Research

When a baby dies: Motherhood,
psychosocial care and negative affect
Abstract
Background: The process of giving birth to a baby who has died is a
significantly traumatic experience for the mother and her family and
also for health professionals. Support, or even the perceived lack of
support, from professionals often influences whether or not the parents
choose to see and hold their baby. Psychosocial clinical care may also
affect long-term psychiatric sequelae. The purpose of this study is to
explore the lived experiences of mothers following the death of a baby
and their interaction with healthcare professionals. Methods: Through
a web-based survey, a content analysis of this open-ended question
was conducted: ‘Do you currently feel sad, hurt, or angry for something
health professionals did in connection to the birth of your baby?’ Results:
Mothers reported feeling sadness when they perceived too little support
from professionals, particularly related to bonding time with the baby.
They reported feelings of disappointment when health professionals
neither acknowledged nor validated their motherhood. Mothers reported
anger in response to professionals they perceived to be indifferent or
callous toward their loss. They also reported that they felt hurt when
health professionals lacked respect and when they felt abandoned
by the personnel. Conclusions: There are crucial implications for
practice; it is important for women who experience a stillbirth to have
their motherhood actively acknowledged and validated and to have the
humble, empathic presence of their health professionals.
Ewa Nordlund
Midwife, Karolinska University
Hospital, Huddinge
Astrid Börjesson
Midwife, Karolinska University
Hospital, Huddinge
Joanne Cacciatore
Assistant Professor, School
of Social Work, Arizona State
University
Carissa Pappas
BSW Student, Arizona State
University
Ingrid Randers
Associate Professor
Sophiahemmet University
College, Stockholm
Ingela Rådestad
Professor Sophiahemmet
University College, Stockholm
780

T

he death of an infant is one of the hardest
losses to bear. Previous research on this
subject explores the direct effects that
the infant’s death had on the parents and the
various clinical interventions for coping with
the grief. Lang and Goulet (2003) proposed that
the ways in which parents coped with their
child’s death was best predicted by parents’ level
of hardiness or resilience. This included the
extent to which they exercised locus of control,
the degree to which a person feels they have
control over their experiences, their willingness
to seek support, and how they made sense of
the event (Lang et al, 2003). Another study
showed the same effect in relation to spirituality
(Brotherson and Soderquist, 2002). Feeley and
Gottlieb (1988) found that mothers use social
support, avoidance strategies, and distraction to
cope with the deaths of their newborns. They also
found that couples who engage in respectful and
open communication cope better than couples
whose communication was discordant (Feeley
and Gottlieb, 1988).
Many studies, however, fail to explore the

external influences which might hinder a parent’s
ability to cope with the death of their child. The
psychological milieu in which the death of a
child has occurred may influence bereavement
outcomes and psychological distress (Cacciatore,
2011). Physicians who experience fear around
the death of a baby even if there is no evidence
of liability, report higher levels of fatigue and
distress. Thus the physicians’ psychological
state may directly affect their ability to provide
compassionate psychosocial care (West et al,
2009), particularly in the aftermath of a baby’s
death. Kaunonen et al (2000) found that health
care providers experience a sense of injustice
when a baby dies. Furthermore, their study also
revealed that health professionals felt inadequate
in their roles as caregivers, and they did not
feel supported by their colleagues when a baby
died (Kaunonen et al, 2000). Additionally, there
is evidence to support that some professionals
are detached and reluctant to express sympathy
or apology to a patient or a patient’s family in
the face of trauma or death (Coulehan, 2009).
Any instance in which a family feels that health
professionals have ‘hurried up, disallowed,
trivialised or not recognised’ them, avoiding
their profound sense of grief and loss, seems to
exacerbate and prolong their dissatisfaction with
care (Neimeyer, 2002).
Indeed, health professionals may be
insufficiently trained to provide patient-focused
psychosocial care, particularly in the aftermath
of traumatic death. This is likely to arouse
anxiety and trigger experiential avoidance in the
professionals (Reese and Brown, 1997; Neimeyer,
2002; Cacciatore and Flint, 2012). The degree
to which a health professional feels attuned to
the patient’s emotional state can predict their
willingness and ability to provide compassionate
psychosocial care (Chibnall et al 2004; Kruijver
et al 2006; Cacciatore and Flint, 2012). In some
fields of nursing, for example, oncology, nurses
accept a dual, psychosocially focused role as
both a health professional and a therapist for the
family (Arving and Holmström, 2011). Peplau’s
(1997) theory of interpersonal relations proposed
that nursing, specifically, is a healing art that
is fluid, intuitive, and personalised as opposed
to a rigid protocol, and recognised the differing
British Journal of Midwifery • November 2012 • Vol 20, No 11

