Commentary

DOI: 10.1111/1471-0528.13009
www.bjog.org

Meeting the needs of parents after a stillbirth or
neonatal death
V Flenady,a,g F Boyle,b,g L Koopmans,c T Wilson,d W Stones,e J Cacciatoref,g
a
Translating Research into Practice Centre, Mater Research Institute, Mater Health Services, University of Queensland, b School of Population
Health, The University of Queensland, Herston, Brisbane, c Child Protection, Mater Health Services, d Bereavement Support Programme,
Mater Mother’s Hospitals, South Brisbane, Qld, Australia e Ann Gloag Chair of Global Health Implementation, University of St Andrews, Fife,
UK and College of Medicine, Blantyre, Malawi f School of Social Work, Arizona State University, Phoenix, AZ, USA g International Stillbirth
Alliance, Bristol, UK
Correspondence: V Flenady, Translating Research Into Practice Centre, Mater Research Institute, University of Queensland, Level 2, Aubigny
Place, Mater Health Services, Raymond Terrace, South Brisbane, Qld 4101, Australia. Email vflenady@mmri.mater.org.au

Accepted 18 June 2014.
Please cite this paper as: Flenady V, Boyle F, Koopmans L, Wilson T, Stones W, Cacciatore J. Meeting the needs of parents after a stillbirth or neonatal
death. BJOG 2014; 121 (Suppl. 4): 137–140

Impact of stillbirth and neonatal
death on mothers, fathers and
families
The death of a child around the time of birth is highly
contradictory to the ‘natural order’ of life, and has profound effects on parents and families. Shock, anger, emptiness, helplessness and loneliness are common responses for
mothers and fathers. Even in high-income settings, where
support services are more likely to be available, approximately one in five parents whose baby dies at or soon after
birth will display intense and enduring grief following the
loss.1–3 Maternal distress from the loss of a baby can exert
intergenerational consequences, affecting the family constellation for surviving children as well as carrying over into a
subsequent pregnancy.2 Families suffer disruption to family
relationships and substantial economic burden.2 In the
USA perinatal and child death is conservatively estimated
to cost about $1.5 billion per year with the global costs
likely to far exceed this figure.4
Around the world four million babies die each year, and
an additional three million babies die as late pregnancy
stillbirths (after 28 weeks). These numbers almost double
when using the definitions of stillbirth and neonatal deaths
of high-income countries (i.e. from 20 weeks of gestation).5
The vast majority of these deaths occur in low- and
middle-income countries with around half occurring in
labour.6 The reality behind these data is grim: every hour
of every day more than one thousand families experience
the loss of a child around the time of birth. As many of

ª 2014 Royal College of Obstetricians and Gynaecologists

the deaths are not counted in mortality data, even these
numbers are an underestimate of actual rates. Underreporting is linked to negative attitudes about the value of these
lost lives and reflects the lack of support mothers and
fathers receive during this time of significant tragedy.7

Attitudes and perceptions—holding
back progress
In regions of the world where most deaths occur, maternal
grief may be compounded by social stigma, blame and marginalisation.7 Practices of isolating women and their newborns and a perception that the newborn is not a person8
contribute to suboptimal care for parents when a baby dies.
Under the most extreme conditions, where a family cannot
meet basic needs for food and shelter, the time and
resources to grieve are unlikely to be available. Moreover,
the close linkages between poverty, education of women and
disempowerment mean that women who have lost a baby
are especially vulnerable. Stigma associated with a baby’s
death is prevalent across the economic spectrum and contributes to social isolation and feelings of shame to further
undermine the support available to grieving mothers.7
A survey of 2490 healthcare professionals across 135
countries showed that in low- and middle-income settings,
disposal of the baby’s body frequently occurs without any
recognition or ritual, such as naming, funeral rites, or the
baby being held or dressed by the mother.7 Similarly, the
survey showed beliefs in the mother’s ‘sins’ and evil spirits
as causes of stillbirth are rife, and that stillbirth is

