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Abstract
Background Stillbirth remains a prevalent issue worldwide, particularly affecting low-income and middle-income countries, where it brings immense sorrow and suffering to families, especially mothers. Sadly, support for women coping with this loss is inadequate, particularly in regions like Africa, where literature on women’s experiences of stillbirth is lacking.
Methods This qualitative study employed a narrative design guided by William Worden’s Four Task Theory to explore the experiences of 15 women who had experienced stillbirth, selected through purposive sampling. Semistructured interviews were conducted face to face with participants, and thematic analysis was used to analyse the data.
Results The study identified three overarching themes and nine subthemes, revealing participants’ perspectives on factors contributing to stillbirth, the experiences of women dealing with this loss and their accounts of the care provided by healthcare professionals focusing on communication, response and logistical aspects.
Conclusion Mothers revealed a multitude of challenges following the loss, underscoring the imperative of providing them with essential support to navigate these difficulties. Future research should delve into coping strategies and interventions aimed at enhancing the coping mechanisms of these mothers.
- Reproductive Health
- Women's Health
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. All supporting data for this manuscript have been made available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Experiences and coping strategies of mothers with stillbirth in high-income countries.
WHAT THIS STUDY ADDS
Factors leading to stillbirth from participants’ perspectives.
Mothers’ experiences with stillbirth in a developing country, Ghana.
Using the Worden’s Four Task Theory as a guiding theoretical framework.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Findings may inspire further investigation into coping strategies and interventions for women with stillbirth.
Additionally, the insights gained from this study could inform clinical practice by emphasising the importance of tailored support for mothers navigating the challenges of stillbirth.
Moreover, policy-makers may consider incorporating the findings of this study into policies aimed at improving the care and support provided to women and families affected by stillbirth.
Introduction
Stillbirth remains a significant concern contributing to elevated infant mortality rates, and its incidence continues to increase.1 2 A diagnosis of stillbirth is established when an infant passes away after 22 weeks in utero or immediately after birth during the intrapartum period, with a minimum weight of 500 g.1 Contributing factors to stillbirth encompass antepartum death of unspecified cause (33.7%), acute antepartum events such as hypoxia (33.7%) and congenital malformations and chromosomal abnormalities (13.3%).1 3
Stillbirth poses an even greater burden in low-income and middle-income countries, where the absence of guidelines and targets for crucial areas of stillbirth prevention exacerbates the issue.4 However, misconceptions about stillbirth persist in these regions. For instance, mothers have been reported to attribute stillbirth to their own sins and the influence of evil spirits. Additionally, there is a prevailing belief that stillbirth affects babies who were never meant to live.5 6
The complications arising from stillbirth encompass profound sadness, suffering and grief experienced by families, with women often bearing a significant burden.7 In addition to these emotional challenges, individuals may also grapple with psychological symptoms such as anxiety, depression, stress and post-traumatic stress syndrome, alongside physical difficulties.8 9 Despite the crucial need for support, mothers navigating stillbirth often face a stark lack of adequate assistance.8,10 Furthermore, the loss of a newborn can precipitate shifts in family roles, particularly for the mother, thereby impacting other family members as well.11
In Ghana, the stillbirth rate dropped significantly from 3.4% between 2003 and 2013 to 2% in 2017.12 13 A comprehensive study found a stillbirth incidence of 31.3 per 1000 births, with 17 out of 22 stillbirths classified as antepartum.14 Notably, research highlighted that completing the recommended four antenatal visits can reduce the risk of stillbirth.14 However, Ghana faces numerous challenges, including inadequate infrastructure like insufficient beds and physical space, a shortage of midwifery staff, logistical hurdles, lack of motivation and limited in-service training opportunities. These factors hinder midwives’ ability to provide optimal care for women in such circumstances and others.15
Ghanaian families, like those worldwide, face the profound impact of stillbirths, which can create personal, familial or relational challenges.16 Despite this, there is limited literature on stillbirth experiences specifically in Ghana. Therefore, the authors will employ Worden’s Four Task Theory (WTT) to explore the experiences of Ghanaian women affected by stillbirth.
