Re: Impact of holding the baby following stillbirth on maternal mental health and well-being: findings from a national survey. BMJ Open 2016;6(8):e010996

Response to 'Impact of holding the baby following stillbirth on maternal mental health and well-being: findings from a national survey' BMJ Open 2016, 6(8), e010996 (9pp). doi: 10.1136/bmjopen-2015-010996. Response available at: https://bmjopen.bmj.com/content/6/8/e010996.responses (Accessed: 19 January 2023)Dear Editor: We were interested in the recent article by Redshaw et al. which reported higher rates of mental health and relationship difficulties among women who held their stillborn baby.1 We agree this is an important topic, but after reviewing the article in depth, we would like to raise several concerns. (1) We note that this was a retrospective survey with a 30.2% response rate in which just 3% of women did not see and 16% did not hold their baby; these limitations were acknowledged but we believe they also restrict the ability to draw broad conclusions. (2) There was little exploration into the reasons why women did not hold their babies and if they had any regrets about their decisions. While four out of five women reported they did not hold because they could not or did not want to, the study did not account for the fact that women who declined may be fundamentally different at baseline, so that mental health outcomes may be due to underlying differences in mothers rather than their choices or experiences at birth. (3) While the authors emphasize that holding was associated with a trend toward worse mental health outcomes, their actual multivariable analyses show that at 9 months, the only statistically significant difference was higher odds of anxiety. Pre-existing anxiety could contribute to a woman's hesitance to hold the baby after delivery and separately serves as a predictor of postpartum mental health. (4) Even though there are many validated, widely-tested measures to assess postpartum depression,2-5 anxiety,6 and PTSD,7, 8 in both live birth and bereaved mothers, this study used non-validated self-report measures which leads to the need for very cautious interpretation of the results. (5) The factors which have been demonstrated to be strong predictors of postpartum depression and PTSD include prior mental health conditions, interpersonal violence, and lack of social support.9-12 This study did not measure or control for any of these factors. (6) Another issue not addressed in this article is the well-acknowledged preference by parents to be given the option to see or hold their baby and strong evidence that the majority of women are satisfied with their decision.10, 13 Events surrounding the birth of a stillborn baby can have lasting impact on how a mother experiences, remembers, and copes with this event.14 The decision to see or hold a stillborn baby warrants additional investigation, but research must adjust for the known confounders which have been shown to predict development of mental health problems. Moreover, there should be recognition that the experience of a mother at the time of delivery is complex, and multiple pre-existing and intrapartum factors may affect subsequent outcomes and grief. In summary, we believe it is not possible to reach a conclusion from this study about whether the decision to see or hold a stillborn baby is detrimental or helpful to bereaved parents and urge research to gain a more nuanced understanding of the factors which contribute to parental experiences at the time of delivery and which may influence long-term mental health outcomes. We strongly urge health care providers to continue to offer women the option to hold their stillborn baby, and to make this offer in a respectful, supportive, and normative manner

Stillbirths: recall to action in high-income countries.

Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19,439 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20-30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities.Mater Research Institute – The University of Queensland provided infrastructure and funding for the research team to enable this work to be undertaken. The Canadian Research Chair in Psychosocial Family Health provided funding for revision of the translation of the French web-based survey of care providers.This is the author accepted manuscript. The final version is available from Elsevier via http://dx.doi.org/10.1016/S0140-6736(15)01020-

Care in subsequent pregnancies following stillbirth: An international survey of parents

Objective: To assess the frequency of additional care, and parents' perceptions of quality, respectful care in pregnancies subsequent to stillbirth. Design: Multi-language web-based survey. Setting: International. Population: 2,716 parents, from 40 high- and middle-income countries. Methods: Data were obtained from a broader survey of parentsâ experiences of stillbirth. Data were analyzed using descriptive statistics and stratified by geographical region. Subgroup analyses explored variation in additional care by gestational age at index stillbirth. Main outcome measures: Frequency of additional care, and perceptions of quality, respectful care. Results: The majority (66%) of parents conceived their subsequent pregnancy within one year of stillbirth. Additional antenatal care visits and ultrasound scans were provided for 67% and 70% of all parents, respectively, although there was wide variation across geographical regions. Care addressing psychosocial needs was less frequently provided, such as visits to a bereavement counsellor (10%) and access to named care provider's phone number (27%). Compared to parents whose stillbirth occurred at 29 weeks' gestation or less, parents whose stillbirth occurred at 30 weeksâ gestation or greater were more likely to receive various forms of additional care, particularly the option for early delivery after 37 weeks. Around half (47-63%) of all parents felt that elements of quality, respectful care were consistently applied, such as spending enough time with parents and involving parents in decision-making. Conclusions: Care in pregnancies subsequent to stillbirth appears inconsistent. Greater attention is required to providing thoughtful, empathic, and collaborative care in all pregnancies following stillbirth. Training for health professionals is needed

Multicountry study protocol of COCOON: COntinuing Care in COVID-19 Outbreak global survey of New, expectant, and bereaved parent experiences

