Midwifery ] (]]]]) ]]]–]]]

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Midwifery
journal homepage: www.elsevier.com/midw

Seeing and holding a stillborn baby: Mothers’ feelings in relation to how their
babies were presented to them after birth—Findings from an
online questionnaire
Kerstin Erlandsson, RN, RM, PhD (Senior Lecturer)a,n, Jane Warland, RN, RM, PhD (Senior Lecturer)b,
Joanne Cacciatore, PhD (Social Worker, Professor)c, Ingela Rådestad, RN, RM, PhD (Professor)d
a

School of Health, Care and Social Welfare, Mälardalen University, Eskilstuna/Västerås, Box 883, S-721 23 Västerås, Sweden
School of Nursing and Midwifery, University of South Australia, Adelaide, Australia
School of Social Work, Arizona State University, AZ, USA
d
Sophiahemmet University College, Stockholm, Sweden
b
c

a r t i c l e i n f o

abstract

Article history:
Received 29 September 2011
Received in revised form
28 December 2011
Accepted 7 January 2012

Objective: to determine if the way caregivers offer opportunities to see and hold a stillborn baby
impacts a mother’s feelings about the experience of seeing and holding her newborn.
Design and setting: a web questionnaire hosted by the Swedish National Infant Foundation from March
2008 to April 2010.
Participants: 840 eligible participants who had experienced a stillbirth after the 22nd gestational week
from 1955 to 2010 and completed an online questionnaire about their experiences.
Methods: descriptive and inferential statistics.
Findings: when mothers were presented the baby as a normal part of birth without being asked if they
wanted to see, they more often reported that the experience was comfortable compared to mothers
who were asked if they wanted to see the baby 86% vs. 76% (p ¼ o 0.01). The incitation of fear in
mothers was 70% vs. 80% (p ¼0.02) in favour of mothers who were not asked. Furthermore the mothers
who were not asked more often stated that it felt natural and good when compared to those who said
staff asked if the mother wanted to see, 73% vs. 61% (p¼ 0.07) and (78%) vs. (69%) p ¼0.19, respectively.
A trend was seen toward more mothers feeling natural, good, comfortable, and less frightened if the
provider engaged in ‘assumptive bonding’, that is the baby is simply and naturally presented to the
mother without asking her to choose.
Key conclusions: mothers of stillborn babies felt more natural, good, comfortable and less frightened if
the staff supported assumptive bonding by simply offering the baby to the mother.
Implications for practice: care providers should approach caring for grieving mothers with tenderness
and humility, assuming that they will wish to see and hold their stillborn baby.
& 2012 Elsevier Ltd. All rights reserved.

Keywords:
Stillbirth
Birth
Midwifery roles
Women’s health issues

Introduction
The birth of a stillborn baby is one of the most evocative of all
human experiences despite the fact that the understanding of
people’s perception of death and bereavement is related to
different cultural influences (Spector, 2002). Health-care provider
attitudes and behaviours, as well as the atmosphere surrounding
the stillborn baby’s birth, may influence the nature of parents’
contact with their baby. In Sweden as in many other countries
during the mid-twentieth century, when both birth and death
n

Corresponding author.
E-mail addresses: kerstin.erlandsson@mdh.se (K. Erlandsson),
jane.warland@unisa.edu.au (J. Warland),
joanne.cacciatore@asu.edu (J. Cacciatore), ingela.radestad@shh.se (I. Rådestad).

were institutionalised, health-care professionals took over both
the management and rituals of stillbirth (Cacciatore and Flint,
2011). Parents were not usually offered the opportunity to see
their stillborn baby because the staff believed that this routine
would minimise psychological trauma (Lasker and Toedter, 1994).
In the late 1970s, and the early 1980s this practice shifted as a
result of both professionals in the field and an outcry from
bereaved parents. Standards-of-care and best practice guidelines
promoted parents having contact with their babies in order to
meet and say farewell to their baby (Lewis, 1979) and stillborn
babies were treated as live-born babies concerning respect and
tenderness (Rådestad et al., 1996).
Studies exploring contact with stillborn babies demonstrate
positive outcomes in both mothers perception of the experience
and in measurable outcomes such as maternal depression and

0266-6138/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2012.01.007

Please cite this article as: Erlandsson, K., et al., Seeing and holding a stillborn baby: Mothers’ feelings in relation to how their babies
were presented to them after birth—Findings from an online questionnaire. Midwifery (2012), doi:10.1016/j.midw.2012.01.007

