313

BIRTH 35:4 December 2008

Effects of Contact with Stillborn Babies
on Maternal Anxiety and Depression
Joanne Cacciatore, PhD, MSW, FT, Ingela Rådestad, PhD, and J. Frederik Frøen, MD, PhD
Abstract: Background: Some guidelines encourage mothers to see and hold their babies after
stillbirth, which might be traumatizing. The study objective was to investigate the effects of women
seeing and holding their stillborn baby on the risk of anxiety and depression in a subsequent
pregnancy and in the long term. Methods: Thirty-seven organizations recruited women who had
experienced stillbirth (N = 2,292 of whom 286 reported being pregnant). Anxiety and depressive
symptoms were assessed by using the 25-item Hopkins Symptom Check List. Results: Among
nonpregnant women, seeing and holding their stillborn baby were associated with lower anxiety
symptoms (OR 0.68, 95% CI 0.49–0.95) and a tendency toward fewer symptoms of depression (OR
0.72, 95% CI 0.51–1.02), compared with pregnant women. Participants who were pregnant also had
less depressive symptomatology (OR 0.57, 95% CI 0.43–0.75), but more symptoms of anxiety if they
had seen and held their baby (OR 3.79, 95% CI 1.42–10.1). Conclusions: Seeing and holding the
baby are associated with fewer anxiety and depressive symptoms among mothers of stillborn babies
than not doing so, although this beneficial effect may be temporarily reversed during a subsequent
pregnancy. (BIRTH 35:4 December 2008)

Key words: stillbirth, fetal death, psychosocial care, anxiety, depression

During the mid-20th century, when both birth and
death were institutionalized in the Western world,
hospitals took over the management of stillbirth.
Mothers rarely had an opportunity to see, hold, or
take photographs of their stillborn babies. Instead,
‘‘babies were whisked away and disposed of’’ to minimize the psychological trauma of the experience (1).
However, in the late-1970s, physicians, such as
Emmanuel Lewis, began to criticize the ‘‘rugby pass
management of stillbirth . . . the catching of a stillbirth
after delivery, the quick accurate back-pass through
the labor room door to someone who catches the
baby’’ (1).

In 1983, Lovell reported on 22 mothers of whom 12
never saw or held their stillborn babies (2). She found
that women ‘‘usually relied on the judgment of the
health professionals . . . and took her cues from the
experts.’’ Women trusted those in authority as to
whether or not they should see or hold their stillborn
babies. Their narratives showed that they regretted
not having contact with their babies, and these mothers had difficulty reconciling: ‘‘Sandy wonders what
happened to her stillborn son: ‘I have a recurring
dream that I’m in the hospital searching for him. I
feel it is the most important event in my life. And
yet, it is a terrible nothingness’’’ (2, p 758).

Joanne Cacciatore is an Assistant Professor in the College of Human
Services at Arizona State University, Phoenix, Arizona, USA; Ingela
Rådestad is an Associate Professor in the Department of Caring
Sciences and Public Health at Mälardalens University, Eskilstuna,
Sweden; and J. Frederik Frøen is a Director and an Associate Professor
in the Department of Genes and Environment, Division of Epidemiology
at the Norwegian Institute of Public Health, Oslo, Norway.

Address correspondence to Joanne Cacciatore, College of Human
Services, Arizona State University, 4701 West Thunderbird Road,
Glendale, Arizona 85308, USA.

The study received financial support from the Norwegian Society for
Unexpected Infant Death, Oslo, Norway.

Ó 2008, Copyright the Authors
Journal compilation Ó 2008, Wiley Periodicals, Inc.

