What is stillbirth?

When parents hear the heartbreaking news that their baby has died in the womb, their grief can be overwhelming. In a few brief moments, they go from happy anticipation of their baby's birth to the intense pain of confronting his death.

When fetal death occurs after 20 weeks of pregnancy, it is referred to as stillbirth. (A fetal death prior to 20 weeks is a miscarriage).

Stillbirth Facts

• Approximately 3.3 million stillborn in the world per year; highest rates in developing countries where stillbirths are "invisible" deaths (4/1000 vs 24/1000)
• In developing countries pregnancy complications and infections more often occur to explain stillbirths
• In developed countries stillbirths more often unexplained. Stillbirth rates often as high as infant mortality rates
• Possible interventions multiple and well known, especially quality maternity care (little access in developing countries)
• Emerging problems with more multiple births, obesity and increasing maternal age at pregnancy - now known risk factors for stillbirths
• WHO millennium declaration - proposed to reduce infant mortality but did not mention stillbirths

What are the causes of stillbirth?

After delivery, the baby and placenta are examined carefully to determine why the death occurred. An autopsy often is recommended. Even after extensive testing, however, in more than one-third of cases the cause of stillbirth cannot be determined. In some causes, the coroner refers to the death as SIDS Inuterine.

Major contributing factors to stillbirths in developed countries:

• Infection (15-24%)
• Malformations and genetic abnormalities (7-20%)
• Placental abruption (15-20%)
• Placental insufficiency/IUGR (3-22%)

THE LOSS

Life changes when you see a pair of pink lines on a pregnancy test strip. If it's good news, your life becomes a 38-week countdown to holding your future, safely swaddled in your arms. You read books, you post sonogram pictures on the fridge, you make plans for a nursery, you put your name on child care center waiting lists.

You don't plan for the doctor to tell you your future has no heartbeat. You don't plan to deliver a baby who will never open his eyes. You don't plan on coming home with an urn of ashes instead of a bag of diapers.

Before my son died, I had every hope -- and worry -- of being a good mother... more.

The following was presented by Ann Douglas at the CFSID Baby's Breath Conference in October 2005

Stillborn - Still Unanswered, Always Remembered: "The Powerful Legacy of Stillbirth"

Presented by Ann Douglas, Author
Canadian Foundation for the Study of Infant Deaths Conference
October 7, 2005

• "Childbearing losses may affect women and their families for a lifetime. The effects of childbearing losses may occur well after the childbearing years have ended." - Wisconsin Association for Perinatal Care.
  
  
• "Grief reflects the psychological and spiritual attachment to the baby that was lost physically and strongly resists abandonment of the baby. It is based on the primeval energy of parental attachment, which is used, although there is no baby." - Leena Väisänen, Family Grief and Recovery Process When a Baby Dies: A Qualitative Study of Family Grief and Healing Processes After Fetal or Baby Loss. Department of Psychiatry and Department of Nursing, University of Oulu, Finland, 1996.
  
  

Perinatal losses need to be treated as unique bereavements that are different from other types of bereavements. According to Leon (1990), these loses disrupt a significant milestone (pregnancy/birth/infancy); cause isolation from peers; cause inner conflicts for the griever; and reorganize self-esteem.

A 1995 study by Zeanah et al reported that stillborn and the deaths of infants are equally painful to parents and that the length of the gestation does not affect the extent of the parental attachment.

The Sound of Silence

And no baby cried...

Haunting silence

Overwhelming emptiness

The quest for answers

Why did this happen? Only one quarter to one half of losses can be explained.

Why did this happen to me?

Contemplating the unfathomable: unknotting the paradoxes of stillbirth and grief

• The feeling of incompleteness, an issue first raised by L.L. Layne in her journal article "Motherhood Lost: Cultural Dimensions of Miscarriage and Stillbirth in America" (1990) which became the basis for a book.
• Death can happen before birth.
• You can go through pregnancy and give birth without ending up with a baby.
• Your body behaves as if there's a baby in need of nurturing and care.
• Somehow, you can go on living after your baby has been stillborn.

