Grief and Bereavement in Parents After the Death of a Child in Low- and Middle-Income Countries

Community perspectives and experiences of quality maternal and newborn care in East New Britain, Papua New Guinea

BACKGROUND

Quality maternal and newborn care is essential for improving the health of mothers and babies. Low- and middle-income countries, such as Papua New Guinea (PNG), face many barriers to achieving quality care for all. Efforts to improve the quality of maternal and newborn care must involve community in the design, implementation, and evaluation of initiatives to ensure that interventions are appropriate and relevant for the target community. We aimed to describe community members' perspectives and experiences of maternal and newborn care, and their ideas for improvement in one province, East New Britain, in PNG.

METHODS

We undertook a qualitative descriptive study in partnership with and alongside five local health facilities, health care workers and community members, using a Partnership Defined Quality Approach. We conducted ten focus group discussions with 68 community members (identified through church, market and other community-based groups) in East New Britain PNG to explore perspectives and experiences of maternal and newborn care, identify enablers and barriers to quality care and interventions to improve care. Discussions were transcribed verbatim. A mixed inductive and deductive analysis was conducted including application of the World Health Organisation (WHO) Quality Maternal and Newborn Care framework.

RESULTS

Using the WHO framework, we present the findings in accordance with the five experience of care domains. We found that the community reported multiple challenges in accessing care and facilities were described as under-staffed and under resourced. Community members emphasised the importance of good communication and competent, caring and respectful healthcare workers. Both women and men expressed a strong desire for companionship during labor and birth. Several changes were suggested by the community that could immediately improve the quality of care.

CONCLUSIONS

Community perspectives and experiences are critical for informing effective and sustainable interventions to improve the quality of maternal and newborn care and increasing facility-based births in PNG. A greater understanding of the care experience as a key component of quality care is needed and any quality improvement initiatives must include the user experience as a key outcome measure.

Bereavement issues and prolonged grief disorder: A global perspective

The death of a loved one - bereavement - is a universal experience that marks the human mental health condition. Grief - the cognitive, emotional, and behavioral responses to bereavement - is thus experienced by virtually everyone at some point in life, while mourning is a process through which grievers come to terms with the loss envisioning life without the deceased. Although distress subsides over time among most bereaved individuals, a minority will develop a condition recently identified as prolonged grief disorder (PGD). The present review provides a global perspective on bereavement, grief reactions, and PGD. Although the loss of a loved one and grief reactions are in general experienced consistently across different cultures, differences and variations in their expression may exist across cultures. Especially within specific populations that may be more at risk for PGD, possibly due to risk factors associated with the mechanisms of loss (e.g., refugees, migrants, and conflict survivors). The diagnostic criteria for PGD are mostly based on Western grieving populations, and cultural adaptations of PGD treatments are limited. Therefore, cross-cultural development and validation of PGD screening/assessment is critical to support future research on grief reactions and PGD, especially in non-Western contexts, and concerning the potential future global changes and challenges that appear to have a major impact on PGD. More transcultural research on PGD is needed to contextualize and will lead to culture-bound symptom identification of PGD, and the adaptation of current treatment protocols, which may ultimately improve health at the individual level, and health-care systems.

Life in armed conflict: A phenomenological approach to examine the bereavement experiences of parents living in Indian-administered Kashmir

Research on the experiences of parents who have lost a child to armed conflict is limited. The current study aimed to explore the bereaved experiences of those parents. An interpretative phenomenological approach was used to explore the experiences of 15 participants. The analysis resulted in two broad themes followed by subthemes-The theme Traumatic Grief comprised three subthemes: feeling that life is empty; hearing, seeing, and sensing the presence of dead; and unfair to be alive. The theme Meaning making Coping Methods comprised two subthemes: social support as meaning making, and religious coping as meaning making. These findings, based on the phenomenological approach, help to better understand the bereaved experiences of the parents affected by armed conflict.

Serious health-related suffering experienced by children with disability and their families living in Bangladesh: A scoping review

BACKGROUND

In 2020, the International Association for Hospice and Palliative Care redefined palliative care to incorporate the concept of serious health-related suffering. An estimated 21 million children globally live with conditions which would benefit from a palliative approach to relieve suffering. Bangladesh is a lower-middle income country with isolated provision of palliative care.

AIM

To synthesise existing evidence describing serious health-related suffering of children with disability and their families living in Bangladesh and the intersection between this suffering, palliative care and rehabilitation.

DESIGN

Scoping review methodology.

DATA SOURCES

A search strategy related to serious health-related suffering and childhood disability was applied to online databases and grey literature. English language studies (1990-2021) were included. Papers pertaining to serious health-related suffering of typically developing children and those over eighteen years were excluded. Data which addressed the three domains of serious health-related suffering (physical, social and emotional/spiritual) were extracted. Palliative care interventions were assessed with a pre-existing checklist.