2

K. Erlandsson et al. / Midwifery ] (]]]]) ]]]–]]]

anxiety (Rådestad et al., 2009). In 2008, Cacciatore and Rådestad
et al. found that mothers did, indeed, benefit from contact with
stillborn babies and, in fact, the mothers who fared worse in
psychological outcomes were the mothers who were offered the
baby to see and hold yet they declined to do so at the time. Yet, in
one small study published in 2002, the authors proposed that
women who had contact with their baby following stillbirth were
at increased risk of a range of negative psychological sequelae
such as depression and anxiety (Hughes et al., 2002). The
recommendation arising from this study was that if bereaved
parents were reluctant to see and hold their newborn following
stillbirth, they should not be encouraged to do so. This recommendation sparked significant controversy at the time of publication (Hughes et al., 2002), a controversy which still endures
(Cacciatore et al., 2008). Part of this dispute centres on the
counterintuitive nature of Hughes’ recommendation: if seeing
and holding a live born baby is a normal maternal response, it is
illogical to assume that a mother would not also wish to see and
hold her baby after stillbirth. Furthermore, Hughes’ study failed to
fully explore the context under which contact with the stillborn
baby occurred or how the mother came to decide whether or not
she would have contact with her baby. Exploring these unaddressed questions may provide meaningful data about how
mothers respond to seeing and holding their baby, enhancing
provider understanding about how best to offer parental contact
with the baby. The National Institute for Health and Clinical
Excellence (NICE) provides evidence-based guidance for clinical
practice. They recommend that parents should be offered
informed choice as to whether or not they see and hold their
stillborn baby rather than being encouraged to do so (NICE, 2010).
However, in a recent study evaluating care after stillbirth,
mothers were thankful for being encouraged to see, hold and be
with their stillborn baby (Rådestad et al., 2011). In light of these
conflicting findings in this area of practice, this piece of research
sought to determine if the way in which providers offer opportunities to see and hold a stillborn baby affects a mother’s feelings
about the process.

Methods
The web questionnaire for this study was conducted from 27
March 2008 to 1 April 2010 on the homepage of the Swedish
National Infant Foundation. The foundation supports parents after
perinatal loss and is a member organisation of the International
Stillbirth Alliance (ISA). The participants were self-recruited after
being informed about the study through newspapers, social
media venues, and newsletters within the organisation. Informed
consent was completed online by participants prior to the start of
the survey. The study was approved by the Regional Ethics
Committee, Lund, Dnr 467/2006. The inclusion criteria for this
study was women who had experienced a stillbirth after the 22nd
week of gestation; define as an intrauterine death in Sweden
(Socialstyrelsen, 2008), and who were willing to answer questions
about their feelings when seeing and holding their stillborn baby.
The web questionnaire consisted of 94 items took about 30 mins
to answer and were developed on the basis of theoretical knowledge and clinical experience of meeting parents after the loss of a
baby. The questionnaire was tested; face-to-face validity by 15
mothers to stillborn babies. Except the two initial questions about
seeing and holding it also included a range of questions about
memories and rituals, items not covered in this current paper.
Demographic information such as maternal age and gestation age
was collected.
Participants who selected that they had seen (n¼668) and/or
held (n ¼547) their baby soon after birth with the alternatives

‘Yes’ or ‘No’ (whether vaginal or operative) where given some
multiple choice alternatives to the question: ‘How was the baby
presented to you?’; Options were as follows’: Staff showed/gave
my baby to me without asking’; ‘Staff asked if I wanted to see/
hold my baby’; ‘I asked if I could see/hold my baby’ or ‘Staff
pressured me to see/hold my baby’. The question about holding
the baby also included a fifth alternative—‘I took the baby in my
arms by myself’. Participants were also asked how they felt when
they saw and held their baby with the following choices: ‘natural’,
‘good’, ‘uncomfortable’ or ‘frightened’ and asked to rank their
feelings on four point Likert scales (ranging from not at all to
very much).

Data analysis
Information gained from questionnaires was entered into
SPSSs (SPSS statistical package social sciences version 17,
2007). Demographic data were analysed using the Mann–
Whitney U-test for ordinal data sets (such as age) and paired
t-test for categorical data sets (such as marital and employment
status) to determine any statistical difference between seeing and
holding groups, simple descriptive statistics such as numbers (n),
medians (Md), as well as inferential statistics such as relative risk
(RR), 95% confidence interval (CI) and percentages (%) were used.

