Experiences with perinatal death among midwives, obstetricians, and assistant nurses: Results from a qualitative study in Norway / Erfahrungen von Hebammen, Geburtshelfern und Kinderpflegern mit perinatalem Tod: Ergebnisse einer qualitativen Studie in Norwegen

Midwives, obstetricians, and the assistant nurses, as well as other healthcare professions, are exposed to stress at work (Borritz et al., 2006). Critical events may lead to extreme stress for healthcare professionals (de Boer, van Rikxoort, Bakker, & Smit, 2014). Perinatal death is defined as a stillbirth occurring at ≥22 completed weeks of gestation, a death during birth, or a death during the first week of life (Zegers-Hochschild et al., 2009).

Encountering perinatal death has a severe influence on healthcare personnel. Common reactions are worry, strain, blame, and self-blame (Andre, Dahlø, Eilertsen, & Ringdal, 2016). The absence of acknowledging the responses among midwives, obstetricians, and nurses appears to be most provoking and can cause suppression of emotions. This may further lead to unprocessed sad experiences and low self-confidence among concerned professionals (McCreight, 2005; Walker, Mashiach, & Manny, 2016). Withdrawal and rejection were shared responses to perinatal death among healthcare professionals. These responses may further influence the care and support they offer to the grieving relatives (Andre et al., 2016). Previous literature have highlighted the need of supporting healthcare professionals by providing them training in communication with grieving relatives and support from supervisors to handle their responses in a more successful manner (Andre et al., 2016; B. André, Frigstad, S.A., Nøst, T.H., Sjøvold, E, 2016).

The communication of feelings by the healthcare professionals needs to be implanted in the work culture and as an element of specialized training for nurses (Andre et al., 2016; Shorey, André, & Lopez, 2016). However, in acknowledging emotional responses, there seems to be a dissimilarity among nurses and midwives as well as doctors and obstetricians. Although nurses found it normal to acknowledge and share their feelings, the doctors, on the other hand, found it undesirable to show and share their emotions (Farrow, Goldenberg, Fretts, & Schulkin, 2013). Previous literature have shown that those healthcare professionals who do not share or acknowledge their emotional distress after perinatal death tend to leave the organization, suffer with psychological distress, and have feelings of burnout (Gold, Kuznia, & Hayward, 2008; McCool, Guidera, Stenson, & Dauphinee, 2009). Although midwives were found to acknowledge and share their emotional distress, lack of organizational support made them feel burnout and they consider leaving the profession (Shorey et al., 2016). Even if different professions seem to have different approaches and experiences to the perinatal death, the burden they experience in these situations can be equated. Other studies found no variances between the professions in their understanding of the emotional consequences associated with perinatal death. The feelings of pressure, sadness, blame, grief, and mourning are the shared feelings exhibited by midwives, obstetricians, and nurses (Farrow et al., 2013; Gold et al., 2008; Jones & Smythe, 2015; McCool et al., 2009; Nallen, 2007; Pastor Montero et al., 2011; Wallbank, 2010). The need of individualized, cultural-specific informational support and implementing such supportive interventions right from the professionals training schools in their curriculums have been recommended (Ben-Ezra M, 2014; Steen, 2015; Walker et al., 2016). Reactions from healthcare personnel meeting perinatal death in clinical practice are encircled by “a conspiracy of silence” and “denial within the profession” (Cowan & Wainwright, 2001; Mander, 2009; Redinbaugh et al., 2003). These responses are not only distressing for healthcare personnel who experience this avoidance behavior but can also affect care given to parents (Cowan & Wainwright, 2001).

Research has shown that healthcare professionals working in maternity units exhibit moderate secondary stress (Beck & Gable, 2012) and midwives have experienced clinical post-traumatic stress disorder, which is further associated with burnout (Sheen, Spiby, & Slade, 2015). Doctors who cared for parents with perinatal death experienced considerable emotional trauma, and some of them considered abandoning their obstetric practice (Gold et al., 2008). Seeing the importance of healthcare professionals’ experiences and needs in caring for bereaved parents, recent reviews have focused on the perspectives of healthcare professionals working in maternity units (Ellis et al., 2016; Wallbank & Robertson, 2008). As culture influences expressions and attitudes about grief, it is important to examine the experiences and needs of healthcare professionals from diverse cultures (Gibson, 2006; Shorey et al., 2016). Given this background, the following research question will be explored:

As such this study aimed to explore the experiences of Norwegian healthcare professionals, including midwives, obstetricians, and assistant nurses, after experiencing perinatal death related to -

How do the leadership at the hospitals support healthcare professionals in processing their emotions and reactions?

A descriptive qualitative study design was used. We chose this design because there are few studies on this topic (Malterud, 2001) and because this is a sensitive topic. A semi-structured interview guide was used to interview the participants. Data collection took place from October 2016 to December 2016 at two public hospitals located at the central Norway. The data were collected in Norwegian and translated into English.

The findings are organized in three categories with subcategories that emerged from the data. These categories are: (i) external responses, (ii) internal responses, and (iii) personal responses. Healthcare professionals commented on external responses, when issues outside their own control or influence, that prejudiced on their experiences with perinatal death. Internal responses are comments that label issues related to their performance as a professional and how they describe their feelings in these situations. Personal responses are comments concerning themselves as a person and the affect these experiences have on their personal life. Categories and subcategories are presented in Table 2. The participants were consecutively numbered, and these numbers have been put in parentheses at the end of each statement.

