and 47% would take the baby away immediately if the parents express their desire not to look at them. On the other hand, only 58% would be in favor of taking pictures for the creation of mementos, 47% would bath and dress the baby in every case, and 33.3% would allow the company of other relatives. The percentage that adapted to every recommendation in creating mementos was 58%, 41.9% adapted to the recommendations on respect for the baby and parents, and 23% and 10.3% adapted to the appropriate birth options and later follow-up, respectively. Factors associated with 100% of recommendations, depending on the care sector, included being a woman, midwife, having specific training, and having experienced such situation personally. Key conclusions Although the observed adaptation levels are more favorable than those of other nearby contexts, serious deficiencies are identified in the Granada province regarding internationally agreed recommendations on perinatal bereavement care. The need for more training and sensitization on the part of health care providers is evidenced, which should also consider the factors related to better compliance. Implication for practice This is the first study to quantify the degree of adaptation to international recommendations in Spain reported by health care providers, as well as individual factors associated with a higher level of compliance. Areas of improvement and explanatory variables of adaptation are identified, which allow us to support possible training and sensitization programs aimed at improving the quality of the care provided to grieving families. Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation HIGHLIGHTS  Attitudes of healthcare providers toward perinatal bereavement are evaluated.  The adaptation of practices to international recommendations is poor.  Midwifes have a higher degree of compliance with international standards.  Specific training is associated with higher degree of compliance with international standards. Highlights (for review) 1 TITLE Good practices in perinatal bereavement care in public maternity hospitals in Southern Spain. ABSTRACT Objective To assess attitudes and practices of health care providers in the Granada province with respect to perinatal bereavement care, determine their degree of compliance with international standards, and identify potential differences in personal factors among those who better adapted to said recommendations. Design A local survey was conducted on 117 nurses and midwives from the five maternity hospitals in the province using the Lucina questionnaire developed to explore professionals’ emotions, opinions, and knowledge during perinatal loss care. Adaptation of practices to international recommendations was assessed by means of the CiaoLApo Stillbirth Support (CLASS) checklist. Sociodemographic data were gathered to determine their association with a higher degree of compliance with recommendations. Findings The response rate was 75.4%, the majority were female (88.9%), with a mean age of 40.9 (SD=1.4) and 17.4 (SD= 10.58) years of work experience. Midwives were the most represented (67.5%) and they reported having taken care of more cases of perinatal death (p=0.010) and having more specific training (p<0.001.) Out of them, 57.3% would recommend immediate birth, 26.5% would recommend the use of pharmacological sedation during birth, and 47% would take the baby away immediately if the parents express their desire not to look at them. On the other hand, only 58% would be in favour of taking pictures for the creation of mementos, 47% would bath and dress the baby in every case, and 33.3% would allow the company of other relatives. The percentage that adapted to every recommendation in creating mementos was 58%, 41.9% adapted to the recommendations on respect for the baby and parents, and 23% and 10.3% adapted to the appropriate birth options and later follow-up, respectively. Factors associated with 100% of recommendations, depending on the care sector, included being a woman, midwife, having specific training, and having experienced such situation personally. Key conclusions Although the observed adaptation levels are more favourable than those of other nearby contexts, serious deficiencies are identified in the Granada province regarding internationally agreed recommendations on perinatal bereavement care. The need for more training and sensitization on the part of health care providers is evidenced, which should also consider the factors related to better compliance. Implication for practice This is the first study to quantify the degree of adaptation to international recommendations in Spain reported by health care providers, as well as individual factors associated with a higher level of compliance. Areas of improvement and explanatory variables of adaptation are identified, which allow us to support possible training and sensitization programmes aimed at improving the quality of the care provided to grieving families. Manuscript (without author details, affiliations and acknowledgments) Click here to view linked References 2 KEYWORDS Stillbirth; care providers, perinatal bereavement care; midwifes; guidelines. INTRODUCTION Stillbirth is a traumatic event that can dramatically change the life of parents and families (Abiola et al., 2022; Fernández-Sola, et al., 2020, Cacciatore et al., 2019, Nuzum et al., 2018; Heazell et al., 2016).More specifically, it is described as the involuntary pregnancy loss due to miscarriage (less than 24 weeks of gestation), foetal death (more than 24 weeks of gestation) or neonatal death (death of baby within the first 28 days of life) (Kelly et al., 2021; Sheresti et al., 2016). The period after the loss of a stillborn baby has extensive consequences, mainly due to the negative effects of grief, anxiety, fear, and suffering experienced by some bereaved parents, described as perinatal bereavement (Siadatnezhand et al., 2018; Burden et al., 2016; Al-Maharma et al., 2016; Gold et al., 2016; Sheresti et al., 2016). Every year there are 2.6 million cases of foetal death worldwide, 3.0 million cases of neonatal death and around 1/4–5 pregnancies end up in a miscarriage (Lawn et al., 2016; World Health Organization, 2022). In addition, some women show high obstetric risks, which increases even more their levels of anxiety and emotional anguish, also in subsequent pregnancies (FernándezSola et al., 2020; Sundermann et al, 2017; Gunnarsdottir et al., 2014). That is why perinatal bereavement is deemed a global health problem (World Health Organization, 2022; De Bernis et al., 2016). Background The adequate approach to death and perinatal bereavement encompasses an integral care focused on parents, but also on relatives and society in general, as well as on health care providers (HCPs). In 2016, Lancet published a series of documents requesting more efforts from the international community to address the disparity in mortinatality rates among countries, as well as within them. They also asked that preventable stillborn be ended, demanding a “global consensus on a care approach after death during pregnancy or birth for the affected parents and their family, community and carers from all contexts” (De Bernis et al., 2016, L). In response to such demand, countries like Ireland (NSBCPLPD, 2016), the United Kingdom (NBCP, 2018) or Australia (PSANZ, 2019) have established over the last years national standards on perinatal bereavement care. These recommendations