Findings
In total, 1,034 women answered the web questionnaire including women who gave birth prior to the 22nd week of gestation,
however, only women giving birth after the 22nd gestational
week were included in the study (n ¼840). Demographic data on
women and their babies are indicated in Table 1.
Table 2 shows mother’s feelings when seeing their stillborn
baby in relation to how the baby was presented to them. Of the
840 mothers who responded to the survey, 692 stated that they
saw their baby. Of these, 668 answered the questions about how
the baby was presented and how they felt when seeing the baby.
It was most common that the providers asked if the mother wanted
to see, 366 (54%), followed by providers offered the baby without
asking 217/668 (32%). Mothers’ self-request was less common
82/668 (12%) with only three women who reported feeling
pressured by the staff to see the baby (0.4%). The group who
most commonly reported they were not at all frightened was the
group assumptively offered the baby (p ¼0.02). This same group
also reported that seeing the baby was not at all uncomfortable compared to the group who were asked if they wanted to
see the baby 86% vs. 76% (p ¼ o0.01). While not statistically
significant, when providers offered the baby without asking,
mothers more often reported that it felt very natural compared
to those who were asked, 73% vs. 61% (p¼0.07). This trend was
also noticed for mothers who stated it felt very good (78%) when
offered the baby compared to the group who were asked if they
wanted to see their baby (69%) p ¼0.19. Only three/668 (0.4%)
mothers stated that providers pressured them to see their baby,
and as a result of these small numbers these data were not
included in the analysis.
Table 3 shows women’s feelings when holding their stillborn
baby in relation to how the baby was presented to them. There
were 578 mothers who indicated that they held their baby, and
547 answered the question about how they felt during the
experience. Once again the most commonly chosen option was
that providers asked if the mother if she wanted to hold, 279/547
(51%), followed by providers assumptively offering the baby to the
mother without asking 141/547 (26%), mothers’ self-request was

Please cite this article as: Erlandsson, K., et al., Seeing and holding a stillborn baby: Mothers’ feelings in relation to how their babies
were presented to them after birth—Findings from an online questionnaire. Midwifery (2012), doi:10.1016/j.midw.2012.01.007

K. Erlandsson et al. / Midwifery ] (]]]]) ]]]–]]]

Table 1
Demographic factors among 840 mothers* with stillbirth and their babies.
n

%

Year of birth
o1990y
1990–1999
2000–2010
Not stated

119
106
574
41

14.1
12.6
68.3
4.9

Parity
First pregnancy
Second pregnancy
Third pregnancy
Fourth pregnancy or more

476
216
104
44

56.7
25.7
12.4
5.2

The labour started
Spontaneously
Induction
Caesarean section

274
524
42

32.6
62.4
5.0

Sex of the child
Girl
Boy

404
436

48.1
51.9

Baby’s weight
500 GM or less
500 but less than 2000 GM
2000 GM or more
Not stated

31
202
549
58

3.7
24.0
65.4
6.9

Baby’s week of gestation
22–28
29–37
38 or more

115
309
416

14.8
6.8
49.5

n
The mothers were 16–44 years at the time of the stillbirth (mean 30.4, SD
5.1, median 30).
y
Range: 1955–1989.

Table 2
Women’s feelings when seeing their stillborn baby in relation to how the baby
was presented to them.
Staff showed Staff asked if I asked if I
could see
I wanted to
my baby to
me without see my baby my baby
asking

Staff
pressured
me to see
my baby

n¼ 217

%

n ¼ 366

%

n ¼82

%

n¼3

%

Natural
A lot
Quite a bit
Somewhat
Not at all

159
23
18
17

73
11
8
8

224
77
34
31

61
21
9
8

57
12
4
9

70
15
5
11

1
0
0
2

33
0
0
67

Good
A lot of
Quite a bit
Somewhat
Not at all

170
21
8
18

78
10
4
8

254
63
19
30

69
17
5
8

61
9
4
8

74
11
5
10

1
0
0
2

33
0
0
67

Uncomfortable
Not at all
Somewhat
Quite a bit
A lot of

187
18
8
4

86
8
4
2

277
55
23
11

76
15
6
3

66
8
3
5

80
10
4
6

1
1
0
1

33
33
0
33

Frightening
Not at all
Somewhat
Quite a bit
A lot

173
28
8
8

80
13
4
4

258
63
30
15

70
17
8
4

64
10
4
4

78
12
5
5

1
0
0
2

33
0
0
67

Total

n ¼668

82/547 (15%), mothers who took the baby in her arms by herself 60/
547 (11%) and 2/547 (0.4%) mothers reported feeling pressured by
providers to hold the baby. There were no statistically significant
figures; however, there was a trend toward mothers feeling