"The world changed in an instant..." - The clock starts ticking at the moment of diagnosis, what Leena Väisänen describes as the explosion of "a psychological bomb." You start thinking of your life in terms of before/after your baby's stillbirth. It becomes a dividing line ÷ a milestone moment in your life. Marking milestones: what should have been your baby's due date, other "should have been" anniversaries, significant anniversary during the next calendar year, gestational milestones in your next pregnancy.

Mother's Grief

Some statistics on mothers and grief:

Mothers who experience the sudden death of a child (e.g., stillbirth, SIDS) tend to have more intense grief reactions than those mothers whose children die as a result of a chronic condition.

Mortality rates are higher in mothers who have experienced the death of a child (2003 study conducted in Denmark).

20% of mothers who have experienced stillbirth experience a prolonged episode of depression and one in five mothers suffers from post-traumatic stress disorder (2002 UK study).

The death of a baby is always a traumatic event. Recently, there has been growing evidence to show that stillbirth (like SIDS) can result in post-traumatic shock disorder. A study in the Netherlands found that 25% of women displayed symptoms of post-traumatic stress disorder one month after the stillbirth and 7% displayed such symptoms four months after the stillbirth.

Some of what a mother experiences when her baby is stillborn is so traumatic that she may not feel comfortable discussing the details of her baby's stillbirth with anyone other than another stillbirth parent or a professional with expertise in perinatal bereavement.

Mothers who experience stillbirth are at risk of developing postpartum major depression. The risk of depression is highest within the first six months after delivery. The mothers who are at greatest risk of becoming depressed are those who fail to show any signs of grief during the first two weeks after the stillbirth or whose grief does not show any signs of diminishing six to nine months after the stillbirth.

Thoughts of suicide are not unusual in the aftermath of stillbirth. 30% of mothers report having had such feelings.

The mother's grief process and recovery play a key role in determining how well the entire family is likely to fare down the road. So who's caring for mom?

The grieving mother tends to receive her primary support from her partner.

Her natural tendency is to want to withdraw from the world. Her partner and any living children may be the only things that drag her out of the darkness. They have a vital role to play in giving her a reason to focus on the near and now, but she also needs to have time to grieve.

Her grief symptoms may be scary to her. She needs someone to help her to know that these are common.

• She may experience physical as well as emotional pain.
• She may detect "phantom" fetal movements or hear the cries of a "phantom" baby who never had a chance to cry.
• Her arms may literally ache for the baby that she didn't get to take home from the hospital.

Father's Grief

Some statistics on fathers and grief:

Because fathers tend to be less verbal about their grief, their grief has been underestimated in grief research.

Grief in fathers tends to peak around 30 months after the death of a baby, whether that baby is stillborn or whether that baby dies shortly after birth (2002 study, University of Queensland, Australia)

Study conducted by Swedish researchers (2001) concluded that fathers "general trust in life and the natural order was suddenly and severely tested by the death of their child, which they perceived as a terrible waste of life." Being able to protect their partner and grieve in their own way was important to the fathers interviewed by this group of researchers.

Father's initially grieve by doing by caring for the mother.

They may try to mask their own grief in order to protect her.

Fathers can have a difficult time separating their own grief from the mother's grief. This is because they play such a key role in supporting the mother: "To reach this no-man's-land, the man must pass through his wife's grief and find a place which is the destination of lonely grieving men." - Joanne Cacciatore, MSW. Sudden Intrauterine Death and Traumatic Grief Peroria, Arizona: Miss Foundation, 2005.

Fathers can experience both physical and emotional pain in response to their grief.

The father's grief feelings may not be validated to the same degree as the mother's grief feelings.

Children's Grief

Some statistics on children and grief:

Children who have lost a sibling through stillbirth may tend to minimize their own grief symptoms in order to avoid "upsetting" their parents. This is more likely to happen if the child feels that their parents can't cope with the child's grief. Children sometimes delay their own grief reaction because they don't want to "burden" their parents with their own grief feelings.

Girls who are age 7 to 12 and who had strongly identified with their mother's pregnancy are especially likely to want to "fix" their mother's grief. They may also feel the loss of the baby particularly acutely or may fear for their own death.

Children don't have the same social support systems as adults to help them cope. They need to have an opportunity to work through their feelings, particularly if they had expressed feelings that they may feel ashamed or embarrassed about (e.g., jealousy about or resentment towards the new baby, who subsequently died).

