Continuing bonds following stillbirth: protective and risk factors associated with parental bereavement adaptation.

OBJECTIVE: To investigate any association between expressions of parents' continuing bond with their stillborn baby and bereavement adaptation. BACKGROUND: Continuing bonds theory suggests that bereaved parents adapt to the loss of their child by sharing and transforming mental representations of the child, allowing them to be integrated into parents' everyday lives. Little is known about the mental health benefits of expressing continuing bonds following stillbirth. This study examined any association between aspects of parents' relationship with their stillborn baby, social support for the relationship, and bereavement adaptation. METHODS: Cross-sectional questionnaire study. Parents of stillborn babies (N=170) completed an online questionnaire examining engagement in continuing bonds expressions; characteristics of parents' relationship with their stillborn baby and their experience of sharing it; social support, and meaning-making. Measures of mental health were included to quantify bereavement adaptation. RESULTS: Regression analyses showed that time since death, meaning-making, engaging with nature, and legacy building are positively linked to bereavement adaptation. Risk factors included inadequate social support for the relationship, a greater desire to share it more freely, an increased sense of integration with baby, and societal pressure to move on. CONCLUSION: Key aspects of parents' ongoing relationship with their stillborn baby and the social context are related to bereavement adaptation.

What are women stressed about after birth?

BACKGROUND: Having a baby is associated with a variety of stressors, change, and adjustment. This study aimed to identify what women find stressful during the early postpartum period in contemporary Western society. METHODS: Women (n = 148) 6-12 weeks postpartum wrote anonymously about a situation they found stressful as part of the Health after Birth Trial (HABiT) of expressive writing. Transcripts were analyzed for categories of stressors and cross-cutting themes. RESULTS: Five categories of stressors were identified. Stressors in pregnancy, labor, and the early postpartum period (49.3%) included physical and emotional difficulties, and insensitive treatment by health professionals. Stressors related to adjusting to life with a baby (35.8%) included difficulties coping with a new baby, parenting, juggling responsibilities, changes to physical health, and loneliness. Stressors related to the baby's health (32.4%) included infant digestive problems, acute health problems, long-term impact, and neonatal intensive care unit experiences. Stressors related to breastfeeding (23.7%) included pressure to breastfeed, feeling like a 'bad mum' for not breastfeeding, or wanting to breastfeed and not being able to. Other stressors related to changing relationships (18.2%): with their partner, children, and other family members. Cross-cutting themes that emerged in different stressor categories were women making negative self-appraisals (eg, a bad mum, failure), feeling guilty, and lack of support from others. DISCUSSION: Our findings emphasize the importance of exploring stressors and psychological well-being with women to provide support, help women's adjustment postpartum, and ensure interventions are offered when appropriate.

Evaluation of expressive writing for postpartum health: a randomised controlled trial.

Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect the health of women. There is some evidence that expressive writing can have positive effects on psychological and physical health, particularly during stressful periods. The current study aimed to evaluate whether expressive writing would improve women's postpartum health. A randomized controlled trial was conducted with three conditions: expressive writing (n = 188), a control writing task (n = 213), or normal care (n = 163). Measures of psychological health, physical health and quality of life were measured at baseline (6-12 weeks postpartum), 1 and 6 months later. Ratings of stress were taken before and after the expressive writing task. Intent-to-treat analyses showed no significant differences between women in the expressive writing, control writing and normal care groups on measures of physical health, anxiety, depression, mood or quality of life at 1 and 6 months. Uptake and adherence to the writing tasks was low. However, women in the expressive writing group rated their stress as significantly reduced after completing the task. Cost analysis suggest women who did expressive writing had the lowest costs in terms of healthcare service use and lowest cost per unit of improvement in quality of life. Results suggest expressive writing is not effective as a universal intervention for all women 6-12 weeks postpartum. Future research should examine expressive writing as a targeted intervention for women in high-risk groups, such as those with mild or moderate depression, and further examine cost-effectiveness.Clinical trial registration number ISRCTN58399513 www.isrctn.com.

Feasibility and acceptability of expressive writing with postpartum women: a randomised controlled trial.

BACKGROUND: Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect women's mental and physical health. Expressive writing, where people write about a stressful event for at least 15 min on three consecutive days, has been associated with improved health in some groups but it is not clear whether it is feasible and acceptable for use with postpartum women. This study therefore examined the feasibility and acceptability of expressive writing for postpartum women as part of a randomised controlled trial (RCT). METHODS: The Health After Birth Trial (HABiT) was an RCT evaluating expressive writing for postpartum women which included measures of feasibility and acceptability. At 6 to 12 weeks after birth 854 women were randomised to expressive writing, a control writing task or normal care, and outcome measures of health were measured at baseline, one month later and six months later. Feasibility was measured by recruitment, attrition, and adherence to the intervention. Quantitative and qualitative measures of acceptability of the materials and the task were completed six months after the intervention. RESULTS: Recruitment was low (10.7% of those invited to participate) and the recruited sample was from a restricted sociodemographic range. Attrition was high, increased as the study progressed (35.8% at baseline, 57.5% at one month, and 68.1% at six months) and was higher in the writing groups than in the normal care group. Women complied with instructions to write expressively or not, but adherence to the instruction to write for 15 min per day for three days was low (Expressive writing: 29.3%; Control writing: 23.5%). Acceptability measures showed that women who wrote expressively rated the materials/task both more positively and more negatively than those in the control writing group, and qualitative comments revealed that women enjoyed the writing and/or found it helpful even when it was upsetting. CONCLUSIONS: The feasibility of offering expressive writing as a universal self-help intervention to all postpartum women 6 to 12 weeks after birth in the HABiT trial was low, but the expressive writing intervention was acceptable to the majority of women who completed it. TRIAL REGISTRATION: ISRCTN58399513, 10/09/2013.