Methodology
Study design
In this study, postnatal women who experienced stillbirth at Shai Osudoku District Hospital constituted the target population, given that issues related to stillbirth typically emerge within 6 weeks post partum. The utilisation of a qualitative narrative design17 facilitated a comprehensive exploration of women’s experiences, providing rich participant perspectives. The study employed the WTT to elucidate the stages of grieving and adaptation following stillbirth.18 Further details can be found in table 1.
William Worden’s Four Task Theory18
William WTT
Table 1 illustrates William Worden’s Four Tasks of Mourning, starting with accepting the reality of the loss, followed by adjusting to life without the deceased, and finally, coping with a new life.
Study setting
The setting for this study is the Shai-Osudoku District Hospital. See details of the prevalence of stillbirth in Shai-Osudoku District Hospital in table 2.
Stillbirth prevalence in Shai-Osudoku District Hospital
Stillbirth prevalence in Shai-Osudoku District Hospital
The table 2 above presents data on various aspects of childbirth and postnatal care for the years 2019–2021 in Shai-Osudoku District Hospital Ghana. Over this period, there is a noticeable increase in live births, rising from 3973 in 2019 to 4607 in 2021.
Inclusion criteria and exclusion criteria
For this study, inclusion criteria comprised puerperal women with stillbirth experience, postnatal mothers between 6 and 24 weeks, and those whose stillbirth occurred between 28 and 37 weeks of gestation. Exclusions were made for individuals unable to communicate in Twi, Ga or English, as well as those who delivered outside the hospital.
Sampling method and sample size
The sampling technique is a statistical research method that involves selecting a fixed number of findings from a larger sample.19 In this study, a non-probability sampling technique known as ‘purposive sampling’ or ‘judgmental sampling’ was employed.20 This method entails selecting individuals believed to be suitable or typical for the study based on the researcher’s knowledge of the population. The sample size was determined by data saturation, whereby no new or relevant data emerged. Data saturation was reached after interviewing 13 participants, leading to the termination of the sample size at 15. All participants agreed to and completed the study.
Patient and public involvement
Participants were engaged in the research process following an explanation of the study’s objectives, verbal consent was obtained and written consent was subsequently acquired. Research questions were developed based on prior literature on stillbirth. Participants were assured of their right to withdraw from the study at any time.
Data gathering and data collection
For data collection, the first author conducted in-depth individual face-to-face semistructured interviews using a guide comprising open-ended questions (online supplemental file 1). Detailed field notes were taken during each session to capture observations and mannerisms not recorded in audio. The interviews focused on participants’ demographics, obstetrical details and their experiences as mothers who had experienced stillbirths, as well as the care received. The labour ward manager facilitated the identification of postpartum bereaved mothers. Participants were briefed on the study’s purpose, and verbal and written consent were obtained. The location for data collection was chosen by participants, typically outside hospital settings and interviews lasted between 45 and 60 min. Information was digitally recorded with the participant’s permission, using an interview guide to structure the questions.
Supplemental material
Data analysis
Thematic content analysis was used in this study to condense extensive data into manageable fragments, identifying prevalent words, themes and concepts within qualitative data.21 22 Initially, data were transcribed verbatim from audio recordings to ensure accuracy, with careful consideration of trustworthiness. Non-English interviews were translated into English and then back into the interview language to ensure precision. Coding categories were then established, guided by the theoretical framework of WTT, facilitating the identification of recurring themes across the data. Data reduction techniques were employed to collapse information into labels, aligning with the predefined codes and themes outlined by the WTT. Finally, member checking was conducted with one participant to ensure accuracy, and pseudonyms were assigned to maintain anonymity.
Methodological rigour
Methodological rigour encompasses credibility, transferability, dependability and confirmability,23 factors that determine confidence in drawing conclusions from evaluation results. To ensure rigour, only participants who provided informed consent and met inclusion criteria were included. Their information was quoted verbatim, and the study methodology was thoroughly explained, covering research design, participant selection, data collection and analysis procedures. Additionally, the researcher provided a reflexive account of the research process, and direct quotes from audio recordings were used to support emerging themes.
Results
Sociodemographic data of participants
The sociodemographic characteristics of the participants (n=15) indicate that the majority are aged 36 and above (46.7%) and are primarily self-employed (66.7%). Most participants have a basic educational background (86.7%), identify as Christian (60%) and receive antenatal care services (66.7%). Please find the detailed information in table 3.