Accepted June 5, 2008

314

BIRTH 35:4 December 2008

In response to criticism by some physicians, nurses,
and grieving mothers, many hospitals began to promote rituals through which mothers could see and
hold their stillborn babies, believing this process
would facilitate healthy maternal grief responses (3).
Staff stopped acting as if stillbirth was a nonevent,
and caregivers began to encourage mothers to meet
and say farewell to their babies (4,5). It was an important change in policy (6–8). DeFrain et al studied 350
families experiencing stillbirth, concluding that seeing
and remembering the stillborn baby ‘‘is essential to the
vast majority’’ (3). In a study of 314 women in a population-based setting, Rådestad et al found improved
long-term outcomes for mothers who have had contact with their stillborn babies compared with mothers
who did not have such contact (4).
However, more recently, this protocol has been called
into question. In a study of 53 mothers with a previous
pregnancy ending in a stillbirth, Hughes et al reported
a higher risk of disorganization in children of mothers
who had experiences of seeing and holding their stillborn baby compared with mothers who had no such
experiences (9). In another study, the same research
group examined 65 women during a subsequent pregnancy after a stillbirth and reported that behaviors that
promoted contact with the stillborn baby were associated with a worse outcome (10). These findings suggest
that, rather than facilitating healthy grieving, seeing
and holding the stillborn baby are correlated with
depression and anxiety in bereaved mothers.
The level of contact between a mother and her stillborn is not amenable to controlled trials and the existing evidence to guide care is scant. Until the studies by
Hughes et al were published, the development of care
protocols was driven by the consensus of observational studies. Whether the results of Hughes et al
truly represent a discrepancy from earlier studies,
are confounded by small numbers and lacking covariates, or only describe a transient effect in a subsequent pregnancy remains an important question for
future improvements of care.
The aim of this study was to determine the associations of seeing and holding the stillborn baby with
maternal anxiety and depression using the 25-item
Hopkins Symptom Check List (HSCL) to estimate the
main outcomes. We assessed factors affecting both the
mothers’ probability of seeing and holding their babies
and the risk for symptoms of anxiety and depression
during a subsequent pregnancy and in the long term.

or ‘‘fetal death.’’ Where possible, we included all inflections of the terms and we updated the past 3 months only
in pages in English. From the first 100 matches from
each search engine, 749 Web pages were identified,
which were examined to identify organizations and
Web sites offering free information on pregnancy and
childbirth (including stillbirth) or information, support,
or Web forums for families affected by stillbirth. We
excluded sites presenting only sporadic information as,
for example, online scientific journals, dictionaries or
databases, and sites for scientific, professional, or governmental use, such as the American College of Obstetricians and Gynecologists or U.S. National Center for
Health Statistics. The 104 sites or organizations were
invited to recruit women affected by stillbirth to respond
to a questionnaire through their Web sites, mailing lists,
newsletters, forums, or other means using ready-made
invitations. Thirty-seven organizations accepted.
The study Maternal Observations and Memories of
Stillbirth (MOMStudy) was established, and the Web
site http://www.momstudy.com, containing the questionnaire was open in the period from February 8,
2004, to September 15, 2005. We monitored entries
by a single Internet protocol address using The
WebalizerÓ, freeware from http://www.mrunix.net.
In all, 3,519 women reported a stillbirth. Among
them, 2,900 participants completed the entire questionnaire and confirmed their submission (completion rate
82.4%). These stillbirths included 2,769 singletons, 119
twins, and 12 triplets. We included the 2,292 women who
reported a singleton stillbirth after 20 weeks’ gestation
and certainty about whether or not they were currently
pregnant (n = 286). Participants were mainly recruited
from the United States (72%), United Kingdom (11%),
Australia (9%), and Canada (5%). Among the stillborns
were 52.2 percent boys and 47.8 percent girls.
The questionnaire was interactive to minimize the
number of nonapplicable questions to each participant.
The questionnaire explored various topics related to
stillbirths, including also indirect repeat questions to
confirm accuracy (e.g., asking the participant’s current
age and later asking her age when experiencing stillbirth
and years since it happened). Cases with inconsistencies
were reviewed for extreme values, but only one report
was excluded due to inconsistencies that could not be
explained by obvious unintended errors.
The study protocol was approved by the Regional
Ethics Committee for medical research of Southern
Norway.

Methods

Data Analysis

We searched 12 Internet search engines and directories
for the terms ‘‘stillbirth,’’ ‘‘pregnancy loss,’’ ‘‘fetal loss,’’

Anxiety- and depression-related symptoms were measured at the beginning of the questionnaire by the

315
Notes. The table presents 1) percentages of women having experienced different levels of contact with their stillborn or rituals for maternal bonding, 2) their recollection of the circumstances under which
decisions of such contact or rituals were made, and 3) their retrospective content with having, or not having, such contact or rituals at the time of stillbirth.