RESULTS

Forty-six studies were included, representing ten different methodologies. Sample sizes ranged from 11 to 2582 participants, with 87% of studies including children with cerebral palsy. Serious health-related suffering was described in 100% of the studies, only 14 of the studies described specific interventions to mitigate suffering. Convergence between palliative care and rehabilitation approaches was evident.

CONCLUSION

Findings document the extensive nature and burden of serious childhood health-related suffering that may be remediated by a palliative approach. They highlight the urgent need to prioritise service development and research in this area.

'It was like an airbag, it cushioned the blow': A multi-site qualitative study of bereaved parents' experiences of using cooling facilities

BACKGROUND

Evidence on the benefits to parents of spending time with their child in the hours after their death means this is now routine practice. UK children's hospices offer parents the opportunity to extend this period by using cooling facilities (i.e. cooled 'bedrooms'; cooling blankets/mattresses) to slow deterioration.

AIM

To explore parents' experiences of using cooling facilities and beliefs about how it shaped experiences of the very early days of bereavement, and on-going grieving processes.

METHODS

Multi-site study involving in-depth interviews with parents bereaved in the previous 3 years. Grief theories informed data analysis, which employed narrative and thematic approaches. Eight hospices supported recruitment.

RESULTS

Twenty-two mothers and eight fathers were recruited, representing 25% of families approached. Duration of use of a cooling facility varied, as did the amount of time spent with the child. All parents treasured this period, valuing the way it eased separation from their child and gave some control over when this happened. They believed all bereaved parents should have the opportunity to use a cooling facility. Using a cooling facility supported parents' engagement with grief tasks including acceptance of loss, processing emotional pain and facing changes to their lives brought about by their child's death. Memories and mementoes created during this period served to support on-going connections with the child. Parents who used a cooling facility at a hospice reported benefits of the setting itself.

CONCLUSIONS

As well as easing the very early days of loss, use of cooling facilities may influence longer-term bereavement outcomes.

"Still Caring for the Family": Condolence Expression Training for Pediatric Residents

CONTEXT

Insufficient communication from the medical team following a child's death may compound parental grief. Pediatric residents care for children who die, yet the landscape of condolence expression education within residency programs has not been studied.

OBJECTIVES

The objective of this study was to evaluate pediatric residents' levels of experience and comfort with condolence expression and to assess their needs and desires for training in condolence expression.

METHODS

A cross-sectional, mixed-methods survey was developed by palliative care clinicians in collaboration with bereaved parents. In 2020, following pilot testing, an electronic survey measuring resident experience with, comfort with, and training on condolence expression was distributed to 202 third-year pediatric residents across 17 Accreditation Council for Graduate Medical Education-accredited programs representing varying sizes and geographic regions.

RESULTS

Ten percent of pediatric residents surveyed reported having training on condolence expression. Almost all residents considered condolence expression to be beneficial for bereaved families and most for clinicians, too, yet very very few had formally expressed condolences in their roles as physicians: 83.1% had never written a condolence letter; 85% had never made a condolence phone call; and 90.5% had never attended a memorial event. Commonly reported barriers to condolence expression included lack of experience and training, as well as concern about upsetting families.

CONCLUSIONS

Pediatric residents lack comfort with and training in condolence expression and desire education to address these gaps. These findings should inform development and investigation of educational resources and training opportunities for residents to learn and practice compassionate provision of condolences to grieving families.

Specialized Pediatric Palliative Care Services in Pediatric Hematopoietic Stem Cell Transplant Centers

Hematopoietic stem cell transplantation (HSCT) is widely used in pediatric patients as a successful curative therapy for life-threatening conditions. The treatment is intensive, with risks of serious complications and lethal outcomes. This study aimed to provide insight into current data on the place and cause of death of transplanted children, the available specialized pediatric palliative care services (SPPCS), and what services HSCT professionals feel the SPPCS team should provide. First, a retrospective database analysis on the place and cause of death of transplanted pediatric HSCT patients was performed. Second, a survey was performed addressing the availability of and views on SPPCS among HSCT professionals. Database analysis included 233 patients of whom the majority died in-hospital: 38% in the pediatric intensive care unit, 20% in HSCT units, 17% in other hospitals, and 14% at home or in a hospice (11% unknown). For the survey, 98 HSCT professionals from 54 centers participated. Nearly all professionals indicated that HSCT patients should have access to SPPCS, especially for pain management, but less than half routinely referred to this service at an early stage. We, therefore, advise HSCT teams to integrate advance care planning for pediatric HSCT patients actively, ideally from diagnosis, to ensure timely SPPCS involvement and maximize end-of-life preparation.

