Predicting pregnancy loss and its determinants among reproductive-aged women using supervised machine learning algorithms in Sub-Saharan Africa

Background

Pregnancy loss is a significant public health issue globally, particularly in Sub-Saharan Africa (SSA), where maternal health outcomes continue to be a major concern. Despite notable progress in improving maternal health, pregnancy-related complications, including s due to miscarriages, stillbirths, and induced abortions, continue to impact women's health, social wellbeing, and economic stability in the region. This study aims to identify the key predictors of pregnancy loss and develop effective predictive models for pregnancy loss among reproductive-aged women in SSA.

Methods

We derived the data for this cross-sectional study from the most recent Demographic and Health Survey of Sub-Saharan African countries. Python software was used to process the data, and machine learning techniques such as Random Forest, Decision Tree, Logistic Regression, Extreme Gradient Boosting, and Gaussian were applied. The performance of the predictive models was evaluated using several standard metrics, including the ROC curve, accuracy score, precision, recall, and F-measure.

Result

The final experimental results indicated that the Random Forest model performed the best in predicting pregnancy loss, achieving an accuracy of 98%, precision of 98%, F-measure of 83%, ROC curve of 94%, and recall of 77%. The Gaussian model had the lowest classification accuracy, with an accuracy of 92.64% compared to the others. Based on SHPY values, unmarried women may be more likely to experience pregnancy loss, particularly in contexts where premarital pregnancies are stigmatized. The use of antenatal care and family planning services can significantly impact the risk of pregnancy loss. Women from lower-income backgrounds may face challenges in accessing prenatal care or safe reproductive health services, leading to higher risks of loss. Additionally, higher levels of education are often correlated with increased awareness of family planning methods and better access to healthcare, which can reduce the likelihood of unintended pregnancy loss.

Conclusion

The Random Forest machine learning model demonstrates greater predictive power in estimating pregnancy loss risk factors. Machine learning can help facilitate early prediction and intervention for women at high risk of pregnancy loss. Based on these findings, we recommend policy measures aimed at reducing pregnancy loss Sub-Saharan African countries.

Cultural differences on baby loss experiences: A comparison of the US and New Zealand

Prior research has shown that the death of a baby (whether it be through miscarriage, stillbirth, or infant loss) can have profound effects on the parents involved. However, research has yet to adequately understand how these effects differ cross-culturally. Our research addresses these issues through a qualitative study of 47 bereaved mothers in the United States and New Zealand-cultures that have differing perspectives on death. Findings reveal that bereaved mothers in each country do not process grief the same but do have an equal end desire to find meaning and give back. In terms of processing grief, bereaved mothers in New Zealand rely more on spending time with the deceased, utilizing spirituality for comfort and connection, and prioritizing self-care. In contrast, bereaved mothers in the United States rely more on easy access to qualified counselors, utilizing religion for comfort and connection, and continuing parenting actions in the long-term.

Comparison of depression, anxiety, perceived stress, and resilience in parents faced with abortion in Iran: a longitudinal study

BACKGROUND

Abortion could impact the mental well-being of parents. Resilience also has a significant effect on the mental health of the family as a factor in coping with abortion. This study aimed to compare depression, anxiety, perceived stress, and resilience in parents after abortion.

METHODS

The present longitudinal study was performed on 200 hospitalized women and their spouses in the post-partum department of Shiraz hospitals in 2023. The instruments used in this study included questionnaires of fertility and demographic characteristics, hospital depression and anxiety (HADS), Connor's resilience, and Cohen's perceived stress. Data analysis was performed using SPSS 25.

RESULTS

The mean age of the fathers was 35.37 ± 4.99 and that of mothers was 31.35 ± 6.23. The scores of parents' anxiety, depression, and perceived stress in the first 24 h after facing abortion were in the highest possible state and decreased in 12 weeks, and their resilience also increased. In all three time periods, the mean scores of the fathers' anxiety, depression, and perceived stress were lower than those of the mothers, but the mean score of resilience was always higher in fathers. Fathers´ age and mothers' age, mothers' age at the time of marriage, fathers' job, number of children, gender of the last child (boy or girl), and unwanted pregnancy were among the predicting variables of anxiety, depression, perceived stress, and resilience of both parents faced with abortion.

CONCLUSION

Although mental disorders in fathers were fewer than mothers compared to post-abortion resilience, identifying and managing these issues promptly is crucial for enhancing post-abortion mental well-being in both parents. How parents navigate the challenges of pregnancy, childbirth, and abortion can significantly impact the couple's health.

Bereavement care guidelines used in health care facilities immediately following perinatal loss: a scoping review

OBJECTIVE

The objective of the scoping review was to explore the evidence and describe what is known about perinatal bereavement care guidelines provided within health care facilities prior to discharge. Additionally, the review sought to identify what is known about parents' mental health outcomes, and map these outcomes to the characteristics of the bereavement care guidelines.

INTRODUCTION

Perinatal loss poses a serious risk of emotional trauma and mental health sequelae. Conflicting evidence for international bereavement care guidelines and inconsistent implementation, a lack of experimental studies, and older syntheses with a limited focus or population made synthesis complex. Therefore, a scoping review was undertaken to determine the breadth and depth of the existing literature on this topic.

INCLUSION CRITERIA

Sources pertaining to bereavement care guidelines used in health care facilities immediately after perinatal loss (miscarriage, stillbirth, or neonatal death) and parents' mental health outcomes were included. Sources pertaining to family members other than parents, perinatal loss occurring outside of a health care facility, and physical care guidelines were excluded.

METHODS

The review was conducted using JBI methodology for scoping reviews. The team considered quantitative and qualitative studies, practice guidelines, case reports, expert opinions, systematic reviews, professional organization websites, and gray literature. CINAHL (EBSCOhost), PsycINFO (EBSCOhost), SocINDEX (EBSCOhost), Cochrane Library, JBI Evidence-based Practice Database (Ovid), Embase, PubMed, ProQuest Dissertations and Theses A&I (ProQuest), Web of Science Core Collection, and Epistemonikos were the major databases searched. OpenGrey, Google Scholar, and organizational websites were also searched. The earliest empirical study publication found (1976) served as the starting date limit. After pilot-testing the screening process, data were extracted, collated, and presented in narrative format as well as in tables and figures. The search was first conducted in September and October 2021, and an updated search was performed on February 9, 2023.

