About 20 percent of mothers who have a stillbirth experience prolonged depression afterward, and one in five suffers post-traumatic stress disorder (PTSD) in a subsequent pregnancy. Maternal anxiety, unresolved mourning, and other psychologic problems related to stillbirth are thought to be major contributors to long-term adverse effects on the family, particularly on children. In Great Britain, current practice encourages parents to see and hold their dead child, conduct funeral services, and retain mementos, in the belief that these actions promote recovery, although no systematic outcome assessments have been conducted to support the practices. Hughes and colleagues studied the effect of these behaviors on the psychologic health of the mother and her next child.
They identified mothers who had no living children and were attending one of three district hospitals in England for antenatal care in the pregnancy following a stillbirth. Mothers were excluded if they were receiving treatment for any physical or psychologic condition or if the stillbirth resulted from elective termination because of fetal abnormality. Researchers matched 65 women with 60 control nulliparous women attending the same clinics. All mothers had partners and were thought to be carrying healthy singleton fetuses. Mothers were interviewed during the third trimester of pregnancy and one year after the birth. Information was gathered on demographic, relationship, employment, and socioeconomic factors, and several standardized measurement scales were used to assess different aspects of functioning. Depression was assessed using the Edinburgh Postnatal Depression Scale and the 21-item Beck Depression Inventory. The Spielberger State Anxiety scale provided measures of anxiety, and the PTSD-1 interview, based on criteria from the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders, was used to assess symptoms of PTSD. The security of attachment of infant and mother were scored using the Strange Situation Procedure, a 20-minute standardized assessment of behavior during two brief separations and reunions.
More than 85 percent of eligible mothers who had experienced stillbirth agreed to participate. The average age of mothers was 29 to 30 years, and two thirds were white. Case and control patients were well matched, but mothers in the stillbirth group had more measures of social disadvantage, such as unemployment, low income, or poor housing. Mothers with previous stillbirth were significantly more likely to be depressed in the third trimester than control patients, but these differences were not apparent at one year after the birth. Twenty-one percent of mothers who had previously experienced stillbirth had measurable PTSD during the third trimester, but only 4 percent were affected at one year after delivery. Much of the overall poor outcome that was documented in 65 percent of mothers who had a stillborn child and 38 percent of control patients was attributed to disorganized attachment with the infant. This was present in 36 percent of mothers of previous stillbirths and 15 percent of control patients.
Of the 65 mothers of stillborn children, about one fourth (26 percent) had not seen the dead infant, 22 percent reported seeing but not holding the dead infant, and 52 percent had held the stillborn infant. Overall, adverse outcomes were significantly more common in mothers who held the infant (79 percent) than in mothers who only saw the infant (64 percent) or did not see or hold the infant (24 percent). All scores indicated better outcomes in mothers who did not have contact with the stillborn child (see the accompanying table). The effects of having a funeral and keeping mementos were too closely related to holding the child to be independently analyzed.
|Adverse outcome||Did not see stillborn infant, n = 17 (%)||Saw but did not hold stillborn infant, n = 14 (%)||Held stillborn infant, n = 34 (%)||P|
|Third-trimester depression (EPDS >14)||1 (6)||3 (21)||13 (39)||0.03|
|Third-trimester anxiety (SSA >44)||3 (18)||4 (31)||13 (45)||0.17|
|Post-traumatic stress disorder||1 (6)||2 (14)||10 (30)||0.13|
|One-year depression (BDI >10)||2 (15)||1 (8)||8 (26)||0.49|
|One-year anxiety (SSA >44)||2 (18)||0||8 (26)||0.18|
|Infant attachment disorganized||1 (8)||5 (42)||13 (42)||0.10|
|Overall adverse outcome (1 score above cutoff)||4 (24)||9 (64)||27 (79)||<0.0001|
The authors conclude that encouraging parents to view and hold stillborn infants does not benefit mothers and could have an adverse effect. They advocate that the wishes of parents who do not want contact with the stillborn infant be respected.
editor's note: Much of the support for policies that encourage families to have contact with the stillborn child comes from anecdotes and a single study in which this was only part of several innovations to improve care after this traumatic event. The actual contact with the dead child should not be allowed to become the issue. Some of the mothers in the study reported that they felt uneasy or ambivalent about seeing their child, but that they were vulnerable to pressure from staff who said “it would be good for me.” Families in crisis after a stillbirth need the security of empathic and practical support from health professionals, regardless of how they choose to handle the event. This is particularly important now that every community is much more ethnically diverse. Family physicians also need to be alert for the very long shadow of stillbirth—I have known elderly women who still talk about stillbirths that happened 60 years earlier. These women appreciate acknowledgment of that loss and reassurance that they did the best they could to recover, even if success was limited.—a.d.w.