Children who have lost a sibling through stillbirth suffer in other ways as well. At the very time they need their parents most, their grieving parents may be emotionally treading water themselves.

Grandparent's Grief

Some statistics on grandparents and grief:

Grandparents grieve a stillbirth on two levels: they grieve the death of their grandchild and they hurt because their children are hurting.

Sometimes a bereaved grandmother will try to "shut down" her daughter's grief - an indication about her own feelings about the power of grief and the fact that women are vulnerable to suffer losses like stillbirth.

The Grieving Family - Families need a chance to grieve separately as well as together. Some researchers have noted that one person does a lot of "grief work" on his/her own, the family system can be thrown out of balance. Families need some time to grieve in privacy-some time and space to process their loss without a constant stampede of visitors. This needs to be balanced with the need for care and support from the community. Maybe we need to think about having a "familymoon" whenever there is a milestone event in our family's lives - kind of like the "honeymoon" or the "babymoon". First-time parents who experience a stillbirth may not have their support networks in place. They may be new to a community. It is particularly important for friends, family members, and health care professionals working with these parents to help them to tap into both formal and informal supports in the community. Sexual intimacy will provide comfort to some couples, allow others to express affection, and act as a painful reminder of the loss to others (1995 study, Child Bereavement Trust, UK).

The Unholy Trio: Grief, Trauma, and Guilt - Trauma can freeze or delay grief, but it doesn't make grief go away. Grief is like the world's most persistent debt collector. It doesn't give up easily. Complicated grief is believed to occur in 21% of cases of perinatal bereavement. The loss of one or more multiples can take a particularly long time for a parent to process. One study found that it took parents three to five years to be able to incorporate their loss without significant sadness or depression. Part of the challenge is having the language to label surviving children (e.g., two surviving triplets are not twins). Dealing with guilt (in most cases, unwarranted guilt) and regret about difficult decisions that were made with regard to their baby's stillbirth only adds to the pain.

Pregnancy After a Loss - Parents need to be empowered to make their pregnancy decisions on their own timeline. They already feel like they have lost so much power over what has happened to them. Mothers who conceive quickly may have a tendency to believe that the new baby will help to repair a lot of the expectations lost with the previous baby's death. Moms who are due around the time of their previous baby's anniversary are at particular risk of experiencing such feelings. (1995 study, Child Bereavement Trust, UK) Other studies suggest that getting pregnant right away may allow grief feelings to begin to dissipate sooner. Guarded emotions, heightened anxiety, a tendency to mark off time by waiting for particular pregnancy milestones to come and go, and a need to seek out or avoid particular behaviours are common ways of coping with pregnancy after a loss. (Syracuse University, 1999) Support groups can be very helpful in providing support to women going through pregnancy after a loss. Help them to recognize that others are going through the same experience, remember the babies who have died, learn new coping skills, and begin to relate to their living babies. Bereaved parents who subsequently give birth need to consider the place of the stillborn child in the family and the relationship of the children who were born before the stillborn child to those who arrive afterward.

Fumbling Towards the New Normal

Adrift and lost

A life in which the reality of your loss is now part of your daily landscape.

Having your faith in the universe shattered.

Feeling like an outsider-like a person who has seen too much of life and death.

Belonging to a "club" which you never wanted to join - and losing some friends because you belong to a "club" that frightens them.

Finding your way

Feeling okay about life in the present.

Beginning to feel hopeful about the future.

Having the energy and the courage to invest in relationships with others and activities that you find meaningful.

Being tuned into the needs of your living children and being capable of responding like the loving, caring parent that you so want to be.

Feeling physically and emotionally well.

Being able to consider another pregnancy without becoming extremely distressed (assuming another pregnancy is desired and/or an option).

Finding new meaning in life that includes a desire to find meaning in your baby's death and a new appreciation for the value and uniqueness of life.

• A study by researchers at Millersville, Pennsylvania (2001) found that the majority of parents describe their child's death as precipitating a crisis in meaning that resulted in stronger connections with other people, desire to engage in activities that would give their child's life and death meaning, enriched beliefs/values, personal growth, and feelings of connection with the child who had died.
  
  

There is no statute of limitations on grief. It's a matter of learning to live with grief.

STILLBIRTH Research
Used with permission
http://www.sidscenter.org/stillbirth.pdf