Perinatal loss is a common global public health concern (Kissane and Parnes, 2014). Despite significant reductions in global perinatal mortality rates over the last two decades, the World Health Organization (WHO, 2020; 2022) estimated there were 2.4 million neonatal deaths in 2020 and over 2 million stillbirths. Charrois et al (2020) indicated that 15–20% of pregnancies in the UK end in miscarriage, based on data from a number of sources. In the UK, the extended perinatal mortality rate is 5.13 per 1000 births (Draper et al, 2020). South Africa has high numbers of perinatal losses, with perinatal deaths set at 18 683 in 2016 (Statistics South Africa, 2018) or approximately double that of the UK, at 11.5 per 1000 births. These data indicate that large numbers of women and their families experience the pain and trauma of perinatal loss.
Owing to their key role before, during and after birth, midwives are critical in assisting women and their families to cope with the initial trauma of perinatal loss. In the UK, as a result of the nature of such care, there is a growing movement towards the use of specialist bereavement midwives (Higson, 2015). However, such midwives are not universal, either in the UK or in other parts of the world. Andre et al (2016) noted that stress and shock, guilt and self-blame are frequently reported to be experienced by midwives after perinatal loss. Furthermore, midwives are often reported to have difficulty in addressing adverse perinatal outcomes, which demand great emotional competency (Montero et al, 2011).
Despite their crucial function in caring for women experiencing perinatal loss, in South Africa and in other parts of the world, midwives are not adequately supported to cope with the burden of providing bereavement care to mothers experiencing perinatal loss. In a systematic review by Shorey et al (2017), perinatal loss in maternity units took an emotional toll on the psychological wellbeing of midwives, who felt ill-prepared for such losses. Midwives felt demotivated or overwhelmed and even experienced the symptoms of secondary traumatic stress disorder (Shorey et al, 2017). In another UK study, it was found that caring for families experiencing perinatal loss can make midwives feel vulnerable, causing considerable stress and anxiety (Wallbank and Robertson, 2013). A South African study highlighted that perinatal loss was seen as an indication of failure, as midwives are expected to preserve life and prevent adverse outcomes, which may cause feelings of guilt, helplessness and anxiety (Morake et al, 2016). Perinatal loss events affect midwives and may lead to signs and symptoms of psychological distress. However, there is little formal support available for midwives caring for women with perinatal loss in South Africa. The purpose of this study was to explore the coping behaviours and support needs of midwives caring for women with perinatal loss.
Methods
Design
The study used a qualitative approach, with an exploratory-descriptive design. Gray et al (2017) described an exploratory-descriptive design as research that seeks to address an issue or solve a particular problem.
The study was conducted at five midwifery obstetric units and two high-risk referral hospitals in the Nelson Mandela Bay Health District. Approximately 37 midwives work in the five midwifery obstetric units and approximately 100 work in the two high-risk referral hospitals. According to the Perinatal Problem Identification Program (2018) from April 2017 to April 2018, the area chosen for the study had the highest prevalence of perinatal loss.
Data collection
The participants were midwives recruited from midwifery obstetric units with a minimum of 1 year's experience caring for women with perinatal loss in facilities in the district. The participants were purposively sampled between November 2018 and January 2019. A total of 13 midwives were recruited, whose ages ranged from 31–51 years. Only women participated as no men were employed in maternity units at the time of data collection.
Semi-structured one-on-one audio-recorded interviews were conducted with the midwives, where they were asked about their experiences of providing care for women with perinatal loss. An interview guide was used, and probing was based on the responses of each participant. Interviews took place between November 2018 and January 2019 in a location of the participants' choice; the venue chosen by most participants was a room in the facility where they worked. Each interview lasted approximately 30 minutes.
