Stillbirth Patient Centered Psychosocial Care Final Cacciatore 2010

Stillbirth:Patient-centeredPsychosocial Care

JOANNE CACCIATORE, PhD, FT, LMSW

School of Social Work, Arizona State University, Phoenix, Arizona

Abstract: Evidence-based practice and patient-cen-tered practice are not mutually exclusive clinicalideals. Instead, both styles hold tremendous potentialfor complementarity in healthcare and should beused to enhance clinical relationships in which car-ing is humble, mindful, and nuanced. The onus of theresponsibility for many decisions about care afterstillbirth falls on clinical staff. Yet, even in the dearthof literature exploring standards of care during still-birth the results can be conflicting. Thus, research inboth patient-centered and evidence-based approachessuggest that less emphasis should be placed on thestandardization of care; rather, the focus should be onrelational caregiving that underscores the uniquenessof each patient and their family, recognizes culture,and encourages affirmative, rather than traumatizing,provider reactions.Key words: stillbirth, psychosocial care, patient-cen-tered care, evidence-based practice, psychotherapy

‘‘Not long ago, a baby’s death was an unspeakable eventin a hospitaly. The baby was whisked away beforeparents could see or hold their babyy. The mother wasgiven tranquilizer if she became too upset, if she lost[control].’’

I. Leon

The Cost of LossBereavement, particularly when suddenand traumatic such as in the case ofstillbirth, poses the risk of many negativelong-term social, psychological, and bio-logical outcomes. Some of those hazardsinclude anxiety, dysthymia, suicidality,loneliness, anhedonism, substance abuse,inorganic pain, and attachment andrelational problems as well as increasedpremature mortality.1–4 Complicated, orprolonged grief, has been recognized byclinicians as a problem facing a percen-tage of those traumatically bereaved,however, only recently has a psycho-metric validation of diagnostic criteriabeen proposed for inclusion in the Diag-nostic and Statistical Manual of MentalDisorder-V.2

Somewomen experiencing the stillbirthof a baby meet the risk criteria for com-plicated and traumatic grief resultingin significantly diminished functioning.Rando3 suggests that certain circum-stances increase the likelihood of compli-cated grief including: sudden death that isespecially traumatic, violent, mutilating,or random; the death of a baby or child;the perception that the death was preven-table; a markedly dependent relationship;

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Correspondence: Joanne Cacciatore, PhD, FT, LMSW,Arizona State University West campus, School ofSocial Work, PO Box 37100, Phoenix, AZ 85069-7100. E-mail: [email protected].

Joanne Cacciatore is an Assistant Professor in theSchool of Social Work at Arizona State University.She holds a Fellowship in Thanatology and is theDirector of the Center for Loss and Trauma in Phoenix,Arizona.

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 53 / NUMBER 3 / SEPTEMBER 2010

CLINICAL OBSTETRICS AND GYNECOLOGYVolume 53, Number 3, 691–699r 2010, Lippincott Williams & Wilkins

concurrent mental health problems; anda perceived lack of social support duringand after the loss. Similarly, according toWorden,4 complicated grief reactions in-clude: (1) chronic grief that is excessive induration, (2) delayed grief that has beeninhibited by suppression, (3) exaggeratedgrief that is exacerbated by multiplefactors such as marginalization, shame-induced stigma, or physiological trauma,and (4) masked grief that results in so-matic symptoms or alexythmia. The high-est risk to the individual is when all the4 criteria overlap. That is, grief becomesprotracted, the griever has no safe place toexpress grief, the loss was socially stigma-tized or invisibilized, and eventually theemotions associated with the loss areexpressed through somatic ailments orself-harming behaviors, such as socialwithdrawal, cutting, eating disorders, orengaging in risky behaviors. To date, nostudies have measured the economicimpact of stillbirth. Yet, considering thepsychosocial risks to women and theirfamilies, inarguably, the aggregate costto society is quite high.

The Exigency forPatient-centered Care‘‘Somehow I feel I’ve failed as a woman.I just didn’t get it quite right. Most womencome homewith a baby after ninemonths ofpregnancy. I came homewith a tabletop fullof drugs. And let me tell you, that Percocetis good stuff. Not a baby, but damn goodstuff.’’

