Background
Pregnancy loss is referred to the loss of a pregnancy by miscarriage, stillbirth or termination for fetal abnormalities [
1]. Miscarriage is generally defined as an unintentional pregnancy termination before foetal viability [
2]. Miscarriages can be grouped into early (< 10–14 weeks) and late (> 10–14 weeks). Inevitable abortion usually develops from threatened abortion. It is vaginal bleeding with an open cervical os and viable pregnancy [
3]. Globally, an estimated 23 million miscarriages occur every year [
2]. The overall incidence of miscarriage is 25% [
4]. Stillbirth is defined as the death of a fetus after 20 weeks gestation with a birthweight of more than 500 g. There were approximately 2.6 million stillbirths worldwide in 2015 [
5]. Pregnancy terminations for foetal abnormalities including chromosomal problems, and maternal anatomic factors, immunologic factors, infection, and thrombophilia are highly stressful events [
6]. In China, the reported overall incidence of foetal anomalies is 5.6%, and the termination rate of these cases is approximately 70.66% [
7]. Late miscarriage, stillbirth and foetal abnormality were research emphases of this study. Because women in these cases had more interactions with nurses and midwives compared with women who experienced early pregnancy loss.
Pregnancy loss can cause destructive psychological problems [
8‐
11], which might persist into the next pregnancy [
12]. Psychological outcomes of miscarriage include increases in the risk of anxiety, depression, post-traumatic stress disorder, and suicide [
2]. Women defined late miscarriage as a significant loss, a disaster, a catastrophe, or even death [
13]. Stillbirth is related with a number of negative psychological symptoms including social phobia, agoraphobia, anger, a sense of failure and long-term guilt [
11]. The discovery of a foetal abnormality is a shock for pregnant women and they may have psychological responses including denial of reality, reaction avoidance and self-punishing thinking [
14]. In addition, the experiences of pregnancy loss may not only lead to negative psychological issues but also generate positive psychological changes. Positive psychological experiences included new life attitude, feelings of gratitude and so on [
15]. Women undergoing pregnancy termination for foetal abnormality described feelings of unprecedented ease and relief of the body and mind after induced abortion [
14].
It is reported that stillbirth, birth defects and mental health of pregnant women are the key issues of maternal and infant health in China [
4]. In Chinese traditional culture, there is a big taboo about death. Psychological issues related to pregnancy loss are often ignored. Therefore, it has become an urgent problem to be concerned about pregnancy loss and to think about how to provide high-quality bereavement care for the women.
In China, if a definitive diagnosis of foetal death is made, abortion would be suggested to parents by doctors. For nonfatal foetal malformations, parents would sign informed consent if they decide to terminate the pregnancy. Abortion regimes are different according to women’s gestational length. Drug abortion and artificial abortion operation are applicable to women who have been pregnant within 7 weeks and for 6 ~ 14 weeks, respectively. Women are usually given an injection of Ethacridine (Rivanol) after they have been pregnant for more than14 weeks. Women have to go into labour to deliver a dead fetus in hospital [
16] and their support people are not allowed to enter the labour room or delivery room. The length of their hospitalisation usually ranges from 5 to 7 days.
Studies have shown that the care parents receive around the loss has a large influence on their abilities to deal with the loss [
17,
18]. However, contradictory interactions between bereaved women and obstetric nursing staff are becoming increasingly prominent [
19]. In an international online survey of bereaved parents (
n = 3769) of stillborn babies, a quarter (25.4%) of respondents reported disrespectful care and 23.5% reported disrespectful care of their baby [
20]. Women having an abortion experience identified nursing care as based on physical aspects, without considering their individuality and specificities [
21]. Women report that the heavy physical and mental burden of the medical staff, a lack of good communication and ineffective pain management were the main factors leading to dissatisfaction with their service [
22,
23]. In contrast, nurses and midwives believe that keeping a distance from bereaved parents and focusing on nursing tasks are coping strategies they should adopt, which unfortunately adds to the distress of the parents [
17,
24]. On the one hand, nurses and midwives have deficiencies in counseling and communication skills [
25]. Specifically, they do not know how to use the correct expression to comfort the mother and worry that inappropriate words may upset the women further [
26]. On the other hand, burnout, secondary traumatic stress and other negative emotions suggested that nurses and midwives bore a heavy emotional burden during the care process [
27,
28]. The pressure to provide psychological support and the negative emotional distress of obstetric nursing staff are the main factors preventing them from providing high-quality bereavement care [
29]. Therefore, they tended to adopt strategies of suppressing emotions and reduce communication with mothers [
30,
31]. At present, there is no routine emotional support for the women and obstetric nursing staff in China. The majority of nurses and midwives had not received training in perinatal bereavement care (85.2%) [
32].
Previous qualitative studies merely focused on women’s or healthcare providers’ broad emotional experiences [
33‐
35]. Little attention has been given to the interaction process from both the perspectives of women and the nursing staff to comprehensively reflect the interaction issues and influencing factors in the context of pregnancy loss. Interaction refers to the process of interdependent behavior between individuals through language or other means of disseminating information. In this study, several aspects of the interaction including communication, psychological feelings, experiences of care among women who have experienced pregnancy loss and obstetrics medical staff were focused on. Appropriate communication that reflects parents’ preferences are vital for shaping women’s experience of pregnancy loss [
36]. However, it is often neglected [
37]. Therefore, this study aimed to explore the interactions between women who have experienced pregnancy loss and obstetric nursing staff. The findings of this study would increase our understanding of the interaction process and identify problems during the interactions, thus promoting benign interactions and improving women’s experiences in the context of perinatal bereavement care.