RESULTS

The results provide a broad view of bereavement care guidelines to support grieving parents' mental health. The included sources (n=195) were comprised of 28 syntheses, 96 primary studies, and 71 literature review/text and opinion. From the studies that specified the number of participants, 47,598 participants were included. Key characteristics of bereavement care guidelines were categorized as i) making meaning/memories, ii) good communication, iii) shared decision-making, iv) effective emotional and social support, and v) organizational response. Parents' reported mental health outcomes included both negative outcomes, such as depression, anxiety, anger, and helplessness, and positive outcomes, including coping, healing, recovery, and well-being.

CONCLUSIONS

Conceptually, the characteristics of published guidelines are fairly consistent across settings, with cultural variations in specific components of the guidelines. Despite the exponential increase in research on bereavement care after perinatal loss, there is a gap in research pertaining to certain characteristics of bereavement care guidelines that are accepted as best practice to support parents' mental health outcomes. This review provides support for future research given the trauma and mental health risks following perinatal loss. Policies ensuring consistent and appropriate implementation of bereavement care guidelines are essential to improve parents' mental health outcomes.

SUPPLEMENTAL DIGITAL CONTENT

A Spanish-language version of the abstract of this review is available: http://links.lww.com/SRX/A66 .

Investigating depression, anxiety, perceived stress and resilience in fathers faced with their spouse's abortion in Iran: a longitudinal study

BACKGROUND

Abortion is a stressful event that can often affect the mental health of both parents. It seems that resilient people can adapt to stressful situations. The mental health of fathers plays an important role in improving the mental health of the family, but few studies have been conducted in this regard. Therefore, this study aimed to investigate depression, anxiety, perceived stress and resilience of fathers faced with their spouse's abortion.

METHODS

This longitudinal study was conducted on 125 spouses of women hospitalized in the post-partum department of Shiraz hospitals in 2023. Data collection tools included questionnaires of demographic and fertility characteristics, hospital depression and anxiety (HADS), Cohen's perceived stress, and Connor's resilience. The data were analyzed through Spss24 software using Friedman's tests and post hoc tests, Adjusted Bonferroni, Kruskal-Wallis and Mann-Whitney tests.

RESULTS

The mean age of the fathers was 35.02 ± 6.22. The scores of the father's anxiety, depression, and perceived stress from 24 h to 12 weeks after abortion were decreased significantly. However, their resilience score increased significantly. Also, there was a significant relationship between the fathers' age, education, job, duration of marriage, type of abortion, number and history of abortion, unwanted pregnancy, number of children and economic status with the mean score of anxiety, depression, perceived stress, and resilience in fathers over time.

CONCLUSION

This research pointed out the effect of abortion on depression, anxiety, and perceived stress in fathers; also, resilience as a coping factor could affect these disorders and improve the fathers' mental health. Therefore, screening and managing mental disorders in them are important to improve family health.

Support interventions to reduce psychological distress in families experiencing stillbirth in high income countries: A systematic review

BACKGROUND

Previous research indicates disparities in the care of bereaved parents and siblings following a stillbirth in the family. The aim of this systematic review was to assess the effects of interventions aimed at reducing psychological distress among parents or siblings in high-income countries after experiencing a stillbirth.

METHODS

The databases CINAHL, Medline, PsycInfo, Cochrane Library, and EMBASE were searched in August 2022.

RESULTS

Four intervention studies from the United States (US), the United Kingdom (UK), Finland, and Australia, met the inclusion criteria. The interventions comprised a perinatal grief support team; a perinatal counselling service; a grief support program; and a support package including contacts with peer supporters and health care staff. No studies of interventions for siblings were found. The results could not be synthesised due to disparities in interventions and outcome measures. The risk of bias was assessed as high in all four studies and the certainty for all outcomes was rated as very low.

CONCLUSION

More controlled trials with rigorous methods are needed to evaluate the effect of bereavement support interventions in parents and siblings after stillbirth. Future studies should include a core outcome set to make them more comparable. Most of the studies in this review were assessed to have an overall high risk of bias, mainly due to problems with missing outcome data; thus, future studies could specifically target this problem.

Comparing posttraumatic growth in mothers after stillbirth or early miscarriage

The possibility of posttraumatic growth in the aftermath of pregnancy loss has received limited attention to date. This study investigated posttraumatic growth in mothers following stillbirth compared to early miscarriage. It was hypothesised that mothers following stillbirth will demonstrate more posttraumatic growth, challenge to assumptive beliefs, and disclosure than mothers following early miscarriage. The study also sought to understand how theoretically-derived variables of the Model of Growth in Grief (challenge to assumptive beliefs and disclosure) explained unique variance in posttraumatic growth when key factors were controlled for. One-hundred and twenty women who had experienced a stillbirth (N = 57) or early miscarriage (N = 63) within the last two to six years completed validated questionnaires in an online survey relating to posttraumatic growth and key variables relevant to emotional adjustment post-bereavement. Participants who had experienced a stillbirth demonstrated significantly higher levels of posttraumatic growth, posttraumatic stress symptoms, perinatal grief, disclosure, challenge to assumptive beliefs and rumination than participants who had experienced an early miscarriage (Cohen’s d ranged .38-.94). In a hierarchical stepwise regression analysis, challenge to assumptive beliefs alone predicted 17.5% of the variance in posttraumatic growth. Intrusive and deliberate rumination predicted an additional 5.5% of variance, with urge to talk, reluctance to talk, and actual self-disclosure predicting a further 15.3%. A final model including these variables explained 47.9% of the variance in posttraumatic growth. Interventions targeting challenge to assumptive beliefs, disclosure, and rumination are likely to be clinically useful to promote psychological adjustment in mothers who have experienced stillbirth and early miscarriage.

