Stillbirth: Patient-Centered Psychosocial Care

CLINICAL OBSTETRICS AND GYNECOLOGY Volume 53, Number 3, 691–699 r 2010, Lippincott Williams & Wilkins

Stillbirth: Patient-centered Psychosocial Care

JOANNE CACCIATORE, PhD, FT, LMSW School of Social Work, Arizona State University, Phoenix, Arizona

Abstract: Evidence-based practice and patient-centered practice are not mutually exclusive clinical The Cost of Loss ideals. Instead, both styles hold tremendous potential Bereavement, particularly when sudden for complementarity in healthcare and should be and traumatic such as in the case of used to enhance clinical relationships in which car- stillbirth, poses the risk of many negative ing is humble, mindful, and nuanced. The onus of the long-term social, psychological, and bio- responsibility for many decisions about care after logical outcomes. Some of those hazards stillbirth falls on clinical staff. Yet, even in the dearth of literature exploring standards of care during still- include anxiety, dysthymia, suicidality, birth the results can be conflicting. Thus, research in loneliness, anhedonism, substance abuse, both patient-centered and evidence-based approaches inorganic pain, and attachment and suggest that less emphasis should be placed on the relational problems as well as increased standardization of care; rather, the focus should be on premature mortality.1–4 Complicated, or relational caregiving that underscores the uniqueness of each patient and their family, recognizes culture, prolonged grief, has been recognized by and encourages affirmative, rather than traumatizing, clinicians as a problem facing a percen- provider reactions. tage of those traumatically bereaved, Key words: stillbirth, psychosocial care, patient-cen- however, only recently has a psycho- tered care, evidence-based practice, psychotherapy metric validation of diagnostic criteria ‘‘Not long ago, a baby’s death was an unspeakable event been proposed for inclusion in the Diag- in a hospital y. The baby was whisked away before nostic and Statistical Manual of Mental parents could see or hold their baby y. The mother was Disorder-V.2 given tranquilizer if she became too upset, if she lost Some women experiencing the stillbirth [control].’’ of a baby meet the risk criteria for com- I. Leon plicated and traumatic grief resulting in significantly diminished functioning. Correspondence: Joanne Cacciatore, PhD, FT, LMSW, Rando3 suggests that certain circum- Arizona State University West campus, School of stances increase the likelihood of compli- Social Work, PO Box 37100, Phoenix, AZ 85069- 7100. E-mail: [email protected]. cated grief including: sudden death that is Joanne Cacciatore is an Assistant Professor in the especially traumatic, violent, mutilating, School of Social Work at Arizona State University. or random; the death of a baby or child; She holds a Fellowship in Thanatology and is the the perception that the death was preven- Director of the Center for Loss and Trauma in Phoenix, Arizona. table; a markedly dependent relationship;

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 53 / NUMBER 3 / SEPTEMBER 2010