Kara Jones, Flash of Life

If birth, even when the outcome is a livebaby, can result in posttraumatic stressand depression for many women,5,6 still-birthwould significantly increase both therisk and the likelihood of poor psycholo-gical adjustment in the postpartum peri-od. Rowe-Murray and Fisher7 found 3variables affecting postpartumdepression

following a live birth: lack of support,pain, and suboptimal contact with thebaby right after birth. Each of these isoften manifested and exaggerated in theinstance of stillbirth, thus, the exigencyfor social support, as with any child’sdeath. However, stillbirth also presentswith some peculiarities.

One such idiosyncratic difference is apsychological phenomenon known as am-biguous loss, based on the work of PaulineBoss.8,9 Ambiguous loss may arouse pro-foundly debilitating grief responses, occur-ring in situations where there is physicalabsence and psychological presence. Hertheory can be readily applied to stillbirth:though the child is physically absent afterdeath, psychological presence and piningoften continue for months or years, mani-festing in many ways. The lack of tangibleevidenceof thebaby’s existencemayunder-mine the legitimacyof amother’s emotions,provoking role distress. Adding to thecomplex nuances of stillbirth is its societaldemarcation from other types of childdeath. Stillbirth is often regarded by aca-demics, clinicians, and the general popula-tion as a ‘‘pregnancy loss’’ rather than thedeath of a baby. These merging influencesmake some women feel marginalized andmay actuate ambiguous grief.10 Ambi-guity is manifested through protracted de-nial, indistinguishable boundaries, relent-less information seeking, and emotionaloutbursts. In particular, clinicians havethe opportunity to circumvent and attenu-ate some of the effects of boundary ambi-guity, perhaps by helping women actua-lize their losses through patient-centeredcaring.

As early as the 1970s, researchers dis-covered links between compassionate pro-vider reactions and grief responses.1,8–15

Mothers who experienced stillbirth re-ported very high levels of anxiety, and thisstate could be reliably predicted by psycho-social conditions, including a perceivedlack of support from others.13,16,17 Theimmediate care a woman receives during

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stillbirth has a significant affect on heremotional status up to 3 years after thebaby’s death.17 Rather than using strictguidelines, preset protocol, checklists, andplatitudes when interacting with grievingmothers, caregivers should, instead, focuson the relationship itself as an axiom ofperson-centered care.

Clinical Recommendations forCare in the Era of Evidence-based Practice‘‘I like to blame the caseworker, as if it is herfault I did not hold my son. But, at thatmoment in time I refused to hold him.What Idid not know, until I saw the photos the nursetook, was that death was a full 6 lbs 4 oz withperfect hands and feet, full lips full head ofdark curly hairy I did not know that hold-ingmy sonwould have been the sameaswhenRomeo held Juliet’s lifeless body to him,embracing a flash of life.’’

Kara Jones, Flash of Life

Evidence-based practice and patient-centered practice are not mutually exclu-sive ideals towardwhich a clinician shouldstrive. Instead, both styles hold tremen-dous potential for complementarity inhealthcare and should be used to enhancepatient-centered care that is humble,mindful, and nuanced.14,15,17,18

There are many experiential aspectsrelated to stillbirths, and all child deathsfor thatmatter, ofwhich clinicians need tobe aware.19Women—and their families—need to decide whether or not they wish tosee, hold, and photograph the dead baby.They will need to choose which, if any,mementos they want to keep, such ashand and foot prints andmolds, blankets,or a lock of hair. They will need to decidewhether or not to have an autopsy, and ifso, where that autopsy will occur. Theywill need to choose the form of final dis-position, burial or cremation, and choosean appropriate mortuary—or home fun-

eral—for the baby. They will need to fillout legal documents. In some states, this isa Certificate of Fetal Death. In others,they may have the option of choosing aCertificate of Birth resulting in Stillbirth.They will need guidance around survivingchildren, deciding whether or not to in-clude them in the hospital event or thesuccessive memorial service. They willneed to be educated about the experienceof traumatic loss, efficacious of interven-tions, such as support groups or psy-chotherapy, and future family planning.Often, the onus of many of these respon-sibilities falls on clinical staff. Yet, even inthe dearth of literature on standards ofcare following stillbirth, the empiricaloutcomes can be conflicting.