share some key points on the care provided to women and families going through perinatal death. They recommend that: HCPs should use simple language, show a non- 3 judgmental sense of caring and personal involvement; enable parents to spend as much time as they need with their baby; facilitate the creation of mementos; provide information regarding the post-mortem examination; make time for discussion with parents; respect their cultural and religious background; and arrange follow-up meetings to discuss the results of the examination and to address unanswered questions during the first moments, or during hospitalisation (PSANZ, 2019; NBCP, 2018; NSBCPLPD, 2016). Furthermore, eight basic and feasible principles have been agreed based on evidence for bereavement care after foetal death. Although comparable findings have been identified at a worldwide level, some indicators were very different, in particular between high-income and lowincome countries. For instance, in lower-income countries, the priority is given to respectful maternal care and counselling on future pregnancy, including family planning. In higher-income countries, it is essential that parents shall receive clear and easy-to-understand information on available options to manage the loss or birth, as well as adequate information before hospital discharge, including contact with a reference professional during the follow-up period (Shakespeare et al., 2020). Nevertheless, available evidence on practices associated with death and perinatal bereavement care is limited in most contexts, particularly in those with low and middle income where the burden is higher (Horey et al., 2021; WHO, 2018; Lawn et al., 2016). Many authors agree that, in general, care received by parents and families after perinatal death does not satisfy their needs (Atkins et al., 2022; Helps et al., 2020; Shakespeare et al., 2019, Siassakos et al., 2018; Ellis et al., 2016), especially in Latin America and Southern Europe, like Spain (Horey et al., 2021). There are many factors involved, and interrelated, having an influence on the quality of perinatal bereavement care: some are related to women and families (shock, pain, embarrassment, guilt, rage, ignorance, stigma, isolation, culture) (Westby et al., 2021; Pollock et al., 2020; Martinez-Soriano et al., 2019; Marwah et al., 2019; O’Connell et al., 2016); others are external or due to the social and/or health system organization (legislation, local culture, family and social support, health care personnel, time, physical space, hospital infrastructure and policies, coordination among medical care departments) (Shakespeare et al., 2020; Fernández-Basanta et al., 2021; Beaudoin et al., 2018; Lee, 2012; Kelley and Trinidad, 2012), and others are internal or personal for HCPs (attitude towards bereavement, sorrow, fear, insecurity, sadness, frustration, anxiety, impotence, fatigue, training, confidence, communication skills) (Arach et al., 2022; Pollock et al., 2021; Gandino et al., 2019; Kalu et al., 2018; Martinez-Soriano et al., 2018; Hutti et al, 2015; Steen et al., 2015). Moreover, the quality of the relationship established between professionals and 4 parents (Beaudoin et al., 2018; Siassakos et al., 2018) and HCPs’ individual variables with epidemiological relevance, and less explored, such as gender, age, years of work experience, number of cases taken care of or personal experience, may impact on their attitudes and behaviour (Fernández-Basanta et al., 2021; Ben-Ezra et al, 2014; Gandino et al., 2014). In Spain, data on perinatal death have decreased gradually as from 1975, currently being below the European average (Euro-Peristat Project, 2018). The Granada province, Southern Spain, with more than 230,000 inhabitants and around 7,000 births a year, has exhibited a perinatal mortality rate above the national average on a constant basis over the years. The latest data published in 2021 show a rate of 3.89 in Spain and of 4.37 in Granada (Statistics National Institute, 2022), which reveals a higher impact of such phenomenon and the need for research focused on bridging the gap. Although health care is universal and free of charge, and almost all maternity hospitals have particular recommendations on death and perinatal bereavement care, no interventions have been reported in them, and their level of adaptation to international recommendations has not been assessed either. Study objectives The objectives of this study are to assess HCPs’ attitudes and health care practices in the Granada province in relation to death and perinatal bereavement care, determine their degree of compliance with international standards, and identify potential differences in personal factors among those who better adapted to said recommendations. METHODS This is a multi-centre, cross-sectional study conducted in five maternity hospitals in the Granada province (two of them urban and three, rural), which hospitals provide services within the Andalusian Public Health System, with no exclusion criteria. Participants Midwives and nurses working in the obstetric, surgery, or emergency departments were selected for being the reference professionals for parents (Qian, et al., 2021; Fernández-Basanta et al., 2021; Kalu et al, 2020; Meaney et al., 2017; Steen et al., 2015; Ellis et al., 2016). The negative impact on grieving parents’ emotional trauma depends, to a large extent, on their ability to provide adequate bereavement care (Aileen and Trish, 2014; Meredith et al., 2017). Furthermore, they constitute quite homogeneous groups to be analysed (Fernández-Basanta et al., 2020; Gandino et al., 2019, Ellis et al., 2016) and to assess most recommended interventions. 5 Data collection Between November 2020 and May 2021, all participants were informed of the study objectives and their informed consent was gathered thus guaranteeing the voluntary and confidential nature of data with the help of the maternity department heads. The Lucina questionnaire developed by the CiaoLapo charity organization to provide support to families who face perinatal loss was employed. This questionnaire has 23 questions with 3 answer options (Yes; No; Do not know) and explores emotions, beliefs, and knowledge of professionals with focus on the care of women experiencing stillbirth and perinatal loss. It also assesses compliance of practices with international recommendations, through questions selected from the CiaoLApo Stillbirth Support checklist (CLASS) also designed by said organization and published in a previous document (Ravaldi el al., 2018). This list is a summary of the best evidence of international guidelines documented in the Irish health system (NSBCPLPD, 2016); indicated by the Perinatal Society of Australia and New Zealand (PSANZ, 2019); integrated with those of the Canadian Paediatric Society (van Aerde et al., 2001), and following the UNICEF-OMS-UNFPA guidelines (UNICEF-WHO-UNFPA, 2017). Likewise, it contemplates measures indicated in the final eight principles recently and globally agreed by international experts on perinatal bereavement (Shakespeare et al., 2020). The original questionnaire, published in English by its authors (Ravaldi et al., 2018), was translated into Spanish by two professional translators specialised in health topics, one of them, a native Spanish speaker and the other a native English speaker, following a validated procedure. Then, four researchers specialised in perinatal bereavement reviewed the