"If no one grieves, no one will remember": Cultural palimpsests and the creation of social ties through rituals

Classic sociological theories hold that rituals offer opportunities for community integration and cohesion. Rituals allow people to come together across many differences and experience similar thoughts and feelings. Death rituals raise existential questions about the purpose of society and generally foster preexisting social ties. This paper examines the efforts of a US community of volunteers who gather to bury unclaimed, or "abandoned," babies. Drawing on ethnographic research over a two-year period, we advance the concept of cultural palimpsest to capture the process by which a gathering of strangers turns a potentially divisive political issue in to a community forming event. We find that in their efforts to mourn babies to whom they have no connection, these volunteers temporarily foster new social bonds that allow them to work through unresolved grief. Similar processes of ritualistically inverting social meanings occur whenever people gather to turn potentially negative into group forming events.

Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review

BACKGROUND

This systematic review aimed to provide an updated summary of studies investigating depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) in parents after stillbirth (from 20 weeks gestational age until birth).

METHODS

A literature search was conducted in the databases Web of Science and PsychINFO. Main inclusion criteria were 1) peer-reviewed, quantitative, English-language articles published from 1980; (2) studies investigating depression, anxiety, PTSD, or OCD among parents following stillbirth; and (3) studies defining stillbirth as equal to or after 20 weeks of gestation.

RESULTS

Thirteen quantitative, peer-reviewed articles were eligible for inclusion. Selected articles investigated depression, anxiety, and PTSD, while no studies on OCD met our inclusion criteria. The majority of studies investigated women, while only two studies included men. The results indicated heightened short- and long-term levels of depression, anxiety, and PTSD in parents after stillbirth compared to those of parents with live birth. Studies investigating predictors found that social support, marital status, negative appraisals, and variables related to care and management after stillbirth affected levels of symptoms.

CONCLUSIONS

Parents who experience stillbirth have a considerably higher risk of reporting symptoms of depression, anxiety, and PTSD compared with parents with live births. More longitudinal studies are needed to increase our knowledge of how symptoms develop over time, and more research on fathers, transgender, non-binary and gender fluid individuals is needed. Research on the association between stillbirth and OCD is also warranted. Knowledge of the severity of anxiety, depression, and PTSD after stillbirth, and predictors associated with symptom severity could provide healthcare professionals with valuable information on how to provide beneficial postpartum care.

'This is time we'll never get back': a qualitative study of mothers' experiences of care associated with neonatal death

AIMS

To explore the perceptions and experience of women whose baby died in the neonatal period about their care in the perinatal period, on delivery suite, in the neonatal unit and afterwards, expressed in their own words.

DESIGN

Secondary analysis of the Listening to Parents study, using thematic analysis based on the open text responses from a postal survey of parents whose baby died in the neonatal period in England. Women were asked about care during the pregnancy, labour and birth, around the time the baby died and about neonatal care. Women whose pregnancy was terminated for fetal abnormality were excluded from this analysis.

RESULTS

Completed questionnaires were received from 249 mothers of whom most (78%) responded with open text. Overarching themes identified were 'the importance of proximity', 'recognition of role and identity as a parent' and 'the experience of care' and subthemes included 'hours and moments', 'barriers to contact', ' being able to parent, even for a short time', 'missed opportunities', 'being heard' and 'sensitive and responsive care'.

CONCLUSION

The findings identify what is most important for mothers in experiencing the life and death of a baby as a newborn. Physical contact with the baby was paramount, as was being treated as a mother and a parent and being able to function as such. The way in which healthcare staff behaved and how their babies were cared for was critical to how mothers felt supported and enabled at this time. If all women whose babies die in the neonatal period after birth are to receive the responsive care they need, greater understanding of the primary need for closeness and proximity, for active recognition of their parental role and staff awareness of the limited time window available is essential.

Developing an Infrastructure for Bereavement Outreach in a Maternal-Fetal Care Center

Although bereavement programs are a common element of palliative medicine and hospice programs, few maternal-fetal care centers offer universal bereavement outreach services following perinatal loss. In this article, we describe the implementation of a bereavement outreach program at the Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia. The four primary goals identified when developing the bereavement outreach protocol included: (1) centralize communication for patient tracking when a perinatal loss occurs, (2) provide individualized and consistent resource support for grieving patients and families, (3) identify strategic outreach points throughout the first year post-loss, and (4) instate programmatic improvements in response to feedback from patients and their families. Strategies for establishing standardized follow-up protocols and operationalizing methods to address outreach initiatives will be shared, with the primary aim of providing other fetal care centers with a proposed model for perinatal bereavement outreach services.

Men and Miscarriage: A Systematic Review and Thematic Synthesis

Miscarriage is common, affecting one in five pregnancies, but the psychosocial effects often go unrecognized and unsupported. The effects on men may be subject to unintentional neglect by health care practitioners, who typically focus on biological symptoms, confined to women. Therefore, we set out to systematically review the evidence of lived experiences of male partners in high-income countries. Our search and thematic synthesis of the relevant literature identified 27 manuscripts reporting 22 studies with qualitative methods. The studies collected data from 231 male participants, and revealed the powerful effect of identities assumed and performed by men or constructed for them in the context of miscarriage. We identified perceptions of female precedence, uncertain transition to parenthood, gendered coping responses, and ambiguous relations with health care practitioners. Men were often cast into roles that seemed secondary to others, with limited opportunities to articulate and address any emotions and uncertainties engendered by loss.

Impact of Anxiety, Social Support, and Taegyo Practice on Maternal-Fetal Attachment in Pregnant Women Having an Abortion

PURPOSE

The purpose of the study was to identify effects of anxiety, social support, and Taegyo practice toward maternal-fetal attachment in pregnant women having an abortion. METHOD: Participants included 99 pregnant women having an abortion, who participated in this study. Collected data were analyzed using descriptive statistics, t-test, ANOVA, Pearson's correlation, and multiple regression with the SPSS WIN 23.0 program.

RESULTS

Maternal-fetal attachment was significantly negatively correlated with anxiety, and significantly positively correlated with social support and Taegyo practice. Spousal support and Taegyo practice, explained 43.8% of participants' maternal-fetal attachment.

CONCLUSION

Results indicate that less anxiety and more social support, and Taegyo practice in pregnant women having an abortion, were associated with stronger maternal-fetal attachment. To strengthen the maternal-fetal attachment of pregnant women having an abortion experience, it would be necessary to develop and implement the Taegyo program, focusing on practicing Taegyo-related encouragement. Additionally, it is recommended that nursing intervention is provided, to encourage families to participate in the Taegyo practice together throughout the gestational period, and to maintain a positive relationship among partners.

