Dr. Sheeba Marwah is currently working as an assistant professor in the Department of Obstetrics and Gynecology in VMMC and Safdarjung Hospital in Delhi. After completing her post-graduation from Chandigarh, she finished her senior residency from VMMC and Safdarjung Hospital in New Delhi. She was a senior research associate in the same hospital under WHO-funded project ‘DELHI STILL BIRTH REGISTRY including ten government hospitals of Delhi for 1.5 years before joining NDMC Medical College and Hindu Rao Hospital in August 2017 as assistant professor OBGY, where she worked for 6 months. With a keen interest in high-risk pregnancy and minimally invasive surgery, she has around 30 international publications to her name and has fervor to excel in academics even further.
Background: When a mother loses a baby after the period of viability, there is no way to fathom her grief, neither any words, nor an explanation. It is an unexpected event. Stillbirth presents a situation where the early activation of the grief process primarily in mother is exacerbated by the circumstances surrounding the loss. It thus becomes imperative for the healthcare providers to evaluate the significance of parent’s perception on the loss and the factors contributing to it before the initiation of therapy. Objective To evaluate the psychosocial impact of stillbirth among mothers and its contributing factors.
Materials and Methods: A WHO-funded prospective study was conducted in VMMC and Safdarjung Hospital from September 2015 to August 2016 on all women who gave birth to a stillborn baby, using a questionnaire based on EPDS, after taking their written informed consent. Data were entered on the predesigned proforma and analyzed after applying Chi-square test, keeping a null hypothesis value of 15% for all the variables.
Results: Out of the 709 women who delivered stillborn babies, 645 respondents, who willingly consented to participate, were included in the study. There was a significant relationship between psychosocial impact after perinatal loss and support from caregiver and family.
Conclusion: Mothers with stillborn fetuses should be screened for psychosocial impact and offered support when needed. Appropriate counseling by healthcare providers and continued psychosocial and emotional support by family members must be provided.
Keywords : Stillbirth, Consequences, Psychological effects, Social impact
Stillbirth is defined as a baby born with no signs of life after 22 weeks of gestation. There were around 2.7 million stillbirths worldwide in 2015 [1]. Besides, being an unfortunate event for the family, it is a source of subjugated grief for the couple [2]. This initiates many complex emotional responses having psychological sequelae [3, 4].
Also, there is a perceived loss of parental identity [5, 6]. It is associated with loss of hopes and potential for fulfilling dreams related to childbearing.
The bereaved couple constitute a high-risk group for complicated grief with up to 25% suffering severe symptoms years after the death of their baby [7]. Studies have proven it to be one of the major stress-inducing phenomena associated with post-traumatic stress disorder (PTSD), and these parents are more likely to develop prolonged psychological problems if professional support is not given [7, 8].
The bereavement period is characterized by feelings of denial, emptiness and sense of failure for the mother.
Besides, they are more prone to anxiety, depression, selfblame, guilt toward the loss and feel isolated socially [9].
These parents might have future pregnancy apprehensions due to either external or internal pressures. Some are pressed to prove their reproductive capabilities as soon as possible, and as such the desire to have a newborn to nurture could be overwhelming [10]. Few want to delay next pregnancy due to fear of recurrence of stillbirth.
Stillbirth can also have intergenerational consequences such as an adverse impact on siblings and complicate attachment for parents, in case of a surviving twin and subsequent children including next child-replacement child syndrome, vulnerable child syndrome [8, 9].
Critically, the provision of care for families when a child is stillborn is immensely significant to avert short- and long-term deleterious aftermaths. Also there is a paucity of literature focusing on needs and perception of women with stillborn babies. Most of the conclusions come from smaller studies in the west [1–10].
Till date, there is no Indian study exploring the impact of this condition depriving a woman from the joy of motherhood. Though not finding much place in the literature, these issues may actually influence couple’s coping mechanisms to grief and the meaning they attribute to their loss [11]. Also, it remains an area in which most obstetricians and midwives receive little or no training or inadequate training.
With the above viewpoint in focus, the present study was planned to evaluate the psychosocial impact among mothers and families with stillborn fetuses. Also it was proposed to assess the contributing factors to the same.
This was a prospective study conducted in the Department of Obstetrics and Gynecology of Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India, for a period of 12 months from September 1, 2015 to August 31, 2016. All patients delivering a stillborn fetus in the hospital during this period were enrolled in the study. Patients who consented to be part of the study were included. After a mother delivered a stillborn baby, a detailed discussion was ensued by the investigator along with a psychologist as per a questionnaire based on Edinburgh Postnatal Depression Scale [12]. Mothers’ feelings surrounding the event, its impact on relationships and family were assessed after developing an emotional rapport with her, besides ensuring her privacy. Also the mothers’ attendants particularly the husband was interviewed to express concerns and feelings. Follow-up was done at 6 weeks telephonically. All comments were noted verbatim and later on entered in the predesigned preformat. Data were analyzed using SPSS 21 version for windows, considering null hypothesis value of 15% for all variables under study. p value of\0.05 was considered significant.