translation and assessed the cultural adaptation of each item in order to determine the validity of the questionnaire contents within the Spanish context, making small adjustments to items in the four sections and some items based on literature. The final questionnaire was divided into two sections with a total of 17 questions (Appendix 1). The variables analysed in the study were: I) Participant’s profile: gender, age, professional category, years of work as midwife and/or nurse, and level of education (5 questions). II) Background: training on perinatal bereavement, number of cases of perinatal death taken care of, and personal experience of perinatal death (3 questions). III) Compliance: practices related to the following areas are explored: • Respect: respectful attitudes towards stillborn babies and their parents. The most important items evaluated are: naming the baby; bathing and dressing the baby; 6 providing privacy enabling partners to spend time together. Corresponding Lucina items: 9c, 9e, 11b, 12d, and 12i. • Birth care: addressing possible birth options. The most important items evaluated are: supporting parents in adequate decision-making regarding birth, offering the option of staying at home before birth, and offering obstetric analgesia to avoid sedation. Corresponding Lucina items: 9f, 9g, 10b, 10c, 10e, 11a, 11c, 13a, 13b, and 13e. • Creation of memories: helping parents create memories of their babies. The most important items evaluated are: taking pictures of the baby as a memory; helping parents to see, carry, bath and dress their babies; provide parents with memories like a lock of hair, hand and/or footprints, or the identification bracelet. Corresponding Lucina items: 12a, 12f, 12g, 13f, 13g, 13h, 13i. • Aftercare: providing adequate care and support immediately after labour and later. The most important items evaluated are: informing mothers on the physical and psychological consequences of perinatal bereavement; providing early psychological support; offering written information on support services; discussing implications in future pregnancies and arranging follow-up meetings. Corresponding Lucina items: 13j, 13l, 13m, 14, 15, and 16a. Ethical considerations This study has been authorized by the participating health centres and complies with the good clinical practice guidelines, pursuant to European Directive 2001/20/EC and Law 14/2007, of 3 July, on biomedical research. Treatment of personal data in health research is regulated by the provisions of Organic Law 3/2018 of 5 December on Protection of Personal Data and Guarantee of Digital Rights in Spain. The research protocol received a favourable resolution from the Research Ethics Committee of the Granada province under code 0097-N-21. Data analysis The questionnaire data were analysed on a descriptive basis and the number of health professionals who correctly adapted in 80% and 100% to all recommendations was analysed based on the four defined sections, as previously described by Ravaldi et al. (Ravaldi et al, 2018). Subsequently, a bivariate analysis was conducted to explore any possible association between HCPs’ personal variables and a higher degree of adaptation to the four areas defined through Fisher’s exact test establishing the significance level at p<0.05. For such analysis, quantitative variables (age, years of work, and number of cases taken care of or) were dichotomized taking the median value into account. Analyses were carried out using the SPSS vs. 25 statistical software (IBM, New York, NY, USA). 7 RESULTS A total of 155 questionnaires were distributed among health care providers and 117 were completed, which results in a response rate of 75.48%. Out of them, 88.9% were women and the mean age was 40.9 (SD=11.4). Midwives were the most represented (67.5%), and, on average, professionals stated 17.4 (SD=10.8) years of working experience; 58% have not studied postgraduate studies, although one out of four (74%) had received specific training on perinatal bereavement; 61% reported having taken care of five or fewer women experiencing perinatal death, and 15% had experienced perinatal death at a personal level. Compared to nurses, midwives reported having received more training on the topic (p<0.001) and having taken care of more cases (p=0.010) (Table 1). Table 2 shows HCPs’ attitudes toward perinatal death. Almost all participants stated that they are able to help families by providing an intimate and comfortable environment (95.7%), listening empathetically (94.9%), and allowing the couple to stay together (94%). On the other hand, almost half of the sample thought the baby should be immediately taken away if that is what the parents expressed (49.6%), 47% stated the baby should be bathed and dressed in every case, and 33% would allow the presence of other relatives. The perinatal bereavement care practices and strategies deemed the most appropriate by health care providers are shown in Table 3. As regards labor, between 8% and 26% of participants did not know clearly which were the best options: 81% stated that the most indicated type is vaginal delivery, and 3.4% opted for caesarean section; 70% thought the use of obstetric analgesia is a good practice and a third (26.5%) chose pharmacological sedation. As regards strategies to help families, most of them thought it was important to support mothers during dilation and labor (93.2%) and allow the baby to stay with their parents as much time as they deem convenient (89.7%). Taking pictures of the baby as memories was approved by 58% of the sample. As useful measures for parents during postpartum, the most important thing for health care providers was to arrange a follow-up meeting (91.5%), as well as to offer them resources to be able to manage their own grief (84.6%). On the other hand, 10.3% thought that commenting on a future pregnancy as soon as possible would be of help. The number of health care providers that adapted 100%, 80%, or less, to recommendations pursuant to international guidelines in the four areas selected from the CLASS checklist: respect, birth, memories, and aftercare, is shown in Table 4. Between 30% and 46% of health care providers did not adapt in an 80%, and only between 10% and 58% did so in 100%, according to the analyzed 8 area. A larger gap between international recommendations and actual practice is observed in relation to birth options (10.3%) and follow-up (23.9%). Table 5 shows associations between sociodemographic variables and HCPs’ personal background, exhibiting 100% adaptation to recommendations in the four sections. Respect was associated with professional category (p<0.001), training on perinatal bereavement (p=0.005), and own experience (p=0.034); creation of memories was associated with gender (p=0.041), professional category, training on perinatal bereavement (p<0.001), and own experience (p<0.001); and finally, follow-up was associated with gender (p=0.036) and professional category (p<0.001). DISCUSSION As far as we know, this is the first study in Spain to assess adaptation of attitudes and behavior of midwives and nurses from public maternity hospitals to international recommendations currently agreed toward perinatal bereavement care. We have had access to primary sources, and identified individual factors related to a higher degree of compliance, thus contributing evidence in an almost unexplored area (Ravaldi et al., 2018). We have received more answers from women, which reflects