Wish I did

78.6
79.5
65.5
3.2
12.3
22.1
18.3
8.2
12.4
27.8
30.3
84.3
10.3
2.5
0.0
39.7
46.2
14.4
12.7
18.5
0.7
9.5
2.5
0.7
Mothers who did not . . .
See the baby
116 (5.1)
Hold the baby
226 (10.1)
Dress or wash the baby 1,784 (79.0)

It feels indifferent
that I did not
Glad
I did not
It was not
offered
I felt pressured
not to
It was
offered
It was
recommended
I felt
pressured to

0.2
0.2
0.2
0.1
0.3
1.5
99.7
99.5
98.3
3.4
2.2
2.7
66.4
73.5
72.7
12.3
10.8
18.5
17.3
12.8
5.9
0.6
0.7
0.2
Mothers who did . . .
See the baby
2,159 (94.9)
Hold the baby
2,035 (89.9)
Dress or wash the baby
473 (21.0)

Indifferent
Glad I did
No options
were offered
I absolutely
wanted to
I was
offered to
I was
recommended to
I felt
pressured to
No. (%)
Level of Contact

The great majority of the mothers saw (95%) and held
(90%) their stillborn babies and very few expressed
regret. However, almost 80 percent of those who did
not see and hold the baby regretted that they did not
do so (Table 1). The main reason for the lack of contact with the baby was maternal choice; but for dressing or washing the baby, 84.3 percent did not perceive
that as an option. Few women felt any pressure to
have contact or to avoid contact with their babies.
Among mothers who did not see their babies, 9.5 percent had felt pressured to do so; conversely, 10.3
percent had felt pressured not to do so.
Fewer mothers saw or held their babies if they were
born with congenital anomalies compared with mothers whose babies died of other causes (OR 0.37,
95%CI 0.20–0.69). Congenital malformations, gender, and living in the U.S. or other countries had no
effect on any of the analyses presented here and were
excluded as covariates. The characteristics of participants are presented in Table 2 and only two of these
factors differed significantly among those exposed to
their stillborn or not: mothers who saw and held their
stillborn experienced a third trimester loss more often
(81 vs 66%, p<0.001) and they also experienced their
loss 1.09 years later (p<0.001) than those who did not
(Table 3).
Among participants, 42 and 62 percent reported
symptoms of anxiety and depression, respectively.

Table 1. Level of Contact between the Mother and Her Stillborn Baby

Results

The Mother’s Retrospective View on the Circumstances under Which
Decisions Were Made about Contact with Her Stillborn (%)

The Mother’s Retrospective Feelings about
the Contact She Had (%)

25-item HSCL (11). We defined an average symptom
score for anxiety symptoms greater than 1.75 as anxiety and likewise for depression (11) and used these
scores as dichotomous dependent variables for logistic
regressions of the main outcomes presented in
Tables 3 and 4.
We used SPSS 14.0 for all statistical analyses (12).
Maternal characteristics are presented in Table 2, and
all potentially confounding factors (associated with
both the dependent and the independent variable)
with p<0.2 were introduced in multivariable stepwise
backward logistic regressions in all further analyses.
All covariates were entered in the regressions as continuous, dichotomous, or categorical data. Participant’s pregnancy status while responding, marital
status, and mode of recruitment had no confounding
effects. Pregnancy status was used for stratification
and marital status was excluded, whereas mode of
recruitment was introduced in subsequent analyses
despite the lack of confounding effect. No final
analysis of nonpregnant (n = 2,006) or pregnant (n =
286) women included more than 6 or 3 covariates,
respectively.

Wish
I did not

BIRTH 35:4 December 2008

(90.1)
(2.5)
(2.0)
(0.6)
(3.8)
(1.0)

2,081
58
47
14
87
22
233 (10.0)
519 (22.3)
1,577 (67.7)

(51.4)
(14.8)
(8.9)
(24.8)
(80.1)
(5.6)
(22.5)
(1.0)
(1.0)

1,196
344
208
577
1,865
28.7
525
0.66
0.63

1,853 (79.5)
2.0 (0.8)
286 (12.3)

No. (%) or Mean (SD)

p

(0.62–1.79)
(0.36–1.26)
(0.36–3.03)
(0.67–1.60)
(0.86–4.47)

(0.60–0.97)
(0.40–0.74)
(0.42–0.63)
(0.54–0.81)
(0.95–0.98)
(0.65–0.97)
(0.97–1.16)
(0.73–0.87)

