Women’s Experiences in the Antenatal and Perinatal Period Following a Stillbirth or Neonatal Death: A Multicentre Cohort Study

Abstract

Background The death of a baby before or shortly after birth is a profoundly distressing experience for women and their families. Although grieving the death of their baby, most women will embark on another pregnancy. Specialist antenatal services have been proposed to address the increased biomedical and psychological risks in pregnancies after perinatal death. This study aimed to explore the experiences of women in and shortly after pregnancy after loss to determine the psychological and economic impact and the effect of a specialist service. Methods This study adopted a mixed-methods approach using several sources of data: i) validated measures of psychological state (Cambridge Worry Score, Edinburgh Postnatal Depression Score (EPDS), Generalized Anxiety Disorder 7-item score), ii) measurement of hair cortisol, iii) face-to-face semi-structured interviews to explore women’s views and experiences of care during their pregnancy, and iv) a Social Return on Investment (SROI) analysis with a subgroup of women and staff participants at the lead site. Results In total 112 women participated in the study. Measures of anxiety and depressive symptoms decreased from the highest levels at 15 weeks’ gestation to 6-weeks postnatal (for example mean GAD-7: 15 weeks 8.2 ± 5.5, 6 weeks postnatal 4.4 ± 5.0, p < 0.001). Hair cortisol levels fell in a similar profile to anxiety and depression symptoms (p < 0.05). Thematic analysis of interviews (n = 20) described how stillbirth was a quiet, unspoken subject and that navigating subsequent pregnancies relied on expecting the worst and hoping for the best; mapping these themes onto the Dual Process Model of Bereavement found being pregnant complicated the grieving process as increased awareness of the risk of stillbirth drew parents focus back to loss. Attendance at a specialist service was valued; SROI analysis found that for £1 invested, £6.10 of value was generated, mostly relating to reduced negative psychological symptoms. Conclusions This mixed-methods study demonstrated heightened anxiety and depressive symptoms and elevated cortisol levels which decrease as pregnancy progresses. Specialist care was viewed favourably, and is cost-effective, but comparative studies are required to determine whether this model is superior to routine high-risk care and to identify which components are most valued.

Women’s Experiences of a Specialist Antenatal Service for Pregnancies After a Stillbirth or Neonatal Death: A Qualitative Interview Study and Social Return on Investment Analysis

“…Semi-structured interviews and qualitative analysis Face-to-face semi-structured interviews were conducted with a sub-group of women from a larger study to explore their views and experiences of care during their pregnancy [3]. The interview topic guide was designed by research team with input from a patient panel who had attended the research clinics at St Mary's Hospital.…”

“…A pregnancy following a stillbirth or neonatal death in a prior pregnancy is associated with a series of emotional and psychological challenges for pregnant women and their families; these pregnancies are characterised by increased anxiety, depression and perceived stress, emotional vulnerability and decreased con dence that the next pregnancy will have a healthy outcome [1][2][3]. In a subsequent pregnancy, many mothers and fathers report the loss of 'normal' positive feelings they expected and have described how their subsequent pregnancies were characterised by heightened anxiety and fear [2].…”