the general gender-based distribution within such professional categories, midwives being the most represented HCPs, like in other studies on perinatal bereavement care (Ravaldi et al., 2018, Brierley-Jones et al., 2018; Wallbank and Robertson, 2013; Fenwick et al., 2007). Within the Spanish health system, midwives are the ones dealing with bereavement after 28 weeks of gestation and care in delivery rooms in the selected centers, where perinatal death is more tangible and painful (Martínez-Soriano et al., 2018; Hernández-Garre et al, 2017). In fact, they are the ones having taken care of more cases and having received more training on bereavement, hence they may be more willing to participate in this kind of study. With respect to HCPs’ beliefs and behavior as to what may be useful and help parents in such a situation and recommendations based on evidence, we have found certain mismatch among many of them. The most generalized opinions as well as those distant from recommendations include putting an end to pregnancy as soon as possible (57%), taking the baby away immediately if parents do not want to see them (49.6%), using pharmacological sedation during labor (26.5%), and recommending a future pregnancy as soon as possible (10.3%). Other recommended practices followed by a limited number of health care providers included taking pictures as memories (58.1%), bathing and dressing the baby in every case (47%) and allowing the presence of other 9 relatives (33.3%). Therefore, our findings coincide with the literature asserting that in Western industrialized countries, the care provided to families, both immediately after labor and during the following days and months, is weak and often inadequate (Cassidy, 2022; Ravaldi et al., 2020; Burden et al., 2016; Steen et al., 2015). In this sense, it should be added that in European countries such as the United Kingdom 25% of parents report that HCPs, on a repeatedly basis, do not provide high-quality perinatal bereavement care (NBCP, 2020). In Italy, after a survey on HCPs, substantial gaps were found between the care standards defined by international guidelines and the practices currently in force in said country (Ravaldi et al., 2020). Also, in Spain, Cassidy et al, in their large study conducted via survey of 796 women who had experienced intrauterine foetal death, concluded that many care practices performed on a standard basis in other high-income countries are not conducted as routine in Spanish hospitals (Cassidy, 2018). Although adoption of an individualized and flexible approach is supported, taking into account parents’ individual and cultural response to death (Bakhbakhi et al, 2017; Cacciatore et al., 2010), the absence of established perinatal bereavement care guidelines leads to wide variability of intervention on the part of HCPs (Fernández-Alcántara et al., 2020). It is also reported that such practices are frequently based on intuition and personal beliefs rather than on better evidence (Cassidy et al., 2022; Fernandez-Basanta et al., 2021 Martínez-Soriano et al., 2018; Steen et al., 2015). In this sense, Zhuang et al., in their recent review of Clinical Practice Guidelines for perinatal bereavement care, conclude that if they are of good quality, they are useful instruments that may provide reliable evidence to increase the capacity of health care providers, standardize the management of perinatal death and improve clinical practice results (Zhuang et al., 2022). Nevertheless, when assessing the degree of compliance with international recommendations, we may observe that our results are significantly more favorable than those reported by Ravaldi et al. in Italy, whose method we have reproduced (Ravaldi et al., 2018). The main differences with respect to this study have been the limitation of professional category (midwives and nurses) and the moment at which it was conducted (6-11 years of difference). Literature usually states that nurses’ and midwives’ practices are more empathic and humane toward the emotional experience of loss, compared to physicians, with whom they may even differ regarding what adequate care is (Cassidy, 2022; Beaudoin et al., 2018; Aiyelaagbe et al., 2017; O’Connell et al, 2016; Gold et al., 2007, Fenwick et al., 2007). On the other hand, over the last decade in Spain there has been more professional sensitization toward grieving parents’ suffering (SEGO, 2021; Cassidy, 2018; Hernández-Garre et al., 2017), a trend that may be reflected in this study. 10 Attitudes and practices related to the birth and follow-up areas were the ones with more mismatch with international recommendations, maybe the more clinical and technical areas of care. That is why we agree with other authors in that some of the most specific aspects of intrauterine foetal death treatment seem to have been neglected by HCPs (Fernández-Alcántara et al., 2020; Ravaldi et al., 2018; Steen et al., 2015). However, such a finding disagrees with the studies evidencing how care providers usually feel more confident with biological care, treatment of physical aspects that are so common in such situations, as opposed to psychological or psychosocial care (FernándezBasanta et al., 2021; Fernández-Alcántara et al., 2020; Martínez-Soriano, et al., 2018; HernándezGarre et al., 2017, Ellis et al., 2016). With respect to variables related to a higher degree of compliance, we observe that midwives adapted, to a larger extent, to standards when it comes to respect, creation of memories and followup, three of the four areas analyzed. In Spain, midwives and nurses, as compared to physicians, usually have subordinate positions associated with traditional care and support roles (Cassidy, 2022), and nurses may believe that certain interventions when addressing perinatal death and bereavement are not part of their responsibility (Steen et al., 2015), which requires further investigation. On the other hand, it is striking that midwives do not show a higher level of compliance in the birth area, both for their specialization and for having duties that are related to such task in the Spanish health system. These results reaffirm the need for continued and updated training on the best practices to address perinatal bereavement among HCPs involved, as vigorously asserted in literature (Aggaral and Moati, 2022; Atkins et al., 2022; Fernández-Alcántara et al., 2020; Gandino et al. 2019, Bakhabakhi et al., 2017, De Bernis et al, 2016). Having received specific training on perinatal bereavement and having experienced such situation personally were associated with better adaptation to the respect and creation of memories areas. Significant learning, or that reached through experience, seems to make it easier for professionals to acquire the appropriate skills to address such a complex situation, mainly for self-management of feelings that, to a great extent, determine their attitudes and behavior in the most emotional or psychological areas of care (Martínez-Soriano et al., 2018; Hernández- Garre et al, 2017, Heazell et al., 2016; Nuzum et al., 2014). In fact, professional training exclusively based on academic knowledge has proven to be quite ineffective when it comes to facing grieving parents’ emotional needs (Siassakos et al., 2028; Gondino et al., 2019), the most appreciated ones (Cassidy, 2022; Redshaw et al., 2021; Horey et al., 2021; Nuzum et al., 2018; Peters et al., 2016). Being a woman was related to 100% compliance with recommendations in the