The paradox of awareness of death in parenthood transition-A qualitative study.

In the high-income countries of Scandinavia, there is a low statistical risk of death during childbirth. However, awareness of the possibility of death seems to have prevailed. In existential psychology and philosophy, awareness of death is a universal condition in life, and facing the anxiety this awareness might invoke has the potential of being life-invigorating. In a hermeneutic analysis of Qualitative data, generated in a study on new parents' existential meaning-making, this study aimed to explore awareness of death as experienced in parenthood transition. The results found two overarching themes: Awareness of my own Finitude and Fragility of our loved ones. These were interpreted in existential philosophical and psychological theories, and concludes that awareness of death might signify an existential integration of 'self' in the new role of parenthood. Acknowledging these thoughts as healthcare professionals could support the meaning-making of parenthood transition, by normalizing their universal nature.

Continuing bonds in parents after a loss in pregnancy, or a death at or shortly after birth: A population-based study.

In this study, we describe continuing bonds and grief reactions and assess their association in 980 parents bereaved in pregnancy, at or shortly after birth. We found that most parents experienced continuing bonds. However, they differed by type of loss. Parents losing their child due to termination of pregnancy or miscarriage experienced bonds less frequently and had the least intense grief reaction. Parents losing their child postpartum experienced bonds most frequently and had the most intense grief reaction. Continuing bonds were associated with intensified grief in parents losing their child after termination or miscarriage, while this relationship was less obvious after stillbirth or postpartum death.

Carrying Death: A Qualitative Study of Women's Bodily Perceptions After Their Baby Died in Utero.

When a child dies in utero death becomes an integrated part of the mothers living body and this complex experience places a heavy existential and bodily burden on a woman experiencing stillbirth. This study uses a phenomenological approach with focus groups and individual interviews and data is discussed within a theoretical existential framework. Interviews of six women who experienced stillbirth within a range of 5 years were performed in Denmark. The participants experienced the dissonance of carrying death in their living body, expressed heightened existential considerations, a sense of transgression and of feeling trapped in an unbearable situation, and an experience of both dislocation from their body and an extreme bodily awareness. The study generates new knowledge and understanding of the how stillbirth is experienced as incomprehensible and as a violent bodily invasion of death with deep existential impact.

Parents' religious/spiritual beliefs, practices, changes and needs after pregnancy or neonatal loss-A Danish cross-sectional study.

This study describes religious/spiritual beliefs, practices, changes, and needs among parents bereaved by pregnancy or neonatal loss, and assess gender differences in religiosity/spirituality, in this population. A cross-sectional study using data from the Danish cohort Life After the Loss was conducted. Data were gathered from a questionnaire survey collected between January 2016 and December 2019. Among 713 respondents, several answered in the affirmative to items related to religious/spiritual beliefs and practices. Some experienced changes in religious/spiritual beliefs and practices, and some wished to talk to someone about these questions. Women reported higher levels of religiosity/spirituality than men.

Stillbirth - transitions and rituals when birth brings death: Data from a danish national cohort seen through an anthropological lens.

BACKGROUND: Many parents bereaved of a stillborn baby spend time with the child. In this time frame, different acts with the child in focus may occur. Some parents invite others to see the child too. Parents who suffer the loss of a newborn are vulnerable, and understanding acts and practices surrounding the dead newborn is important knowledge for caretakers. AIMS: This article aims to enlighten the amount of time Danish parents spend with their stillborn in hospital settings that encourage this practice. Furthermore, it aims to transcend the mere quantitative numbers through a theoretical approach that frames the analysis and discussion of possible layers of meaning imbedded in time spent with a dead newborn. STUDY DESIGN: Data from a Danish cohort of bereaved parents were collected using web-based questionnaires. These numbers were successively interpreted through an anthropological lens within the perspective of transition and ritualisation. Knowledge from existing empirical literature was also fused. RESULTS FROM THE COHORT: Danish parents spend hours or days with their stillborn child. They feel supported in this by healthcare professionals. Mainly close relatives join the parents while admitted to the hospital to see the stillborn child, followed by other family members and friends. CONCLUSION: Danish parents engage to a very high degree in contact with their dead baby. The analysis points out that 'Time' and 'Others' are needed to create a socially comprehensible status for parents and child when birth brings death. In liminal space during the transition, healthcare professionals act as ritual experts, supporting parents and their relatives to ascribe social status to the dead body of the child through ritualised acts. Instead of only thinking of this period as 'memory-making', we suggest regarding it as a time of ontological clarification as well.