www.clinicalobgyn.com | 691 692 Cacciatore concurrent mental health problems; and following a live birth: lack of support, a perceived lack of social support during pain, and suboptimal contact with the and after the loss. Similarly, according to baby right after birth. Each of these is Worden,4 complicated grief reactions in- often manifested and exaggerated in the clude: (1) chronic grief that is excessive in instance of stillbirth, thus, the exigency duration, (2) delayed grief that has been for social support, as with any child’s inhibited by suppression, (3) exaggerated death. However, stillbirth also presents grief that is exacerbated by multiple with some peculiarities. factors such as marginalization, shame- One such idiosyncratic difference is a induced stigma, or physiological trauma, psychological phenomenon known as am- and (4) masked grief that results in so- biguous loss, based on the work of Pauline matic symptoms or alexythmia. The high- Boss.8,9 Ambiguous loss may arouse pro- est risk to the individual is when all the foundly debilitating grief responses, occur- 4 criteria overlap. That is, grief becomes ring in situations where there is physical protracted, the griever has no safe place to absence and psychological presence. Her express grief, the loss was socially stigma- theory can be readily applied to stillbirth: tized or invisibilized, and eventually the though the child is physically absent after emotions associated with the loss are death, psychological presence and pining expressed through somatic ailments or often continue for months or years, mani- self-harming behaviors, such as social festing in many ways. The lack of tangible withdrawal, cutting, eating disorders, or evidence of the baby’s existence may under- engaging in risky behaviors. To date, no mine the legitimacy of a mother’s emotions, studies have measured the economic provoking role distress. Adding to the impact of stillbirth. Yet, considering the complex nuances of stillbirth is its societal psychosocial risks to women and their demarcation from other types of child families, inarguably, the aggregate cost death. Stillbirth is often regarded by aca- to society is quite high. demics, clinicians, and the general population as a ‘‘pregnancy loss’’ rather than the death of a baby. These merging influences make some women feel marginalized and The Exigency for may actuate ambiguous grief.10 Ambi- Patient-centered Care guity is manifested through protracted de- ‘‘Somehow I feel I’ve failed as a woman. nial, indistinguishable boundaries, relent- I just didn’t get it quite right. Most women less information seeking, and emotional come home with a baby after nine months of outbursts. In particular, clinicians have pregnancy. I came home with a tabletop full the opportunity to circumvent and attenu- of drugs. And let me tell you, that Percocet ate some of the effects of boundary ambi- is good stuff. Not a baby, but damn good guity, perhaps by helping women actua- stuff.’’ lize their losses through patient-centered Kara Jones, Flash of Life caring. As early as the 1970s, researchers dis- If birth, even when the outcome is a live covered links between compassionate pro- baby, can result in posttraumatic stress vider reactions and grief responses.1,8–15 and depression for many women,5,6 still- Mothers who experienced stillbirth re- birth would significantly increase both the ported very high levels of anxiety, and this risk and the likelihood of poor psycholo- state could be reliably predicted by psycho- gical adjustment in the postpartum peri- social conditions, including a perceived od. Rowe-Murray and Fisher7 found 3 lack of support from others.13,16,17 The variables affecting postpartum depression immediate care a woman receives during www.clinicalobgyn.com Stillbirth: Patient-centered Psychosocial Care 693 stillbirth has a significant affect on her eral—for the baby. They will need to fill emotional status up to 3 years after the out legal documents. In some states, this is baby’s death.17 Rather than using strict a Certificate of Fetal Death. In others, guidelines, preset protocol, checklists, and they may have the option of choosing a platitudes when interacting with grieving Certificate of Birth resulting in Stillbirth. mothers, caregivers should, instead, focus They will need guidance around surviving on the relationship itself as an axiom of children, deciding whether or not to in- person-centered care. clude them in the hospital event or the successive memorial service. They will need to be educated about the experience of traumatic loss, efficacious of interven- Clinical Recommendations for tions, such as support groups or psy- Care in the Era of Evidence- chotherapy, and future family planning. based Practice Often, the onus of many of these respon- ‘‘I like to blame the caseworker, as if it is her sibilities falls on clinical staff. Yet, even in fault I did not hold my son. But, at that the dearth of literature on standards of moment in time I refused to hold him. What I care following stillbirth, the empirical did not know, until I saw the photos the nurse outcomes can be conflicting. took, was that death was a full 6 lbs 4 oz with For example, amidst the evidence in perfect hands and feet, full lips full head of stillbirth research, there exists significant dark curly hair y I did not know that hold- discrepancy in outcomes over specific re- ingmysonwouldhavebeenthesameaswhen commendations in the standardization of Romeo held Juliet’s lifeless body to him, care. Most of the dispute in the evidence embracing a flash of life.’’ revolves around seeing and holding the Kara Jones, Flash of Life dead baby. Some studies suggest that such rituals increase the risk of long-term psy- Evidence-based practice and patient- chological harm to women and their sub- centered practice are not mutually exclu- sequent children20 whereas other studies sive ideals toward which a clinician should show the opposite effect.15,17,20 In a longi- strive. Instead, both styles hold tremen- tudinal study of Dutch parents whose dous potential for complementarity in children died at various ages ranging from healthcare and should be used to enhance stillbirth to 29 years of age, parents who patient-centered care that is humble, had an opportunity to say farewell had mindful, and nuanced.14,15,17,18 lower grief scores than those who did not There are many experiential aspects across the age groups. In addition, those related to stillbirths, and all child deaths who chose home funerals, that is, they for that matter, of which clinicians need to cared for their child’s body during the be aware.19 Women—and their families— postmortem period in their home, also need to decide whether or not they wish to reported lower grief scores 2 years follow- see, hold, and photograph the dead baby. ing the loss. The researchers suggest that They will need to choose which, if any, this process assists parents in confronting mementos they want to keep, such as and realizing their loss.21 Boss agrees that hand and foot prints and molds, blankets, seeing the baby’s body helps a mother to or a lock of hair. They will need to decide begin the process of relinquishment while whether or not to have an autopsy, and if revising attachment. Not having seen the so, where that autopsy will occur. They remains, she contends, interferes with that will need to choose the form of final dis- process and incites ambiguous grief.9 position, burial or cremation, and choose What do clinicians do when empirical an appropriate mortuary—or home fun- evidence is seemingly contradictory?