For example, amidst the evidence instillbirth research, there exists significantdiscrepancy in outcomes over specific re-commendations in the standardization ofcare. Most of the dispute in the evidencerevolves around seeing and holding thedead baby. Some studies suggest that suchrituals increase the risk of long-term psy-chological harm to women and their sub-sequent children20 whereas other studiesshow the opposite effect.15,17,20 In a longi-tudinal study of Dutch parents whosechildren died at various ages ranging fromstillbirth to 29 years of age, parents whohad an opportunity to say farewell hadlower grief scores than those who did notacross the age groups. In addition, thosewho chose home funerals, that is, theycared for their child’s body during thepostmortem period in their home, alsoreported lower grief scores 2 years follow-ing the loss. The researchers suggest thatthis process assists parents in confrontingand realizing their loss.21 Boss agrees thatseeing the baby’s body helps a mother tobegin the process of relinquishment whilerevising attachment. Not having seen theremains, she contends, interferes with thatprocess and incites ambiguous grief.9

What do clinicians do when empiricalevidence is seemingly contradictory?

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Researchers in patient-centered appro-aches suggest that less emphasis shouldbe placed on the standardization of care;rather, the focus should be on relationalcaregiving that underscores the unique-ness of each patient and their family,recognizes culture, and encourages affir-mative, rather than traumatizing, provi-der reactions. It is a model based onauthentic, mutual relationships.

In a population-based study of 636postpartum women, of whom 314 had astillbirth and 322 had a live birth, Rades-tad et al17 found that the process ofbirth was physically and psychologicallymore painful when the babywas stillborn.The hospital stay was also briefer, andmothers were less satisfied with the carethey received. Thus, an expedited hospitaldischarge may replace the provision ofemotional support from medical staff.17

Other mothers have expressed feelingignored during the postpartum period.Fear, misinformation, and the lack oftraining may contribute to avoidant staffresponses. There have beenmany contrib-uting factors to the misinformation andinadequate care following stillbirths, in-cluding concern over litigation, personalfear, and anxiety around death, a politicalenvironment that has failed to accept still-birth—even when late and unexplained—as the death of a child, and a historicallypaternalistic system that wrests controlfrom women over their birth experiences.Patients whose providers were perceivedto be insensitive to their emotional stateduring traumatic births claimed they feltvulnerable and helpless as a direct resultof their interactions.17,22 Ineffectivecommunication that incited feelings ofdisrespect, indignity, and paternalismincreased the likelihood of dissatisfaction,negative psychological outcomes forwomen, and litigation.17,19,22–24 Thesedisaffirming and traumatizing providerreactions to loss compromise relationaltrust and exacerbate fragilities duringstillbirth.

Conversely, person-centered carewherein the relationship is the apogee‘‘alleviates vulnerability in all of itsforms’’23,24 and may help to buffer thenegative effects of traumatic events likestillbirth. Interdisciplinary bereavementteams addressing perinatal death at hos-pitals ameliorate somatic distress andrelieve hostility in grieving mothers. Thebenefits of these interactions are particu-larly discernible in cases in which womenreported low social support from familyand friends.

Although clinicians are often facedwith a constellation of familial and indi-vidual needs, bereaved mothers may beunable to coordinate services, navigatean overwhelming hospital system, or askthe right questions without guidance andsupport. Thus, clinicians should strivetoward a baseline knowledge about theepidemiology of stillbirth, relevant psy-chological theories for traumatic bereave-ment and interventions; expertise inverbal and nonverbal communicationduring a crisis (including a supportiveand noncoercive style); commitment toboth evidence and patient-based care thatis culturally competent; mastering theability to coordinate appropriate serviceswithin the community; and making timeto advocate, when necessary, for systemicchange.

The 3-function doctor-patient modelcan be used as an evidence-based, rela-tional guide for clinicians working withthe bereaved.25 This trilogy emphasizes(1) gathering data to understand the pa-tient, (2) developing rapport and respond-ing to the emotions of patients, and (3)psychoeducation.Under thismodel, com-munication provides an exchange of use-ful information, promotes action andinteraction, allows the patient to accessfeelings about an experience, and pro-vides an opportunity for caregivers toexpress caring by addressing the 3 fieldsof understanding: cognitive, emotional,and psychomotor.

