It is well recognised in the literature that the quality of the relationship between the midwife and the woman is central to the quality of care provided during pregnancy, childbirth and the postnatal period (Hunter, 2006; Ólafsdóttir, 2006; Hunter et al, 2008; Dahlberg and Aune, 2013). Within this unique relationship with their midwife, women highlight the importance of an emotional connection, trust, presence, empathy and being valued as a unique person (Dahlberg and Aune, 2013).
Sadly, not all pregnancies result in the birth of a live baby. However, the presence of quality relational care, which is embedded in maternity care, remains particularly crucial when caring for parents who experience a perinatal death.
The essence of compassionate relational care
Compassionate relationships are core elements in creating a safe relational space for the provision of quality clinical and perinatal bereavement care. Bereaved parents' journeys through the maternity services may be greatly influenced, either positively or negatively, by the quality of the relationships that emerge between them and each health professional they encounter. Dewar et al (2014: 1745) describe compassion as ‘a skilled interpersonal and relational process’. Embracing a relational approach to bereavement care requires a compassionate relationship to develop between the individual worlds of the caring midwife and the wounded parents. This unique relationship is epitomised by kindness, openness, trust, dignity, mutual respect, collaborative care, sensitive and honest communication, consistent and accurate information, guidance, and support (Papadatou, 2009; Emanuel and Pryce-Miller, 2013). The unwavering presence of this relationship creates a unique shared, relational space where the bereaved parents and the midwife emotionally connect and collaborate (Papadatou, 2009). Within this space, the midwife relates with sensitivity, is open to meet with the parents' experience in a meaningful way, and is emotionally present with them in supporting and bearing witness to their unique grieving journey.
Self-reflection
To create and share in this unique relational space with bereaved parents and their families, the midwife must embark on a journey of continuous self-reflection (Papadatou, 2009). Each midwife's unique life story, attitudes, values, experiences and commitment will influence his or her behaviours, either negatively or positively. Ultimately, it will shape the quality of relationships with bereaved families and colleagues and the quality of care provided. Self-reflection enables midwives to explore their emotions and experiences. It highlights the individual's strengths and limitations, and the insight gained may necessitate that the midwife adapts his or her attitudes and behaviours in order to enhance the quality of the approach in relating to bereaved parents. Following a baby's death, the midwife's approach in relating to bereaved parents remains deeply etched in parents' memories. Midwives who are self-aware are empowered to create a relational space where parents experience a sense of belonging, a genuine acknowledgement of the magnitude of their baby's death and their overwhelming grief, together with a compassionate response to their needs and preferences. In the midst of the parents' profound grief, possessing positive memories of the relationships that were created with midwives and the care that was provided enables them to store those meaningful memories, provides comfort, and ultimately shapes their onward grieving journey (Downe et al, 2013).
For parents who experience early miscarriage, the focus of care is often on physical needs, with less emphasis on the relational aspect of care. Midwives should be constantly mindful of creating positive relationships with parents, by acknowledging their miscarriage, communicating sensitively and effectively, providing support, quality information and choices, and engaging them in decision-making (Geller et al, 2010; Rowlands and Lee, 2010). Studies suggest that the presence of a compassionate relationship eases the woman's grief following miscarriage and has a positive influence on how she negotiates her grieving journey (Simmons et al, 2006; Murphy and Merrell, 2009; Séjourné et al, 2010).
Creating a safe relational space
When parents receive the news that their baby has died or is dying, it is usually unexpected and often results in significant shock, profound grief, fear and uncertainty. In an instant, their lives have totally changed. The safe relational space that is created becomes a crucial stable and healing sanctuary in sustaining or ‘holding’ bereaved parents as they are bombarded with unexpected, unfamiliar and unwelcome feelings. Creating and maintaining a safe relational space is greatly influenced by the midwife's attitude and behaviour, along with his or her willingness and capacity to be emotionally present with parents.