Prayer and meditation among Danish first time mothers-a questionnaire study.

BACKGROUND: Mothers' existential dimensions in the transition to motherhood have not been described thoroughly. They might experience disruption and new perspectives in existential ways and this may especially be the case in preterm birth. The aim of this study was twofold. First we investigated the existential dimension of motherhood transition in a secularized context, through practices of prayer and meditation. Second we described the relationship between time of birth (term/preterm) and the prayer/meditation practices of the mothers. METHODS: Data were gathered from a nationwide questionnaire survey among first time mothers conducted during the summer 2011. All Danish women who gave birth before the 32(nd) pregnancy week (n = 255), and double the number of mothers who gave birth at full term (n = 658) in 2010 were included (total n = 913). The questionnaire consisted of 46 overall items categorized in seven sections, which independently cover important aspects of existential meaning-making related to becoming a mother. The respondent rate was 57% (n = 517). RESULTS: Moments of praying or meditation 6-18 months post partum were reported by 65%, and mothers who responded affirmatively, practiced prayer (n = 286) more than meditation (n = 89), p < 0,001. We did not observe differences in affirmative responses to prayer or meditation between mothers of full term or preterm born children, not even after controlling for perinatal or post partum loss, mode of birth, age, status of cohabiting or education. CONCLUSIONS: In this explorative study we found specific practices of existential meaning-making through prayer and/or meditation among first time mothers, living in a very secularized context. Yet we know only little about character or importance of these practices among mothers, and hardly anything about existential meaning-making among new fathers. Hence the implications of meaning-making practices related to other dimensions of health are difficult to address in a qualified way in care for new mothers and families.

Differences in Religiousness in Opposite-Sex and Same-Sex Twins in a Secular Society.

Sex differences in religion are well known, with females generally being more religious than males, and shared environmental factors have been suggested to have a large influence on religiousness. Twins from opposite-sex (OS) and same-sex (SS) pairs may differ because of a dissimilar psycho-social rearing environment and/or because of different exposures to hormones in utero. We hypothesized that OS females may display more masculine patterns of religiousness and, vice versa, that OS males may display more feminine patterns. We used a web-based survey conducted in Denmark, which is a secular society. The survey included 2,997 twins aged 20-40 years, identified through the population-based Danish Twin Registry. We applied la Cour and Hvidt's adaptation of Fishman's three conceptual dimensions of meaning: Cognition, Practice, and Importance, and we used Pargament's measure of religious coping (RCOPE) for the assessment of positive and negative religious coping patterns. Differences between OS and SS twins were investigated using logistic regression for each sex. The analyses were adjusted for dependence within twin pairs. No significant differences in religiousness and religious coping were found for OS and SS twins except that more OS than SS females were members of the Danish National Evangelical Lutheran Church and fewer OS than SS females were Catholic, Muslim, or belonged to other religious denominations. Moreover, OS males at age 12 had higher rates of church attendance than did SS males. This study did not provide evidence for masculinization of female twins with male co-twins with regard to religiousness. Nor did it show any significant differences between OS and SS males except from higher rates of church attendance in childhood among males with female co-twins.

Existential meaning among first-time full-term and preterm mothers: a questionnaire study.