www.clinicalobgyn.com 694 Cacciatore

Researchers in patient-centered appro- Conversely, person-centered care aches suggest that less emphasis should wherein the relationship is the apogee be placed on the standardization of care; ‘‘alleviates vulnerability in all of its rather, the focus should be on relational forms’’23,24 and may help to buffer the caregiving that underscores the unique- negative effects of traumatic events like ness of each patient and their family, stillbirth. Interdisciplinary bereavement recognizes culture, and encourages affir- teams addressing perinatal death at hos- mative, rather than traumatizing, provi- pitals ameliorate somatic distress and der reactions. It is a model based on relieve hostility in grieving mothers. The authentic, mutual relationships. benefits of these interactions are particu- In a population-based study of 636 larly discernible in cases in which women postpartum women, of whom 314 had a reported low social support from family stillbirth and 322 had a live birth, Ra˚des- and friends. tad et al17 found that the process of Although clinicians are often faced birth was physically and psychologically with a constellation of familial and indi- more painful when the baby was stillborn. vidual needs, bereaved mothers may be The hospital stay was also briefer, and unable to coordinate services, navigate mothers were less satisfied with the care an overwhelming hospital system, or ask they received. Thus, an expedited hospital the right questions without guidance and discharge may replace the provision of support. Thus, clinicians should strive emotional support from medical staff.17 toward a baseline knowledge about the Other mothers have expressed feeling epidemiology of stillbirth, relevant psy- ignored during the postpartum period. chological theories for traumatic bereave- Fear, misinformation, and the lack of ment and interventions; expertise in training may contribute to avoidant staff verbal and nonverbal communication responses. There have been many contrib- during a crisis (including a supportive uting factors to the misinformation and and noncoercive style); commitment to inadequate care following stillbirths, in- both evidence and patient-based care that cluding concern over litigation, personal is culturally competent; mastering the fear, and anxiety around death, a political ability to coordinate appropriate services environment that has failed to accept still- within the community; and making time birth—even when late and unexplained— to advocate, when necessary, for systemic as the death of a child, and a historically change. paternalistic system that wrests control The 3-function doctor-patient model from women over their birth experiences. can be used as an evidence-based, rela- Patients whose providers were perceived tional guide for clinicians working with to be insensitive to their emotional state the bereaved.25 This trilogy emphasizes during traumatic births claimed they felt (1) gathering data to understand the pa- vulnerable and helpless as a direct result tient, (2) developing rapport and respond- of their interactions.17,22 Ineffective ing to the emotions of patients, and (3) communication that incited feelings of psychoeducation. Under this model, com- disrespect, indignity, and paternalism munication provides an exchange of use- increased the likelihood of dissatisfaction, ful information, promotes action and negative psychological outcomes for interaction, allows the patient to access women, and litigation.17,19,22–24 These feelings about an experience, and pro- disaffirming and traumatizing provider vides an opportunity for caregivers to reactions to loss compromise relational express caring by addressing the 3 fields trust and exacerbate fragilities during of understanding: cognitive, emotional, stillbirth. and psychomotor. www.clinicalobgyn.com Stillbirth: Patient-centered Psychosocial Care 695