creation of memories and follow-up areas. Martínez-Soriano et al. did not find any gender-based differences 11 among midwives regarding sensitization toward perinatal death (Martínez-Soriano et al., 2018), but they seem to exist in their behavior. In fact, there exists evidence documenting strong interactions of this variable with a wide range of interventions carried out by health care providers during their clinical practice (Neugut et al., 2022; Eggermont et al., 2018). Therefore, we suggest the incorporation of a gender-based perspective as a future line of research on perinatal death and bereavement. Finally, it is worth noting that the findings of this study not only require training and research to improve the training and support of HCPs facing such losses, but also care guidelines or Clinical Practice Guidelines based on better tests, culturally specific and adapted to our context, as recommended at worldwide level (Flenady and Boyle, 2020; Zhuang et al., 2022). Furthermore, our perinatal mortality rates, above the national mean, demand that, on a frequently basis, variability be identified, as well as adaptation of health practices performed after death, but it is essential to do so during pregnancy, to try to prevent it, through local audits and specific care programs (Norris et al., 2017; Andrews, et al., 2020; Winddons et al., 2018). Strengths and limitations The cross-sectional design of the study has allowed a global approach to the current reality of nurses and midwives in the Granada province who take care of families going through perinatal bereavement. Since it is an exploratory study, no power calculations have been made, although the univariate analysis allowed us to identify some HCPs’ individual factors related to higher compliance with international recommendations, which are consistent with literature. The internal validity of the study may be deemed adequate, based on its good acceptance among the professionals involved, and even the external validity, to infer the public maternity hospitals results in the province, when involving all of them. In addition, such results may be extrapolated to other similar provinces since we have counted with big university hospitals and small non-university hospitals (with less than 200 beds) which are the most common in Spain and are underrepresented in this type of studies (Power et al., 2022; Christou et al., 2021; Munin et al., 2021; Camacho-Avila, 2020). When accessing primary sources, formed by health care providers, and after having guaranteed the voluntary and anonymous nature of participants, any information bias was minimized. Although the questionnaire data have not been completed with a qualitative analysis, and have not been compared with clinical records nor with the satisfaction of women and families attending such centers to observe their convergence, studies previously conducted in our environment reported the existence of such deficiencies (Fernández-Alcántara et al, 2020; 12 Camacho-Avila et al., 2020; Martínez-Soriano et al., 2018; Hernández-Garre et al, 2017; Steen et al., 2015). Due to the selection of midwives and nurses sharing care tasks, the answers may be more homogeneous than those observed in other studies where more professional categories participated (Fernández-Alcántara et al., 2020, Ravaldi et al., 2018; Martínez-Soriano et al., 2018). Nevertheless, we are aware that they also have very different responsibilities depending on their working environment and the moment of the process the family is going through (Hutti et al., 2016, McCreight, 2005). Furthermore, since this is not a representative sample of the HCPs having contact, or that may have it, with families during their perinatal death experience in hospitals or primary care centers, including students and non-technical personnel (Aggarwal and Moatti, 2022), we cannot extrapolate the results to other members of the care team. Assessing adaptation of interventions to international recommendations, both by midwives and nurses independently, and by other care providers, and in different contexts, will help broaden our knowledge in this area. CONCLUSION The findings of this study point out certain deficiencies in the adaptation of midwives’ and nurses’ interventions to international standards on perinatal death and bereavement care in the Granada province and, consequently, areas of improvement. However, the compliance levels observed are, in general, more favorable than those published in geographic areas near our environment, and they seem to confirm certain transitions to health approaches more focused on the psychosocial aspects of care. Still, given the current interest in measuring the quality of care, and considering the impact of perinatal mortality on our province, bridging such gaps requires training and sensitization resources, whose design could take into account, among other factors, HCPs’ professional category, gender, previous training level, and personal experience in perinatal bereavement. 13 Table 1 Sociodemographic characteristics and background by professional category (N=117) Midwives n (%) 79 (67.5) Nurses n (%) 38 (32.5) Total n (%) 117 (100) p value Age (years) (Mean (SD)) 41.52 (12.24) 40.03 (9.78) 40.98 (11.47) 0.533 Work experience (years) (Mean (SD)) 18.46 (11.36) 15.42 (9.55) 17.47 (10.86) 0.158 Gender Male 6 (7.6) 7 (18.4) 13 (11.1) 0.081 Female 73 (92.4) 31 (81.6) 104 (88.9) Studies achieved Postgraduate 32 (40.5) 17 (44.7) 49 (41.9) 0.664 Others 47 (59.5) 21 (55.3) 68 (58.1) Training in stillbirth Yes 68 (86.1) 19 (50) 87 (74.4) <0.001 No 11 (13.9) 19 (50) 30 (25.6) Professional experience in stillbirth Yes 9 (11.4) 8 (21.1) 17 (14.5) 0.165 No 70 (88.6) 30 (78.9) 100 (85.5) Cases of stillbirth taken care of ≤ 5 24 (30.8) 17 (44.7) 72 (61.5) 0.010 > 5 55 (69.6) 21 (55.3) 45 (38.5) Abbreviation: SD: Standard deviation. Table 2 Attitudes of HCPs toward parents and stillborn babies How can HCPs help parents after a stillbirth Yes n (%) No n (%) Do not know n (%) Allowing the couple to stay together (n=111) 110 (94) 0 (0) 1 (0.9) Explaining all possible procedures (n=113) 97 (82.9) 7 (6) 9 (7.7) Providing one-to-one assistance (n=112) 96 (57.3) 21 (17.9) 22 (18.8) Delivering as soon as possible (n=110) 67 (57.3) 21 (17.9) 22 (18.8) Washing, dressing, and preparing the baby anyway (n=106) 55 (47) 26 (22.2) 25 (21.4) Immediately taking the baby away if parents do not want to see it (n=107) 58 (49.6) 30 (25.6) 19(16.2) Creating an intimate and comfortable environment (n=112) 112 (95.7) 0 (0) 0 (0) Providing accompaniment and support(n=111) 108 (92.3) 1 (0.9) 3 (2.6) Providing information on what is happening (n=112) 106 (90.6) 4 (3.4) 2 (1.7) Listening empathetically (n=113) 111 (94.9) 2 (1.7) 0 (0) Involving them in decision making (n=109) 98 (83.8) 4 (3.4) 7 (6) Presence of the partner (n=112) 108 (92.3) 1 (0.9) 3 (2.6) Presence of relatives (n=111) 39 (33.3) 25 (21.4) 47 (40.2) Abbreviation: HCPs: health care providers. 