0.98 (0.71–1.36)
1.57 (1.18–2.10)

1.06
0.68
1.05
1.03
2.02

0.76
0.55
0.51
0.66
0.96
0.79
1.06
0.80

<0.001
0.921
0.002

0.515
0.835
0.217
0.932
0.883
0.108

<0.001
0.028
<0.001
<0.001
<0.001
<0.001
0.022
0.173
<0.001

0.73 (0.59–0.89)
0.002
0.77 (0.69–0.86) <0.001
1.25 (0.97–1.60)
0.084

OR (95% CI)

0.061

0.024

p

0.94 (0.65–1.13)
1.31 (0.94–1.81)

Excluded
—
—
—
—
—
0.012
0.725
0.131

<0.001
0.86 (0.65–1.13)
0.263
0.56 (0.39–0.80)
0.002
0.53 (0.42–0.67) <0.001
0.73 (0.57–0.94)
0.013
0.96 (0.94–0.97) <0.001
Excluded
1.17 (1.07–1.29)
0.001
Excluded

0.77 (0.61–0.97)
Excluded
1.31 (0.99–1.73)

OR (95% CI)

Multivariable
p

0.355
0.995
0.205
0.828
0.583
0.061

<0.001
<0.001
<0.001
<0.001
<0.001
0.023
<0.001
0.103
<0.001

<0.001
1.03 (0.75–1.40)
0.869
2.01 (1.52–2.66) <0.001

1.00 (0.58–1.71)
0.69 (0.38–1.23)
1.13 (0.38–3.38)
1.13 (0.73–1.77)
2.82 (0.95–8.38)

0.53 (0.39–0.65)
0.36 (0.29–0.49)
0.31 (0.25–0.39)
0.53 (0.42–0.66)
0.98 (0.97–1.00)
0.66 (0.54–0.81)
1.08 (0.99–1.18)
0.67 (0.61–0.73)

0.92 (0.74–1.13)
0.405
0.77 (0.68–0.86) <0.001
0.63 (0.49–0.81) <0.001

OR (95% CI)

Univariate

p

1.05 (0.74–1.49)
1.55 (1.13–2.13)

Excluded
—
—
—
—
—
0.001
0.773
0.007

<0.001
0.61 (0.46–0.82)
0.001
0.38 (0.27–0.55) <0.001
0.37 (0.27–0.51) <0.001
0.68 (0.52–0.89)
0.005
Excluded
Excluded
1.11 (1.01–1.23)
0.030
0.89 (0.79–1.01)
0.066

Excluded
0.81 (0.71–0.92)
0.001
0.56 (0.42–0.75) <0.001

OR (95% CI)

Multivariable

Depression Symptoms

Notes. Odds ratios and 95% confidence interval from univariate and stepwise backward multivariable logistic regression analysis of maternal characteristics and the associations with Hopkins Symptom
Check List (mean > 1.75) symptoms of anxiety or depression.
*Education is based on four groups: 1 ( high school), 2 (college  4 yr), 3 (college  5 yr), and 4 (PhD).

Third trimester loss
Education*
Pregnant while responding
Time since loss (yr)
Reference =<1
 1 and<2
 2 and<3
3
Married
Maternal age
Having a live birth before loss
Number of births before loss
Number of pregnancies after loss
Primary ethnicity
Reference = white
Black
Asian
Pacific Islands
Hispanic
Native minority
Recruitment
Reference = coincidence
Contacted personally
Seeking information or support

Characteristic

Univariate

Anxiety Symptoms

Table 2. Maternal Characteristics and the Association with Symptoms of Anxiety and Depression

316
BIRTH 35:4 December 2008

317

BIRTH 35:4 December 2008

Table 3. Maternal Characteristics and the Association with Whether or Not the Mother Held Her Baby

Did Not Hold
Her Stillborn Held Her Stillborn
No. (%) or
No. (%) or
Mean (SD)
Mean (SD)

Characteristic
Third trimester loss
Education*
Pregnant while responding
Time since loss (yr)
Reference =<1
 1 and<2
 2 and<3
3
Married
Maternal age
Having a live birth before loss
Number of births before loss
Number of pregnancies after loss
Primary ethnicity
Reference = white
Black
Asian
Pacific Islands
Hispanic
Native minority
Recruitment
Reference = coincidence
Contacted personally
Seeking information
or support