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First, gathering data to understand thepatient requires that caregivers take timeto become familiar with the socioculturalintricacies of each patient. It prompts theacquisition of information, such as reli-gious beliefs, previous history of loss, andstructure of the family system, that will beimportant in building trust and mutualunderstanding. This process of relationalknowing may also serve to enhancejoint decision-making processes. For ex-ample, the religious views of woman whohas experienced stillbirth may informher attitude toward an autopsy or finaldisposition. The second principle, devel-oping rapport—or a relationship—withthe grieving mother and then respondingto her emotions is imperative. Ritualiza-tion may be especially important forwomen after the death of a baby. How-ever, a mother who is too fearful to holdher stillborn baby may make irreversibledecisions because she is emotionally over-whelmed, or she may be feeling pressuredby others not to see the baby. This maylead to later regret, particularly if she wasoffered a brief opportunity to hold thebaby but she denied.15 Although ritualsare a profoundly intimate decision,through a caring relationship with theclinician, a woman can make decisionsbased on her authentic desires rather thanbased on fear. Through this relationship,the caregiver is able to respond empathi-cally and patiently to amother’s authenticneeds. Finally, psychoeducation that isconveyedwith warmth and honesty aboutwhat to expect during and after the birth,offering ritual options such as holding thebaby, photographs, or mementos, maygive them a sense of informed control.Effective communication during psychoe-ducation hinges on 9 very important prin-ciples: (1) never interrupt the speaker, andallow for a pause between main thoughts;(2) avoid jumping to conclusions; (3) payattention and engage easily; (4) listen forfeelings, beliefs, and ideas; (5) avoid im-pulsive reactions or solutions; (6) pay

attention to the patient; (7) maintain re-spectful nonverbal communication; (8)accept the emotional sentiment of theother person; and (9) listen attentively.This model, overall, sets the stage for acaring environment in which important,potentially irreversible, decisions can bemade without coercion or regret. Clini-cians should also avoid paternalisticresponses because it is inconsistent withwoman-centered principles for care. Theyshould, instead, build rich relationshipsthat empower women to make their ownhealthcare choices after stillbirth, andfacilitate rather than denigrate their ma-ternal, feminine responses to loss.

Narrative intervention is both evidence-based and patient-centered and has provenhelpful in reducing adverse psychologicaloutcomes for women. Women who re-ceived as little as 30 minutes of supportivecounseling experienced a significant reduc-tion in anxious and depressive symptomsduring the postpartum period.26 One post-vention program that included telephonecounseling commencing 72 hours afterbirth and lasted for 3 months revealedmarkedly decreased posttraumatic stresssymptoms in women.27 Another random-ized, controlled study showed that eventhose suffering from complicated grief ben-efit from narrative psychotherapy. Inter-ventions included retelling the story,exposure therapy, and confrontation overthe course of about 6 months.28 The pro-cess by which a clinician listens and is fullypresent with a patient is an expression ofcaring. Swanson29 researched caring as anurturingwayof relating toandvaluing theother. The expression of caring for anothermanifests as

� Knowing: Striving to understand an eventas it has meaning in the life of the otherby avoiding assumptions, centering onthe other, assessing, seeking cues, andengaging;� Being with: Becoming emotionally present

to the other by being there, conveyingavailability, and not burdening;



� Doing for: Helping by action through com-fort, anticipation, competence, protection,and preserving dignity;� Enabling: Facilitating the other’s experi-

ence through unfamiliar events by in-forming and explaining, supporting andallowing, generating options, validation,and feedback; and� Maintaining belief: Faith in the other’s

ability to handle a difficult event and findmeaning by holding the other in esteem,hope, realistic optimism, and stability.29

Boss suggests that a worthwhile ther-apeutic goal is to help patients normalizetheir experiences when grief is ambiguousand complicated. She suggests normaliz-ing guilt and other negative emotions byallowing a place for the story to be toldand retold until there are more associatedpositive attributions.8 She discouragespathologizing responses and encourageslistening. Another important interventionincludes modalities in the creative arts tohelp patients manage and express distressassociated with traumatic loss. And herapproach supports holding a psychologi-cal space for the stillborn child within thefamily, as a reconstruction and reassess-ment occurs after the loss. Boss extendsthe responsibility of caring to the broadercommunity.8 Caring requires attendanceand attendance takes time. Indeed, thesetypes of person-centered interventionsrequire clinical, and administrative, com-mitment to person-centered caring.Nevertheless, best practice should includeenacting and enforcing techniques that‘‘prevent the genesis of psychologicaltrauma’’ and advocating patient rightswhich may require systemic changes incurrent administrative policies and proce-dures,22 including time delegation andstaffing issues.

