Baby loss, grief, and the quest for community: A mixed methods study investigating stillbirth bereavement support pathways for ethnically diverse bereaved parents

Stillbirth is a silent public health crisis that affects families across the UK. According to a recent NHS figure, one in every 250 births ended in stillbirth, which is approximately eight babies every day (NHS, 2021). While preventative measures have been put into place reducing this silent epidemic, much more action is needed to decrease the number of families experiencing child loss. Year after year, reports (Woods & Heazell, 2018; RCOG, 2020; Widdows et al., 2021) show the national stillbirth rates decrease, however, the stillbirth rate among Black and Asian communities continues to remain particularly high compared to white British families (Garcia et al., 2015; MBRRACE, 2021).Despite the documented disparity of perinatal loss between white British and minority ethnic communities, there is a lack of evidence documenting the best and preferred means to support Black, Asian, and Minority Ethnic (BAME) bereaved families. It is clear that more research is needed to better support minority ethnic families as they grieve the loss of a child and the loss of a future they planned (Campbell-Jackson & Horsch, 2014). Whilst it is important to remember that there will be shared bereavement experiences amongst stillbirth bereaved parents regardless of ethnicity (Garcia et al., 2020), it is imperative to identify how to provide culturally competent bereavement support (Shaw, 2013; Rogers & Greenfields, 2017). Many baby loss charities across the country have implemented bereavement support programming which may include peer-to-peer support groups and befriending programmes in person and online (Killeen, 2015; Mills et al., 2016; Smith et al., 2020). Despite bereavement support being available across the UK in different formats, not all stillbirth bereaved parents access opportunities provided by these organisations. Within the current literature, it appears that minority ethnic parents are less likely to access this type of bereavement support due to the noticeable gap between minority ethnic parent and white parent participation within the baby loss bereavement support research (Cacciatore, 2007; Kingdon et al., 2019; Garcia et al., 2020). Often parents from minority ethnic communities are underrepresented or go underreported within the literature (Downe et al., 2013; Murphy & Cacciatore, 2017; Heazell et al., 2021). The paucity of research representing minority ethnic bereaved parents’ experiences fails to recognise the diverse the narratives of baby loss are within different communities who are high risk for perinatal loss (ONS, 2021; MBRRACE, 2021). The aim of this study is to explore how parents from different ethnic communities seek support through befriending programmes and peer support groups and to examine their experiences in selecting the group that is the most appropriate to support them along their grief journey. This project will also highlight barriers felt by parents that lead to them deciding to not engage with peer-to-peer support. To carry out this work, I follow a Transformative Paradigm (TP) theoretical framework (Mertens, 2007; 2008; 2010; 2011; 2012; 2017) from which the methodology arises. TP emphasizes the link between social research and action which calls upon research to further investigate social inequity and social justice (Mertens, 2008). Therefore, TP is an appropriate framework from which to explore the experiences of stillbirth in minority communities. I am using a double qualitative mixed methodsapproach to collect data for this study which involves a core component and a supplementary component (Morse & Niehaus, 2009). Triangulation of qualitative data through different approaches may generate more significant findings compared to a study employing a single method (Briller et al., 2008). The core component project consists of 16 semi-structured interviews with bereaved parents who self-identify as belonging to minority ethnic communities. I use constructivist grounded theory (Charmaz, 2006; 2014) to generate a theory as to why there’s such a disparity between minority ethnic families accessing bereavement support (Murray, 2020). The secondary component features creative methods approach by facilitating the creation of collages by eight participants analysed through thematic analysis. The purpose of incorporating these different research methods is to generate rich data which will better answer the research question highlight the difference of data that is spoken and that which is visually created (Chilton & Scotti, 2014; Yuen,2018; Dutton et al., 2019). Themes from the collages are discussed and are applied to the generated theory. I examine my positionality in this research through collage as a reflexive exercise, documenting my experience of grief and loss during my PhD. Throughout the duration of collecting data, I created a series of collages that reflect my experience as a researcher who has experienced personal bereavement and loss during my studies. Incorporating an autoethnographic lens to this project has facilitated a deeper rapport with the research participants and with the topic (Ellis & Bochner, 2000; Ellis, 2009; Ngunjiri Hernandez, & Chang, 2010)