Univariate

Multivariable

OR
(95% CI)

p

OR
(95% CI)

p

150 (66.4)
2.0 (0.8)
25 (11.1)

1,651 (81.1)
2.1 (0.8)
249 (12.2)

2.18 (1.62–2.93) <0.001 2.34 (1.73–3.16) <0.001
1.15 (0.96–1.39)
0.133 Excluded
1.12 (0.73–1.73)
0.608 Excluded

87 (49.7)
22 (12.6)
8 (4.6)
58 (33.1)
182 (80.5)
27.8 (5.8)
41 (18.1)
0.59 (1.0)
0.66 (1.1)

746
268
163
385
1,638
28.7
463
0.66
0.62

(47.8)
(17.2)
(10.4)
(24.6)
(80.6)
(5.5)
(22.8)
(1.0)
(1.0)

1.18
2.11
0.76
1.00
1.03
1.33
1.07
0.96

(0.77–1.81)
(1.09–4.10)
(0.55–1.04)
(0.71–1.42)
(1.01–1.06)
(0.93–1.89)
(0.92–1.25)
(0.85–1.10)

0.014
0.440
0.028
0.084
0.989
0.13
0.114
0.363
0.582

197 (87.9)
5 (2.2)
9 (4.0)
2 (0.9)
11 (4.9)
0 (0.0)

1,827
51
35
10
74
21

(90.5)
(2.5)
(1.7)
(0.5)
(3.7)
(1.0)

1.10
0.42
0.54
0.73

(0.43–2.79)
(0.20–0.89)
(0.12–2.47)
(0.38–1.39)
—

0.253 Excluded
0.841
—
0.023
—
0.427
—
0.725
—
—
—

42 (10.6)
44 (19.5)
158 (69.9)

205 (10.1)
459 (22.6)
1,368 (67.3)

1.22 (0.72–2.06)
1.01 (0.64–1.60)

0.564 Excluded
0.455
0.953

1.17 (0.76–1.79)
2.24 (1.15–4.37)
0.70 (0.51–0.96)
Excluded
Excluded
Excluded
Excluded
Excluded

0.003
0.486
0.018
0.029

Notes. Odds ratios and 95% confidence interval from univariate and stepwise backward multivariable logistic regression analysis of the associations of
maternal characteristics with whether she held her stillborn or not.
*Education is based on four groups: 1 ( high school), 2 (college  4 yr), 3 (college  5 yr), and 4 (PhD).

Table 4. Maternal Symptoms and the Association with the Conditions under Which the Mother Decided to See Her Stillborn
Child

Anxiety Symptoms
Contact with
Baby or Not
Did not see her
stillborn (n = 116)

Saw her stillborn
(n = 2,129)

Conditions under Which Mother
Had Contact with Baby
Conditions (reference = own wish)
Felt pressured to see the stillborn
Was not given any option
Was offered to see the
stillborn as an option
Was recommended to
see the stillborn
Conditions (reference = own wish)
Felt pressured to see the stillborn
Was not given any option
Was offered to see the
stillborn as an option
Was recommended to
see the stillborn

Depression Symptoms

%

OR (95% CI)

p

OR (95% CI)

p

10.3
9.5
27.8
39.7

2.05 (0.29–14.6)
4.93 (0.89–27.4.)
2.17 (0.42–11.3)

0.215
0.476
0.068
0.358

0.80 (0.10–6.64)
0.62 (0.11–3.53)
0.75 (0.14–4.16)

0.786
0.832
0.588
0.745

12.7

5.69 (0.80–40.3)

0.082

1.99 (0.24–16.8)

0.526

66.4
0.6
3.4
12.3

2.22 (0.74–6.69)
0.97 (0.58–1.62)
1.04 (0.78–1.39)

0.684
0.156
0.909
0.790

2.29 (0.67–7.84)
0.58 (0.35–0.96)
1.40 (1.03–1.91)

0.019
0.187
0.035
0.033

17.3

0.96 (0.74–1.24)

0.733

0.97 (0.75–1.25)

0.783

Notes. Adjusted odds ratios and 95% confidence interval from multivariable logistic regression analysis of the associations of maternal symptoms with
the conditions under which women made the decision to see or not see their stillborn after delivery.