Other policy changesmay affectmentalhealth clinicians in hospital settings. ElioFrattaroli,30 posits that current standardsof psychiatric care may result in the ob-jectification of patients wherein relation-ships are devoid of humanity and

connectedness. For example, he is criticalof clinicians who habitually supplant clin-ical time in psychotherapy with psycho-pharmacology, suggesting that it is ‘‘asubtle but powerful dehumanizing forcethat undermines the life of the spirit andsubverts the fundamental human questfor a more genuine transformationy.’’30

By focusing on emotions such as anxiety,guilt, and shame, clinicians can be moreaccepting, less alienated from themselvesand the patient. It is through the ‘‘feel-ing,’’ not ‘‘thinking,’’ where the discoveryof self and other can occur. Frattaroliwarns against what Freud termed furorsanandi, the rage to cure. Instead, hesuggests that clinicians treat with compas-sion, and to respect the patient’s symp-toms or emotional state as a cue towardthe path to wellness. Parental bereave-ment is most often not a disease to cure.Rather, it is a normal response to anaberrant and tragic outcome. The keyfor clinicians ismeeting the patient in theirgrief and providing an opportunity forhealing to occur within the frameworkof compassionate interventions.

Communicating Caring‘‘Grief remains of the few things that havethe power to silence us.’’

Anna Quindlen

Much of a patient’s feeling of beingcared for hinges on effective communica-tion. Humanistic communication is aquintessential characteristic of high-con-text, patient-centered care. Minoritygroups and women tend to be high-con-text communicators. This means theyplace less meaning on the actual wordsbeing spoken, and more emphasis on thenonverbal communication and context.This style of communication is more feel-ing-centered and intuitive. Conversely,low-context communicators rely heavilyon the precise spoken word. This resultsin reduced empathy and perceptivity,

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particularly during crises. In high-context communication, the culturalfilters decipher implied meanings aris-ing from the physical milieu, nonverbalcommunication, relationship interaction,or shared understanding of symbols. Inlow-context communication, the filtersdirect attention toward the literal mean-ings and interpretation of words and lessto the subtle cues of nonverbal commu-nication or the context surrounding thewords.31,32

Ways to communicate caring nonverb-ally include: being fully present with thepatient; using silence when appropriate;and, maintaining close, but nonintrusiveproxemics, respectful eye contact (whenculturally appropriate), open posturing(hands behind the back or at sides ratherthan crossed in the front), caring facialgestures and gentle tone of voice, and anunrushed demeanor. For example, anemphasis on certain words, tone of voice,and the speed of articulation all affectthe receiver’s perception of the messageof caring. Slightly quieter speech, slowedspeech, and an emphasis on caring wordsconvey empathy.14,31,32

In oculesics, the use of eye contactwhen communicating, clinicians shouldpay attention to cultural cues.Most often,direct eye contact communicates caringand attention toward the other, and ithelps the receiver unconsciously acceptthe truthfulness and sincerity of the sen-der. Western culture, in particular, valuesdirect eye contact. However, some heri-tage-consistent Native American tribalmembers or Asians will avoid sustainedeye contact. This nuance in communica-tion styles calls for a sensitive, intuitive,and flexible responsewherein the clinicianadapts to the other person’s communica-tion style.31,32 Effective nonverbal com-munication is important in conveyingmeaning that is congruent with the de-siredmessage: Verbal and nonverbal mes-sages need to be congruent, as most of themeaning extracted by the receiver is done

so through the nonverbal message. Insum, eye contact when culturally appro-priate, a moderated tone and pace ofspeech, the judicious use of touch (thetop of the hand, closest shoulder, or onthe back between the shoulders), andstrategically applied silencewill often con-vey a supportive, caring presence.