Implementing creative methods in baby loss research: Exploring stillbirth bereaved parents’ journeys through collage

Grieving the loss of a baby may feel excruciatingly painful for parents. The rate of stillbirth in the United Kingdom is approximately eight babies per day. However, the rate of stillbirth disproportionally affects Black, Asian and Minority Ethnic (BAME) families. This paper explores an ongoing doctoral project which incorporates collage-making as a creative method to explore how BAME stillbirth bereaved parents access bereavement support. Creative methods may generate findings that can better reach public audiences to spark transformational change. Collage is a visual interpretive tool that is generally accessible to the public. Collages are often created by selecting images from magazines or newspapers or textured paper mediums, where the participants cut or alters the images and arranges and attaches them to mediums such as cardboard or paper. Incorporating collage in research can serve as a useful method when engaging with participants who are perhaps not comfortable communicating their thoughts about sensitive subjects. In addition to using collage as a creative research method, this study also features collage as a reflexive tool. Collage is an efficient tool for uncovering what is not said out loud about grief, but which is very much present within a grieving person. Breaking the silence and sharing the loss of a child through creative methods enhances the understanding of the experience of perinatal loss and provides a voice to those who would otherwise remain unheard

Tissue engineering: construction of a multicellular 3D scaffold for the delivery of layered cell sheets.

Many tissues, such as the adult human hearts, are unable to adequately regenerate after damage.(2,3) Strategies in tissue engineering propose innovations to assist the body in recovery and repair. For example, TE approaches may be able to attenuate heart remodeling after myocardial infarction (MI) and possibly increase total heart function to a near normal pre-MI level.(4) As with any functional tissue, successful regeneration of cardiac tissue involves the proper delivery of multiple cell types with environmental cues favoring integration and survival of the implanted cell/tissue graft. Engineered tissues should address multiple parameters including: soluble signals, cell-to-cell interactions, and matrix materials evaluated as delivery vehicles, their effects on cell survival, material strength, and facilitation of cell-to-tissue organization. Studies employing the direct injection of graft cells only ignore these essential elements.(2,5,6) A tissue design combining these ingredients has yet to be developed. Here, we present an example of integrated designs using layering of patterned cell sheets with two distinct types of biological-derived materials containing the target organ cell type and endothelial cells for enhancing new vessels formation in the "tissue". Although these studies focus on the generation of heart-like tissue, this tissue design can be applied to many organs other than heart with minimal design and material changes, and is meant to be an off-the-shelf product for regenerative therapies. The protocol contains five detailed steps. A temperature sensitive Poly(N-isopropylacrylamide) (pNIPAAM) is used to coat tissue culture dishes. Then, tissue specific cells are cultured on the surface of the coated plates/micropattern surfaces to form cell sheets with strong lateral adhesions. Thirdly, a base matrix is created for the tissue by combining porous matrix with neovascular permissive hydrogels and endothelial cells. Finally, the cell sheets are lifted from the pNIPAAM coated dishes and transferred to the base element, making the complete construct

Specialized mouse embryonic stem cells for studying vascular development.