Discussion
Main findings
Our study showed that different approaches used by nursing professionals in interactions might lead to different outcomes. Generally, women were sensitive and distressing during the interactions. The interaction process could have both impact on psychological well-being of providers and the women. Ignoring women’s needs and using disrespectful words were main reasons for interaction contradiction. Heavy clinical workload, lack of ability and awareness and the heavy emotional burden on the nursing staff were the main influencing factors of interactions. Training needs for clinical professional skills and humanistic care skills were highlighted. Some helpful suggestions were proposed to facilitate benign interactions including improvement of the medical environment and management, optimization of bereavement care and competent nursing professionals.
Comparison with literature
Respectful communication is crucial for this sensitive population, which is consistent with the framework and principles of the practice of respectful and supportive perinatal bereavement care [
42,
43]. Good communication is the issue most often mentioned in studies of parents’ experiences of bereavement care [
44,
45]. In our study, it was suggested that healthcare staff should show their sympathy and patience with a sensitive attitude. It could provide a feeling of support so that women are more able to adapt to the crisis. Moreover, women-centred care and providing adequate information are also important aspects of benign interaction. These results are similar to previous findings [
37,
46,
47]. In contrast, task-based communication, disrespectful words, neglecting women’s needs and delayed responses may lead to undesirable interactions and even conflicts, which should be avoided. The emphasis on women’s needs varied in different stages [
14,
48]. Therefore, prompt feedback and targeted care should be given to women based on their needs and psychological responses.
In regard to influencing factors of interactions, a heavy workload and insufficient human resources could significantly affect the quality of bereavement care, which is similar to previous findings [
25,
49]. It is necessary to add personnel and provide equal care to all women. Burnout, emotional exhaustion and other negative emotions among healthcare staff may lead to reduced quality of care [
17], and sufficient emotional support should be offered to relieve their emotional labour [
50]. There is a need for employee assistance programmes, including group psychological interventions and meditation, to relieve negative moods [
27,
51,
52].
Previous studies showed that the highest quality of bereavement care could be guaranteed by providing comprehensive and ongoing training for healthcare staff [
53‐
55]. Hence, training nurses and midwives in perinatal bereavement care is necessary [
56]. In this study, lack of ability and awareness were influencing factors of interactions. Cultivating healthcare staff’s awareness of caring for women with sympathy and respect is important and should be included in the training. Insufficient treatment of pain and dissatisfaction with pain management were commonly seen during abortions [
23]. Effective pain management strategies [
57‐
60] and continuous professional attendance [
61] should be provided to women to cope with the pain and improve their satisfaction with the overall experience. Requirements of receiving training about clinical professional knowledge and humanistic care skills were put forward. More dialogue with psychologists and education on the causes of pregnancy loss could improve nursing staff’s professional knowledge and enhance the women’s trust in them [
50]. In terms of humanistic care skills, active listening and responding empathically to women are useful skills that could be adopted by nursing staff [
47,
62,
63].
For the medical environment, providing a private space to accelerate the women’s feelings of comfort and to enable providers to satisfy women’s needs is necessary [
62]. In regard to abortion services, uniform training related to bereavement care strategies such as seeing the baby and making memories should be offered to providers [
47]. Instructions should be given to families to enhance family support for these vulnerable women [
64,
65] because family support is the most significant support required by women who have lost babies [
66]. Integrating partners into abortion care to enhance the quality of companions during the entire process is worth consideration [
67]. During the interview, we found that nurses and midwives who had children were more likely understand women’s experiences and emotional pain. Nursing staff without childbirth experience felt a little difficult to express their sympathy. Therefore, training for healthcare providers with little clinical experience of pregnancy loss, especially those with no kids, is a priority. They are in greater needs of receiving training to guide their practice. Our findings showed that nurses and midwives should learn to provide respectful care via introspecting their practice. Because reflection (e.g. writing or talking with colleagues) can provide us with insights that bring clarity and wisdom [
68].
Implications for hospital policies
First, provider training should be regularly organised to guide obstetric nursing staff how to provide sensitive and respectful care for women who have experienced pregnancy loss. Our findings including approaches to interactions, characteristics of the grieving women, approaches of avoiding interaction contradiction should be integrated into the training. Nurses’ and midwives’ learning needs including clinical professional knowledge and humanistic care skills should be satisfied. Second, hospitals also need to pay close attention to the mental health of providers. Providing sufficient support for obstetrics medical staff via providing establishing professional psychological support team in hospitals could be considered. More effective human resources management can be useful to ease the heavy workload. Thereby, nurses and midwives could provide high-quality bereavement care for the women in good mental state. Last but not least, it is important to forming systematic and standardized bereavement care policies covering information support, emotional support, communication and so on. Intimate service such as providing private space for the bereaved women could be offered in bereavement care.
Strengths and limitations
The COREQ checklist was used for the study design and reporting, ensuring the quality and rigour of this qualitative study. A representative sample of stakeholders guaranteed a wide range of data sources from which to draw conclusions. Our study not only focused on interaction conflicts and clinical deficiencies but also paid attention to benign interaction experiences. This was helpful to provide enlightenment about improving clinical services and future training for medical staff during pregnancy termination.
A limitation of this study is that nurses and midwives might be cautious when they describe conflicts during an interaction, although we explained that the interview was anonymous. This may have an impact on thoroughly exploring conditions of interactive contradictions. Although researchers interviewed 13 midwives and 7 nurses until saturation was reached, the perceptions expressed may not be representative of these communities as a whole. Besides, we only interviewed women who were pregnant for more than 14 weeks for gaining more information of their interaction experiences. Women experiencing early pregnancy loss (< 14 weeks) have been excluded, which may influence the representativeness of our findings to some extent.
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