A total of 26,213 deliveries took place in the hospital during the study period, out of which 709 (2.7%) patients delivered a stillborn baby. Among these 64 patients who did not wish to discuss about stillbirth were excluded from the study.
Mean age of patients was 25.5 years (ranging from 19 to 38 years). Majority of cases hailed from rural areas (94.88%) belonging to lower socioeconomic status (17.05%-Class V, 42.79%-Class IV, 40.46%-Class III).
Most women were illiterate (64.34%) and housewives (93.33%). Higher parity was seen in 6.36% patients; earlier miscarriages and bad obstetric history were seen in 29% of them (p\0.0001).
Hindu women were a majority (89.92%). Proportionately, a large number mothers who lost their babies did not have a peri-conceptional care (p\0.0001). There was a definite history of domestic violence in the family in some form in 34.42% of cases during the antenatal period. This was in the form of physical bashing by partner and verbal abuse as per history given by 33 cases, whereas some women reported partners not taking them to health facility on scheduled visits. However, further details of physical abuse could not be extracted as they were reluctant in sharing the same considering it to be a personal matter (Table 1).
The main causes that led to stillbirth are tabulated in Table 2. Abruptio placentae topped the list, followed only by fetal growth restriction. The associated conditions were hypertensive disorders of pregnancy, diabetes, maternal anemia, heart disease. There were 359 unexplained cases in which no cause was found.
There were 360 patients who delivered a macerated baby. There was a male preponderance among all stillbirths (55.8%, p\0.01). Most of these pregnancies failed to reach term gestation in 445 patients, 495 patients went into spontaneous labor and 568 patients delivered vaginally. These were statistically significant findings. Notably, in 88.02% cases, a plausible cause leading to stillbirth could be identified (p\0.0001) (Table 3).
Approximately 57.67% mothers had prior knowledge about baby’s demise on admission (p value\0.0001).
Five hundred eighty two couples were informed and counseled about the loss by the obstetrician, and 386 were explained about the cause (p value\0.0001). However, only 37.21% couples seemed satisfied about the information (Table 4).
On assessing the parents reaction to the loss, with respect to confusion, parental grief, emotional response and tearfulness, anger or guilt, varied types of grief reaction were seen in 616 women. Some mothers were confused as they did not know how to react to the situation. When the news of a dead baby was broken, some cried and laughed successively and showed signs of stress, while others refused to eat the meals or drink water, after hearing the news. Approximately 19% and 11% of women reported spousal abuse and rejection by extended family, respectively. Around 5% women remained indifferent to the news emotionally (p value\0.03). Around 5% women showed no effect following the fetal loss (Table 5).
When enquired about having seen/wishing to see their dead babies, a large number of women (295) saw their stillborn fetus; some even held the baby for some time, either themselves or after being encouraged by the obstetricians, and most of these women reported to experience calmness after holding the baby (p\0.0001) (Table 6).
Almost all couples said that they received voluminous emotional support by the care providers following the loss of their baby, followed by family support in the grief (53.8%) (p\0.0001). This was mostly in the form of sympathy and encouragement (94.42%).
Seventy seven percent couples were found to be in a dilemma following the loss 6 weeks later (p value\0.0001), whereas 203 had accepted the same and moved on. Few others were still reliving the circumstances related to the stillbirth and thinking about the triggers
When questioned about their thoughts on future pregnancy, 50% of the bereaved couples were thinking to conceive again, though 358 of them were uncertain of the outcome, while a few were fearful in expecting the worst to happen again.
In the present study, the ratio of stillbirths was 27/1000 live births, which was similar to the rate across the world [1–4]. The patients belonged to the younger age-group as compared to their counterparts seen in American and European studies [1–11].
In contrast to western literature, most of the study participants were illiterate, hailing from rural background and belonged to lower socioeconomic strata, engaged in household work and were majorly following Hindu religion [1–11, 13, 14]. Illiteracy leading to lack of awareness about antenatal care and deficient counseling probably made them vulnerable to suffer from the wide range of emotions ranging from sadness, fear, anger, denial, guilt and worthlessness. Cultural sensitivities in the region often disempower young female population by getting them marry at a relatively younger age than their counterparts in developed nations, thus embarking on pregnancy also at an early age.