14 Table 3. Practices and strategies of HCPs when dealing with stillbirth Which is the most suitable type of delivery in case of stillbirth? Yes n (%) No n (%) Do not know n (%) Vaginal delivery (n=107) 95 (81.2) 2 (1.7) 10 (8.5) Induced labor (n=106) 68 (58.1) 7 (6) 31 (26.5) Caesarean section (n=99) 4 (3.4) 79 (67.5) 16 (13.7) Use of analgesia during labor (n=108) 82 (70.1) 3 (2.6) 23 (19.7) Use of sedatives during labor (n=101) 31 (26.5) 43 (36.8) 27 (23.1) What are the best strategies to help parents cope with grief and loss? Yes n (%) No n (%) Do not know n (%) Supporting mothers during labor/delivery (n=112) 109 (93.2) 3 (2.6) 0 (0) Shortening the length of stay (n=107) 87 (74.4) 10 (8.5) 10 (8.5) Letting the couple with the baby for as long as they need (n=113) 105 (89.7) 4 (3.4) 4 (3.4) Taking pictures of the babies as mementos (n=118) 68 (58.1) 13 (11.1) 27 (23.1) What are the best ways that HCPs can offer adequate support to the family in the postpartum? Yes n (%) No n (%) Do not know n (%) Refer to psychology/mental health (n=108) 71 (60.7) 11 (9.4) 26 (22.2) Provide a follow-up appointment to parents (n=114) 107 (91.5) 1 (0.9) 6 (5.1) Offer resources for self-management of grief (n=108) 99 (84.6) 3 (2.6) 6 (5.1) Suggest a self-help group (n=112) 67 (57.3) 43 (36.8) 2 (1.7) Recommend a new pregnancy as soon as possible (n=114) 12 (10.3) 52 (44.4) 50 (42.7) Abbreviation: HCPs: health care providers. Table 4. Number of perinatal HCPs complying with the International Guidelines in each section (N=117) HCP aware of guidelines recommendation n (%) Less than 80% Aware of at least 80% Aware of all items Respect for baby and parents 36 (30.76) 32 (27.4) 49 (41.9) Birth options 38 (32.47) 67 (57.3) 12 (10.3) Creating memories 31 (26.49) 18 (15.4) 68 (58.1) Aftercare 54 (46.15) 35 (29.9) 28 (23.9) Abbreviation: HCPs: health care providers. 15 Table 5. Factors associated with 100% of recommendations in each section Respect 100% Birth 100% Mementos 100% Follow-up 100% Yes No p value Yes No p value Yes No p value n (%) n (%) n (%) n (%) n (%) n (%) n (%) Gender Male 2 (4.1) 11 (16.2) 0.070 1 (8.3) 12 (11.4) 1.000 4 (5.9) 9 (18.4) 0.041 0 (0) 13 (14.6) 0.036 Female 47 (95.9) 57 (83.8) 11 (91.7) 93 (88.6) 64 (94.1) 40 (81.6) 28 (100) 76 (85.4) Age ≤ 40 26 (53.1) 34 (50) 0.852 5 (41.7) 55 (52.4) 0.552 39 (57.4) 21 (42.9) 0.137 19 (67.9) 41 (46.1) 0.053 >40 23 (46.9) 34 (50) 7 (58.3) 50 (47.6) 29 (42.9) 28 (57.1) 9 (32.1) 48 (53.9) Professional Category Nurse 7 (14.3) 31 (45.6) <0.001 2 (16.7) 36 (34.3) 0.332 12 (17.6) 26 (53.1) <0.001 2 (7.1) 36 (40.4) 0.001 Midwife 42 (85.7) 37 (54.4) 10 (83.3) 69 (65.7) 56 (82.4) 23 (46.9) 26 (92.9) 53 (59.6) Training on PB Yes 43 (7.8) 44 (64.7) 0.005 11 (91.7) 76 (72.4) 0.292 60 (88.2) 27 (55.1) <0.001 24 (85.7) 63 (70.8) 0.141 No 6 (12.2) 24 (35.3) 1 (8.3) 29 (27.6) 8 (11.8) 22 (44.9) 4 (14.3) 26 (29.2) Cases taken care of ≤ 5 18 (36.7) 27 (39.7) 0.848 2 (16.7) 43 (41) 0.126 25 (36.8) 20 (40.8) 0.703 11 (39.3) 34 (38.2) 1.000 >5 31 (63.3) 41 (60.3) 10 (83.3) 62 (59) 43 (63.2) 29 (59.2) 17 (60.7) 55 (61.8) Time worked ≤16 25 (51) 36 (52.9) 0.853 6 (50) 55 (52.4) 1.000 38 (55.9) 23 (46.9) 0.355 18 (64.3) 43 (48.3) 0.193 >16 24 (49) 32 (47.1) 6 (50) 50 (47.6) 30 (44.1) 26 (53.1) 10 (35.7) 46 (51.7) PB own experience Yes 3 (6.1) 14 (20.6) 0.034 0 (0) 17 (16.2) 0.210 3 (4.4) 14 (28.6) <0.001 4 (14.3) 13 (14.6) 1.000 No 46 (93.9) 54 (79.4) 12 (100) 88 (83.8) 65 (95.6) 35 (71.4) 24 (85.7) 76 (85.4) Abbreviation: PB: Perinatal bereavement. 16 REFERENCES Abiola, L., Legendre, G., Spiers, A., et al., 2022. Late fetal demise, a risk factor for post-traumatic stress disorder. Scientific Reports 12, 12364. doi: 10.1038/s41598-022-16683-5. Aggarwal, N., Moatti, Z., 2022. “Getting it right when it goes wrong – Effective bereavement care requires training of the whole maternity team”. Best Practice & Research Clinical Obstetrics & Gynaecoly 80, 92-104. doi: 10.1016/j.bpobgyn.2021.10.008. Aileen, M., Trish, W.,2014. Pregnancy loss in rural Ireland: an experience of Disenfranchised grief. British Journal of Social Work, 2290–306. Aiyelaagbe, E., Scott, R.W., Holmes, V., et al., 2017. Assessing the quality of bereavement care after perinatal death: development and piloting of a questionnaire to assess parents’ experiences. Journal of Obstetrics & Gynaecology 37, 931-936. https://doi.org/10.1080/01443615.2017.1316710 Al-Maharma, D.Y., Abujaradeh, H., Mahmoud, K.F., et al., 2016. Maternal grieving and perception of and attachment to children born subsequent to a perinatal loss. Infant Mental Health Journal 37, 411–23. Andrews, C.J., Ellwood, D., Middleton, P.F., et al., 2020. Safer Baby Bundle collaborators. Implementation and evaluation of a quality improvement initiative to reduce late gestation stillbirths in Australia: Safer Baby Bundle study protocol. BMC Pregnancy Childbirth 20, 694. doi: 10.1186/s12884-020-03401-0. Arach, A., Kiguli, J., Nankabirwa, V., et al., 2022. “Your heart keeps bleeding”: lived experiences of parents with a perinatal death in Northern Uganda. BMC Pregnancy & Childbirth 22, 491. https://doi.org/10.1186/s12884-022-04788-8. Atkins, B., Blencowe, H., Boyle, F.M., et al., 2022. Is care of stillborn babies and their parents respectful? Results from an international online survey. BJOG: An Internacional Journal of Obstetric & Gynaecology 129,1731-1739. doi: 10.1111/1471-0528.17138. Bakhbakhi, D., Burden, C., Storey, C. et al., 2017. Care following stillbirth in high-resource settings: Latest evidence, guidelines, and best practice points. Seminars in Fetal & Neonatal Medicine 22, 161-166. doi: 10.1016/j.siny.2017.02.008. Beaudoin, M.A., Ouellet N, 2018. An exploration of factors influencing nursing practice with families experiencing perinatal loss. Recherche en Soins Infirmiers 133, 58-69. doi: 10.3917/rsi.133.0058. 17 Ben-Ezra, M., Palgi, Y., Walker, et al., 2014. The impact of perinatal death on obstetrics nurses: a longitudinal and cross-sectional examination. Journal of Perinatal Medicine 42,75-81. doi: 10.1515/jpm-2013-0071. PMID: 24062545. Brierley-Jones, L., Crawley, R., Jones, E., et al., 2018. Supporting parents through stillbirth: A qualitative study exploring the views of health professionals and health care staff in three hospitals in England. European Journal of Obstetrics & Gynecology & Reproductive Biology 222, 45-51. https://doi.org/10.1016/j.ejogrb.2018.01.007. Burden, C., Bradley, S., Storey, C. et al., 2016. From grief, guilt pain and stigma to hope and pride – a systematic review and meta-analysis of mixed-method research of the psychosocial impact of stillbirth. BMC Pregnancy Childbirth 16, 9. doi: 10.1186/s12884-016-0800-8. Cacciatore, J., 2010. Stillbirth: patient-centered psychosocial care. Clinical Obstetrics & Gynecology 53, 691-699. doi: 10.1097/GRF.0b013e3181eba1c6. Cacciatore, J., Thieleman, K., 2019. Normal complications and abnormal assumptions after perinatal death. MCN American Journal of Maternal/Child Nursing 44, 6-12. doi: 10.1097/NMC.0000000000000486.J. Camacho-Ávila, M., Fernández-Medina, I.M., Jiménez-López F.R., et al., 2020. Parents’ experiences about support following stillbirth and neonatal death. Advances in Neonatal Care. 20,151-160. doi: 10.1097/ANC.0000000000000703. PMID: 31917696. Cassidy, P.R., 2018. Care quality following intrauterine death in Spanish hospitals: results from an online survey. BMC Pregancy Childbirth, 18:22. https://doi.org/10.1186/s12884-017-1630-z Cassidy, P.R., 2022. Beyond emotional support: predictors of satisfaction and perceived care quality following the death of a baby during pregnancy. Journal of Perinatal Medicine 50,832- 843. doi: 10.1515/jpm-2021-0489. Christou, A., Alam, A., Hofiani, S.M.S., et al., 2021. ‘I should have seen her face at least once’: parent’s and healthcare providers’ experiences and practices of care after stillbirth in Kabul province, Afghanistan. Journal of Perinatology 41, 2182-2195. doi: 10.1038/s41372-020-00907- 5. De Bernis, L., Kinney, M.V., Stones, W., et al., 2016. Stillbirths: ending preventable deaths by 2030. Lancet 387, 703-716. 