The Call for SystemicChangeDeath education targeted toward clinicalstaff can be helpful in significantly in-creasing confidence making them morecomfortable when dealing with bereavedparents. Some degree of grief sensitivitytraining should be extended to all staffincluding patient intake staff, pastoralstaff, interns and residents, and even non-clinical staff. Yet, administrators do notalways provide necessary training evenfor clinical staff. Chan et al, found thatnurses’ comfortable attitudes towardbereavement were directly correlated withtheir knowledge of the death of a baby.Nurses wanted more formalized trainingthat emphasizes death studies, ‘‘improvedcommunication skills, and greater sup-port from hospital policy and team mem-bers relative to bereavement care.’’33

Hospital administrators may want toconsider the implementation of a woman-centered education program focusing onrelationships: one that is family inclusiveand that supports, educates, and providesdebriefing for partners and family mem-bers on how to help the grieving mother inthemonths subsequent to the baby’s death.Hagenow recommends that the focusshould be on the woman, rather than thehospital system. Recognizing the adminis-trative barriers to person-centered care,such as managed care, economics, andcompromised organizational structure,she calls on managers to change ‘‘tradi-tional measures of corporate wealth’’ inwhich ‘‘financial assets derived fromproductivity and profits are broadened



to include community responsibility, socialaccountability, and personal fulfillment ofemployees.’’24 Another policy change mightbe to implement apostventionprogramwiththe grieving mother and her family. A cost-effective way to do this would be throughformalized partnerships with well-estab-lished, nonprofit organizations that servefamilies who have experienced stillbirth.

In SumThe death of a child is a complex andtraumatic experience for women and theirfamilies, traversing culture, socioeconomicstatus, religion, and ethnicity. In particular,bereaved mothers, often overwhelmed bythe traumatic nature of stillbirth, take theircues about how to interact with their deadbaby from caregivers.13–15,17 For this rea-son, clinicians should use an evidence-based approach that is patient-centered,careful not to impose their own valuesand beliefs. Rather, clinicians should takethe time necessary to establish an intimaterelationship with the patient, gently guid-ing the decisions that will be the leastdamaging and reap the most beneficiallong-term choices for her and her family.

These choices, and their ramifications,may last a lifetime and are often not re-dressable. In the words of Adrienne Rich,‘‘whatever is unnamed, undepicted inimages, whatever is omitted from biogra-phy, censored in collectionsof letters,what-ever is misnamed as something else, madedifficult-to-come-by, whatever is buried inthe memory by the collapse of meaningunder an inadequate or lying language—this will become, not merely unspoken, butunspeakable.’’ In addition, for the grievingmother who is having the ‘‘unspeakable’’experience, the sense of aloneness absent acaringmilieu contributes to her invisibility,ushering her into the shadows, and exacer-bating her loneliness and angst.

However,patient-centeredcare thathum-ble, mindful, and nuanced builds authentic,meaningful, and healing human relation-

ships after stillbirth and may mitigate long-term negative psychological outcomes formothers and their families. This type ofrelational caring moves beyond the acquies-cence of ‘‘first, do no harm’’ prompting theimperative to ‘‘then do good.’’

References1. Stroebe M, Schut H, Stroebe W. Health

outcomes of bereavement. Lancet. 2007;370:1960–1969.

2. Prigerson HG, Horowitz M, Jacobs S,et al. Prolonged grief disorder: psycho-metric validation of criteria proposedfor DSM-V and ICD-11. PLoS Med.2009;6:e1000121. doi: 10.1371/journal.pmed.1000121

3. Rando TA. Parental Loss of a Child:Differences of Grief Intensity in BereavedParents. Champaign, IL: Research Press;1986.

4. Worden JW. Grief Counseling and Ther-apy. London: Springer; 1991.

5. Slade P. Toward a conceptual frameworkfor understanding post-traumatic stresssymptoms following childbirth and im-plications for further research. J Psycho-som Obstet Gynecol. 2006;27:99–105.

6. Beck CT. Birth trauma: in the eye of thebeholder. Nurs Res. 2004;53:28–35.

7. Rowe-Murray HJ, Fisher J. Operativeintervention in delivery is associated withcompromised early mother-infant inter-action. Br J Obstet Gynaecol. 2001;108:1068–1075.