Research indicates that childbirth is a time when a woman might experience existential disruptions and gain new perspectives on life. The 2-fold aim of this study was to investigate whether attitudes related to existential meaning among first-time mothers intensify and whether they differ between mothers who gave birth at full term and those who gave birth preterm. All first-time mothers who gave birth in Denmark in 2010 before the 32nd week of pregnancy and twice that number of full-term mothers (randomly sampled) were invited to participate in a national cross-sectional survey. Five core items concerning meaning in life, vulnerability of life, responsibility, thoughts about life and death, and "something bigger than oneself" were analyzed to compare mothers' attitudes on existential meaning. The overall response rate was 57% (517/913). Contrary to the hypothesis, attitudes related to existential meaning intensified to the same degree among mothers of full-term and preterm infants, with no statistically significant differences in terms of age, marital status, educational level, or birth method. Danish first-time mothers' attitudes related to existential meaning measured in 5 core items were intensified and almost similar, regardless of whether they gave birth full-term or preterm.

Religiousness and religious coping in a secular society: the gender perspective.

Women are found to be more religious than men and more likely to use religious coping. Only few studies have explored religious gender differences in more secular societies. This population-based study comprised 3,000 Danish men and women (response rate 45 %) between 20 and 40 years of age. Information about demographics, religiousness and religious coping was obtained through a web-based questionnaire. We organized religiousness in the three dimensions: Cognition, Practice and Importance, and we assessed religious coping using the brief RCOPE questionnaire. We found substantial gender differences in both religiousness and religious coping. Nearly, 60 % of the women believed in some sort of spirit or in God compared to 40 % of the men. Generally, both men and women scored low on the RCOPE scale. However, for respondents reporting high levels of religiousness, the proportion of men who scored high in the RCOPE exceeded the proportion of women in using positive and especially negative coping strategies. Also, in a secular society, women are found to be more religious than men, but in a subset of the most religious respondents, men were more inclined to use religious coping. Further studies on religious coping in secular societies are required.

Existential communication in maternity care - Mixed method evaluation of a postgraduate short course.

OBJECTIVE: The birth of a child is a significant life event, possibly accompanied by thoughts and feelings of existential turmoil, which some parents need to share. Maternity care professionals may be unprepared for this, as very few educational initiatives exist with a focus on existential communication. We evaluated the curriculum and delivery of a course in existential communication for midwives. The evaluation was based on participants' experiences of self-reported self-efficacy and self-reflection before and after participation. METHODS: A parallel mixed methods design with pre- and post-course questionnaires and field observations. Quantitative data were evaluated using Mann-Whitney analyses, and open-ended questions and field observations were thematised for further analysis. RESULTS: Seventy-three maternity care professionals participated in the course. Of these, 69 (95%) completed a pre-course questionnaire, and 71 (97%) a post-course questionnaire. The quantitative data found a significant difference in various participant measures such as increase in self-efficacy in existential communication and understanding of existential communication. Qualitative data from the questionnaires and field observations led to six different themes including topics such as the need for reflection with peers and the presence of existential within maternity care. CONCLUSIONS: The course evaluation suggested an increase in participants' awareness of existential aspects of maternity care and improved self-reflection and existential awareness.

Familial resemblance in religiousness in a secular society: a twin study.

It is well known that human behavior and individual psychological traits are moderately to substantially heritable. Over the past decade, an increasing number of studies have explored the genetic and environmental influence on religiousness. These studies originate predominantly from countries generally considered more religious than the very secular northern European countries. Comparisons of the results are complicated by diverse definitions of religiousness, but several studies indicate that the influence of the family environment is most predominant in early life, whereas genetic influences increase with age. We performed a population-based twin study of religiousness in a secular society using data from a Web-based survey sent to 6,707 Danish twins born 1970-1989, who were identified in the Danish Twin Registry. We applied Fishman's three conceptual dimensions of religiousness: cognition, practice, and importance. In all polygenic models and biometric analyses, we controlled for gender and age. The study sample comprised 2,237 same sex twins, a response rate of 45%. We found high correlations within both monozygotic and dizygotic twin pairs in most items of religiousness, indicating a large influence from shared environmental factors. Personal religiousness such as praying to God, believing in God, and finding strength and comfort in religion were more influenced by genetic factors than were social forms of religiousness such as church attendance. We found a small tendency for increasing genetic influence with increasing age for some religious items, but not for all.

Existential aspects of parenthood transition seen from the health professionals' perspective - an interview and theatre workshop study.