18 Eggermont, D., Smit, M.A.M., Kwestroo, G.A., et al.,2018. The influence of gender concordance between general practitioner and patient on antibiotic prescribing for sore throat symptoms: a retrospective study. BMC Family Practice 19, 175. doi: 10.1186/s12875-018-0859-6. Ellis, A., Chebsey, C., Storey C., et al., 2016. Systematic review to understand ad improve care after stillbirth: a review of parents’ and healthcare professionals’ experiences. BMC Pregnancy Childbirth 16:1-19. http://doi.org/10.1186/s12884-016-0806-2. Euro-Peristat Project, 2018. Core indicators of the health and care of pregnant women and babies in Europe in 2015. European Perinatal Health Report. https://www.europeristat.com/index.php/reports/european-perinatal-health-report-2015.html. Fenwick, J., Jennings, B., Downie, J., et al., 2007. Providing perinatal loss care: satisfying and dissatisfying aspects for midwives. Women Birth 20, 153-60. doi: 10.1016/j.wombi.2007.09.002. Fernández-Alcántara, M., Schul-Martin, L., García-Caro, M.P., et al., 2020. ‘In the hospital there are no care guidelines’: experiences and practices in perinatal loss in Spain. Scandinavian Journal of Caring Sciences 34, 1063-1073. doi: 10.1111/scs.12816. Fernández-Basanta, S., Movilla-Fernández, M.J., Coronado, C., et al., 2020. Involuntary Pregnancy Loss and Nursing Care: A Meta-Ethnography. International Journal of Environmental Research & Public Health 17, 1486. doi: 10.3390/ijerph17051486. Fernández-Sola, C., Camacho-Ávila, M., Hernández-Padilla ,J.M., et al., 2020. Impact of perinatal death on the social and family context of the parents. International Journal of Environmental Research & Public Health 17,3421. doi:103390/ijerph17103421. Flenady, V., Boyle, F.M., 2020. Towards respectful supportive care after stillbirth for every woman. BJOG: An International Journal of Obstetrics & Gynaecology 128, 110. doi: 10.1111/1471- 0528.16455. Gandino, G., Anfossi, M., Vanni, I., et al., 2014. Perinatal loss from the health workers point of view: Perception and reaction to an unexpected and potentially traumatic event. Minerva Psichiatrica 55, 57–68. Gandino, G., Bernaudo, A., Di Fini, G., Vanni, I., et al., 2019. Healthcare professionals’ experiences of perinatal loss: A systematic review. Journal of Health Psychology 24, 65–78. https://doi.org/10.1177/1359105317705981. Gold, K.J., Leon, I., Boggs, M.E., et al., 2016. Depression and posttraumatic stress symptoms after perinatal loss in a population-based sample. Journal of Women´s Health 25,263–9. 19 Gunnarsdottir, J., Stephansson, O., Cnattingius, S., et al., 2014. Risks of placental dysfunction disorders after prior miscarriages: a population based study. American Journal of Obstetrics & Gynaecoly 211, e1 -8. doi: 10.1016/j.ajog.2014.01.041. Heazell, A.E.P., Siassakos, D., Blencowe, H., et al., 2016. Stillbirths: economic and psychosocial consequences. Lancet 387,604–16. doi:10.1016/S0140-6736(15)00836-3. Helps, Ä., O’Donoghue, K., O’Byrne, L., et al., 2020. Impact of bereavement care and pregnancy loss services on families: Findings and recommendations from Irish inquiry reports. Midwifery, 91, 102841. https://doi.org/10.1016/j.midw.2020.102841 Hernández-Garre, J. M., Sánchez- Sánchez F.C, Echevarría-Pérez, P., 2017. “Alumbrando la muerte. Profesionales de la vida gestionando el duelo”. Revista Internacional de Sociología, 75 , e070. doi: http://dx.doi.org/10.3989/ris.2017.75.3.15.189 Horey, D., Boyle, F., Cassidy, J., et al., 2021. Parents’ experiences of care offered after stillbirth: an international online survey of high and middle-income countries. Birth. 48,366–74. Hutti, M.H., Armstrong, D.S., Myers, J.A. et al., 2015. Grief intensity, psychological well-being, and the intimate partner relationship in the subsequent pregnancy after a perinatal loss. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 44, 42–50. https://doi.org/10.1111/1552- 6909.12539JOGNN 44, 42–50. Hutti, M. H., Polivka, B., White, S., et al., 2016. Experiences of nurses who care for women after fetal loss. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 45, 17–27. Kalu, F., Coughlan, B., Larkin, P, 2018. A mixed methods sequential explanatory study of the psychosocial factors that impact on midwives’ confidence to provide bereavement support to parents who have experienced a perinatal loss. Midwifery 64, 69–76. doi:10.1016/j.midw.2018.06.011. Kalu, F., Larkin P., Coughlan B., 2020. Development, validation and reliability testing of “Perinatal Bereavement Care Confidence Scale (PBCCS). Women & Birth: Journal of the Australian College of Midwives 33, e311-e319. Kelley, M.C., Trinidad, S.B., 2012. Silent loss and the clinical encounter: Parents’ and physicians’ experiences of stillbirth-a qualitative analysis. BMC pregnancy and childbirth, 12, 137. https://doi.org/10.1186/1471-2393-12-137. 20 Kelly, K., Meaney, S., Leitao, S., et al., 2021. A review of stillbirth definitions: A rationale for change. European Journal of Obstetrics, Gynecology, & Reproductive Biology 256, 235–245. https://doi.org/10.1016/j.ejogrb.2020.11.015 Lawn, J.E., Blencowe, H., Waiswa, P., et al., 2016. Stillbirths: Rates, risk factors, and acceleration towards 2030. Lancet 387, 587-603. doi: 10.1016/S0140-6736(15)00837-5. Lee, C., 2012. ‘She was a person, she was here’: The experience of late pregnancy loss in Australia, Journal of Reproductive and Infant Psychology 1, 62-76. doi: 10.1080/02646838.2012.661849. Martínez-Serrano, P., Palmar-Santos, A.M., Solís-Muñoz, M., et al., 2018. Midwives’ experience of delivery care in late fetal death: a qualitative study. Midwifery 66, 127-133. https://doi.org/10.1016/j.midw.2018.08.010 Martínez-Serrano, P., Pedraz-Marcos, A., M. Solís-Muñoz, M., et al., 2019. The experience of mothers and fathers in cases of stillbirth in Spain. A qualitative study. Midwifery 77, 37-44. https://doi.org/10.1016/j.midw.2019.06.013 Marwah, S., Gaikwad, H.S., Mittal, P,2019. Psychosocial implications of stillborn babies on mother and family: A review from tertiary care infirmary in India. Journal of obstetrics and gynaecology of India, 69(3), 232–238. https://doi.org/10.1007/s13224-018-1173-x. McCreight, B.S., 2005. Perinatal grief and emotional labour: a study of nurses’ experiences in gynae wards. International Journal of Nursing Studies, 42(4), 439–448. https://doi.org/10.1016/j.ijnurstu.2004.07.004. Meaney, S., Corcoran, P., Spillane, N., et al., 2017. Experience of miscarriage: an interpretative phenomenological analysis. BMJ Open, 7, e011382. https://doi.org/10.1136/bmjopen-2016- 011382. Meredith, P., Wilson, T., Branjerdporn, G., et al., 2017. “Not just a normal mum”: a qualitative investigation of a support service for women who are pregnant subsequent to perinatal loss. BMC Pregnancy & Childbirth, 17, 6. https://doi.org/10.1186/s12884-016-1200-9 Muin, D.A., Erlacher, J. S., Leutgeb, S., et al., 2021. Facilitators and Strategies for Breaking the News of an Intrauterine Death-A Mixed Methods Study among Obstetricians. Journal of Clinical Medicine, 10, 5347. https://doi.org/10.3390/jcm10225347. 