Vascular progenitor cells are desirable in a variety of therapeutic strategies; however, the lineage commitment of endothelial and smooth muscle cell from a common progenitor is not well-understood. Here, we report the generation of the first dual reporter mouse embryonic stem cell (mESC) lines designed to facilitate the study of vascular endothelial and smooth muscle development in vitro. These mESC lines express green fluorescent protein (GFP) under the endothelial promoter, Tie-2, and Discomsoma sp. red fluorescent protein (RFP) under the promoter for alpha-smooth muscle actin (α-SMA). The lines were then characterized for morphology, marker expression, and pluripotency. The mESC colonies were found to exhibit dome-shaped morphology, alkaline phosphotase activity, as well as expression of Oct 3/4 and stage-specific embryonic antigen-1. The mESC colonies were also found to display normal karyotypes and are able to generate cells from all three germ layers, verifying pluripotency. Tissue staining confirmed the coexpression of VE (vascular endothelial)-cadherin with the Tie-2 GFP+ expression on endothelial structures and smooth muscle myosin heavy chain with the α-SMA RFP+ smooth muscle cells. Lastly, it was verified that the developing mESC do express Tie-2 GFP+ and α-SMA RFP+ cells during differentiation and that the GFP+ cells colocalize with the vascular-like structures surrounded by α-SMA-RFP cells. These dual reporter vascular-specific mESC permit visualization and cell tracking of individual endothelial and smooth muscle cells over time and in multiple dimensions, a powerful new tool for studying vascular development in real time

Leaf-inspired microcontact printing vascular patterns.

The vascularization of tissue grafts is critical for maintaining viability of the cells within a transplanted graft. A number of strategies are currently being investigated including very promising microfluidics systems. Here, we explored the potential for generating a vasculature-patterned endothelial cells that could be integrated into distinct layers between sheets of primary cells. Bioinspired from the leaf veins, we generated a reverse mold with a fractal vascular-branching pattern that models the unique spatial arrangement over multiple length scales that precisely mimic branching vasculature. By coating the reverse mold with 50 μg ml-1 of fibronectin and stamping enabled selective adhesion of the human umbilical vein endothelial cells (HUVECs) to the patterned adhesive matrix, we show that a vascular-branching pattern can be transferred by microcontact printing. Moreover, this pattern can be maintained and transferred to a 3D hydrogel matrix and remains stable for up to 4 d. After 4 d, HUVECs can be observed migrating and sprouting into Matrigel. These printed vascular branching patterns, especially after transfer to 3D hydrogels, provide a viable alternative strategy to the prevascularization of complex tissues

The effects of multiple aerospace environmental stressors on human performance

An extended Fitt's law paradigm reaction time (RT) task was used to evaluate the effects of acceleration on human performance in the Dynamic Environment Simulator (DES) at Armstrong Laboratory, Wright-Patterson AFB, Ohio. This effort was combined with an evaluation of the standard CSU-13 P anti-gravity suit versus three configurations of a 'retrograde inflation anti-G suit'. Results indicated that RT and error rates increased 17 percent and 14 percent respectively from baseline to the end of the simulated aerial combat maneuver and that the most common error was pressing too few buttons

Co-Emergence of Specialized Endothelial Cells from Embryonic Stem Cells.

A well-formed and robust vasculature is critical to the health of most organ systems in the body. However, the endothelial cells (ECs) forming the vasculature can exhibit a number of distinct functional subphenotypes like arterial or venous ECs, as well as angiogenic tip and stalk ECs. In this study, we investigate the in vitro differentiation of EC subphenotypes from embryonic stem cells (ESCs). Using our staged induction methods and chemically defined mediums, highly angiogenic EC subpopulations, as well as less proliferative and less migratory EC subpopulations, are derived. Furthermore, the EC subphenotypes exhibit distinct surface markers, gene expression profiles, and positional affinities during sprouting. While both subpopulations contained greater than 80% VE-cad+/CD31+ cells, the tip/stalk-like EC contained predominantly Flt4+/Dll4+/CXCR4+/Flt-1- cells, while the phalanx-like EC was composed of higher numbers of Flt-1+ cells. These studies suggest that the tip-specific EC can be derived in vitro from stem cells as a distinct and relatively stable EC subphenotype without the benefit of its morphological positioning in the sprouting vessel

Can we improve the prediction of hip fracture by assessing bone structure using shape and appearance modelling?

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