3

natural, good, less frightened, and less uncomforted when providers offered the baby to the mother without asking.
Table 4 shows the frequency in number (n) and per cent (%) of
seeing and holding the baby in relation to time since birth. Among
the mothers who gave birth before 1990, 50/119 (42%) saw their
baby and for mothers who gave birth after 1990 the figures for
seeing were 609/680 (90%), RR 2.1, CI 1.7–2.6. For holding, the
figures were 24/119 (20%) before 1990 and 527/680 (78%) after
1990, RR 3.9, CI 2.7–5.5.

Discussion
Our results indicate, despite statistically insignificant findings,
that mothers feel more natural, good, and less frightened and
uncomfortable when they see and hold their stillborn baby if
providers assumptively offer the baby, rather than asking. This
finding is interesting in light of research that suggests that
mothers who declined when asked if they wanted to see or hold
their babies have more severe long-term psychiatric sequelae
than mothers who either saw or held their babies or who were
never offered that same opportunity (Cacciatore et al., 2008). In
addition, providers must be aware that mothers may decline
seeing and holding their baby because of the nature of psychological trauma and profound fear.
There may be a variety of reasons why mothers report their
experiences of seeing and holding more positively. One likely
hypothesis is that provider comfort and acceptance may cue and
normalise the mother’s natural desire to see and hold her baby.
Thus, simply offering the baby to the parents without asking may
be the most helpful and natural way to provide psychosocial care.
Conversely, asking if a mother whether or not she desires to see
her baby is an unnatural question. Mothers of babies born alive
are not routinely asked if they want to see their baby. Therefore,
the mere positing of the question may incite a feeling of
abnormity (Cacciatore et al., 2008), raising doubts in their minds
about accepting their babys dead body into their arms. Stillbirth is
an exceedingly traumatic event, and of course mothers are
unprepared to manage a stillbirth: they often defer to the advice
of providers, simply doing whatever providers lead them to do.
Asking mothers this crucial and irreversible question may imply
that some mothers would not want to see or hold the baby, thus a
spontaneous reaction under the emotional and physiological
traumatic state of stillbirth may be to reply with a refusal. In
addition, researchers have found that the spontaneous refusal to
see the dead baby usually changes later when mothers have had
an opportunity to think more clearly and are offered subsequent
opportunities for contact (Rådestad and Christoffersen, 2008).
During the interval between the refusal and a change of mind, a
dead body undergoes many changes. For the first 30 mins, a
stillborn baby feels soft and warm, much like a live baby, and
many have later noted that contact during this initial period is
invaluable (Rådestad et al., 2009, 2011). Our findings indicate that
the mother’s natural instincts to have contact with her baby can
be supported if providers respond to a stillborn baby with the
same approaching care, rather than avoidance, as a live born baby.
Further, our findings support Cacciatore’s theory of assumptive
bonding, that is the process by which providers tenderly treat a
baby who is stillborn just as a live born, assuming mothers will want
to see and hold them following birth (Cacciatore, 2010).
However, some protocols now suggest that parents should be
given a choice whether or not to see and hold their baby (Schott
et al., 2007; NICE, 2010). This may be problematic because in
order to give the parent’s choice some providers may feel that
they need to ask, ‘Do you wish to see and hold your baby?’ Asking
this question implies that this may be an abnormal course of

Please cite this article as: Erlandsson, K., et al., Seeing and holding a stillborn baby: Mothers’ feelings in relation to how their babies
were presented to them after birth—Findings from an online questionnaire. Midwifery (2012), doi:10.1016/j.midw.2012.01.007