[An exploration of factors influencing nursing practice with families experiencing perinatal loss ]

INTRODUCTION

Perinatal loss is a complex phenomenon with multiple dimensions and represents a professional challenge for nurses. There are as many different ways of coping with bereavement as there are parents, and nurses must adapt their intervention in order to adequately support grieving parents.

PURPOSE

This qualitative study explored the factors that influence nursing practice with bereaved families in a secondary obstetric care center in Quebec.

METHODS

Guba and Lincoln's fourth generation evaluation approach was used. Ten nurses participated in this qualitative study. Data collection was performed using semi-structured interviews. Validation interviews were conducted with three nurses and two gynecologists. The analysis was performed within the perspective of Watson's theory of caring.

RESULTS

A thematic analysis was performed and five themes were identified: the relational quality between the nurse and the family, personal characteristics of the nurse, the feelings expressed by nurses, the working environment, and the context in which the nursing care is provided to the family.

CONCLUSION

In light of the results, some aspects of nursing practice should be encouraged in order to assure adequate support is provided to grieving families.

Social work intervention for women experiencing early pregnancy loss in the emergency department

Often referred to as miscarriage, Early Pregnancy Loss (EPL) is the spontaneous death of a fetus experienced within the first 20 weeks of gestation and is the most common complication in pregnancy. Symptoms of an impending EPL are routinely managed in the Emergency Department (ED). EPL can have a substantial impact on women, potentially leading to psychological and emotional health issues and risks to future pregnancies. Despite the high prevalence of EPL, many women suffer in silence due to the common societal belief that EPL are insignificant. Many women experience EPL as an ambiguous loss and are at risk for disenfranchised grief. Compassionate, patient-centred care has been identified by women as an essential and often missing aspect of ED care and can have a profound impact on the overall well-being of women after EPL. Social workers play a critical role in the ED given that they prioritize the psychosocial well-being of patients in a system that is structured to primarily address trauma care. In an effort to reduce the psychological impact and complicated grief reactions of women experiencing EPL, specific recommendations for social work intervention to address the individual needs of women experiencing EPL in the ED are presented. These include acknowledging the loss, providing psychoeducation, honouring the loss, assessing resources, referral and additional information, and building capacity in the ED.

Angels in the Clouds: Stillbirth and Virtual Cemeteries on 50 YouTube Videos

Today every aspect of our life is published and shared online, including grief. The virtual cemeteries and social networks' use could be considered as a new modern mortuary ritual. Starting from the keyword stillbirth, 50 videos published on YouTube since 2008 have been analyzed qualitatively. The videos, 70% published by the mother, with an average length of 5.52 minutes, a mean of 2,429,576 views and 2,563 of comments, follow a sort of script: the second part with black and white photos, background music, and religious references. Could the continuous access to the child's technological grave encourage a complicated grief or be a support, given by the interaction with users, limiting the sense of isolation. The parent shows his or her own conceptions about death and, as a modern baptism, presents the child to the whole society. Videos keep child's memory alive and fuel a process of personalization and tenderness in the user.

Mothers' experience of maternity and neonatal care when babies die: A quantitative study

BACKGROUND

The death of a newborn baby is devastating. While clinical issues may be a primary concern, interpersonal aspects can impact significantly. Mothers in this situation are not easy to access for research and little quantitative evidence is available. In this study we aimed to describe their experience of care, emphasising associations with infant gestational age.

METHODS

Secondary analysis of population-based survey data collected through the Office for National Statistics following neonatal death in England in 2012-13. Women were asked about clinical events and care during pregnancy, labour and birth, when the baby died, postnatally and in the neonatal unit.

RESULTS

249 mothers returned completed questionnaires (30% response rate), 50% of births were at 28 weeks' gestation or less and 66% had babies admitted for neonatal care. 24% of women were left alone and worried during labour and 18% after birth. Only 49% felt sufficiently involved in decision-making at this time. Postnatally only 53% were cared for away from other mothers and babies, 47% could not have their partner stay with them, and 55% were not located close to their baby. Mothers of term babies were significantly less likely to report confidence in staff, feeling listened to and having concerns taken seriously during labour, and postnatally many felt insufficiently informed about their baby's condition, and that neonatal staff were not always aware of parental needs. However, most mothers (84%) were satisfied with neonatal care.

CONCLUSIONS

There is room for improvement if women whose babies die in the neonatal period are to receive the care and support they need. Women who have a baby admitted to a neonatal unit should be cared for nearby, with room for their partner and with greater involvement in decision-making, particularly where withdrawal of life support is considered.

Hospital Practices for Parents Following Perinatal Loss

The aim of this study is to provide comprehensive and current information on hospital practices following perinatal death. The provinces with the highest number of hospitals in Turkey were selected for the study. To collect data, the questionnaire form of Canadian hospitals maternity policies and practices survey was sent to the appropriate respondents in hospitals. The study showed that encouraging parents to have photos of the deceased baby and preparing a remembrance pack were the most problematic issues and were not available at the majority of hospitals. The most common supportive practices in hospitals were the opportunity to see the deceased baby, assisting with funeral options and autopsies, and support for completing the necessary legal documents. The result indicated that hospitals implement varied practices in assisting the bereaved parents. The study recommended developing hospital policies and practices related to perinatal death and supporting families during their loss and grief.

The effect of a grief support program on Turkish parents whose babies have died

The purpose of this study was to determine the effect of the Grief Support Program on the bereavement of parents whose babies had died. The sample consisted of 77 couples. The data was collected by the Texas Revised Inventory of Grief and the Coping Strategies Inventory. The intervention group was offered before, immediately after, and a month after death of their baby in accordance with the Grief Support Program guideline. The Grief Support Program did not affect grief intensity in the short term but had a positive effect 1 year later.

Care Experiences of Women Who Used Opioids and Experienced Fetal or Infant Loss

OBJECTIVE

To explore care experiences of women who used prescription or illicit opioids and experienced fetal or infant loss.