8. Boss P.Ambiguous Loss: Learning to LiveWith Unresolved Grief. Cambridge, MA:Harvard University Press; 1999.

9. Boss P. Loss, Trauma, and Resilience:Therapeutic Work With Ambiguous Loss.New York, NY: WW Norton & Com-pany; 2006.

10. Cacciatore J, DeFrain J, JonesK. Bound-ary ambiguity and the death of a child.Marriage Fam Rev. 2008;44:439–454.

11. Rowe J, ClymanR,GreenC, et al. Followup of families who experience a perinataldeath. Pediatrics. 1978;62:166–170.

12. Hunfield J, Wladimiroff J, Verhage F,et al. Previous stress and acute psycho-logical defense as predictors of perinatalgrief. Soc Sci Med. 1995;40:829–835.

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13. Cacciatore J, Schnebly S, Froen F. Theeffects of social support on maternalanxiety and depression after the death ofa child. Health Soc Care Commun. 2009;17:167–176.

14. Cacciatore J. Appropriate bereavementpractice after the death of a Native Amer-ican child. Fam Soc. 2009;90:46–50.

15. Cacciatore J, FroenF,Radestad I. Effectsof contact with their stillborn babies onmaternal anxiety and depression. BirthIssue Perinatal Care. 2008;35:313–320.

16. Dyregrov A,Matthiesen SB. Anxiety andvulnerability in parents following thedeath of an infant. Scand J Psychol. 1987;28:16–25.

17. Radestad I,NordinC, SteineckG, et al. Acomparison of women’s memories of careduring pregnancy, labour and deliveryafter stillbirth or live birth. Midwifery.1998;14:111–117.

18. Hasnain-Wynia R. Is evidence-basedmedicine patient-centered and is patient-centered care evidence-based? HealthServ Res. 2006;41:1–8.

19. GoldKJ,DaltonV, SchwenkTL.Hospitalcare for parents after perinatal death.Obstet Gynecol. 2007;109:1156–1166.

20. Hughes P, Turton P, Hopper E, et al.Assessment of guidelines for good prac-tice in psychosocial care of mothers afterstillbirth: a cohort study. Lancet. 2002;360:114–118.

21. Wijngaards-De Meij L, Stroebe M,Stroebe W, et al. The impact of the cir-cumstances surrounding the death of achild on parents’ grief. Death Stud. 2008;32:237–252.

22. Spies SorensonDS. Healing traumatizingprovider interactions among womenthrough short-term group therapy. ArchPsychiatr Nurs. 2003;17:259–269.

23. Levinson W. Physician-patient commu-nication: a key to malpractice prevention.JAMA. 1994;272:1619–1621.

24. Hagenow NR. Why not person-centeredcare? The challenges of implementation.Nurs Adm Q 2003;27:203.

25. Bird J, Cohen-Cole SA. The three-func-tion model of the medical interview: aneducational device. Adv Psychosom Med.1990;20:65–88.

26. Lavender T, Walkinshaw SA. Can mid-wives reduce postpartum psychologicalmorbidity? A randomized trial. Birth.1998;25:215–219.

27. Gamble J, Creedy D, Moyle W, et al.Effectiveness of a counseling interven-tion after a traumatic childbirth: a ran-domized controlled trial. Birth. 2005;32:11–19.

28. Shear K, Frank E, Houck P, et al. Treat-ment of complicated grief: a random-ized controlled trial. JAMA. 2009;293:2601–2608.

29. Swanson K. Empirical development of amiddle range theory of caring. Nurs Res.1991;40:161–166.

30. Frattaroli E. Healing the Soul in the Ageof the Brain: Becoming Conscious in anUnconscious World. New York: PenguinGroup; 1997.

31. Haase RF, Tepper DT. Nonverbal com-ponents of empathic communication.J Couns Psychol. 1972;19:417–424.

32. Hall ET. The Hidden Dimensions of Timeand Space in Today’s World: Cross-Cul-tural Perspectives in Non-verbal Commu-nication. Germany: Hogrefe & Huber;1988:145–152.

33. Chan MF, Wu LH, Day MC, et al. Atti-tudes of nurses toward perinatal bereave-ment. J Perinat Neonatal Nurs. 2005;19:240–252.



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Stillbirth Patient Centered Psychosocial Care Final Cacciatore 2010