Support and training for midwives working in partnership with families

Caring for distressed parents is difficult and demanding, and requires staff who are in a working environment that considers their needs and values them as individuals. Where appropriate support mechanisms are in place, midwifery teams are able to provide the best possible care to families. Bereaved parents are deeply grateful and remember the care they received throughout their lives (see website).

Bereavement skills training and support should be an intrinsic part of maternity care, whatever the setting (Schott et al 2007). Using counselling and listening skills is an essential part of the professional’s role and requires training, enabling midwives to care effectively when managing the death of a baby.

It is important that the midwife is aware of:

When staff do take the time to talk about their needs, their feelings, their reactions to situations and to understand their strengths and limitations, then working with families in grief is special and rewarding.

Accepting the reality of the loss

Initially, the parents are unlikely to believe the bad news and will be in a state of shock and denial, even when a death has been anticipated. Some bereaved parents cry uncontrollably, become hysterical or collapse, whereas others feel faint or numb and display few signs of emotion, appearing very controlled, calm and detached. The initial shock may last for hours or several days. This natural reaction is a form of emotional protection that disappears as parents gradually take in the full impact of events. Each experience of grief is unique and previous losses may also complicate the reaction to this current bereavement.

Parents may initially be unable to acknowledge what has happened and may manage by denying the reality. These parents need time and help to do what is right for them. It is not helpful for professionals to collude with denial and unreality, for example by avoiding talking about the dead baby, somehow making the child’s death seem less important – not showing or fully acknowledging its significance.

Midwives can help enable parents to gradually face reality. Being sensitive to parents’ needs, discussing what other parents have valued, offering choices, such as seeing and holding their dead baby, being involved as much as possible in the preparations for the funeral, and observing rituals and traditions, all help to make what has happened real. Families from different faiths need support for the mourning rituals appropriate to their culture (Thomas 2001, Schott et al 2007, CBC 2007d).

Working through to the pain of grief

As denial and numbness gradually subside, the bereaved parents usually experience the full impact of what has happened. Intensely painful feelings may last many weeks or months. This normal reaction to an abnormal event can be overwhelming as they think about what could have been and what the future now holds. Bereaved mothers are often incapable of thinking about anything or anybody else and are consumed with their child, themselves and how they feel. Painful reminders get in the way and are all around them. Innocent comments may get misinterpreted and cause distress and irritability. Susan Hill (1990), a writer and bereaved mother, eloquently described her extreme sensitivity after the death of her baby Imogen as ‘like having one skin less’, and appreciated the professionals who treated her gently.

It is normal to feel extremely sad, guilty, angry and resentful. Many parents struggle with guilty feelings about some aspect of their baby’s death, especially if they were initially ambivalent about becoming parents. Mothers may think about their behaviours or actions taken which they may blame for causing the death of their baby, such as running for a bus or carrying heavy shopping. These punishing thoughts can intrude into all aspects of their life.

Feelings of anger are often unexpected and hard to manage. The father or mother may feel anger for the loss of control that death brings; their anger can be directed at the medical and midwifery team for not recognizing the problem sooner, for not keeping their baby alive; anger at a God who allowed it to happen; and possibly anger towards their baby for not living and leaving them. Sometimes, unexpected resentment towards a family member or their partner adds to this exhausting and painful time.

Grief is not a mental illness, although sleeplessness, anxiety, fear, anger and a preoccupation with self can all add up to a feeling of ‘going mad’. These feelings are normal, and when experienced and expressed, slowly become less intrusive and frequent. Talking or writing about difficult experiences with someone who is interested and willing to listen is one of the healing ways to express grief. Attempts to cut short these emotions rarely help in the long term and may cause deep-seated problems in the years ahead. If grief is denied, or anger and guilt persist to the exclusion of other feelings over a number of months, help may be needed from someone trained in counselling.

Adjusting to an environment in which the deceased is missing

However short a time the parents had to get to know their baby, both during pregnancy and after the birth, facing a future without this child in the family is a difficult and painful process. Nothing can fill the aching void their baby has left and each day of life brings constant reminders of their baby’s absence. The future seems uncertain and frightening, while a tremendous effort is required to carry on as normal.