DESIGN

A qualitative, descriptive design with secondary data analysis.

SETTING

The Fetal and Infant Mortality Review program in an urban Midwestern county in the United States.

PARTICIPANTS

Eleven women with histories of prescription or illicit opioid use who experienced fetal or infant loss participated in the semistructured telephone or in-person interview portion of the mortality case review.

METHODS

We used thematic analysis to analyze interview data.

RESULTS

Five themes were identified related to the care experiences of participants throughout pregnancy and fetal/infant loss: Frustration and anger related to not being heard, feeling minimalized; Being overwhelmed with attempts to process and understand medical complications and outcomes; Profound sense of grief and coping with loss; Need to understand why and make difficult decisions; and Placing blame and guilt over death.

CONCLUSION

Our findings suggest that women who use opioids and experience fetal or infant loss have complex care, educational, and emotional needs. In the development of interventions for these women, it is important to address their unique and complex circumstances.

Mindfulness-Based Intervention for Perinatal Grief in Rural India: Improved Mental Health at 12 Months Follow-Up

Stillbirth is a significant global health problem that frequently results in perinatal grief with compound negative psychosocial impact. In low-resource settings with exceedingly high stillbirth rates, such as rural Chhattisgarh, India, it is vital to utilize low-cost, effective interventions. Mindfulness-based stress reduction is an evidence-based intervention utilized for a broad range of physical and mental health problems, and is adaptable to specific populations. The objective of this study was to explore the sustained effectiveness of a shortened, culturally adapted mindfulness-based intervention (MBI) designed to address complex grief after stillbirth. We used an observational, mixed-methods pre-post study design with 6-week and 12-month follow-up assessments among women with a history of stillbirth (N = 22). Analyses explored study outcomes and continued use of mindfulness skills. Pretest results showed elevated psychological symptoms and high levels of perinatal grief. General linear modeling repeated measures was used to explore 6-week and 12-month follow-up changes from baseline, controlling for significantly correlated demographic variables. Longitudinal results indicated significant reductions in perinatal grief and psychological symptoms; four of the five facets of mindfulness changed in the desired direction; and resilience scores indicated thriving. The shortened, culturally adapted, MBI pilot brought about sustained, significant reductions of perinatal grief and mental health symptoms, and participants reported use of mindfulness skills in day-to-day life. This study shows that the significant mental health needs among rural women of various castes and ethnicities in Chhattisgarh following stillbirth were successfully addressed by a promising MBI with potential scalability and sustainability.

Mindfulness-based Intervention for Perinatal Grief Education and Reduction among Poor Women in Chhattisgarh, India: a Pilot Study

INTRODUCTION

Stillbirth is a significant public health problem in low-to-middle-income countries and results in perinatal grief, often with negative psychosocial impact. In low-resource settings, such as Chhattisgarh, India, where needs are high, it is imperative to utilize low-cost, effective interventions. Mindfulness-based stress reduction (MBSR) is an empirically sound intervention that has been utilized for a broad range of physical and mental health problems, and is adaptable to specific populations. The main objective of this pilot study was to explore the feasibility and effectiveness of a shortened, culturally adapted mindfulness-based intervention to address complex grief after stillbirth.

METHODS

We used an observational, pre-post-6-week post study design. The study instrument was made up of descriptive demographic questions and validated scales and was administered as a structured interview due to low literacy rates. We used a community participatory approach to culturally adapt the five-week mindfulness-based intervention and delivered it through two trained local nurses. Quantitative and qualitative data analyses explored study outcomes as well as acceptability and feasibility of the intervention.

RESULTS

29 women with a history of stillbirth enrolled, completed the pretest and began the intervention; 26 completed the five-week intervention and post-test (89.7%), and 23 completed the six-week follow-up assessment (88.5%). Pretest results included elevated psychological symptoms and high levels of perinatal grief, including the active grief, difficulty coping, and despair subscales. General linear modeling repeated measures was used to explore posttest and six-week follow up changes from baseline, controlling for significantly correlated demographic variables. These longitudinal results included significant reduction in psychological symptoms; four of the five facets of mindfulness changed in the desired direction, two significantly; as well as significant reduction in overall perinatal grief and on each of the three subscales.

DISCUSSION

The shortened, culturally adapted, mindfulness-based intervention pilot study was well received and had very low attrition. We also found significant reductions of perinatal grief and mental health symptoms over time, as well as a high degree of practice of mindfulness skills by participants. This study not only sheds light on the tremendous mental health needs among rural women of various castes who have experienced stillbirth in Chhattisgarh, it also points to a promising effective intervention with potential to be taken to scale for wider delivery.

Seeing and Holding Baby: Systematic Review of Clinical Management and Parental Outcomes After Stillbirth

BACKGROUND

In 2009 there were an estimated 2.6 million stillbirths worldwide. In the United States, a 2007 systematic review found little consensus about professional behaviors perceived by parents to be most helpful or most distressing. In the United Kingdom, a bereaved parents' organization has highlighted discordance between parental views and clinical guidelines that recommend clinicians do not encourage parents to see and hold their baby. The objective of this review was to identify and synthesize available research reporting parental outcomes relating to seeing and holding.

METHODS

We undertook a systematic review. We included studies of any design, reporting parental experiences and outcomes. Electronic searches (PubMed and PsychINFO) were conducted in January 2014. Three authors independently screened and assessed the quality of the studies before abstracting data and undertaking thematic analysis.

RESULTS

We reviewed 741 records and included 23 studies (10 quantitative, 12 qualitative, and 1 mixed-method). Twenty-one studies suggested positive outcomes for parents who saw or held their baby. Increased psychological morbidity was associated with current pregnancy, choice not to see their baby, lack of time with their baby and/or insufficient mementos. Three themes were formulated "positive effects of contact within a traumatic life event," "importance of role of health professionals," and "impact on mothers and fathers: similarities and differences."

CONCLUSIONS

Stillbirth is a risk factor for increased psychological morbidity. Parents seeing and holding their stillborn baby can be beneficial to their future well-being. Since 2007, there has been a proliferation of studies that challenge clinical guidelines recommending that clinicians do not encourage parental contact.