First, gathering data to understand the attention to the patient; (7) maintain re- patient requires that caregivers take time spectful nonverbal communication; (8) to become familiar with the sociocultural accept the emotional sentiment of the intricacies of each patient. It prompts the other person; and (9) listen attentively. acquisition of information, such as reli- This model, overall, sets the stage for a gious beliefs, previous history of loss, and caring environment in which important, structure of the family system, that will be potentially irreversible, decisions can be important in building trust and mutual made without coercion or regret. Clini- understanding. This process of relational cians should also avoid paternalistic knowing may also serve to enhance responses because it is inconsistent with joint decision-making processes. For ex- woman-centered principles for care. They ample, the religious views of woman who should, instead, build rich relationships has experienced stillbirth may inform that empower women to make their own her attitude toward an autopsy or final healthcare choices after stillbirth, and disposition. The second principle, devel- facilitate rather than denigrate their ma- oping rapport—or a relationship—with ternal, feminine responses to loss. the grieving mother and then responding Narrative intervention is both evidence- to her emotions is imperative. Ritualiza- based and patient-centered and has proven tion may be especially important for helpful in reducing adverse psychological women after the death of a baby. How- outcomes for women. Women who re- ever, a mother who is too fearful to hold ceived as little as 30 minutes of supportive her stillborn baby may make irreversible counseling experienced a significant reduc- decisions because she is emotionally over- tion in anxious and depressive symptoms whelmed, or she may be feeling pressured during the postpartum period.26 One post- by others not to see the baby. This may vention program that included telephone lead to later regret, particularly if she was counseling commencing 72 hours after offered a brief opportunity to hold the birth and lasted for 3 months revealed baby but she denied.15 Although rituals markedly decreased posttraumatic stress are a profoundly intimate decision, symptoms in women.27 Another random- through a caring relationship with the ized, controlled study showed that even clinician, a woman can make decisions those suffering from complicated grief ben- based on her authentic desires rather than efit from narrative psychotherapy. Inter- based on fear. Through this relationship, ventions included retelling the story, the caregiver is able to respond empathi- exposure therapy, and confrontation over cally and patiently to a mother’s authentic the course of about 6 months.28 The pro- needs. Finally, psychoeducation that is cess by which a clinician listens and is fully conveyed with warmth and honesty about present with a patient is an expression of what to expect during and after the birth, caring. Swanson29 researched caring as a offering ritual options such as holding the nurturing way of relating to and valuing the baby, photographs, or mementos, may other. The expression of caring for another give them a sense of informed control. manifests as Effective communication during psychoe- Knowing: Striving to understand an event ducation hinges on 9 very important prin- as it has meaning in the life of the other ciples: (1) never interrupt the speaker, and by avoiding assumptions, centering on allow for a pause between main thoughts; the other, assessing, seeking cues, and (2) avoid jumping to conclusions; (3) pay engaging; attention and engage easily; (4) listen for Being with: Becoming emotionally present feelings, beliefs, and ideas; (5) avoid im- to the other by being there, conveying pulsive reactions or solutions; (6) pay availability, and not burdening;