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commonly believed to be the natural selection of babies
never meant to live.7 Of the 1070 mothers responding to the
survey from across 32 countries (largely high-income), one
in two reported that grieving is not accepted in public, and
that undivided support for her loss was not provided. In
many settings, reproduction is central to women’s perceived
purpose in society. In this survey, one in five women
responded that women experiencing the loss of a baby to
stillbirth are marginalised as a failure, both as a mother and
as a spouse, and considered impure or taboo. Further, four
of five women live in communities that expect women to
forget their loss and to have another baby.7 To avoid stigmatisation and shame, women may hide their babies’ deaths
completely. However, women need and want recognition
for their babies. A recent study in Ethiopia reported that
despite contrasting community views, women believe stillbirth and neonatal death should be made visible and that
highlighting the magnitude of the problem will ensure
appropriate allocation of resources to reduce these deaths.8
In the global survey mentioned above,7 parents in highincome countries consistently reported that their baby was
perceived as a taboo object and unequal in human value to
an older child who died.7 These findings contrast with
health professionals’ positive views of care provided. Yet,
high-income countries are not homogeneous in their views
as this survey showed; while 18 of 30 (64%) of Norwegian
parents report that a stillborn baby is often or always perceived equally as a deceased child and 22 (78%) report that
mothers receive undivided support, only 42 (12%) and 64
(18%) respectively, of the 390 responses from Italian parents
perceive this recognition and support.7

The needs of parents when their baby
dies
High levels of distress are part of the normal grieving process following a baby’s death and although some parents
develop mental health problems, most do not.2 What helps
to protect and sustain parents and families in the aftermath
of such an unambiguously tragic loss? High-quality evidence on specific support interventions following stillbirth
or neonatal death is lacking9 and different interventions
will be required for different settings and cultural groups,
but essential ingredients of quality care include a deep
respect for the individuality and diversity of parents’ grief
and respect for the deceased child.

Social support
Support from doctors, nurses and particularly family is
associated with lower levels of anxiety and depression in
mothers following a stillbirth.10 Support from partners,
family and wider social networks may reduce maternal

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distress in the long-term. The role of support groups after
perinatal loss is unclear although benefits, particularly for
women, are reported.10

Being a parent and creating memories
In high-income country settings, parenting and caring for
the dead baby have been reported to produce positive
memories and to aid the grieving process by creating a
bond and sense of identity of the child.9 For women in
low- and middle-income countries, such opportunities are
frequently not provided nor an accepted part of care.7
While both harm and benefits have been associated with
seeing and holding a stillborn baby, best practice guidelines
recommend that all parents should be offered a choice and
be supported in their decision making.11,12 Studies suggest
that bereaved parents value and benefit from contact with
their stillborn baby particularly when this occurs in a supportive environment.3 Clinical guidelines support memory-making activities such as bathing and dressing the
baby, talking to the baby and using the baby’s name,
engaging in religious or naming ceremonies, introducing
the baby to extended family, and capturing interactions in
photographs and movies.12 General consensus is that
bereaved parents should be offered items of memorabilia
such as photos, hand/footprints and special clothing or
blankets when a baby dies.12 Having such items has been
found to reduce negative outcomes for parents.2

Counselling and other therapeutic
interventions
Interventions including bereavement counselling, specialised psychotherapy and informal community-based support are suggested to improve outcomes for parents
following perinatal loss but evidence is sparse.8 High-risk
groups such as parents who have previously lost children,
women undergoing termination of pregnancy for fetal
anomalies and parents with grief complicated by other
adverse life events or circumstances may benefit from mental health interventions.13 Prescribing sedatives for women
is common in some settings,14 despite the limited evidence
for benefit. Pharmacological management of grief should
only be considered in the presence of an established psychological disorder for which medication is indicated after
careful assessment by a well-trained mental health expert.10
Web-based mental health services, including informative
websites, online self-help groups, virtual counselling services and automated therapy programmes, have emerged
recently and may be useful support options for some parents. Although online support groups and memorial
websites have become very popular, their value has not
been systematically evaluated.