Research
roles in the job including that of counsellor,
manager of environment, mediator, and technical
expert. Particularly when a baby dies, this wide
range of role shifts may affect and possibly
impede the health professionals ability to provide
psychosocial care (Cacciatore and Flint, 2012).
Experiences and expressions of grief may
be influenced by character traits, resilience,
socioeconomic status, history of loss, education,
help-seeking behaviours, partner concordance,
and spirituality (Feeley and Gottlieb, 1988; Reese
and Brown, 1997; Brotherson and Soderquist,
2002; Lang and Goulet, 2003; Cacciatore et al,
2009). The purpose of this study is to explore the
lived experiences of mothers following the death
of a baby and the quality of their interactions
with health professionals.

Methods
This study emanates from one web-survey
question aimed toward women who lost a baby
before or during birth. The question asked was:
‘Do you currently feel sad, hurt, or angry for
something health professionals did in connection
to the birth of your baby?’ After answering ‘yes’,
’no’, or ’other’, respondents were able to expand
on their answer. The questionnaire was available
through the Swedish National Infant Foundation’s
website between 27 March 2008 and 1 April
2010. The Swedish National Infant Foundation
is an organisation providing support to parents.
Information about the survey was available
through daily papers and at the Swedish National
Infant Foundation’s website. The Regional Ethics
Committee, Lund, Sweden, approved the study
Dnr. 467/2006.

Sample

or cohesive text and were marked in different
colours depending on the context it was written.
They were placed in emotion-focused categories:
ll Sad
ll Hurt
ll Angry.
Sub-categories were established for each category,
these were:
ll Lack of support for bonding rituals with the
baby
ll No acknowledgement of motherhood
ll Lack of respect and offending behaviour
ll The feeling of being abandoned
ll Lack of empathy and understanding.
Direct participant quotes were selected to
represent each sub-category.

Results

Sad over something health professionals
did during the birth
Lack of support for bonding rituals
with the baby
Support and encouragement from professionals
were important to mothers when deciding if
they would be able to hold and spend time
with the baby after birth. Mothers expressed
sadness when they felt health professionals did
not support them in taking time to bond with
their baby. Some expressed regret that they were
unable to weigh, measure, clean, or dress their
baby, noting that they had not been offered the
option to take photographs. Mothers were also
sad when staff had mislaid mementos (such as
the baby’s blanket, cap, and pillow) or when they
had to ‘argue’ with providers to keep mementos of
emotional value (such as the baby’s blanket) that
actually belonged to the hospital.

Data analysis and processing

‘When our son was born he was placed
in a light-blue blanket that belonged to
the delivery ward. When we were going
home and had to leave him there, I
wanted to take the blanket with me. It
was the only thing that was his and that
smelled like him. The staff said that I
could not have it since it belonged to
the hospital. I did get the blanket in the
end, but only after an attack of anxiety
after returning home, and I had to
promise to bring a new blanket to the
ward, and so I did.’

Content analysis was used to analyse this openended question (Elo and Kyngäs, 2008). A
systematic review of the responses, line by line,
was conducted to identify the meaning bearing
units. The units consisted of a single word and/

‘I regret that I never had my son
naked on my skin. He was wrapped
in a blanket when I got him and it is
something I miss that I have never felt.’

The women included in this analysis experienced
a stillbirth after 22 gestational weeks during the
years of 2008, 2009, and the first 3 months in
2010. Eighty-four (39%) of the 213 women who
participated in this survey answered the question:
‘Do you currently feel sad, hurt, or angry for
something health professionals did in connection
to the birth of your baby?’ The other 129 (61%)
had either not answered or replied ‘no’ to the
question or the answers were not related to the
birth of the baby.