Midwives become emotionally present in the bereaved parents' world when they intentionally allow themselves to be guided, not by care plans or pathways, but by their inherent humanness and compassion. In revealing these valued qualities, midwives are empowered to be openhearted, mindful, gentle, respectful and supportive of parents in their overwhelming sadness and vulnerability. They are also in harmony with—and focused on—the parents' unique needs, preferences and concerns. The midwife's emotional presence offers the parents a human connection to guide them to some sense of stability amid the temporary chaos they are experiencing. Initially, parents require a safe relational space to enable them to grasp the enormity of the news they have just received; subsequently, they need a safe space to be present with their baby, their families and friends, to tell their story, share their grief and begin their journey of processing the thoughts and emotions that emerge. It is within this space that midwives will deliver consistent, high-quality and safe clinical care, together with sensitive and collaborative bereavement care. Bereavement care initiatives—for example, care plans or guidelines, which are necessary components in the provision of quality perinatal bereavement care—will only be truly effective when delivered in the presence of a compassionate relationship; if delivered in isolation, they are merely viewed as tasks that must be completed (Hunter et al, 2008). The significance of emotional presence is highlighted in a study conducted by Kelley and Trinidad (2012), where bereaved parents reported that during their entire journey in the maternity services, the most profound aspect of care occurred when staff assigned time to sit, emotionally connect and be fully present with the parents in their grief. Lathrop and Vandevusse (2011) reported in their study that parents valued staff who validated their experience by relating with humanness, listened to their story, supported their wishes, and acknowledged and respected the worth of their baby's life and the significance of their baby's death.
In connecting emotionally and being fully present with vulnerable parents, the midwife assumes the role of a true advocate and remains a constant companion as parents meet with the numerous difficult decisions and challenges ahead, such as induction of labour, labour itself and the birth of their baby. The midwife's consistent openness, compassionate presence and empathetic attitude and behaviour will enable this safe relational space to be maintained with the bereaved family. The process of creating and maintaining compassionate relationships with parents involves vital strands of care being woven together (Box 1).
Quality relationships between colleagues and teams
Quality relational care is dependent on a network of relationships. It embraces the establishment of quality relationships between colleagues, and within and between multidisciplinary teams in the hospital and the community. The presence of quality relationships ensures effective communication between teams, encourages collaboration and transparency, nurtures mutual respect and supports a positive learning environment (Papadatou, 2009; Hedges et al, 2012).
Effective communication
Communicating effectively is also fundamental in maintaining relational care, as the quality of the relationship established between health-care providers and bereaved parents is inevitably linked to the quality of communication that flows between them. Effective communication actively includes parents in all aspects of their own and their baby's care; it should be a continuous process and evident throughout their care. It is particularly crucial in conveying bad news, acknowledging and validating parents' thoughts and emotions, identifying their needs, preferences and concerns, obtaining and sharing information with and between parents, colleagues and teams, offering choices, collaborating in decision-making, obtaining informed consent, and for safe practice.
In the midst of their grief, parents may find it difficult to hear and/or understand the information that is being conveyed to them; therefore, the midwife should sit with them and communicate in a calm, caring tone of voice. Information should be delivered slowly, in small chunks, and the midwife should check frequently to elicit the parents' understanding. Be prepared to repeat information and use supportive written information. If appropriate, it may be worth considering the use of diagrams to aid understanding, and avoid using medical terminology. The midwife's body language should convey openness and kindness, attitudes should be caring and respectful, and behaviours gentle and compassionate during every episode of communication. Actively listen to the parents' story, use a caring touch if appropriate and respect cultural, spiritual and religious values. The use of open-ended questions—for example, ‘What are your feelings about labour/birth?’—will enable parents to express their thoughts and feelings and encourage them to engage in the communication process.
Quality information
When their baby dies, parents are likely to desperately search for answers, information, reassurance, guidance and support. Questions they have may include: Why did our baby die? What tests will be done? Should we tell our other children?