Data analysis
A seven-step framework for critical analysis was used to code and analyse the data (Gale et al, 2013). The seven steps are transcription, familiarisation, coding, developing an analytical framework, applying the framework, charting data into the framework matrix and interpreting the data. Coded data enabled the identification of similarities, differences and consistencies. These were arranged into subthemes and themes. Major themes and subthemes were carefully developed by considering each line, phrase or paragraph of the coded transcript. Transcribed data were interpreted and analysed by the researchers and an independent coder.
Ethical considerations
Ethical approval to conduct the research was obtained from Nelson Mandela University (approval number: H18-HEA-NUR-017). Permission to access public health facilities was obtained from the Eastern Cape Department of Health. Informed consent was obtained in writing from all participants and they were informed that they had the right to withdraw from the study at any time.
Results
Three themes emerged from the data (Table 1). The participants expressed relying on their own coping mechanisms to deal with perinatal loss, how management influenced the way they coped and the need for psychological and emotional support.
Relying on coping mechanisms
The participants expressed feelings of guilt, stress and depression when confronted by the reality of perinatal loss. This led them to adopt coping mechanisms to enable them to continue working as a professional.
Informal peer-debriefing
One coping mechanism used by the participants was engaging in informal peer-debriefing with colleagues after being exposed to a perinatal loss event. One participant highlighted the stress experienced and the relief after talking to a colleague about an event.
‘Talking with colleagues as a way of coping after perinatal loss relieves the stress.’
Participant 7
Family support
The participants appeared to rely heavily on their families to cope with perinatal loss events, especially in cases where there was no opportunity for informal peer-debriefing. One participant expressed the need to offload with her husband regarding the traumatic event and this process of sharing had the effect of a debriefing session.
‘I talk with my husband about the perinatal loss event that has occurred at work as we share everything, it helps me to debrief.’
Participant 9
Prayer
For some participants, prayer was helpful in coping with their experiences of perinatal loss. They described what they viewed as the benefits of prayer during their work as midwives, particularly in the light of perinatal loss events.
‘There are times when you feel helpless due to the rate of perinatal loss, we just pray about it and continue like nothing happened.’
Participant 11
It was not clear if this was a healthy process, as they appeared to be avoiding confronting the issue.
Suppressing feelings
Some participants found it difficult to cope with perinatal loss events that occurred when they were on duty. They felt they had to suppress their feelings during such events.
‘You yourself as a professional nurse, it is very difficult because you cannot really show your emotions because you need to be strong for this person.’
Participant 1
The participants felt they had to suppress their own feelings to adequately support grieving parents.
Follow-up care with women gives closure
The participants expressed the need for follow-up visits with women after a perinatal loss event, as they felt it helped with closure.
‘Tomorrow, if I come and my patient is still here, I will go to her and tell her “if you need help, I'm there, you can phone me or just call me if you need help”. Talking with her after perinatal loss make me feel better.’
Participant 9
The participants felt the need to make contact with women; however, follow-up visits were not always possible.
‘She's emotional, she's crying but you can't even stay with her you have to rush out and go and attend to other administration duties.’
Participant 6
The frustration of not being able to be there for women made it difficult for participants who were obliged to continue with everyday duties rather than provide support to those women who had suffered a loss.
Management influence
The participants expressed their feelings about how management influenced the way they coped with perinatal loss events. They felt that the hospital system was frequently a cause of work-related stress.
Limited support from management
The participants were unhappy with what they perceived to be inadequate support from management during perinatal loss events.
‘You don't get any support, okay, there are managers which you know they feel sorry for you but that's it, it ends there, there's nothing they are doing. You must just carry on with your work, it's over, next page, life must go on.’
Participant 2
The participants perceived a lack of empathy from management, who appeared to expect that midwives should simply keep working.
‘The blame for these losses is put on the midwives, instead of getting support in our workplace, our actions [are] being questioned and the doctors and management…we are being treated differently.’
Participant 6
The participants described how management appeared to blame them rather than the doctors when there was a perinatal loss event. There appeared to be little sympathy or understanding from management.