ª 2014 Royal College of Obstetricians and Gynaecologists

The needs of parents after a stillbirth or neonatal death

Maternity healthcare professionals
play an important role
The actions of healthcare professionals matter for parents’
immediate and longer-term wellbeing. Optimal care
requires awareness of current evidence regarding perinatal
loss, the impact of losing a baby, and the diversity of parents’ experiences. A patient-centred approach that responds
to the sociocultural context and unique needs of each
bereaved parent2 is the foundation of sensitive communication, information provision and supported decision making, all of which are vital elements of perinatal
bereavement care. A recent study in Ireland highlighted the
gap in training and support and the significant impact of
stillbirth on obstetricians, professionally and personally.15
Perinatal bereavement care requires organisational
responses including staff development to address training
gaps and debriefing and clinical supervision to prevent
burnout of staff in highly emotionally demanding roles.

Information for decision making
Parents whose baby has died face many difficult decisions
in the context of overwhelming grief and frequently have
a diminished capacity to absorb and retain information.
Maternity staff who are calm and supportive and who
provide objective information while balancing guidance
with parental autonomy, can assist parents to make
informed decisions while minimising regret. Staff should
ensure that their own values and opinions do not influence grieving parents. Encouraging parents’ autonomy in
decision making can be beneficial in grief in the long
term. Critical information should be repeated, and verbal
information should be reinforced with parent-centred
printed materials.
An autopsy examination remains the standard investigation for stillbirth but in countries where this is available,
the decision can be difficult.16 Emotional, practical and
psychosocial barriers to autopsy consent exist for staff and
parents. To avoid further burden on parents and due to
their own discomfort, healthcare professionals may not
broach the topic well, if at all. However, parents who
decline postmortem examination more often regret this
decision compared with those who accept.16 Education for
healthcare professionals is needed to ensure competency for
the provision of accurate and sensitive counselling about
autopsy.

Birthing options
In low- and middle-income countries, a high proportion of
stillbirths occur intrapartum and may be associated with
serious complications such as prolonged obstructed labour,

ª 2014 Royal College of Obstetricians and Gynaecologists

uterine rupture or hypertensive disease. The need to resolve
the precipitating obstetric complication may determine the
mode of delivery. In well-resourced settings, where fetal
demise is diagnosed, women require information about
how the birth can be achieved and the implications for
safety, for recovery and for future pregnancy. A natural
parental response is sometimes to request immediate operative delivery and a recommendation to proceed with
labour and vaginal delivery may be construed as insensitive.
However, with due attention to individualised advice and
effective arrangements for pain relief during labour, concerns and distress about ‘labouring with a dead baby’ can
be resolved.

Key recommendations for
maternity-care providers
1 Respect: Quality bereavement care demands deep respect
for the individuality and diversity of parents’ grief. Recognition and valuing of the deceased baby is critical.
2 Information: Maternity staff should provide objective
information in a calm, supportive manner, while balancing guidance with parental autonomy. Critical information should be repeated and reinforced with
parent-centred printed materials.
3 Creating memories: Activities such as holding, bathing
and dressing the baby, talking to the baby and using the
baby’s name, engaging in religious or naming ceremonies, introducing the baby to extended family, and capturing interactions in photographs and movies should be
supported. Parents should be offered items of memorabilia such as photos, hand/footprints and special clothing
or blankets when a baby dies.
4 Professional development and support: All maternity-care
providers need to receive training to ensure that they are
equipped to provide appropriate care following a perinatal death. Staff confronted with such losses need ready
access to debriefing and support.

Summary
The death of a child around the time of birth is one of the
most profoundly distressing events any parent will experience. These deaths are not uncommon, but are often hidden, along with the grief of mothers, fathers and families.
Social stigma and negative attitudes are inextricably linked
to underreporting of babies’ deaths in low- and
middle-income countries. A failure to recognise the value
of these lost lives leads to disenfranchised grief and diminished preventive efforts to reduce stillbirth and neonatal
deaths. Acknowledging these deaths to bring them ‘out of
the shadows’17 and compassionate, respectful care for parents suffering perinatal loss, irrespective of country or

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resources, are critical to addressing the totality of the burden of this public health problem.

Disclosure of interests
None to disclose.

Contribution to authorship
VF planned and wrote the manuscript with feedback from
all authors: FB, LK, TW, WS and JC. All authors approved
the final version of the manuscript.

Details of ethics approval
Not required.

Funding
No funding was received for this study.

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ª 2014 Royal College of Obstetricians and Gynaecologists