The aim of this study was to explore the experiences of midwives, obstetricians, and assistant nurses pertaining to perinatal death. Earlier studies showed that there is little or insignificant difference in the emotional experience after experiencing perinatal death among different professional groups (Andre et al., 2016; McCreight, 2005; Rich, 2002). Therefore, in this study, all the professional groups were considered as one inter-professional group during the data collection, analysis, and reporting of the findings.

The participants defined many external factors that influence their experiences after experiencing a perinatal death. They described that they were blamed for what happened without having done anything wrong. This may be described as a “culture of blame” and looking for blame (Andre et al., 2016). These findings are consistent with previous studies that reported fostering a no-blame culture is management’s responsibility (Nallen, 2006). Other researchers also stated that this is an issue that management must face (Jones & Smythe, 2015; McCool et al., 2009; McCreight, 2005; Nallen, 2007). But even having this knowledge, our findings suggest that the leadership at maternity units failed to meet this responsibility. Feeling safe and secure in their professional practice is important for professionals to deal with this challenging situation in the best way. Lack of support may be very challenging for the healthcare personnel at these units because of overall feeling of guilt and self-blame. Some participants also stated that the supervisors or leaders did not ask about them or discuss their feelings associated with perinatal death. This may lead to serious consequences for the concerned professionals. The leadership need to investigate developing a supportive system for the healthcare professionals facing perinatal death (Andre et al., 2016). The participants characterized these situations as traumatic and very emotional, and some of them stated that their feelings “get stuck.” However, if healthcare personnel process these experiences in a better way, they may feel less traumatized and become a greater resource for the bereaved parents (Andre et al., 2016; Shorey et al., 2016). If things such as better support system and knowledge enable healthcare personnel to support the affected parents more appropriately, then this must be developed to foster higher competence. Some participants explained that their experiences led them to “become less sensitive” or “not to show feelings when they are with the parents” or “shut off all feelings” or “try to think of something else.” These statements from the participants describe ways of handling the situation without processing their own emotions. Responses such as this to significant reactions are not just troubling for staff subject to the negation but could also be a challenge for them when giving the parents the best possible treatment (Cowan & Wainwright, 2001).

Many participants also described the contrast of delivering healthy babies in one situation and perinatal death in another as challenging. As stated by participants, it is hard to “wear a mask” when walking between stillbirths and “common” births. This is difficult for the management as well because these situations often occur suddenly and without time to prepare. It seems important, however, for healthcare personnel to be able to concentrate on the perinatal death without having to participate in ordinary births at the same time (André, 2000; Andre et al., 2016; Nallen, 2006, 2007). Concentrating on the perinatal death alone may also be essential in allowing healthcare personnel to have the time to process the experience in a constructive way and may make it easier for them to reflect on the situation (Kahan & Goodstadt, 2001).

When describing internal responses to perinatal death, healthcare personnel described that they felt guilty and blame themselves, even if there was no valid reason to do so. The participants stated that they felt responsible whether they could have done anything to prevent the death, or not. The feeling of responsibility and the seriousness of the situation make healthcare professionals think carefully about what they have done and whether they could have done something differently. Almost all participants talked about guilt and self-blame in some form. It seems natural that this feeling will occur in these situations, and healthcare personnel who work in maternity units should be given knowledge about such circumstances (B. André, 2000; Farrow et al., 2013; Jones & Smythe, 2015; McCool et al., 2009; Nallen, 2006, 2007; Pastor Montero et al., 2011). If one knows that these are common feelings, it may be easier to deal with them (McCreight, 2005; Wallbank, 2010). However, the participants also described other feelings such as sadness and shock. Healthcare personnel must deal with their feelings while simultaneously meeting with the parents in their grief.

One of the most serious implications of not processing the experience in a constructive way is the impact on the healthcare personnel’s private life. Some participants claimed to be experiencing “sleep loss and weight loss.” The participants described post-traumatic stress symptoms and indicated that they had considered leaving the profession because of these events. The participants described difficulty in expressing their feelings. Earlier research has shown that healthcare personnel in maternity units often undergo negative impacts on their psychological well-being; they felt depressed and burned out (Ben-Ezra M, 2014; Shorey et al., 2016; Walker et al., 2016). Other studies have found that post-traumatic stress symptoms were present in healthcare personnel caring for parents with perinatal death (Sheen et al., 2015).

This study has shown that the participants described limited ability to process their emotions constructively. It seems imperative that programs must be implemented (Gold et al., 2008; McCreight, 2005; Wallbank, 2010) to focus on the emotional well-being of healthcare professionals and setbacks that can naturally occur in such positions. The benefit of sharing thoughts and emotions with each other is important knowledge for healthcare personnel who will be involved in such situations (McCreight, 2005; Rich, 2002).

This study focused on factors that characterize the experiences of midwives, obstetricians, and assistant nurses when children died in connection with childbirth at two Norwegian hospitals. The contrast between perinatal death and “normal births” and the lack of time to prepare themselves to take care of bereaved parents in the best way were a significant finding in this study. Healthcare professionals’ personal feelings in these situations, such as guilt, self-blame, sadness, and insecurity, were hardley given attention by the leaders. However, the lack of opportunity to deal with these situations and inappropriate ways to handle their feelings and experiences are important findings in this study. This may lead to serious health challenges in the long term for the concerned healthcare professionals. Future research about support specifically needed for healthcare providers experiencing perinatal death is needed.