British Journal of Midwifery • November 2012 • Vol 20, No 11

781

Research
No acknowledgement of motherhood
Mothers felt that the birth of their baby was a
significant event in their life, even though the
baby was born dead. They expressed sadness when
their feelings of both loss and motherhood were
not acknowledged. They experienced the same
sadness when they felt that professionals focused
solely on the cause of the death rather than on
their emotional distress and grief. Mothers felt
disappointment when the physical and emotional
strength they had shown during the birth was
unrecognised by health professionals. They also
expressed deep sadness when they felt professionals
did not respect the baby who died in the same way
as a live baby, for example, by ignoring the baby or
failing to ask the mother to engage with the baby in
the same way as they would with a living baby. For
example, one mother wished she had been asked
to cut the umbilical cord, just as she would have
if her baby had been alive, and another mother
noted that her baby was not diapered and dressed
after birth.
‘I wanted to go through the birth with the
midwife during my first revisit. The birth
was one of the biggest things that had
ever happened to me but nobody in my
surroundings asked me about it. I never
got to compare like other mothers. I just
received the autopsy report on my first
revisit.’
‘A social worker came and talked to us.
He did not look at our boys.’

Hurt by something health professionals did
during the birth
Lack of respect and offending behaviour
The mothers felt hurt when professionals touched
the baby in a way that they felt was disrespectful.
Mothers in this study were also offended when
health professionals used minimising language such
as referring to the baby who died as a ‘miscarriage’ or
used the pronoun ‘it’, or ‘fetus’ when referring to the
baby. Mothers felt that their emotional states were
disregarded when the professional’s primary focus
was on practical matters such as death reporting
or funeral planning. Mothers also reported feeling
hurt when health professionals conversed with
one another about irrelevant topics during the
birth, interpreting this as a lack of respect and
understanding of their tragedies. For example, one
mother reported that health professionals were
‘telling jokes in the surgical ward’. Mothers reported
occasions when they felt that professionals ‘hurried’
them in their finals moments of goodbye.
782

‘A midwife called my baby ‘the
miscarriage’, despite the fact that the
baby was born in week 25. She also said
‘There are worse things’. It was horrible
to hear her say that.’
‘The paramedics that had taken me to the
surgical ward (operating theatre) when
the death of my baby was established.
They started to hug, comfort, and feel
sorry for each other, something I felt was
wrong. They should have shown those
feelings and sadness toward me instead.’
The feeling of being abandoned
Some mothers in this study expressed feelings of
abandonment and loneliness when being forced
to change rooms at the hospital—their care turned
over to new staff. Mothers found it difficult to
meet new health professionals with whom they
did not have a relationship. Some of the mothers
described distressing situations where they went to
the cafeteria alone and encountered other pregnant
women. Death notification was also particularly
difficult and mothers perceived professionals to
be uncertain, avoidant, and tenuous. Mothers
felt ignored in the corridors, noting that health
professionals often avoided making eye contact.
The intense grief mothers were already suffering
was exacerbating by hearing the cries of other
newborns in the ward and seeing pregnant women.
The hospital discharge process was painful for
mothers as they had to leave the baby. One wished
that a midwife would have taken her baby out of
the room before discharge, as it may have eased her
distress during discharge.
‘The summer substitute personnel,
without experience, could not handle
the grief, they avoided eye-contact or
took a detour whenever we walked in the
corridors.’
‘One thing that was extremely tough
[sic] was to go down to the maternity
care department to take fetal fluid tests
among all the ‘super’ pregnant women.
We just cried. To stay in the delivery
room was also extremely tough [sic] with
all the screams we heard from newborn
babies.’

Angry by something personnel did or
didn’t do during and after the birth
The lack of empathy and understanding
Some of the women reported that professionals
British Journal of Midwifery • November 2012 • Vol 20, No 11