On further scrutiny and unlike previous reports, it was remarkable that majority of the patients were un-booked with neither a preconception nor an antenatal supervision, in the extant pregnancy [1–11, 13, 14]. In under-resourced settings like India, there is a need to segregate un-booked cases coming to hospital from those having a fetal demise in the hospital, as the preponderance of the former indicates a lack of basic infrastructural health facilities pertaining to essential and emergency obstetric care. This further calls for equipping the primary health centers with necessary infrastructure and good number of healthcare providers to offer optimal prenatal and antenatal care to expectant and high-risk mothers and referring them to higher centers in light of identification of any complication at the earliest. Many investigators in Indian studies [14, 15] mention this particular need.
A novel finding observed in the present study was getting a definite history of domestic violence during this pregnancy inflicted on the expectant mother in a large number of participants. Such behavior is entrenched in gender inequality, which is unfortunately still persistent in our country, arguably throughout all societies. These observations support the notion of previous researchers studying the disclosures on domestic violence during pregnancy [16]. A simple assessment to identify abusive behavior during pregnancy by the attending obstetrician, coupled with the timely referral to a secondary agency, whenever needed, may effectively thwart and prevent recurrences of domestic violence and consequently go a long way in averting the fetal morbidity and mortality in such women. Most of the stillborn babies were male in the present study.
More than 60% of women had prior knowledge about baby’s demise. Role of obstetrician has been found to be very significant as a primary counselor regarding sensitization of a couple toward the factors leading to and the cause of stillbirth [8].
Varied types of grief reactions became apparent during the study period ranging from sadness and tearfulness particularly at the sight of attending doctor contemplating discussion about the dead baby, anger, guilt and a challenge to their faith in God, particularly in the primipara. Most of the respondents mentioned that accepting the loss was the foremost difficulty they encountered. They did not know what to enquire for further explanation. However, 5.12% women showed no effect following the fetal loss. This was a startling and an unfamiliar observation when compared to previous researches on the subject [4–10]. A further detailed evaluation unearthed the fact that this was exhibited by those women (4.8%) who were multigravidas with living children and demise of one baby, even though accepted as an invincible loss, did not seem to have much effect to the psychology. Spousal abuse and rejection by extended family were reported in around 20% of women, majorly due to the social stigma associated with giving birth to stillborn baby and discordant relations in these families. The ‘incongruent grief’ of mothers and fathers led to frequent disputes and doubts about fidelity on the part of the partner were seen in a small number of cases, while some even reported physical violence and strained sexual relationships after the stillbirth. They reported guilt and seeing of troubling images, thoughts and feelings that hindered establishing such relations. Women were frequently held accountable for the death of their babies.
On follow-up, most of these women communicated the noteworthy change they observed in relationships with partner and their families. A well-balanced wholesome counseling of the entire family regarding the stillbirth, its exacting causes and prevention would help them change their perception and attitude toward the grieving lady and would go a long way in helping the latter cope up with this tragedy which was quoted in various studies [17–19]. The obstetricians and the psychology support groups while offering them the much-needed care at the institute must therefore adopt these facts.
Some parents stated feeling ripped between dealing with their own anguish of losing a baby and nurturing other children. Few couples sent the children to close relatives who could take good care of them while they mourned the loss. Many parents reported feeling emotionally guarded about their children dreading losing them and going through repeated grief. These were quite similar to the findings in two studies [20, 21].
Holding the stillborn baby had been reported to produce positive memories and to assist the grieving process. In our study, 45% of mothers mustered the courage of seeing their stillborn fetus, and around 192 held the baby. According to the best practice guidelines, all parents should be offered a choice and be supported in their decision making to have a contact with the baby, which was done in our study [5, 6, 21–25].
It has been widely reported that support from doctors, staff and particularly family members is associated with lower levels of anxiety and depression in mothers following a stillbirth [26–37]. The support was acknowledged as voluminous by the care providers in the hospital by majority of them, though the role of family could not be ignored. Some studies advocated allowing of memorabilia related to baby to be given to the grieving parents, which may have a soothing effect [36–41].
On follow-up, 77% of couples were found ambivalent to the loss 6 weeks later, whereas a quarter of the patients had accepted the same and moved on. Fifty percent of couples were hopeful enough to plan for another pregnancy, though fear of recurrence hovered in nearly half of them; this finding was similar to other studies [38–42]. Others felt that they could not contemplate ‘replacing’ that baby and chose to wait for some time. Half of those who were eager to conceive stated external pressures were being imposed on them with the belief of filling the emotional void loss with another baby soon. These observations were similar to the observations made by past few studies [38–42].
The data provided in the tables are based on a self-designed questionnaire based on Edinburgh Postnatal Depression Scale. It is not validated as no such scale is available in India to cater to the local Hindi-speaking population of the region. This is one of the limitations of this study.
Conflict of interest The authors declare that they have no conflict of interest.
Ethical Approval All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Ethical clearance was taken for the study by the then chairman of institute ethics committee, bearing no. IEC/SJH/VMMC/Project/September-14/3/323.
Informed Consent It was taken from each participant enrolled in the study.