4

K. Erlandsson et al. / Midwifery ] (]]]]) ]]]–]]]

Table 3
Women’s feelings when holding their stillborn baby in relation to how the baby was presented to them.
Total

n ¼547

Staff gave the baby to me
without asking

Staff asked if I wanted to hold
my baby

I asked if I could hold
my baby

I took the baby in my arms Staff pressured me to hold
by myself
my baby

n ¼141

26%

n ¼279

51%

n ¼ 65

12%

n ¼ 60

11%

n¼2

0.4%

Natural
Very
Quite a bit
Somewhat
Not at all

108
16
12
5

77
11
9
4

192
49
22
16

69
18
8
6

51
9
3
2

78
14
5
3

44
7
4
5

73
12
7
8

2
0
0
0

100
0
0
0

Good
Very
Quite a bit
Somewhat
Not at all

114
12
8
7

81
9
6
5

215
39
12
13

77
14
4
5

54
8
2
1

83
12
3
2

47
7
2
4

78
12
3
7

1
0
1
0

50
0
50
0

Uncomfortable
Not at all
Somewhat
Quite a bit
Very

127
8
4
2

90
6
3
1

229
32
14
4

82
11
5
1

58
5
0
2

89
77
0
3

54
5
1
0

90
8
2
0

1
1
0
0

50
50
0
0

Frightening
Not at all
Somewhat
Quite a bit
Very

114
21
5
1

81
15
4
1

211
45
18
5

76
16
6
2

57
3
4
1

88
5
6
2

52
5
3
0

87
8
5
0

1
0
1
0

50
0
50
0

Table 4
Seeing and holding the baby in relation to time when giving birth.
Number (n)

Saw the baby n (%)
Hold the baby n (%)

1955–1989
n ¼119

1990–1999
n ¼ 106

2000–2007
n ¼367

2008–2010
n¼ 207

50 (42%)
24 (20%)

96 (91%)
80 (75%)

324 (88%)
279 (76%)

189 (91%)
168 (81%)

action for a mother or father, calling into question any natural
desire to see and hold the baby. Furthermore, stillbirth can often
be a painful and frightening experience for providers (Fenwick
et al., 2007). Inexperienced staff might feel at a loss to know what
to say or do, and perhaps may feel the need to follow protocols
because this gives them reassurance that there is a ‘right’ way to
manage the situation. It is therefore important that these protocols do not imply that the staff member should ask the parents if
they want to see and hold their baby after birth.

Limitations
For the interpretation we must carefully consider that the
stillbirths took place over a long period of time, 1955–2010 and
that the mothers might have forgotten or altered their memory of
what happened. A main limitation is that the respondents in this
study were self-recruited, thus the depended variable ‘how the
stillborn baby was presented to the mothers’ probably did not affect
the mothers decision to participate in the study i.e. no effect on the
validity. However we do not know if the outcome, i.e. feelings when
seeing and holding the baby, may have affected self-selection into
the study. Participants may have been more likely to respond to the
survey if their experiences were good and may not have chosen to
respond to the survey if their experiences had traumatised them.
Other limitations in this study are the conditions to be able to
participate i.e. access to a computer, being informed about the study
and be motivated to answer a Webb questionnaire.
Stillbirths occurred during a broad time period, thus only few
women giving birth before 1990 are included in the analysis of
feelings when seeing and holding the baby due to the small

number of women who were able to see and hold their babies
born prior to 1990. The web questionnaire could be seen as an
exploratory tool, developed on the basis of theoretical knowledge
and clinical experience of meeting parents after the loss of a baby.

Conclusions
Mothers of stillborn babies more often said they felt natural,
good, comfortable and less frightened if the staff supported
assumptive bonding by simply offering the baby to the mother.

Implications for practice and further research
Since the decision not to hold the baby is an irreversible one and
since mothers who are asked and then later decline experience
greater levels of distress than other mothers, providers should
refrain from explicitly asking mothers if they want to see or hold
their babies. Instead, maternity care providers should approach
caring for grieving mothers with tenderness and humility, assuming
that they will wish to see and hold their stillborn baby. Long- term
outcomes on quality of life, effects on partnership, and mental
health would be other potential areas of research.

Conflict of interest
None.
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were presented to them after birth—Findings from an online questionnaire. Midwifery (2012), doi:10.1016/j.midw.2012.01.007

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Please cite this article as: Erlandsson, K., et al., Seeing and holding a stillborn baby: Mothers’ feelings in relation to how their babies
were presented to them after birth—Findings from an online questionnaire. Midwifery (2012), doi:10.1016/j.midw.2012.01.007