‘They don't need to do things like sending us away for debriefing or counselling but by virtue of them showing that they care and support us will really help, especially if they can be there for us in the ground level instead of coming and scrutinise the file and tell us “you didn't do this and that and that” and “why was this not monitored” knowing there's nobody available to monitor that.’
Participant 6
Lack of private rooms for grieving women
The lack of private wards for grieving women was a major issue for the participants, who felt guilty about the situation.
‘You don't know what to say because if she becomes more emotional because she lost a child now and yet we are having a lot of mothers still coming in delivering and giving birth to healthy babies so there are quite a few challenges.’
Participant 1
The lack of private rooms for grieving women was a source of distress for the participants, who felt unable to shield women from witnessing other women giving birth to healthy babies and experiencing the joy that comes with such an occurrence.
‘Then during visiting times the whole family of the other one will come, and they start celebrating next to this one who's lost the baby…the problem is the space, we do not have anywhere to place them. If we could have a ward that is mainly for them, then I think it would be so much better.’
Participant 13
Time constraints in the provision of bereavement care
The participants highlighted the challenges regarding time constraints in the provision of bereavement care to women who were experiencing perinatal loss.
‘We [are] so short-staffed we don't even have time to talk with them…that patient who lost the baby is one of the eight patients you [are] looking after, you [are] rushing through them you don't have time, you only have time at home to process.’
Participant 3
The participants' high workload left them with no time to counsel women and it was often only in the evening that they were able to reflect on what had happened.
Lack of protocols
The participants felt that the responsibility of having to provide immediate grief counselling without suitable protocols left them distressed and frustrated.
‘We also need more protocols, for example, which will help in knowing whatever extra mile you need to walk with the patient through this situation and know that you are being supported by the protocol on it.’
Participant 6
The participants felt that they needed a protocol that would guide the care they provided to women with perinatal loss.
Staff shortages undermine management of women who experience perinatal loss
The participants expressed the challenge of staff shortages, which they felt was being overlooked by management.
‘I think the main problem is shortage of staff, because we have that feeling of not being there for our patient if you have to attend on your own self at the time that you are supposed to look at them.’
Participant 10
The participants reported that staff shortages were a key challenge that impacted their ability to provide the necessary bereavement support to women experiencing perinatal loss.
The need for psychological and emotional support
The participants indicated that they were expected to provide psychological support to women experiencing perinatal loss, but they often became overwhelmed and struggled to provide this care.
Department of Health support services are inadequate
The Department of Health has an employee assistance programme, part of which is a counselling service, but the participants felt that the programme services were inadequate or non-existent.
‘We have an employee assistance programme system in place but really, it's not sufficient for what we sometimes deal with here and is in district offices.’
Participant 1
The participants had a negative perception of the programme, and felt that the service was not suited to their needs.
Shortages of staff prevent midwives from accessing the employee assistance programme
Some participants felt that they were unable to seek employee assistance programme services because of staff shortages. They felt guilty if they contemplated taking time off to obtain counselling from a professional. Such feelings emanated from their sense of duty to labouring women. The participants also felt that taking time off would lead to criticism from colleagues.
‘There's so much in the unit to take care of, so escaping and getting time for me to get to go to the employee assistance programme, it looks as if I'm depriving my patients the care that they need because we are very few. I am not able to run away and to get briefed or to get me taken care of.’
Participant 10
Referral to a specialist for counselling
The participants expressed the need for individual and group counselling other than that provided by the employee assistance programme. They felt that their employer should shoulder the responsibility and liability for their employees' psychological wellbeing.
‘I think if there can be…[a] psychologist who will come and address [the midwives], give them…moral support, emotional, physical [support] and give us a talk after all this…Even if its once a month, maybe it will relieve the stress and depression.’
Participant 2
There was a sense that a psychologist, who is an ‘outsider’ should provide regular counselling support and that this would be more effective than the current support offered by the employee assistance programme.
