An Alternative View on Mothers Holding Stillborn Babies

This letter reflects an additional viewpoint regarding the Medscape Medical News article, "Mothers Should Not Be Forced to View, Hold Stillborn Babies."

The experience of grief is both a personal and a cultural phenomenon. While the study reported reflects the evaluation of a procedure in the United Kingdom, it does so within a specific cultural context, with existing public policies. As noted in the Medscape news article, study limitations of sample size, lack of randomization, between-group differences, and inclusion of other variables of significance are reasons to limit the applicability of study findings.

By highlighting several key issues of concern to women who are affected by loss from stillbirth, it is possible to see the limitations of this study to practice and public policy in the United States. First, there is the issue of matched controls. In the study, first-time mothers are used in a comparison group. This is contrary to the actual experience of women in the experimental study group; the women who are experiencing stillbirth have also experienced the totality of pregnancy and anticipated childbirth that is unknown to first-time mothers. In stillbirth, the outcome is that the mothers do not leave the hospital with a living child; however, the process of pregnancy itself has transformed the psychosocial knowledge and awareness of these women even apart from the experience of loss.

Second, grief theory suggests that perinatal loss and the death of a child, including stillbirth, meets the criterion for complicated mourning (Rando, 1993 and 1986). In addition, empirical studies have demonstrated that 48% to 51% of women were clinically depressed 1-3 months following a miscarriage (Lee, Wong, Ungvari, Cheung, Haines & Chung, 1997) and that perinatal loss has a lasting component much longer than merely the initial few months following the loss (Dyregrov & Dyregrov, 1999). By its nature, perinatal loss appears to produce increased depression, anxiety, and trauma. This may be heightened by social isolation, stress, and factors intrinsic to maternal bonding during pregnancy, unique within each relationship and situation. These same factors may significantly impact the parents' immediate wishes to or not to hold, see, or memorialize following a stillbirth.

While this study views these factors as signs of pathology, knowledge of the grief experience would suggest they are normal following stillbirth, throughout the first year, and beyond for some individuals. In the experience of grief, our individual, familial, and cultural perceptions of how "normal grief" is expressed may influence the ability to objectively study the grief of others and, especially, to generalize that to a larger setting. Clinicians attempt to account for these differences in a nonjudgmental, nonpathologizing manner in order to respect individual and cultural diversity.

As a clinician, I know and anticipate that my clients who experience perinatal loss will experience some degree of depression, anxiety, and trauma. Furthermore, I expect that the first year and the subsequent pregnancy are the peak, and appropriate, times for these reactions to occur and to be dealt with because it allows for the development of healthy and adaptive coping mechanisms. Attachment to subsequent children is an entirely new and different learning experience. What is more difficult to ascertain are the long-term reactions that delayed trauma can produce years beyond such a loss. My concern is that those reporting "favorable outcomes" in this study may be doing so a year past the loss...but may not be doing so long term, even 5 or 10 years later. There is also no accounting for the degree of social support, culturally normative responses, or individual coping mechanisms, and prior losses that may have been encountered by participants in this study, which may greatly impact the results and interpretation. Longitudinal follow-up is certainly needed before policy recommendations are made.

Finally, and perhaps most significantly, is the measure not reflected in the study's implications: perception of choice. In this study, some parents made a choice in their end-of-life wishes, and others felt forced to take an action during a traumatic time that they were unprepared to make. Perhaps what is in question is not the seeing, the holding, or the funeral. Perhaps instead, it is the ability of the parent(s) to have been given some sense of choice and control in an otherwise chaotic and uncontrollable time. By encouraging dialogue and consideration of options and allowing the bereaved to make a choice that is appropriate for her, it is hoped that adaptive adjustment will continue to occur in the coming years. Clinicians who encourage women to actively choose ways of memorializing may also afford these women the opportunity to experience less regret and anguish than would occur if options were unavailable as a result of policy limiting maternal choices.

In summary, this study represents a specific evaluation of a specific public policy in a specific cultural setting. I do not feel it constitutes empirically supported evidence around which healthcare decisions or policies should be based. By approaching the bereaved with compassion and allowing them to make a choice about the way in which this end-of-life experience is recognized, we may instill in women a sense of choice that has far reaching implications for their long-term mental health and well-being. Further study on this important issue and its long-term implications is warranted.

Sarah Kye Price, MSW
NIMH Predoctoral Fellow
Washington University
St. Louis, Missouri

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