The impact of cultural beliefs and practices on parents' experiences of bereavement following stillbirth: a qualitative study in Uganda and Kenya

BACKGROUND

Stillbirth is an extremely traumatic and distressing experience for parents, with profound and long-lasting negative impacts. Cultural beliefs and practices surrounding death vary considerably across different contexts and groups, and are a key influence on individual experiences, impacting grief, adjustment, and support needs. Few studies have explored cultural influences surrounding stillbirth in an African context. This study explored the influence of cultural beliefs and practices on the experiences of bereaved parents and health workers after stillbirth in urban and rural settings in Kenya and Uganda.

METHODS

A qualitative descriptive study design was employed. Face to face interviews were conducted with parents (N = 134) who experienced a stillbirth (≤ 1 year) and health workers (N = 61) at five facilities in Uganda and Kenya. Interviews were conducted in English or the participants' local language, audio-recorded and transcribed verbatim. Analysis was conducted using descriptive thematic analysis.

RESULTS

Commonalities in cultural beliefs and practices existed across the two countries. Three main themes were identified: 1) Gathering round, describes the collective support parents received from family and friends after stillbirth. 2)'It is against our custom' addresses cultural constraints and prohibitions impacting parents' behaviour and coping in the immediate aftermath of the baby's death. 3) 'Maybe it's God's plan or witchcraft' summarises spiritual, supernatural, and social beliefs surrounding the causes of stillbirth.

CONCLUSIONS

Kinship and social support helped parents to cope with the loss and grief. However, other practices and beliefs surrounding stillbirth were sometimes a source of stress, fear, stigma and anxiety especially to the women. Conforming to cultural practices meant that parents were prevented from: holding and seeing their baby, openly discussing the death, memory-making and attending the burial. The conflict between addressing their own needs and complying with community norms hindered parents' grief and adjustment. There is an urgent need to develop culturally sensitive community programmes geared towards demystifying stillbirths and providing an avenue for parents to grieve in their own way.

Men's experiences and need for targeted support after termination of pregnancy for foetal anomaly: A qualitative study

AIMS AND OBJECTIVES

To explore men's experiences of termination of pregnancy for life-limiting foetal anomaly, including how healthcare providers, systems and policies can best support men and their families.

BACKGROUND

While there is a sizable body of research and recommendations relating to women's experiences of grief and support needs following a termination of pregnancy for foetal anomaly, very few studies specifically examine men's experiences.

METHODS

Semi-structured interviews were completed with ten Australian men who had experienced termination of pregnancy for life-limiting foetal anomalies with a female partner between six months and 11 years ago. Interviews were completed over the telephone, and data were analysed using thematic analysis. COREQ guidelines were followed.

RESULTS

Thematic analysis resulted in the identification of three over-arching themes, each with two sub-themes. First, participants described the decision to terminate their pregnancy as The most difficult choice, with two sub-themes detailing 'Challenges of decision-making' and 'Stigma surrounding TOPFA'. Second, participants described that they were Neither patient, nor visitor in the hospital setting, with sub-themes 'Where do men fit?' and 'Dual need to support and be supported'. Finally, Meet me where I am described men's need for specific supports, including the sub-themes 'Contact men directly' and 'Tailor support and services'.

CONCLUSIONS

Findings indicated that termination of pregnancy for life-limiting foetal anomaly (TOPFA) is an extremely difficult experience for men, characterised by challenges in decision-making and perceived stigma. Men felt overlooked by current services and indicated that they need specific support to assist with their grief. Expansion of existing infrastructure and future research should acknowledge the central role of fathers and support them in addressing their grief following TOPFA.

RELEVANCE TO CLINICAL PRACTICE

Nursing/midwifery professionals are well situated to provide men with tailored information and to promote genuine inclusion, acknowledgement of their grief, and facilitate referrals to community supports.

Global burden of maternal bereavement: indicators of the cumulative prevalence of child loss

BACKGROUND

We provide country-level estimates of the cumulative prevalence of mothers bereaved by a child's death in 170 countries and territories.

METHODS

We generate indicators of the cumulative prevalence of mothers who have had an infant, under-five-year-old or any-age child ever die by using publicly available survey data in 89 countries and an indirect approach that combines formal kinship models and life-table methods in an additional 81 countries. We label these measures the maternal cumulative prevalence of infant mortality (mIM), under-five mortality (mU5M) and offspring mortality (mOM) and generate prevalence estimates for 20-44-year-old and 45-49-year-old mothers.

RESULTS

In several Asian and European countries, the mIM and mU5M are below 10 per 1000 mothers yet exceed 200 per 1000 mothers in several Middle Eastern and African countries. Global inequality in mothers' experience of child loss is enormous: mothers in high-mortality-burden African countries are more than 100 times more likely to have had a child die than mothers in low-mortality-burden Asian and European countries. In more than 20 African countries, the mOM exceeds 500 per 1000 mothers, meaning that it is typical for a surviving 45-49-year-old mother to be bereaved.