www.clinicalobgyn.com 696 Cacciatore

Doing for: Helping by action through com- connectedness. For example, he is critical fort, anticipation, competence, protection, of clinicians who habitually supplant clin- and preserving dignity; ical time in psychotherapy with psycho- Enabling: Facilitating the other’s experi- pharmacology, suggesting that it is ‘‘a ence through unfamiliar events by in- subtle but powerful dehumanizing force forming and explaining, supporting and that undermines the life of the spirit and allowing, generating options, validation, subverts the fundamental human quest and feedback; and for a more genuine transformation y.’’30 Maintaining belief: Faith in the other’s ability to handle a difficult event and find By focusing on emotions such as anxiety, meaning by holding the other in esteem, guilt, and shame, clinicians can be more hope, realistic optimism, and stability.29 accepting, less alienated from themselves and the patient. It is through the ‘‘feel- Boss suggests that a worthwhile ther- ing,’’ not ‘‘thinking,’’ where the discovery apeutic goal is to help patients normalize of self and other can occur. Frattaroli their experiences when grief is ambiguous warns against what Freud termed furor and complicated. She suggests normaliz- sanandi, the rage to cure. Instead, he ing guilt and other negative emotions by suggests that clinicians treat with compas- allowing a place for the story to be told sion, and to respect the patient’s symp- and retold until there are more associated toms or emotional state as a cue toward positive attributions.8 She discourages the path to wellness. Parental bereave- pathologizing responses and encourages ment is most often not a disease to cure. listening. Another important intervention Rather, it is a normal response to an includes modalities in the creative arts to aberrant and tragic outcome. The key help patients manage and express distress for clinicians is meeting the patient in their associated with traumatic loss. And her grief and providing an opportunity for approach supports holding a psychologi- healing to occur within the framework cal space for the stillborn child within the of compassionate interventions. family, as a reconstruction and reassess- ment occurs after the loss. Boss extends the responsibility of caring to the broader Communicating Caring community.8 Caring requires attendance ‘‘Grief remains of the few things that have and attendance takes time. Indeed, these the power to silence us.’’ types of person-centered interventions Anna Quindlen require clinical, and administrative, commitment to person-centered caring. Much of a patient’s feeling of being Nevertheless, best practice should include cared for hinges on effective communica- enacting and enforcing techniques that tion. Humanistic communication is a ‘‘prevent the genesis of psychological quintessential characteristic of high-con- trauma’’ and advocating patient rights text, patient-centered care. Minority which may require systemic changes in groups and women tend to be high-concurrent administrative policies and proce- text communicators. This means they dures,22 including time delegation and place less meaning on the actual words staffing issues. being spoken, and more emphasis on the Other policy changes may affect mental nonverbal communication and context. health clinicians in hospital settings. Elio This style of communication is more feel- Frattaroli,30 posits that current standards ing-centered and intuitive. Conversely, of psychiatric care may result in the ob- low-context communicators rely heavily jectification of patients wherein relation- on the precise spoken word. This results ships are devoid of humanity and in reduced empathy and perceptivity, www.clinicalobgyn.com Stillbirth: Patient-centered Psychosocial Care 697 particularly during crises. In high- so through the nonverbal message. In context communication, the cultural sum, eye contact when culturally appro- filters decipher implied meanings aris- priate, a moderated tone and pace of ing from the physical milieu, nonverbal speech, the judicious use of touch (the communication, relationship interaction, top of the hand, closest shoulder, or on or shared understanding of symbols. In the back between the shoulders), and low-context communication, the filters strategically applied silence will often con- direct attention toward the literal mean- vey a supportive, caring presence. ings and interpretation of words and less to the subtle cues of nonverbal communication or the context surrounding the The Call for Systemic words.31,32 Change Ways to communicate caring nonverb- Death education targeted toward clinical ally include: being fully present with the staff can be helpful in significantly in- patient; using silence when appropriate; creasing confidence making them more and, maintaining close, but nonintrusive comfortable when dealing with bereaved proxemics, respectful eye contact (when parents. Some degree of grief sensitivity culturally appropriate), open posturing training should be extended to all staff (hands behind the back or at sides rather including patient intake staff, pastoral than crossed in the front), caring facial staff, interns and residents, and even non- gestures and gentle tone of voice, and an clinical staff. Yet, administrators do not unrushed demeanor. For example, an always provide necessary training even emphasis on certain words, tone of voice, for clinical staff. Chan et al, found that and the speed of articulation all affect nurses’ comfortable attitudes toward the receiver’s perception of the message bereavement were directly correlated with of caring. Slightly quieter speech, slowed their knowledge of the death of a baby. speech, and an emphasis on caring words Nurses wanted more formalized training convey empathy.14,31,32 that emphasizes death studies, ‘‘improved In oculesics, the use of eye contact communication skills, and greater sup- when communicating, clinicians should port from hospital policy and team mem- pay attention to cultural cues. Most often, bers relative to bereavement care.’’33 direct eye contact communicates caring Hospital administrators may want to and attention toward the other, and it consider the implementation of a woman- helps the receiver unconsciously accept centered education program focusing on the truthfulness and sincerity of the sen- relationships: one that is family inclusive der. Western culture, in particular, values and that supports, educates, and provides direct eye contact. However, some heri- debriefing for partners and family mem- tage-consistent Native American tribal bers on how to help the grieving mother in members or Asians will avoid sustained the months subsequent to the baby’s death. eye contact. This nuance in communica- Hagenow recommends that the focus tion styles calls for a sensitive, intuitive, should be on the woman, rather than the and flexible response wherein the clinician hospital system. Recognizing the adminis- adapts to the other person’s communica- trative barriers to person-centered care, tion style.31,32 Effective nonverbal com- such as managed care, economics, and munication is important in conveying compromised organizational structure, meaning that is congruent with the de- she calls on managers to change ‘‘tradi- sired message: Verbal and nonverbal mes- tional measures of corporate wealth’’ in sages need to be congruent, as most of the which ‘‘financial assets derived from meaning extracted by the receiver is done productivity and profits are broadened