Communicating quality information sensitively and honestly creates trust and realistic expectations, and offers parents some sense of control. This is essential in offering parents choice and empowering them in decision-making concerning their own and their baby's care. Insensitive, inconsistent, incorrect and outdated information tends to add to parents' distress, so the midwife must ensure that the information he or she delivers is sensitive, accurate, current, consistent, timely, relevant, concise, clear and complete. To enable parents to reach informed decisions, it is imperative that they are allowed sufficient time to process the information they receive; to ask questions, consider options, change their minds or clarify any lingering concerns e.g. in relation to burial arrangements or postmortem examination. Quality information should flow smoothly between health professionals and the bereaved family, and between colleagues and health-care teams in the hospital, across hospitals and into the community setting. Evidence of both effective and poor communication processes between health professionals and bereaved parents is evident in the literature. In a study by Downe et al (2013), some bereaved women recounted practices and attitudes that they perceived as helpful, such as staff being conscientious and compassionate in every episode of communication, while other women experienced care that was devoid of an emotional connection and communication and reported that information was insensitive, insufficient and inconsistent. A study by Redshaw et al (2014) showed that effective listening, acknowledgement of the parents' concerns, and collaborative decision-making were deemed ‘essential aspects of care by bereaved parents but were sometimes absent, which led to concerns being dismissed.
The reciprocal influence of providing relational care
Because a baby's death is viewed as particularly heartbreaking, bearing witness to the parents’ profound grief can have a considerable emotional impact on health professionals. There is evidence to suggest that the presence of meaningful relationships not only provides support for parents but also has a positive reciprocal influence in supporting health professionals to cope with their own grief (Roehrs et al, 2008; Papadatou 2009; Jonas-Simpson et al, 2010; Dewar et al, 2014). Relational care has the potential to be both enriching and fulfilling for the midwife. In a study by Fenwick et al (2007), the most satisfying aspects of care reported by midwives were being allowed time to establish a meaningful relationship with parents and knowing they had positively influenced the parents' grieving journey. Other studies have found that, although midwives experienced caring for bereaved families as challenging, they genuinely valued the emotional connection they shared with parents (Roehrs et al, 2008; Jonas-Simpson et al, 2010).
Challenges
A daily challenge for all health professionals is to deliver and sustain compassionate relational care. The hospital culture in relation to perinatal bereavement care is greatly influenced by existing practices, attitudes, behaviours, values and priorities. It is essential that organisations and hospital systems support and nurture midwives, along with other health professionals, to create an environment where an open, consistent and compassionate hospital culture is visible and relational care is valued and encouraged. The presence of such a culture will help to ensure bereaved families' needs become the central focus of care.
Conclusion
The process of creating and maintaining compassionate relationships with parents involves vital strands of care being gently woven together to embrace and comfort bereaved parents and positively shape their grieving journey. Evidence strongly suggests that bereaved parents value meaningful relationships with their midwife. These perceptions greatly influence their assessment of the quality of the overall care they receive. Midwives have an integral role in initiating and maintaining compassionate relational care. At the heart of relational care is the creation of a shared relational space where the midwife communicates to parents a readiness to emotionally connect and collaborate with them as they begin their journey of coping with the enormity of their baby's death. The absence of an emotional connection leads to missed opportunities to explore the parents' needs, their overwhelming sadness, their genuine fears and profound vulnerability.
‘There is evidence that the presence of meaningful relationships not only provides support for parents but also has a reciprocal influence in supporting health professionals to cope with their own grief’
Insensitive care that is devoid of a connection or relationship between the midwife and bereaved parents can create an impediment in the family's grieving journey. Negative intense emotions associated with insensitive care often persist unabated and dominate a space in the parent's mind, which rightfully should be a space to grieve and remember their baby. A commitment by midwives to create and maintain a compassionate, safe relational space with parents, will not abolish the profound anguish that the parents experience, but it may temper their grief and create positive memories that will become part of their deceased baby's narrative and flow forward with them on their grieving journey.