OBJECTIVES: A sense of existential vulnerability is embedded in parenthood transition. It is linked to meaning in life, relationship changes, awareness of death, and sometimes a transcendent belief. Nevertheless, in most maternity service guidelines, the existential aspects of life are not an explicit focus. Therefore, this study aimed to explore how health professionals in maternity services experience and understand existential aspects of parenthood transition among new parents. STUDY DESIGN: Data were generated through a user-involving two-phase process inspired by action research consisting of three focus group interviews with health professionals (n = 10) and, subsequently, a theatre workshop for parents, health professionals, and researchers (n = 40). Between the two phases, case narratives were constructed using information from the interviews and, in collaboration with a dramatist, dramatized and then played out at a workshop by professional actors. We used thematic analysis for all data. RESULTS: We identified five themes in the data material: 1. Death and fragility in maternity care, 2. Existential aspects in camouflage, 3. Existential and spiritual aspects of being professional in maternity care, 4. Talking about existential aspects of care, 5. Equipped for providing existential care? CONCLUSIONS: Existential aspects were often recognized during birth, specially in traumatic situations or discerned in the physical and non-verbal relational energy between the birthing woman and midwife or partner. Less often, existential aspects were recognized during pregnancy and the post-partum period.

Grief trajectories after loss in pregnancy and during the neonatal period.

Distinguishing patterns of grief over time in parents with a loss in pregnancy or during the neonatal period is important for identification of parents with severe grief symptoms, who may need additional support. Our aim was to describe grief in this population and to examine variations by type of loss in a large prospective cohort. We used questionnaire data from the Danish longitudinal cohort, Life After the Loss, which contains information on parents with a loss in pregnancy (from 14 weeks) or during the neonatal period. Parents completed the Prolonged Grief-13 scale at 1, 7, and 13 months after their loss. We applied Latent Growth Mixture Modelling to identify prolonged grief trajectories and used multinomial regression models to assess factors associated with class membership. Three distinct trajectories were identified in 676 parents: resilience (73.1%), recovery (16.9%), and chronic (10%). The distribution varied by type of loss, and the chronic group were overrepresented by parents with stillbirths (16.2%) and neonatal deaths (16.1%) in contrast to parents with spontaneous abortions (8.2%) and termination of pregnancy due to fetal anomalies (6.2%). Furthermore, not having a living child or being a woman was associated with following the chronic trajectory. These results underline that, while most bereaved parents are resilient, 10% experience consistently high levels of grief symptoms during the first year after the loss. Information on type of loss, gender, and whether the parent has living children are meaningful indicators of grief class membership.

Existential aspects as an inevitable part of salutogenesis in maternity care - A discussion paper.

BACKGROUND: Poor mental health is considered a major health challenge globally, not least for young people, who will form families within forthcoming years. Research related to childbirth and parenthood transition has focused on how to promote good mental health by preventing mental illness. AIM: We discuss how a salutogenetic approach to mental health in parenthood transition is beneficial, and specifically how the component of meaningfulness in Sense of Coherence (SoC), could be investigated to optimize good mental health during parenthood transition. DISCUSSION: In more recent understandings of meaningfulness, ideas from existential philosophy and psychology have been included. We discuss how, from an existential psychological perspective, open and explorative questioning of life conditions and dilemmas may help to regain one's footing and get in touch with one's driving force - meaningfulness. Such questioning implies that someone, a professional or a friend, actively and relationally helps explore existential aspects of life. CONCLUSION: We believe that investigating and asking research questions pointing at optimizing a salutogenetic perspective, specifically focusing on the component of meaningfulness and its embedded existential aspects of life, could lead to new knowledge on how to promote good mental health in maternity care.

Infertility, infertility treatment and behavioural problems in the offspring.