Discussion
The purpose of the present study was to explore the coping behaviours and support needs of midwives caring for women who have undergone perinatal loss. Perinatal loss is a stressful and overwhelming experience for these women and it is also stressful and overwhelming for midwives who are caring for them. The participants in the present study reported that they rely on their own coping mechanisms to handle perinatal loss events. They also felt that management influenced their ability to cope with such events and expressed the need for additional psychological and emotional support.
Engaging in informal peer-debriefing with midwife colleagues after the loss of a patient's baby helped the participants to cope with perinatal loss events. Similarly, Hutti et al (2016) found that midwives who had been exposed to a perinatal loss event felt the need to share their experiences with their peers. The process of sharing their experiences had the effect of a debriefing. Shore (2014) argued that debriefing after significant events has the potential to improve staff morale and reduce sickness rates.
Families play an important role when it comes to emotional support and the present study's midwives were no exception. The participants described how they often relied on their families for support to cope with perinatal loss events. Families can provide identity, love, care, protection and support (Banovcinova, 2017; Ramalisa et al, 2018). By sharing feelings with their families, the participants were able to verbally express that which was often not possible to express in the workplace. A systematic review on perinatal loss by Gandino et al (2019) highlighted the benefits of healthcare professionals' willingness to share their feelings with their family members.
The spiritual aspect of coping with bereavement and loss was emphasised by the participants. They stated that they often used prayer as a means of coping after a perinatal loss event, which gave them a sense of relief. However, there was also a sense of moving on and not engaging fully with the perinatal loss events, as professional duty appeared to take precedence over any feelings related to the trauma of such an event. The importance of prayer as a means of coping with perinatal loss was also highlighted by nurses and midwives in a Turkish study (Yenal et al, 2021). A scoping review by Shorey et al (2017) confirmed that prayer was frequently used as a coping strategy among healthcare professionals who were struggling with the loss of a patient.
The midwives expressed the need to stay in control of their emotions because of the need ‘to be strong’, so that they could support women who had experienced the loss of their child. They also felt the need to distance themselves emotionally from the patient or the situation to ‘survive’ as a professional midwife. Suppressing feelings is temporary and described as a ‘maladaptive emotion regulation strategy’ used when individuals avoid any in-depth exploration of their reactions to a situation (Subic-Wrana et al, 2014). Jones and Smythe (2015) reported that midwives who experienced perinatal loss expressed that although the loss was not theirs, their own sense of loss was intense and deeply personal, and yet the loss was not theirs to grieve over openly.
This sense of loss led midwives to seek out women whom they had cared for after their perinatal loss. They expressed achieving a sense of closure through follow-up appointments. The need for follow up was emphasised by Fenstermacher and Hupcey (2019) who highlighted that such visits are of benefit to the women. However, there is a paucity of literature showing that midwives also have a need for follow up or connecting with women to achieve some form of closure.
Among the participants, there was a sense that there was limited support from both supervisors and hospital management after a perinatal loss event. There was the perception that management only came to check up on them and to find fault, rather than to provide support. The participants felt that the negative attitude and actions of management influenced their ability to cope. A lack of support from management can cause midwives to lose motivation, especially if there is a lack of advocacy among leaders who sometimes appear to be on the side of the patient during times of conflict (Bremnes et al, 2018). Similarly, Ndikwetepo and Strumpher (2017) found that a lack of support from management affected midwives' morale and increased stress.
A major aspect influencing midwives' perinatal loss experiences concerned the environment where grieving women were given care following perinatal loss. The participants felt that the environment was not conducive to supporting women and their families through the grieving process. When the delivery ward is not set up or equipped to support parents in the time between learning that their baby has died at birth and exposure to the cry of newborn babies and other parents, it can be very distressing (Peters et al, 2015). The participants were unhappy with the lack of compassion that the layout of the ward appeared to communicate to grieving women and their families. It was frustrating for them, as they were not able to change the ward environment despite knowing its effect on grieving women and their families. In the UK, the National Bereavement Care Pathway (2018) requires that bereavement rooms are available and accessible in all hospitals. The authors suggest that this policy would be beneficial in the present study's setting.