318
Maternal age and the amount of time since the stillbirth were associated with fewer symptoms of anxiety;
that is, younger mothers and mothers with a recent
loss had more anxiety symptoms. In addition, third
trimester losses (vs second trimester losses), being
married (vs unmarried or divorced/widowed), low
parity at the time of loss (vs higher parity), and having
experienced births after their loss (vs not having experienced births) were associated with fewer symptoms
of anxiety (Table 2). Likewise, maternal education
level and time since stillbirth were associated with
fewer symptoms of depression (i.e., mothers with little
education and a recent loss had more depression symptoms). In addition, previous live births (vs none),
being married (vs single), low parity at the time of loss
(vs higher parity), and having experienced births after
their loss (vs not having experienced births) were associated with lower levels of depressive symptoms.
Women recruited to the study while actively seeking
support or information had more recent stillbirths and
thus more symptoms than women not actively seeking
support. Being pregnant after a loss was associated
with fewer depressive symptoms and a tendency
toward higher anxiety symptomatology compared with
not being pregnant at the time of the study (Table 2).
Maternal characteristics were not associated with
whether a woman held her stillborn baby or not, but
those who experienced third trimester stillbirths more
often held their baby, and the frequency in holding
differed with the number of years since the stillbirth
occurred (Table 3). Among women who were not
pregnant when responding to the questionnaire, seeing the baby was associated with lower levels of anxiety and depression (table with data available from
authors on request). Compared with the significant
step of seeing the baby, each successive degree of contact did not add significantly to the effect. For pregnant women, the effects were reversed with increased
risk of anxiety if they had held the stillborn baby and
a tendency toward depression.
Among mothers who did not see their stillborn
babies, those who never were given the opportunity
and those who actively resisted tended to have more
anxious symptoms than mothers who simply reported
that they did not wish to see the baby (Table 4).
Among mothers who saw their stillborn babies, those
who reported that they were given no other options or
that it was not a subject that was discussed with them
had fewer symptoms of depression than mothers who
reported to have seen the baby because of their own
wish to do so. Conversely, mothers who perceived that
health care practitioners placed the responsibility of
decision making on them by offering them the option
to see and hold their baby when they had no strong
wishes of their own tended to have more symptoms of

BIRTH 35:4 December 2008

depression than those who spontaneously wished to
see their baby. In terms of the woman’s retrospective
regret over seeing or not seeing her baby, the conditions under which she saw or held her baby had no
impact on regret if the mother actually had the contact
described. However, those who did not have the contact had more regrets if not offered this as an option,
in particular dressing or washing the baby (p<0.001),
compared with women who did have such contact.

Discussion
Ninety-five percent of all mothers in this study saw
and 90 percent held their stillborn baby and nearly all
appreciated the moments they had with their babies.
Seeing and holding their baby were associated with
fewer symptoms of anxiety and depression than not
seeing and holding their baby. Most mothers who did
not see and hold their babies regret lost opportunities
of contact.
Our main findings of a beneficial, long-term effect
for mothers having had contact with their stillborn
babies support findings from previous studies (8,13).
Missed opportunities for contact with the baby were
associated with retrospective regret in this study. The
caregivers’ demeanor at the time of stillbirth was associated with long-term outcomes. Mothers had fewer
depressive symptoms if they perceived that seeing the
baby was not simply an option they could choose
compared with mothers who spontaneously wished
to see their baby. Thus, messages conveyed by the
staff through both verbal and nonverbal communication may influence and shape the mother’s perceptions of expected, normal responses. If caregivers
convey the attitude that seeing and holding the baby
are equally as normal after a stillbirth as after a live
birth, mothers respond positively. Conversely, the
attitude that seeing a stillborn baby is an option the
mother must choose, implying that this behavior is
not necessarily normal or acceptable, may strengthen
the sense of abnormality in the situation.
Among mothers currently pregnant at the time of
investigation, the findings in this study were reversed,
confirming previous reports that seeing and holding
the stillborn baby are associated with more hardships
during future pregnancies (10). Yet, the long-term
results among those who were not pregnant at the
time of the study, compared with those who were
pregnant at the time or who had not had a subsequent
birth after a loss and the fact that having experienced
births after a loss was associated with lower levels of
both anxiety and depression, suggest that these negative effects are transient. Rather than discouraging
contact with the stillborn baby, additional support