DISCUSSION

The study reveals enormous global disparities in mothers' experience of child loss and identifies a need for more research on the downstream mental and physical health risks associated with parental bereavement.

'Cold bedrooms' and other cooling facilities in UK children's hospices, how they are used and why they are offered: A mixed methods study

BACKGROUND

The death of a child is acutely distressing. Evidence on the benefits and value to parents of spending time with their dead child have now been integrated into routine practice and is regarded as a bereavement support intervention. UK children's hospices have a tradition of using 'cooling facilities' (cold bedrooms, cooled blanket/mattress) to extend this period of time by slowing deterioration of the body.

AIMS

To describe: (1) type and use of cooling facilities in UK children's hospices, policies and practices regarding their use, and any changes over time. (2) Director of care's views on the purpose of cooling facilities and the rationale for hospice-specific practices.

METHODS

An explanatory mixed-methods design consisting two phases: a crosssectional survey of directors of care of UK children's hospices (n = 52) followed by semi-structured telephone interviews with a sub-sample of respondents. Survey data were analysed using descriptive statistics and interview data using directed content analysis.

RESULTS

41/52 hospices completed the survey and 13 directors of care were interviewed. All hospices had cooling facilities. Some offered use of portable cooling facilities at home, though take-up appears low. Hospices differed in approaches to managing care and duration of use. Views on whether parents should observe deterioration informed the latter. Directors of care believed they provide families with time to say 'goodbye' and process their loss. Challenges for staff were reported.

Added value of an open narrative in verbal autopsies: a mixed-methods evaluation from Malawi

BACKGROUND

The WHO standardised verbal autopsy (VA) instrument includes closed questions, ascertaining signs and symptoms of illness preceding death, and an optional open narrative. As VA analyses increasingly use automated algorithms, inclusion of narratives should be justified. We evaluated the role of open narratives on VA processes, data quality and respondent's emotional stress.

METHODS

A mixed-methods analysis was conducted using VA data for child deaths (0-59 months), between April 2013 and November 2016 in Mchinji district, Malawi. Deaths were prospectively randomised to receive closed questions only or open narrative followed by closed questions. On concluding the VA, interviewers self-completed questions on respondents' emotional stress. Logistic regression was used to determine associations with visible emotional distress during VAs. A group discussion with interviewers was conducted at the project end, to understand field experiences and explore future recommendations; data were coded using deductive themes.

RESULTS

2509 VAs were included, with 49.8% (n=1341) randomised to open narratives. Narratives lasted a median of 7 minuntes (range: 1-113). Interviewers described improved rapport and felt narratives improved data quality, although there was no difference in the proportion of deaths with an indeterminate cause using an automated algorithm (5.3% vs 6.1%). The majority of respondents did not display visible emotional stress (81%). Those with a narrative had higher, but not statistically significant, odds of emotional distress (adjusted OR: 1.20; 95% CI: 0.98 to 1.47). Factors associated with emotional stress were: infant deaths versus neonates; deaths at a health centre or en-route to hospital versus home; and higher socioeconomic status. Non-parental respondents and increased time between death and interview were associated with lower odds of emotional distress.

CONCLUSION

Conducting an open narrative may help build rapport, something valued by the interviewers. However, additional time and emotional burdens should be further justified, with quality and utility of narratives promoted through standardised recommendations.

Sibling mortality burden in low-income countries: A descriptive analysis of sibling death in Africa, Asia, and Latin America and the Caribbean

In high-income countries, emerging research suggests sibling bereavement can have significant health and life course consequences for young people. Yet, we know far less about its burden in lower-income countries. Due to higher fertility and mortality in lower-income countries, the level, timing, intensity, and circumstances surrounding sibling mortality are likely to follow patterns distinct from those in higher-income settings. Thus, in this study, we offer a descriptive overview of sibling death in 43 countries across sub-Saharan Africa, South and Southeast Asia, and Latin America and the Caribbean. Specifically, we analyze Demographic and Health Survey data from nationally representative samples of 352,930 15- to 34-year-old women, born between 1985 and 2003, to document experiences of sibling death before age 25. On average, roughly one-third of individuals report a deceased sibling in these countries; estimates reach 40-50% of respondents in multiple African countries, particularly those that have experienced conflict and war. Although some sibling deaths occurred before the focal respondent was born, most bereaved individuals recalled a death during their lifetime-often in late childhood/early adolescence. High proportions of bereaved respondents report multiple sibling deaths, highlighting the clustering of deaths within families. Even so, bereaved individuals tend to come from large families and thus frequently have a comparable number of surviving siblings as people who never experienced a sibling die. Together, the results offer a window into global inequality in childhood experiences, and they attest to the need for research that explores the implications of sibling mortality for young people in world regions where the experience is concentrated.