The lack of time was a major challenge for midwives, who expressed being unable to adequately care for grieving women because of time constraints in the workplace. Williamson (2016) reported that owing to the high turnover of patients, midwives had less time to focus and support mothers going through perinatal loss.
The participants of the present study indicated that they needed guidance in providing bereavement care. They felt that they needed a protocol to guide them. Protocols can help facilitate the bereavement process (Martίnez-Serrano et al, 2018). However, Williamson (2016) stated that in many instances where protocols are available, midwives are not always able to interpret them.
The challenges of staff shortages impacted the midwives' ability to adequately care for grieving women. They were frustrated because a lack of staff and subsequent time constraints meant they were constantly having to rush about attending to other labouring women or administrative duties. Hence, they were unable to provide effective support. South African public healthcare facilities face major shortages of highly skilled healthcare professionals, including midwives (Onobanjo, 2013). These staff shortages impact the quality of patient care (Brophy and Rust, 2015) and cause fatigue, burnout and an inability to provide optimum care to labouring women (Lumadi and Matlala, 2019).
According to the participants, staff shortages also prevented them accessing employee assistance programme services. They also felt that the programme services were inadequate for their needs. They felt that they should receive quality psychological care by professionals of their choice. It is critical that midwives who work with bereaved families have appropriate emotional support themselves (Hunter et al, 2016) to enable them to provide the necessary care to grieving families.
Limitations
There were no male midwives in the sample, as no male midwives volunteered to take part. Hence the perspective of male midwives regarding perinatal loss was not obtained. However, the midwifery profession in the Eastern Cape is dominated by female midwives. The study also did not include any members of nursing management, to obtain their perspective of the challenges of supporting nurses caring for mothers experiencing perinatal loss.
Recommendations
The authors have three main coping and support recommendations for midwives caring for women with perinatal loss. First, management should facilitate various forms of peer assistance to prepare and support midwives caring for women with perinatal loss. Second, formal support systems in the labour unit should be provided to assist midwives to care for women with perinatal loss. Finally, existing employee assistance programmes should be strengthened, and provide unit-based psychological and emotional support in order to accommodate the needs of midwives caring for women with perinatal loss. A factor underlying these recommendations, and which has implications for practice, is the problem of staff shortages, which impacts midwives' ability to provide quality bereavement care, and to process and cope with such events in a healthy way.
Conclusions
This study sought to explore the coping behaviours and support needs of midwives caring for women with perinatal loss. It was found that support from management appeared to be lacking, as they did not seem to understand midwives' needs in relation to perinatal loss. The participants expressed the need for a formal support system in the labour unit, so that they could effectively carry out clinical duties when caring for women with perinatal loss. They also identified the need for unit-based psychological and emotional support. A number of structural challenges were highlighted, namely the need for management to provide a protocol for perinatal loss, to adjust the layout of the wards to protect women and their families from unnecessary distress and to address the challenges of staff shortages. The midwives felt management needed to demonstrate visible concern for them and to provide practical solutions to assist them. Research on the role of leadership processes in relation to perinatal loss events, such as managerial support, can assist in furthering what is known about the influence of leaders' behaviours in shaping and improving the midwifery work environment.
Key points
- Midwives are critical in assisting women and their families to cope with the trauma of perinatal loss.
- Owing to their close proximity to the event, midwives often experience stress, shock, guilt and self-blame.
- Midwives felt management did not seem to understand their needs in relation to perinatal loss.
- Staff shortages undermine bereavement care for the women, and prevent midwives from coping with perinatal loss events.
CPD reflective questions
- How can midwifery managers help midwives under their supervision cope with perinatal loss events?
- How can midwifery managers build on existing peer support to assist midwives to cope after perinatal loss?
- What is the role of hospital management in overcoming the problem of staff shortages, particularly in the light of perinatal loss events?