Parents' evaluation of support in Australian hospitals following stillbirth

The present study evaluated the level of support and satisfaction among parents of stillborn babies in Australian hospitals. One-hundred and eighty-nine mothers and fathers completed an online survey designed by the researcher based on the guidelines designed by the Perinatal Society of Australia and New Zealand. Support was inconsistent with guidelines implemented on average only 55% of the time. Areas of support regarding creating memories, birth options and autopsy were most problematic. A significant positive correlation was found between support and satisfaction and there is indication that there has been some increase in support and satisfaction over time. There has been a significant increase in both support and satisfaction since the release of the guidelines in 2009. Creating memories was regarded by parents as the most influential to their grief. It is recommended that health professionals review guidelines and seek feedback from parents as to how they can improve the support they provide.

Cognitive predictors and risk factors of PTSD following stillbirth: a short-term longitudinal study

This short-term longitudinal study investigated cognitive predictors and risk factors of posttraumatic stress disorder (PTSD) in mothers following stillbirth. After a stillbirth at ≥ 24 weeks gestational age, 65 women completed structured clinical interviews and questionnaires assessing PTSD symptoms, cognitive predictors (appraisals, dysfunctional strategies), and risk factors (perceived social support, trauma history, obstetric history) at 3 and 6 months. PTSD symptoms decreased between 3 and 6 months (Cohen's d ranged .34-.52). Regression analyses also revealed a specific positive relationship between Rumination and concurrent frequency of PTSD symptoms (β = .45). Negative Self-View and Negative World-View related positively and Self-Blame related negatively to concurrent number of PTSD symptoms (β = .48, .44, -.45, respectively). Suppression and Distraction predicted a decrease and Numbing predicted an increase in time-lagged number of PTSD symptoms (β = -.33, -.28, .30, respectively). Risk factors for PTSD symptoms were younger age (β = -.25), lower income (β = -.29), fewer previous pregnancies (β = -.31), and poorer perceived social support (β = -.26). Interventions addressing negative appraisals, dysfunctional strategies, and social support are recommended for mothers with PTSD following stillbirth. Knowledge of cognitive predictors and risk factors of PTSD may inform the development of a screening instrument.

Mindfulness-based Intervention for Perinatal Grief after Stillbirth in Rural India

We explored the concept of using a Mindfulness-based intervention to reduce perinatal grief among Indian women. Data were collected using mixed methods to explore concept acceptability, receptivity, modality, and feasibility of the intervention. The intervention was piloted and evaluated with measures of perinatal grief, psychosocial wellbeing, religious coping, perceived social provision of support, and mindfulness. The intervention was well received and effective in teaching skills to help women deal with high levels of grief and subsequent mental health challenges. To overcome attendance barriers modification is necessary. Partnership with a local nursing school is critical to enhance sustainability of the intervention.

Posttraumatic stress and posttraumatic stress disorder after termination of pregnancy and reproductive loss: a systematic review

Objective. The aims of this systematic review were to integrate the research on posttraumatic stress (PTS) and posttraumatic stress disorder (PTSD) after termination of pregnancy (TOP), miscarriage, perinatal death, stillbirth, neonatal death, and failed in vitro fertilisation (IVF). Methods. Electronic databases (AMED, British Nursing Index, CINAHL, MEDLINE, SPORTDiscus, PsycINFO, PubMEd, ScienceDirect) were searched for articles using PRISMA guidelines. Results. Data from 48 studies were included. Quality of the research was generally good. PTS/PTSD has been investigated in TOP and miscarriage more than perinatal loss, stillbirth, and neonatal death. In all reproductive losses and TOPs, the prevalence of PTS was greater than PTSD, both decreased over time, and longer gestational age is associated with higher levels of PTS/PTSD. Women have generally reported more PTS or PTSD than men. Sociodemographic characteristics (e.g., younger age, lower education, and history of previous traumas or mental health problems) and psychsocial factors influence PTS and PTSD after TOP and reproductive loss. Conclusions. This systematic review is the first to investigate PTS/PTSD after reproductive loss. Patients with advanced pregnancies, a history of previous traumas, mental health problems, and adverse psychosocial profiles should be considered as high risk for developing PTS or PTSD following reproductive loss.

The Psychological Impact of Stillbirth on Women: A Systematic Review

This systematic review explored the psychological impact of stillbirth (from 20 weeks gestation) on mothers. A search was conducted in the National Library for Health and Web of Science, Cochrane Review, and Google Scholar. A secondary search based on results from the preliminary search was undertaken. A systematic search identified 26 articles (8 qualitative, 18 quantitative studies), which met criteria and were reviewed according to guidelines. The findings revealed that stillbirth is a distressing experience that can result in high levels of psychological symptoms including anxiety, depression, distress, and negative well-being. Symptoms appear to be highest in the first few months post loss although there is evidence to suggest that for some, symptoms may persist up to 3 years. The long-lasting impact of stillbirth on women was echoed in the qualitative research. Risk factors for higher levels of anxious and depressive symptoms included higher parity at the time of loss and not being married. Social support in particular was identified to be beneficial for women post loss. Longitudinal studies utilizing designs which permit causality to be determined are required to explore the specific experience of stillbirth. Further exploration of risk and protective factors, cultural beliefs, and the impact on partner relationships is needed. Clinical implications of the findings are discussed in light of current guidance.

Coping With Stillbirth Among Ultraorthodox Jewish Women

Stillbirth is a traumatic prenatal loss with personal, familial, and social implications. We explored the meaning of stillbirth for ultraorthodox Israeli women for whom grieving for prenatal loss derived from the power of faith. We conducted semistructured interviews with ten ultraorthodox women, ages 26 to 55, in a qualitative study that was focused on thematic content analysis and influenced by the phenomenological-hermeneutic tradition. The loss of the fetus was experienced as a test to the women's belief in God, and was perceived as a way to experience God's love. The women's faith became stronger and provided relief, calm, and confidence in God as benefactor. The meanings they attributed to their losses enabled them to move on. Findings are discussed in the context of research and theoretical literature on coping, bereavement, and mourning processes, and meaning for pregnancy-related losses. Awareness of ethnic meanings of stillbirth promotes implementation of culture-sensitive psychosocial interventions.