Behavioural patterns in children of infertile couples may be influenced by both the underlying causes of infertility and stress in the couples. Treatment procedures, such as culture media and manipulation of gametes and embryos, may also result in developmental problems. We examined behavioural problems in children as a function of infertility and infertility treatment, using data from three population-based birth cohorts in Denmark (Aalborg-Odense Birth Cohort, Aarhus Birth Cohort and Danish National Birth Cohort). Information on time to pregnancy and infertility treatment was collected during pregnancy. Children aged between 7 and 21 years were assessed using the Strengths and Difficulties Questionnaire (SDQ). The SDQ was completed by mothers in all cohorts and, in addition, by teachers in the Aarhus cohort and by children themselves in the Aalborg-Odense cohort. Children born after a time to pregnancy of >12 months and no infertility treatment had a behavioural pattern similar to children of fertile parents. Teachers reported a higher total difficulties score for children born after infertility treatment, but no significant differences were seen on any subscales of the teachers' report, and neither the mothers nor the children reported any differences on the total difficulties score and the prosocial behaviour score. Our results are thus overall reassuring regarding behavioural problems in children born to infertile couples, regardless of infertility treatment.

"I had to think: This is not a child." A qualitative exploration of how women/couples articulate their relation to the fetus/child following termination of a wanted pregnancy due to Down syndrome.

OBJECTIVE: Termination of a wanted pregnancy due to fetal anomaly may generate complex feelings of grief and loss. The aim of this study was to explore the different ways that women/couples articulated their relation to the fetus/child following a termination of pregnancy due to a prenatal diagnosis of Down syndrome. METHOD: Qualitative interview study with 21 women/couples who had recently terminated a wanted pregnancy. Data were analyzed using thematic analysis. RESULTS: The analysis identified how some women detached themselves from the fetus/child following the diagnosis by mentally separating from the fetus/child, by acting as if they were not pregnant (e.g., by drinking wine), or by deliberately using the term 'fetus' to designate the fetus/child as a biological entity. The analysis also identified accounts of attachment such as singing a lullaby to the fetus/child or using the term 'our child' or 'my baby'. However, accounts of detachment and attachment often intermingled and changed over time. Following the termination, many women/couples felt ambiguous about the sonogram as a symbol of the potential child. Overall, the analysis showed that the relation to and the meaning of the fetus/child was ambiguous and open to reinterpretation. CONCLUSION: The main contribution of this study is the identification of how articulations of attachment and detachment are not mutually exclusive but coexist and may change over time. Furthermore, we argue that detachment does not equal indifference. Thus, healthcare professionals must support the couple in finding a terminology and a narrative that are meaningful for them.

Women's Length of Stay in a Danish Specialized Unit for Perinatally Bereaved Parents.

OBJECTIVE: To describe the clinical characteristics of women admitted to a specialized unit for bereaved parents and to identify the characteristics of women who stayed more than 2 days. DESIGN: A population-based descriptive study. SETTING: A midwifery-led specialized unit for bereaved parents at Aarhus University Hospital, Denmark. PARTICIPANTS: Women with miscarriage (>14 weeks), missed abortion (>14 weeks), termination of pregnancy (>14 weeks), stillbirth, or death of their neonate during the first 48 hours after birth. METHODS: We collected information from the electronic health care records for women admitted to the unit from January 2012 through December 2018, including parity, type of loss, gestational age, mode and duration of birth, pain relief, and duration of stay. RESULTS: From January 1, 2012. to December 31, 2018, 579 women were admitted to the unit. Hospitalization varied from 1 day to 1 week. More women with a loss after 22 gestational weeks stayed for more than 2 days. In multivariate analyses, the hazard ratio (HR) of staying longer than 2 days was 1.3 times greater for primiparous women than for multiparous women (HR = 1.3, 95% confidence interval [1.0, 1.7]) and 2.4 times greater for women with near-term loss compared to women with perinatal loss before gestational week 22 (HR = 2.4, 95% confidence interval [1.7, 3.6]). CONCLUSION: Providing unlimited stay at a specialized unit for perinatal loss resulted in variation in length of stay. Primiparous women and women who lost neonates or fetuses closer to term gestation were more likely to stay in the unit for up to 8 days. This may indicate a need for individual support not available in standard care.

Midwives' experiences of using the Obstetric Norwegian Early Warning System (ONEWS): A national cross-sectional study.