www.clinicalobgyn.com 698 Cacciatore to include community responsibility, social ships after stillbirth and may mitigate long- accountability, and personal fulfillment of term negative psychological outcomes for employees.’’24 Another policy change might mothers and their families. This type of be to implement a postvention program with relational caring moves beyond the acquies- the grieving mother and her family. A cost- cence of ‘‘first, do no harm’’ prompting the effective way to do this would be through imperative to ‘‘then do good.’’ formalized partnerships with well-estab- lished, nonprofit organizations that serve families who have experienced stillbirth. References 1. Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007; 370:1960–1969. In Sum 2. Prigerson HG, Horowitz M, Jacobs S, The death of a child is a complex and et al. Prolonged grief disorder: psycho- traumatic experience for women and their metric validation of criteria proposed families, traversing culture, socioeconomic for DSM-V and ICD-11. PLoS Med. status, religion, and ethnicity. In particular, 2009;6:e1000121. doi: 10.1371/journal. bereaved mothers, often overwhelmed by pmed.1000121 the traumatic nature of stillbirth, take their 3. Rando TA. Parental Loss of a Child: cues about how to interact with their dead Differences of Grief Intensity in Bereaved baby from caregivers.13–15,17 Forthisrea- Parents. Champaign, IL: Research Press; son, clinicians should use an evidence- 1986. 4. Worden JW. Grief Counseling and Ther- based approach that is patient-centered, apy. London: Springer; 1991. careful not to impose their own values 5. Slade P. Toward a conceptual framework and beliefs. Rather, clinicians should take for understanding post-traumatic stress thetimenecessarytoestablishanintimate symptoms following childbirth and im- relationship with the patient, gently guid- plications for further research. J Psycho- ing the decisions that will be the least som Obstet Gynecol. 2006;27:99–105. damaging and reap the most beneficial 6. Beck CT. Birth trauma: in the eye of the long-term choices for her and her family. beholder. Nurs Res. 2004;53:28–35. These choices, and their ramifications, 7. Rowe-Murray HJ, Fisher J. Operative may last a lifetime and are often not re- intervention in delivery is associated with dressable. In the words of Adrienne Rich, compromised early mother-infant interaction. Br J Obstet Gynaecol. 2001;108: ‘‘whatever is unnamed, undepicted in 1068–1075. images, whatever is omitted from biogra- 8. Boss P. Ambiguous Loss: Learning to Live phy,censoredincollections of letters, what- With Unresolved Grief. Cambridge, MA: ever is misnamed as something else, made Harvard University Press; 1999. difficult-to-come-by,whateverisburiedin 9. Boss P. Loss, Trauma, and Resilience: the memory by the collapse of meaning Therapeutic Work With Ambiguous Loss. under an inadequate or lying language— New York, NY: WW Norton & Com- this will become, not merely unspoken, but pany; 2006. unspeakable.’’ In addition, for the grieving 10. Cacciatore J, DeFrain J, Jones K. Bound- mother who is having the ‘‘unspeakable’’ ary ambiguity and the death of a child. experience, the sense of aloneness absent a Marriage Fam Rev. 2008;44:439–454. 11. Rowe J, Clyman R, Green C, et al. Follow caring milieu contributes to her invisibility, up of families who experience a perinatal ushering her into the shadows, and exacer- death. Pediatrics. 1978;62:166–170. bating her loneliness and angst. 12. Hunfield J, Wladimiroff J, Verhage F, However, patient-centered care that hum- et al. Previous stress and acute psycho- ble, mindful, and nuanced builds authentic, logical defense as predictors of perinatal meaningful, and healing human relation- grief. Soc Sci Med. 1995;40:829–835. www.clinicalobgyn.com Stillbirth: Patient-centered Psychosocial Care 699