Stress, Depression, and Fetal Attachment in Pregnant Women having Infertility Treatments

PURPOSE

The purpose of this study was to determine the stress, depression, and fetal attachment of pregnant women who underwent infertility treatment, and to identify factors associated with fetal attachment.

METHODS

As a correlation survey design, data were collected from 136 pregnant women who underwent infertility treatment. Data were analyzed using chi2-test, t-test, ANOVA, Pearson correlation coefficients, and stepwise multiple regression.

RESULTS

Stress, depression, and fetal attachment averaged 3.01+/-0.60 (range of scale 1~5), 10.02+/-6.51 (out of a possible 63), and 3.64+/-0.55 (range of scale 1~5), respectively. Level of fetal attachment was higher when mother's age was less than 35, having other children, and having prenatal education experience. Lower score of depression and client's age less than 35 were significant factors affecting fetal attachment.

CONCLUSION

Infertility is a life-affecting trauma for the individual, and personal and social changes due to infertility cause physical and psychological difficulties even after a successful pregnancy with infertility treatment. Therefore, prenatal management programs need to be developed giving consideration to the emotional and physical changes in order to promote physical and psychological stability in the women pregnant following infertility treatment.

Anxiety disorders and obsessive compulsive disorder 9 months after perinatal loss

OBJECTIVE

Perinatal loss (stillbirth after 20 weeks of gestational age or infant death in the first month) impacts one to two infants per hundred live births in the United States and can be a devastating experience for parents. We assessed prevalence of anxiety disorders and obsessive compulsive disorder (OCD) among bereaved and live-birth mothers.

METHODS

We collaborated with the Michigan Department of Community Health to survey Michigan mothers with perinatal death or live birth. We measured symptoms of generalized anxiety disorder, social phobia, panic disorder and OCD using validated written self-report screens and collected data on maternal demographics, psychiatric history, social support and intimate partner violence.

RESULTS

A total 609/1400 mothers (44%) participated, returning surveys 9 months postdelivery. Two hundred thirty-two mothers had live birth, and 377 had perinatal loss. In unadjusted analyses, bereaved mothers had higher odds of all four disorders. In logistic regression adjusted for covariates, bereaved mothers still had higher odds of moderate-severe generalized anxiety disorder [odds ratio (OR): 2.39, confidence interval (CI): 1.10-5.18, P = .028] and social phobia (OR: 2.32, CI: 1.52-3.54, P < .0005) but not panic disorder or OCD.

CONCLUSION

Bereaved mothers struggle with clinically significant anxiety disorders in the first year after perinatal loss; improved identification and treatment are essential to improve mental health for this vulnerable population.

Pregnancy loss

Women who lose desired pregnancies by miscarriage, stillbirth, or genetic termination are at risk of suffering from grief, anxiety, guilt and self-blame that may even present in subsequent pregnancies. It is important to find effective means of helping women deal with these losses. The approach to stillbirth has shifted from immediately removing the child from the mother to encouraging the parents to view and hold the baby. This approach has been questioned as possibly causing persistent anxiety and post-traumatic stress disorder. Women who miscarry are currently encouraged to find ways to memorialise the lost fetus. Couples who decide to terminate a pregnancy after discovering a defect may deal not only with sadness but also guilt. Immediate crisis intervention and follow-up care should be available, recognising that individual women may experience different reactions and their specific post-loss needs must be assessed.

Women's decision making and experience of subsequent pregnancy following stillbirth

INTRODUCTION

This study sought to increase understanding of women's thoughts and feelings about decision making and the experience of subsequent pregnancy following stillbirth (intrauterine death after 24 weeks' gestation).

METHODS

Eleven women were interviewed, 8 of whom were pregnant at the time of the interview. Modified grounded theory was used to guide the research methodology and to analyze the data.

RESULTS

A model was developed to illustrate women's experiences of decision making in relation to subsequent pregnancy and of subsequent pregnancy itself.

DISCUSSION

The results of the current study have significant implications for women who have experienced stillbirth and the health professionals who work with them. Based on the model, women may find it helpful to discuss their beliefs in relation to healing and health professionals to provide support with this in mind. Women and their partners may also benefit from explanations and support about the potentially conflicting emotions they may experience during this time.

Women's experiences of coping with pregnancy termination for fetal abnormality

Pregnancy termination for fetal abnormality (TFA) can have significant psychological consequences. Most previous research has been focused on measuring the psychological outcomes of TFA, and little is known about the coping strategies involved. In this article, we report on women's coping strategies used during and after the procedure. Our account is based on experiences of 27 women who completed an online survey. We analyzed the data using interpretative phenomenological analysis. Coping comprised four structures, consistent across time points: support, acceptance, avoidance, and meaning attribution. Women mostly used adaptive coping strategies but reported inadequacies in aftercare, which challenged their resources. The study's findings indicate the need to provide sensitive, nondirective care rooted in the acknowledgment of the unique nature of TFA. Enabling women to reciprocate for emotional support, promoting adaptive coping strategies, highlighting the potential value of spending time with the baby, and providing long-term support (including during subsequent pregnancies) might promote psychological adjustment to TFA.

Meaning-making after neonatal death: narratives of Xhosa-speaking women in South Africa

The death of a neonate can be traumatic for mothers, resulting in profound grief which ruptures their sense of coherence and identity. A narrative approach was used to explore how six Xhosa-speaking women tell stories about the death of their baby to help them understand the significance of the loss. They struggled to establish a sense of their baby as a person to be mourned, to redefine their own identity, and to find reasons for the death. Their meaning-making was influenced by the baby's father, older women in their community, and the context of deprivation in which they live.

Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review

Although selective termination of pregnancy and fetal reduction in multiple pregnancy both involve the termination in utero of the development of live fetuses, these two procedures are different in several aspects. Nevertheless, several authors tend to amalgamate and confuse their psychosocial consequences and the ethical issues they raise. Therefore, this narrative review, derived from a comparative analysis of 91 articles, shines a light on these amalgamations and confusions, as well as on the medical, contextual, experiential and ethical differences specific to selective termination and fetal reduction.