Supporting parents through stillbirth: A qualitative study exploring the views of health professionals and health care staff in three hospitals in England.

OBJECTIVE: To investigate the views of a range of hospital based health professionals and health care staff involved in the management of stillbirth. STUDY DESIGN: A qualitative pilot study informed by grounded theory conducted in three hospital trusts in the North East of England. In total, 21 consultant obstetricians, 3 trainees (including 1 senior trainee), 29 midwives, 3 midwife sonographers and 4 chaplains took part in six focus groups and two semi-structured interviews. RESULTS: Two different approaches in stillbirth management could be detected in our study. One approach emphasised the existing evidence-base and patient directed choice whilst the other emphasised tradition and profession-directed care. These differences were particularly apparent in choices over mode of delivery, and the location of women as well as the time interval between diagnosis of an IUD and delivery. The existence of these two approaches was underscored by a lack of high quality evidence. CONCLUSION: Robust, high quality evidence is needed regarding the longer term psychological and emotional sequelae of different modes of delivery and varying time intervals and locations of women between diagnosis and delivery in stillbirth. If the competing discourses demonstrated here are found elsewhere then such need to be considered in any future policy development, evidence implementation and training programmes.

Trait mindfulness and autobiographical memory specificity.

Training in mindfulness skills has been shown to increase autobiographical memory specificity. The aim of this study was to examine whether there is also an association between individual differences in trait mindfulness and memory specificity using a non-clinical student sample (N = 70). Also examined were the relationships between other memory characteristics and trait mindfulness, self-reported depression and rumination. Participants wrote about 12 autobiographical memories, which were recalled in response to emotion word cues in a minimal instruction version of the Autobiographical Memory Test, rated each memory for seven characteristics, and completed the Freiburg Mindfulness Inventory, the Depression, Anxiety, and Stress Scale, and the Ruminative Responses Scale. Higher rumination scores were associated with more reliving and more intense emotion during recall. Depression scores were not associated with any memory variables. Higher trait mindfulness was associated with lower memory specificity and with more intense and more positive emotion during recall. Thus, trait mindfulness is associated with memory specificity, but the association is opposite to that found in mindfulness training studies. It is suggested that this difference may be due to an influence of trait mindfulness on memory encoding as well as retrieval processes and an influence on the mode of self-awareness that leads to a greater focus on momentary rather than narrative self-reference.

The Birth Memories and Recall Questionnaire (BirthMARQ): development and evaluation.

BACKGROUND: Childbirth is a challenging and emotive experience that is accompanied by strong positive and/or negative emotions. Memories of birth may be associated with how women cognitively process birth events postpartum and potentially their adaptation to parenthood. Characteristics of memories for birth may also be associated with postnatal psychological wellbeing. This paper reports the development and evaluation of a questionnaire to measure characteristics of memories of childbirth and to examine the relationship between memories for birth and mental health. METHODS: The Birth Memories and Recall Questionnaire (BirthMARQ) was developed by generating items from literature reviews and general measures of memory characteristics to cover dimensions relevant to childbirth. Fifty nine items were administered to 523 women in the first year after childbirth (M = 23.7 weeks) as part of an online study of childbirth. Validity of the final scale was checked by examining differences between women with and without probable depression and PTSD. RESULTS: Principal components analysis identified 23 items representing six aspects of memory accounting for 64% of the variance. These were: Emotional memory, Centrality of memory to identity, Coherence, Reliving, Involuntary recall, and Sensory memory. Reliability was good (M alpha = .80). Women with probable depression or PTSD reported more emotional memory, centrality of memories and involuntary recall. Women with probable depression also reported more reliving, and those with probable PTSD reported less coherence and sensory memory. CONCLUSION: The results suggest the BirthMARQ is a coherent and valid measure of the characteristics of memory for childbirth which may be important in postnatal mood and psychopathology. While further testing of its reliability and validity is needed, it is a measure capable of becoming a valuable tool for examining memory characteristics in the important context of childbirth.

Stillbirth and stigma: the spoiling and repair of multiple social identities.

This study investigated mothers' experiences surrounding stillbirth in the United Kingdom, their memory making and sharing opportunities, and the effect these opportunities had on them. Qualitative data were generated from free text responses to open-ended questions. Thematic content analysis revealed that "stigma" was experienced by most women and Goffman's (1963) work on stigma was subsequently used as an analytical framework. Results suggest that stillbirth can spoil the identities of "patient," "mother," and "full citizen." Stigma was reported as arising from interactions with professionals, family, friends, work colleagues, and even casual acquaintances. Stillbirth produces common learning experiences often requiring "identity work" (Murphy, 2012). Memory making and sharing may be important in this work and further research is needed. Stigma can reduce the memory sharing opportunities for women after stillbirth and this may explain some of the differential mental health effects of memory making after stillbirth that is documented in the literature.