13. Cacciatore J, Schnebly S, Froen F. The 23. Levinson W. Physician-patient commu- effects of social support on maternal nication: a key to malpractice prevention. anxiety and depression after the death of JAMA. 1994;272:1619–1621. a child. Health Soc Care Commun. 2009; 24. Hagenow NR. Why not person-centered 17:167–176. care? The challenges of implementation. 14. Cacciatore J. Appropriate bereavement Nurs Adm Q 2003;27:203. practice after the death of a Native Amer- 25. Bird J, Cohen-Cole SA. The three-func- ican child. Fam Soc. 2009;90:46–50. tion model of the medical interview: an 15. Cacciatore J, Froen F, Radestad I. Effects educational device. Adv Psychosom Med. of contact with their stillborn babies on 1990;20:65–88. maternal anxiety and depression. Birth 26. Lavender T, Walkinshaw SA. Can mid- Issue Perinatal Care. 2008;35:313–320. wives reduce postpartum psychological 16. Dyregrov A, Matthiesen SB. Anxiety and morbidity? A randomized trial. Birth. vulnerability in parents following the 1998;25:215–219. death of an infant. Scand J Psychol. 1987; 27. Gamble J, Creedy D, Moyle W, et al. 28:16–25. Effectiveness of a counseling interven- 17. Radestad I, Nordin C, Steineck G, et al. A tion after a traumatic childbirth: a ran- comparison of women’s memories of care domized controlled trial. Birth. 2005;32: during pregnancy, labour and delivery 11–19. after stillbirth or live birth. Midwifery. 28. Shear K, Frank E, Houck P, et al. Treat- 1998;14:111–117. ment of complicated grief: a random- 18. Hasnain-Wynia R. Is evidence-based ized controlled trial. JAMA. 2009;293: medicine patient-centered and is patient- 2601–2608. centered care evidence-based? Health 29. Swanson K. Empirical development of a Serv Res. 2006;41:1–8. middle range theory of caring. Nurs Res. 19. GoldKJ,DaltonV,SchwenkTL.Hospital 1991;40:161–166. care for parents after perinatal death. 30. Frattaroli E. Healing the Soul in the Age Obstet Gynecol. 2007;109:1156–1166. of the Brain: Becoming Conscious in an 20. Hughes P, Turton P, Hopper E, et al. Unconscious World. New York: Penguin Assessment of guidelines for good prac- Group; 1997. tice in psychosocial care of mothers after 31. Haase RF, Tepper DT. Nonverbal com- stillbirth: a cohort study. Lancet. 2002; ponents of empathic communication. 360:114–118. J Couns Psychol. 1972;19:417–424. 21. Wijngaards-De Meij L, Stroebe M, 32. Hall ET. The Hidden Dimensions of Time Stroebe W, et al. The impact of the cir- and Space in Today’s World: Cross-Cul- cumstances surrounding the death of a tural Perspectives in Non-verbal Commu- child on parents’ grief. Death Stud. 2008; nication. Germany: Hogrefe & Huber; 32:237–252. 1988:145–152. 22. Spies Sorenson DS. Healing traumatizing 33. Chan MF, Wu LH, Day MC, et al. Atti- provider interactions among women tudes of nurses toward perinatal bereave- through short-term group therapy. Arch ment. J Perinat Neonatal Nurs. 2005;19: Psychiatr Nurs. 2003;17:259–269. 240–252.