INTRODUCTION: Increasing numbers of maternity units are implementing routine and standardized monitoring of all women using a form of Early Warning Score System with the aim to early detect women at risk of developing critical illness or a deterioration of their condition. The implementation in Norway is relatively new. This study aimed to describe Norwegian midwives' experiences with the Obstetric Norwegian Early Warning System (ONEWS). METHODS: We performed a cross-sectional study based on an electronic questionnaire, sent to heads of midwifery at all maternity units in Norway for distribution to their clinically active midwives. Thirty-one of 48 units had implemented ONEWS for over a month. About 1020 midwives received the questionnaire, 232 (23%) responded. RESULTS: Of the participants, 217 (93.5%) reported receiving sufficient training and 230 (99.1%) reported using the same scoring system, including the same vital parameters measured. The criteria for use of ONEWS varied between units regarding inclusion criteria and frequency of scoring. A total of 214 (92.2%) midwives agreed that ONEWS has value in the surveillance of high-risk women, while 152 (65.5%) agreed that ONEWS contributes to medicalization of the care of low-risk women. Some 166 (71.6%) midwives reported that ONEWS was time consuming and 159 (68.5%) that the measures need to be better adapted to childbearing women. CONCLUSIONS: Maternity units in Norway implementing ONEWS use an almost identical scoring system but varying criteria for whom to score and how often. Midwives considered ONEWS particularly suited for high-risk women and not for low-risk childbearing women.

Existential aspects in the transition to parenthood based on interviews and a theatre workshop.

OBJECTIVES: There are multitudes of existential feelings and considerations around childbirth, with both positive and negative sources of existential meaning; often they are mixed up, but they impact parents' ideas of meaning and purpose in life. The aim of this study was to explore existential aspects of parenthood transition among new fathers and mothers in view of a potential training programme for professionals in maternity services. STUDY DESIGN: Data were generated through a user-involving two-phase process inspired by action research consisting of first, four focus group-interviews (n = 10); and second, a theatre workshop for parents, health professionals, and researchers (n = 40). Between the two phases, case-narratives were constructed based on the interviews and, in collaboration with a dramatist, dramatized and then played at the workshop by professional actors. Data from interviews and the workshop were thematised for further analysis. RESULTS: We identified five themes: 1. A turning point of what to hold sacred; 2. Changed relationships - guilt and overwhelming love; 3. Awareness of death; 4. Religiousness embodied; 5. What we talk about. CONCLUSIONS: Existential aspects of parenthood transition were closely related to meaning in life, changes in relationships, awareness of death and relation to a transcendent belief. Existential aspects were explicated and discussed in nuanced ways expressing existential vulnerability. It is therefore important to both acknowledge and address existential aspects in maternity care, for the simple reason (among others) that they matter to parents. Moreover, this might enhance a coherent and authentic parenthood transition embedding the paradoxicalities.

Parental infertility and cerebral palsy in children.

BACKGROUND: Children born after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have been reported to have a higher risk of cerebral palsy (CP), perhaps due to the higher frequency of preterm birth, multiple births or vanishing embryo in the pregnancies. However, it has been suggested that the underlying infertility may be part of the pathway. In this study, we examined whether untreated subfecundity (measured by time to pregnancy) or infertility treatment was associated with an increased risk of CP in the offspring. METHODS: Using the Danish National Birth Cohort (1997-2003), we compared children born after 0-2 months of waiting time to pregnancy (n = 35 848) with those born after a time to pregnancy of 3-5 months (n = 15 361), 6-12 months (n = 11 528) and >12 months (n = 7387), as well as those born after IVF/ICSI (n = 3617), ovulation induction with or without intrauterine insemination (n = 3000), and unplanned pregnancies (n = 13 462). CP cases were identified through the Danish CP Register. RESULTS: In total, 165 (0.18%) children were diagnosed with CP in the entire cohort. We found no significant association between time to pregnancy and the risk of CP in children conceived spontaneously. Children born after IVF/ICSI had an increased risk of CP, even after adjustment for preterm birth and multiplicity (hazard ratio 2.30, 95% confidence interval 1.12-4.73). CONCLUSIONS: Subfecundity per se did not appear to be associated with the risk of CP in children, whereas being born after IVF/ICSI conferred an increased risk.