Introduction Globally, the COVID-19 pandemic has significantly disrupted the provision of healthcare and efficiency of healthcare systems and is likely to have profound implications for pregnant and postpartum women and their families including those who experience the tragedy of stillbirth or neonatal death. This study aims to understand the psychosocial impact of COVID-19 and the experiences of parents who have accessed maternity, neonatal and bereavement care services during this time. Methods and analysis An international, cross-sectional, online and/or telephone-based/face-to-face survey is being administered across 15 countries and available in 11 languages. New, expectant and bereaved parents during the COVID-19 pandemic will be recruited. Validated psychometric scales will be used to measure psychosocial well-being. Data will be analysed descriptively and by assessing multivariable associations of the outcomes with explanatory factors. In seven of these countries, bereaved parents will be recruited to a nested, qualitative interview study. The data will be analysed using a grounded theory analysis (for each country) and thematic framework analysis (for intercountry comparison) to gain further insights into their experiences. Ethics and dissemination Ethics approval for the multicountry online survey, COCOON, has been granted by the Mater Misericordiae Human Research Ethics Committee in Australia (reference number: AM/MML/63526). Ethics approval for the nested qualitative interview study, PUDDLES, has been granted by the King's College London Biomedical & Health Sciences, Dentistry, Medicine and Natural & Mathematical Sciences Research Ethics Subcommittee (reference number: HR-19/20-19455) in the UK. Local ethics committee approvals were granted in participating countries where required. Results of the study will be published in international peer-reviewed journals and through parent support organisations. Findings will contribute to our understanding of delivering maternity care services, particularly bereavement care, in high-income, lower middle-income and low-income countries during this or future health crises

Shifting boundaries : the art of Eileen Mayo

The artist, Eileen Mayo, D.B.E., was born in Norwich, England in 1906. Educated at the Slade School of Art, University of London (1923-24) and at the Central School of Arts and Crafts (1925-1928), she established a career as an illustrator, painter and printmaker in London in the 1930s. Associated with Claude Flight and the Colour Linocut Movement, her works were exhibited at the Royal Academy and extensively elsewhere, and collected by the Victoria and Albert and the British Museums. Mayo was also active as a model and features in works by leading artists such as Dame Laura Knight and Dod Proctor, another influence on her work. During the 1940s she wrote and illustrated books on natural history, a central theme in her work, as well as expanding her range as a printmaker into wood engraving and lithography. In the early 1950s she undertook a comprehensive study of tapestry design in France, rapidly distinguishing herself in this field. Mayo emigrated to Australia in 1952, becoming established as a leading printmaker, poster and stamp designer. Resident in New Zealand from 1962 until her death in 1994, she continued to develop as a printmaker, stretching the possibilities of relief and silk screen techniques, although she achieved greater recognition as a stamp designer during this period. Mayo's career is characterised by her seamless movement between the fine and applied arts, her Arts and Crafts-inspired belief in the right making of things and her uniformly high level of achievement across a wide range of media and genres. Although early works explore the theatrical world of Diaghilev's Ballets Russes, her subject matter is overwhelmingly rooted in meticulous observation of the natural world. Her ability to find underlying patterns in nature links her work to the more conservative strains of British modernism. Mayo was an artist who undertook commercial work in order to support herself. The full range of her output across the diverse media she employed includes illustrations, books, prints, paintings, tapestries, murals, bookplates, posters, tableware, dioramas, stamps and coins and was produced against a background of artistic practice within three countries in which she lived and worked. The artist's working notes and diaries and all known works are documented in a critical catalogue

019 -- The Role of Family in Latinx College Students\u27 Developing Identities

This phenomenological research examined the interaction between sibling relationships and culture in Latinx college students. Thematic analysis revealed participants identifying strongly with Latinx culture describe the importance of inter-familial dialogue and roles in their identity development, while parental expectations and values drove identity development in participants with less cultural exposure

Commemorative Cultures:The American Civil War Monuments Project

The Commemorative Cultures project is a digital heritage web resource which collects, records, maps, and interprets data about American Civil War monuments across the United States, the UK, and internationally. Unlike other mapping sites, our project’s unique aim is to provide interpretive materials with accompanying images, literary texts, and archival documents for each monument recorded. As well as establishing a more diverse account of Civil War commemoration than a focus on Confederate statuary permits, our primary aim is to create an informative digital resource providing access to otherwise inaccessible histories of these culturally contentious objects

Commemorative Cultures:The American Civil War Monuments Project

The Commemorative Cultures project is a digital heritage web resource which collects, records, maps, and interprets data about American Civil War monuments across the United States, the UK, and internationally. Unlike other mapping sites, our project’s unique aim is to provide interpretive materials with accompanying images, literary texts, and archival documents for each monument recorded. As well as establishing a more diverse account of Civil War commemoration than a focus on Confederate statuary permits, our primary aim is to create an informative digital resource providing access to otherwise inaccessible histories of these culturally contentious objects