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should be offered during subsequent pregnancies
after a loss.
Hospital bereavement teams often manage perinatal death programs that support contact with a dead
or dying newborn (1,5). Lasker and Toedter found
that ‘‘parents who experience interventions such as
having a photograph or keepsake were significantly
more satisfied’’ than those having not participated in
such ritualistic acts (1, p 41). In an observational
study, long-term anxiety was lower among women
having tokens of remembrance from their baby than
among women not having them (8). Rituals, such as
holding, caressing, and caring for the dead body of
a loved one, have been used universally by humans
throughout history and across cultures as a way of
realizing and coping with loss (14,15) and they have
been described as the antidote to powerlessness (16).
Rituals transform and mediate grief, facilitating a
symbolic connection to the deceased (17). This type
of contact begets memories that stillbirth families would
not otherwise have an opportunity to create (18).
This study has the advantage of a very large number
of participants needed to enable the inclusion of significant confounders in the analyses. However, despite a broad-based approach for recruitment, bias
may have been introduced not only by depending on
informed consent from participants but also by a
skewed recruitment of participants in comparison
with a total population. Participants represent younger
and higher socioeconomic groups (Internet access),
and the adjustments for age and educational level in
our analyses will not fully correct this fact. A large
proportion of women were recruited while actively
searching for support or information about stillbirths
on the Internet. As seen in our results, these women
had more symptoms than those who were actively contacted by participating organizations. However, no
associations were found between the mode of recruitment and the prevalence of seeing and holding the child
(Table 3). Despite not being a probable confounder,
the mode of recruitment was included as a categorical
covariate in all multivariable analyses.
Participants’ self-selection into the study may have
been correlated with character traits that may influence
the woman’s psychological response to having a stillborn baby. Methodologically, the selection effect from
self-selected participants may compromise the generalizability of the outcomes. In addition, a portion of the
study focuses on the perceptual experiences of women
while interacting with caregivers. The potential for
recall bias may arise in the rating of the experiences
with caregivers, particularly for women who may have
acute depressive disorders that predated the stillbirth;
the potential also exists that caregivers identified the
less anxious mothers, and thus, they may have been

more likely to include them in decision making around
holding and seeing the baby who died.
The use of parental support groups for recruitment
may introduce bias by recruiting stillbirth parents
with fixed views. As the findings of negative effects
of seeing and holding the child caused outrage and
disbelief in much of the stillbirth parent community,
any possible bias would tend to overestimate our findings of positive effects of contact and of regret for
missed opportunities. However, the MOMStudy
addressed many aspects of stillbirth, and no mention
of the fact that these questions would be addressed
was included in any recruitment material for the
study. Rather, the recruitment materials focused on
gaining knowledge for the prevention of stillbirths.
In addition to no effect of mode of recruitment on
level of contact, participants recruited through parental groups had symptoms identical to those who found
the study ‘‘by coincidence’’ (Table 2). The fact that
this study confirms previous reports of negative
effects of contact during subsequent pregnancies contradicts the existence of such bias of significance.

Conclusions
The psychosocial effects of stillbirth are long lasting
and traumatic, leaving those in its wake more vulnerable to anxiety and depression (3,19–21). Women in
this study overwhelmingly wanted to see and hold
their babies and very few expressed regret in doing
so. Seeing and holding a stillborn baby are associated
with fewer anxiety and depressive symptoms among
mothers of stillborn babies than not doing so,
although this beneficial effect may be temporarily reversed during a subsequent pregnancy. Thus, mothers
should be offered additional support during a subsequent pregnancy rather than discouraged from seeing
and holding their stillborn baby. Since caregiver interaction may influence a grieving mother’s responses
during the acute crisis, active management that
includes responsiveness, support, and a staff willing
to facilitate contact with a stillborn baby is necessary
and may provide long-term benefits to the mother.

Acknowledgments
We thank MISS Foundation, the National Stillbirth
Society, all other recruiting organizations, and all participating mothers for their efforts in this study. We
gratefully acknowledge Moni Ryczek, Jon Martin Solaas, and Mary Geitz and Gary McSpadden for coordinating recruitment, development of the interactive
questionnaire, and hosting the Web site, respectively.

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