Research
did not listen well and lacked empathy. This
perceived health professional’s reaction often
provoked a feeling of anger in mothers. The ways
in which information about the baby’s death was
communicated also evoked anger. Some mothers
waited extended periods of time for a physician
to confirm the baby’s death, and others felt that
they did not receive appropriate medical care from
professionals because their baby was dead. For
example, one mother did not receive antibiotics
for an increasing fever nor for the pain relief she
requested. In another instance, a mother described
being very angry that critical information about
her baby’s death did not reach the surgery ward.
This set into motion serious misunderstanding,
and professionals were thus unprepared for the
birth of a baby who died. Situations also occurred
where health professionals did not accept
responsibility for their errors including insufficient
or inadequate communication regarding the baby’s
death, a breach of protocol, misplacement of
mementos, or overlooking important rituals such as
photographing the baby who died. Mothers felt that
professionals blamed them for such transgressions,
even implicitly, and this also incited angry feelings.
‘The physician thought we should go out
for dinner and come back the next day.
Dinner out?! He said that he and his wife
had done that when their daughter was
on intensive care unit and they had said
to each other ´No matter how disabled
she is—as long as she survives´. Our child
was dead; we thought he was unethical
and that he offended us.’
‘I asked when I was going home, if I
shouldn’t have some of that medicine I
got the day before, to prevent the milk
from coming. She then told me that I
did not need that since it (the milk) was
triggered by hearing the baby cry. That
felt terrible to hear.’
‘I was congratulated for having a baby
when I was going to have placenta
removed. I told them, before being
sedated, that she had died. They should
know that before I get there.’

Discussion
The results of this study suggest that grieving
mothers often experience negative emotional
responses during their interaction with health
professionals following a stillbirth. In particular,
mothers reported feeling sadness when professionals
British Journal of Midwifery • November 2012 • Vol 20, No 11

offered little support or encouragement to bond
with the baby who died. They experienced
disappointment when professionals failed to
acknowledge their motherhood and their baby. The
women in this study felt hurt when professionals were
avoidant, detached, and lacked the same respect for
the baby who died as they would for a living baby,
often reporting feelings of abandonment. They felt
angry when professionals were not empathic failed
to understand the magnitude of their losses.
The onus of responsibility falls on health
professionals and administrators to become trained
in dealing with death (Cacciatore, 2011) and thus
become more aware of the emotional, relational,
and even spiritual aspects of the patient’s unique
experiences of loss (Chibnall et al 2004; Kiernan,
2010). Health professionals who have received such
specialised training are better able to acknowledge
the subjectivity, emotional, relationship, and
solidarity, and, when applicable, spirituality of each
mourning family (Chibnall et al 2004; Coulehan,
2009; Cacciatore, 2011). Often, professionals
specifically educated in understanding aspects
of human suffering are more empathic listeners
and will engage in more approaching techniques
with patients facing human suffering. In addition,
these professionals tend to be more self-aware and
self-compassionate (Coulehan, 2009, Cacciatore,
2011, Cacciatore and Flint, 2012). International
leaders in the perinatal bereavement community
convened to assess current empirical evidence and
practice wisdom in standards of care. In particular,
they called on health professionals to engage in
compassionate and open ongoing communication,
facilitate bonding time with the baby who died based
on culturally competent care-giving, collecting
mementos when appropriate, and assisting families
in plans for final disposition. Of critical import is
the health professionals training in bereavement
and death studies.

Conclusions and implications for
practice
It is important for women who experience a stillbirth
to have their motherhood actively acknowledged
and validated and to have the full, empathic presence
of health professionals. They should approach
grieving mothers with compassion, humility, and
mindfulness (Cacciatore, 2011). Also, because
each patient’s needs are unique, a mindfulnessbased approach, which includes death education
(Cacciatore, 2011), is more likely to ensure the needs
of each individual mother are met, consistent with
interpersonal relations theory (Peplau, 1997). Death
education is critical to helping health professionals
feel comfortable in approaching traumatic losses
783

Research

Key points
ll Mothers felt sad when they perceived too little support from their
healthcare professionals, particularly related to bonding time with the
baby
ll Mothers were disappointed when professionals neither acknowledged
nor validated their motherhood
ll Mothers were hurt when healthcare professionals lacked respect and
when they felt abandoned by the personnel. Mothers felt anger in
response to professionals they perceived to be indifferent or callous
toward their loss
ll It is important for women who experience a stillbirth to have their
motherhood actively acknowledged and validated and to have the
humble, empathic presence of their healthcare professionals
so they are better able to focus on caring for
the grieving mother. In addition, this may lessen
tendencies toward avoidance and reduce the risk of
secondary stress in professionals (Reese and Brown
1997; Cacciatore, 2011; Cacciatore and Flint, 2012).
In lieu of a detached protocol, deeply intimate and
respectful relationships with professionals may help
allay fears that result in irremediable decisions,
exacerbating an already excruciating experience for
mothers and their families. Mindful psychosocial
care, ultimately, fosters a healing environment,
which may help diminish unnecessary negative
BJM
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