The Evolution of Group and Online Support for Families Who Have Experienced Perinatal or Neonatal Loss

This article examines how group and online support for bereaved parents has evolved over the past 35 years. From little to no support at all, support for grieving parents has evolved from face-to-face peer support groups and one-on-one telephone support, into online support, specialized groups for pregnancy and parenting after a loss, and, finally, into groups that provide care for those making decisions when the baby is not expected to survive. This article also explores current research into the history and effectiveness of both face-to-face and online support groups. Caregivers will gain information to help them in their work with bereaved families.

Social and cultural factors associated with perinatal grief in Chhattisgarh, India

Stillbirth is a globally significant public health problem with many medical causes. There are also indirect causal pathways including social and cultural factors which are particularly salient in India's traditional society. The purpose of this study was to explore women's perceptions of stillbirth and to determine how issues of gender and power, social support, coping efforts, and religious beliefs influence perinatal grief outcomes among poor women in rural Chhattisgarh, India. Structured interviews were done face-to-face in 21 randomly selected villages among women of reproductive age (N=355) who had experienced stillbirth (n=178) and compared to those who had not (n=177), in the Christian Hospital, Mungeli catchment area. Perinatal grief was significantly higher among women with a history of stillbirth. Greater perinatal grief was associated with lack of support, maternal agreement with social norms, and younger maternal age. These predictors must be understood in light of an additional finding-distorted sex ratios, which reflect gender discrimination in the context of Indian society. The findings of this study will allow the development of a culturally appropriate health education program which should be designed to increase social support and address social norms, thereby reducing psychological distress to prevent complicated perinatal grief. Perinatal grief is a significant social burden which impacts the health women.

Perinatal loss and parental grief: the challenge of ambiguity and disenfranchised grief

Following perinatal loss, a type of ambiguous loss, bereaved couples struggle with and experience distress due to various forms of ambiguity. Moreover, the juxtaposition of their grief with society's minimization often disenfranchises them from traditional grieving processes. The purpose of this study was to explore sources of ambiguity and disenfranchised grief related to perinatal loss. Audio-taped interviews with 13 bereaved couples at 2, 6, and 13 months following the death of their fetus or infant were analyzed. Several categories of ambiguity and disenfranchised grief emerged, pertaining to: (a) the viability of the pregnancy; (b) the physical process of pregnancy loss; (c) making arrangements for the remains; and (d) sharing the news. This study uncovers the many sources of ambiguity and disenfranchised grief that bereaved couples face in interactions with family, friends, society, and healthcare professionals. These insights may inform healthcare professionals in their attempts to ease distress related to perinatal loss.

Dilemmas related to pregnancy loss

Women who lose desired pregnancies by miscarriage, stillbirth, genetic termination, or unsuccessful in vitro fertilization are at risk of suffering from grief, anxiety, guilt, and self-blame that may even present in subsequent pregnancies. A review of the literature reveals the dilemmas about effective means of helping women deal with these losses. The approach to stillbirth has shifted from immediately removing the child from the mother to encouraging viewing and holding the baby. This approach has been questioned as possibly causing persistent anxiety. Women who miscarry are currently encouraged to find ways to memorialize the lost fetus. Immediate crisis intervention and follow-up care should be available, recognizing that individual women may experience different reactions and their specific postloss needs must be assessed.

Provision of bereavement care in neonatal units in the United Kingdom

OBJECTIVE

To establish what bereavement care services are available in neonatal units in the United Kingdom and to establish the availability to staff (doctors, nurses, and chaplains) of bereavement education, training, communication, and multicultural support. For families who lose a baby in the neonatal period, the support they receive from hospital staff can be pivotal in their ability to cope with their grief. Hospital staff are not always trained to provide this support. Limited evidence is available regarding hospital-based bereavement care in neonatology or its impact on outcome.

INTERVENTIONS

Questionnaire survey of selected doctors, nurses, and chaplains in 200 neonatal units in the United Kingdom.

MEASUREMENTS AND MAIN RESULTS

We had responses from 100% of neonatal units surveyed. Of 600 individuals, 320 responded; 11% of doctors had never received any formal training in bereavement care, compared with 0.8% of nurses and 1.2% and chaplains. In addition, 31% of respondents thought the training they received was inadequate. Knowledge of grief theorists was poor. Up to 99% of units were helping parents create memories through photographs or handprints. Parents were uniformly given the chance to be with their baby at the time of death (99% overall). Siblings were encouraged to be present 71% of the time; 75% of respondents felt that information about the needs of different faith groups was available. Formal psychological support was offered to 45% of families after bereavement.

CONCLUSIONS

Studies have shown that parents value clear communication, education about grieving, and demonstrated emotional support by staff. Our study has shown that there are deficiencies in staff training and education in this area. Educators must promote the inclusion of content on bereavement/end-of-life care. Additional education on cultural issues would be helpful. Managing the bereavement process well to minimize morbidity for families and healthcare providers is an important challenge for the future.

Supportive care for women with unexplained recurrent miscarriage: patients' perspectives

BACKGROUND Supportive care is currently the only 'therapy' that can be offered to women with unexplained recurrent miscarriage (RM). What these women themselves prefer as supportive care in their next pregnancy has never been substantiated. Therefore the aim of this study was to explore what women with unexplained RM prefer as supportive care during their next pregnancy. METHODS We performed explorative, semi-structured, in-depth interviews. The interviews were performed with 15 women with unexplained RM who were actively seeking conception. All interviews were conducted by telephone. The interviews were fully transcribed and two researchers independently identified text segments from the transcribed interviews and categorized them in the appropriate domain. RESULTS Women identified 20 different supportive care options; 16 of these options were preferred for their next pregnancy. Examples of the preferred supportive care were early and frequently repeated ultrasounds, βHCG monitoring, practical advice concerning life style and diet, emotional support in the form of counselling, a clear policy for the upcoming 12 weeks and medication. The four supportive care options that were not preferred by the women were admittance to a hospital ward at the same gestational age as previous miscarriages, Complementary Alternative Medicine, ultrasound every other day and receiving supportive care from their general practitioner. CONCLUSIONS Our study identified several relevant preferences for supportive care in women with unexplained RM. Many of these can be offered by the gynaecologist and will help in guaranteeing high-quality patient-centred care.