Grief is exhausting. It may take many months before the mother, particularly, is able to focus less on the sad events surrounding the death and regain some of her interest in life. Parents may also revisit the feelings of loss at what would have been significant milestones in their child’s life, such as expected date of birth, anniversaries and birthdays.

Emotionally relocating the deceased and moving on with life

This involves moving on to a different and new way of life without their child, whilst remembering and holding on to precious memories. It is a process of reinvesting in life again alongside the knowledge that their baby will not be forgotten. This can often feel like a betrayal and is perhaps more difficult than generally recognized.

When parents are able to move on with their lives together, there is a sense of putting the distress aside and looking to the future, whilst recalling memories of their baby and finding comfort and pleasure in these memories. It is a way of making life meaningful again and gaining back some control, so that the bereaved parents are not continually ambushed by memories of the death and trapped by painful feelings.

The importance of the loss

When a baby lives only a short time or dies before birth, because of miscarriage, termination for fetal anomaly or stillbirth, a common assumption is that the loss is not as significant. Pregnancy is a time of anticipation and many parents, particularly mothers, develop a strong bond with their baby long before it is born (Fig. 70.2). When a baby dies, parents grieve for all they had hoped and the lost opportunity of getting to know their child in a future they had planned together.

Figure 70.2 Claire and Joseph with daughter Ellie, who died at birth.

This grief response may be seen in families when a baby is born with a disability, who may experience the same feelings of loss of the healthy baby they were expecting and anger at the extinction of their hopes and plans. For some parents, the need for a caesarean section can result in a sense of failure and a reaction of grief for a different birth expectation.

A Stillbirth and Neonatal Death Society (SANDS) teardrop sticker placed on the mother’s notes after a baby’s death alerts all professionals to the parents’ immediate and long-term need for sensitivity. At initial booking, it is important for the midwife to identify women who have had previous losses – miscarriage, stillbirth or neonatal death – and discuss the implications for the current pregnancy. This requires opening up a potentially painful subject; however, the midwife needs to be aware that this discussion allows the dead child to be acknowledged and their existence as an individual valued.

The midwife can also help prepare the woman for reactions and feelings that she might experience during the pregnancy and birth of this baby, which might include mixed feelings at the birth, and high levels of anxiety concerning the baby’s wellbeing and survival (Caelli et al 1999, Hunfeld et al 1997). The healthcare team can be alert to this mother’s needs, and ensure that support systems are available during the pregnancy and puerperium (Thomas 2001, Schott et al 2007). Bereaved mothers may be inclined to develop postnatal depression, particularly in cases of complicated grief.

Supporting parents

Women and men say that the most supportive care is when professionals are able to help and encourage parents to ‘parent’ (CBT 2003a, 2003c, CBC 2007a), to be involved with their baby before and after death.

Both parents need support and both need information, though it should be remembered that it is often difficult for distressed parents to absorb and understand what they are told. It is useful to ask the parents to explain to you what they have understood. They may want more information about their baby’s condition or to know more about the reason for their baby’s death, and so any help the midwife can provide in obtaining this information will be welcomed (Schott et al 2007).

Parents appreciate staff who offer them warmth and understanding, are able to show they care and are not afraid to express their own emotions. In expressing feelings, professionals act as role models and tears are unlikely to be viewed negatively if genuinely felt. However, parents need support and should not have to be concerned about their midwife’s feelings or experiences of grief.

Touching is the most basic form of comfort and communication. This may be a hand on the arm, or an arm around the parent’s shoulder. Parents need the opportunity to talk about how they feel with someone they trust and if possible to be able to express their emotions openly. It is not helpful for parents to be told how they feel; only they can know. Parents do not want to be told the stage of grief they are seen to be at.

Often midwives spend many hours with a couple. Talking about everyday things, offering opportunities for normal conversation, can be useful, as well as being quiet and recognizing that just being there and being available to the parents is valuable. Self-aware midwives can be intuitive and trust their own instincts when interacting with parents; listening carefully is the key.

It is important to talk to both parents and acknowledge that both parents are grieving. It is helpful to provide information to parents who may want to do the practical things that have to be done, together.

All staff – hospital and community midwife, doctor, chaplain, counsellor and social worker, support staff and, later, GP and health visitor – need to adopt a team approach with everyone being aware of the procedures to follow when a bereavement occurs. Good team relationships are essential to provide the best possible care to bereaved parents.