21 National Bereavement Care Pathway for pregnancy and baby loss, 2020. Progress report June 2020. https://nbcpathway.org.uk/sites/default/files/2020- 07/NBCP_ProgressReport_Jun20_FINAL.pdf. National Bereavement Care Pathway for pregnancy and baby loss. Bereavement Care Standards, 2018. https://nbcpathway.org.uk/nbcp-standards. Neugut, A.I., MacLean, S.A., Dai, W.F., et al., 2019. Physician characteristics and decisions regarding cancer screening: A systematic review. Population Health Management 22 48–62. https://doi.org/10.1089/pop.2017.0206 Norris, T., Manktelow, B. N., Smith, L. K., et al., 2017. Causes and temporal changes in nationally collected stillbirth audit data in high-resource settings. Seminars in Fetal & Neonatal Medicine 22, 118–128. https://doi.org/10.1016/j.siny.2017.02.003. National Standards for Bereavement Care Following Pregnancy Loss and Perinatal Death, 2016. Health Service Executive. https://www.hse.ie/eng/services/list/3/maternity/bereavementcare/national-standards-for-bereavement-care-following-pregnancy-loss-and-perinataldeath.pdf Nuzum, D., Meaney, S., O’Donoghue, K., 2014. The impact of stillbirth on consultant obstetrician gynaecologists: a qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology 121, 1020–1028. https://doi.org/10.1111/1471-0528.12695. Nuzum, D., Meaney, S., O’Donoghue, K., 2018. The impact of stillbirth on bereaved parents: A qualitative study. PloS One, 13, e0191635. https://doi.org/10.1371/journal.pone.0191635. O’Connell, O., Meaney, S., O’Donoghue, K., 2016. Caring for parents at the time of stillbirth: How can we do better?. Women & Birth: Journal of the Australian College of Midwives 29, 345–349. https://doi.org/10.1016/j.wombi.2016.01.003. Perinatal Society of Australia and New Zeeland (PSANZ). Clinical Practice Guideline for Care Around Stillbirth and Neonatal Death, 2019. https://www.stillbirthcre.org.au/resources/clinicalpractice-guidelines/. Pollock, D., Ziaian, T., Pearson, E., et al., 2020. Understanding stillbirth stigma: A scoping literature review. Women & Birth: Journal of the Australian College of Midwives 33, 207–218. https://doi.org/10.1016/j.wombi.2019.05.004. 22 Pollock, D.D., Pearson, D.E., Cooper, D.M., et al., 2021. Breaking the silence: Determining prevalence and understanding stillbirth stigma. Midwifery, 93, 102884. https://doi.org/10.1016/j.midw.2020.102884. Peters, M., Lisy, K., Riitano, D., et al., 2016. Providing meaningful care for families experiencing stillbirth: a meta-synthesis of qualitative evidence. Journal of Perinatology: Official Journal of the California Perinatal Association 36, 3–9. https://doi.org/10.1038/jp.2015.97. Power, A., Atkinson, S., Noonan, M., 2022. “Stranger in a mask” midwives’ experiences of providing perinatal bereavement care to parents during the COVID-19 pandemic in Ireland: A qualitative descriptive study. Midwifery 111, 103356. https://doi.org/10.1016/j.midw.2022.103356. Qian, J., Sun, S., Wu, M., et al., 2021. Preparing nurses and midwives to provide perinatal bereavement care: A systematic scoping review. Nurse Education Today 103, 104962. https://doi.org/10.1016/j.nedt.2021.104962. Ravaldi, C., Levi, M., Angeli, E., et al., 2018. A. Stillbirth and perinatal care: are proffesisionales trained to address parents´needs?. Midwifery 64. 53-59. https://doi.org/10.1016/j.midw.2018.05.008. Redshaw, M., Henderson, J., Bevan, C., 2021. ‘This is time we’ll never get back’: a qualitative study of mothers’ experiences of care associated with neonatal death. BMJ Open 11, e050832. https://doi.org/10.1136/bmjopen-2021-050832. Sociedad Española de Ginecología y Obstetricia, 2021. Guía de asistencia en la muerte perinatal. Progresos de Obstetricia y Ginecología: Revisita Oficial de la Sociedad Española de Ginecología y Obstetricia 64:124-154. https://sego.es/documentos/progresos/v64-2021/n3/04- Guia_de_asistencia_en_la_muerte_perinatal.pdf Sereshti, M., Nahidi, F., Simbar, M.,et al., 2016. Mothers’ perception of quality of services from Health Centers after perinatal loss. Electronic physician 8, 2006–2017. https://doi.org/10.19082/2006 Siassakos, D., Jackson, S., Gleeson, K., et al.,, & INSIGHT Study Group, 2018. All bereaved parents are entitled to good care after stillbirth: a mixed-methods multicentre study (INSIGHT). BJOG: An International Journal of Obstetrics & Gynaecology 125, 160–170. https://doi.org/10.1111/1471-0528.14765. Shakespeare, C., Merriel, A., Bakhbakhi, D., et al., 2019. Parents’ and healthcare professionals’ experiences of care after stillbirth in low- and middle-income countries: a systematic review and 23 meta-summary. BJOG: An International Journal of Obstetrics & Gynaecology 126, 12–21. https://doi.org/10.1111/1471-0528.15430 Shakespeare, C., Merriel, A., Bakhbakhi, D., et al., & RESPECT (Research of Evidence based Stillbirth care Principles to Establish global Consensus on respectful Treatment) working group, 2020. The RESPECT Study for consensus on global bereavement care after stillbirth. International Journal of Gynaecology & Obstetrics: The official organ of the International Federation of Gynaecology & Obstetrics, 149, 137–147. https://doi.org/10.1002/ijgo.13110. Statistics National Institute [Instituto Nacional de Estadística], 2022. Gobierno de España. Estadística de nacimientos, Movimiento natural de población. https://ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736177007&menu =resultados&idp=1254735573002#!tabs-1254736195442. Steen S.E., 2015. Perinatal death: bereavement interventions used by US and Spanish nurses and midwives. International Journal of Palliative Nursing 21, 79–86. https://doi.org/10.12968/ijpn.2015.21.2.79 Sundermann, A.C., Hartmann, K.E., Jones, S.H., et al, 2017. Interpregnancy interval after pregnancy loss and risk of repeat miscarriage. Obstetrics & Gynecology 130, 1312–1318. https://doi.org/10.1097/AOG.0000000000002318. UNICEF, WHO, UNFPA, 2017. Managing complications in pregnancy and childbirth 2nd Ed. World Health Organization (publisher), Geneve (CH) http://www.who.int/ maternal_child_adolescent/documents/managing-complications-pregnancy- childbirth/en/. van Aerde J, Gorodzinsky FP, Canadian Paediatric Society, Fetus and Newborn Committee. Guidelines for health care professionals supporting families experiencing a perinatal loss, 2001. Paediatrics & Child Health 6, 469–490. World Health Organization. Every Newborn Plan, 2018. https://www.who.int/maternal_child_adolescent/documents/every-newborn-action-plan/en/ World Health Organization Newborn mortality, 2022. https://www.who.int/news-room/factsheets/detail/levels-and-trends-in-child-mortality-report2021#:~:text=Globally%202.4%20million%20children%20died,up%20from%2040%25%20in% 201990. 24 Zhuang, S., Ma, X., Xiao, G., et al., 2022. Clinical practice guidelines for perinatal bereavement care: A systematic quality appraisal using AGREE II instrument. Journal of pediatric Nursing 66, 49–56. Advance online publication. https://doi.org/10.1016/j.pedn.2022.04.007. Wallbank, S., Robertson, N., 2013. Predictors of staff distress in response to professionally experienced miscarriage, stillbirth and neonatal loss: a questionnaire survey. International journal of nursing studies, 50(8), 1090–1097. https://doi.org/10.1016/j.ijnurstu.2012.11.022. Westby, C.L., Erlandsen, A.R., Nilsen, S.A., et al., 2021. Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review. BMC Pregnancy and Childbirth, 21, 782. https://doi.org/10.1186/s12884-021-04254-x. Widdows, K., Reid, H. E., Roberts, S. A., et al., 2018. Saving babies’ lives project impact and results evaluation (SPiRE): a mixed methodology study. BMC Pregnancy and Childbirth, 18, 43. https://doi.org/10.1186/s12884-018-1672-x. Supplementary Material Click here to access/download Supplementary Material 5. appendix 1.doc