Sociodemographic characteristics of participants
Organisation of themes and subthemes
The data were meticulously transcribed and subsequently analysed to identify key themes and subthemes. Through this analysis, three main themes and nine subthemes emerged. These themes include factors leading to loss, experiences associated with the loss and instances of poor care. For a detailed overview, refer to table 4.
Themes and subthemes
Theme 1: factors leading to the loss
Women who have experienced stillbirth often struggle with unresolved emotions and fears of recurrence. Contributing factors include refusal of hospital admission 4 (26.7%), delayed referrals 5 (33.3%) and recurrent life-threatening medical conditions in the fetus 6 (40%).
Refusing admission
Four (26.6%) declined admission due to lack of support before delivery, posing challenges for healthcare providers (HCPs) in delivering essential care to prevent such situations.
‘I had no one to pick up my older children from school, so I inquired about alternatives. The doctor proposed waiting for my blood pressure to be rechecked, but since I needed to pick up my child, I declined and left. When I returned on Monday for assessment, I was informed that the baby had passed away, and I believe it was because I had refused admission.’ (Post-Partum Mother (PPM) 4, First pregnancy)
Delay in referral
Delays in decision-making and referral have been identified as significant contributors to maternal and perinatal mortality. Insufficient resources in lower-tier facilities result in prolonged referral delays by midwives at maternity homes, exacerbating risks for both mothers and unborn babies.
‘I was referred when it was too late, and I was told the baby had already passed away. Hmm, I've had this problem before, and I think that’s why I'm experiencing it again the second time.’(PPM 8, Second pregnancy)
Reoccurrences
Three of the women (20%) thought because they had experienced it before
‘This is the second occurrence, and I believe it’s because I experienced it the first time that I'm going through it again now.’(PPM 14, Nulliparous pregnancy)
‘Could the loss of my first pregnancy through abortion be the reason why this is happening again?’ (PPM2, Multipara)
Theme 2: women’s experiences of stillbirth
Psychological experience of women with stillbirth
Women with previous stillbirths felt heightened anxiety as they approached the gestational weeks of their prior losses, especially under similar conditions. Surprisingly, this was even true for those who attended antenatal clinics 10 (66.7%) as advised.
‘I have been questioning myself about what went wrong… because I was going to the hospital as scheduled… I have been purchasing and taking my medications as instructed… there hasn't been a single day when I missed attending the clinic or taking my medicine… so personally, I don't know what caused the death of my child’ (PPM 3, multiple pregnancy)
‘This is a big blow to me and I cannot stop thinking at times I am even afraid I might be seeing her in my dreams’ (PPM 15, Primipara)
Two women (13.3%) attributed the death of their fetus to inadequate care provided by healthcare professionals.
‘I held the hospital staff responsible for inadequate care during my admission. As a layperson, I relied on their expertise to recognize and prevent any potential danger in a timely manner. Their actions led to the death of my child, and they are accountable’. (PPM 14, Multiple pregnancy)
Three women (20%) denied the existence of the problem. ‘At around 4 pm on Tuesday, February 15th, I started feeling the baby’s movements, indicating that I was in labor. That evening, I went to the hospital. The midwife assessed me and noted an elevated heart rate in the baby, but no action was taken that night. I stayed in bed throughout the night. The next morning, they checked the fetal heart rate again and said they couldn't hear it. However, I found it hard to believe, as a baby with a fast heartbeat couldn't suddenly stop.’ (PPM 1, Multiple pregnancy)
‘I experienced guilt when the baby, who was delivered stillborn, was shown to me with peeling skin because I never attended antenatal care.’ (PPM 15, Primipara)
‘If I had received care at the hospital, perhaps my baby wouldn't have died. Hmm… It feels like it’s all my fault.’ (PPM2, Primpara)
Emotional experiences of women with stillbirth
The emotions exhibited by the women had a ripple effect on the other family members as well. Most mothers 11 (73.3%) were overwhelmed with the news and the site of their dead babies.
‘When they placed the baby on me, I felt overwhelmed because the baby’s skin was peeling off. I didn't know what to do. Honestly, I cried and cried. I really cried.’ (PPM 15, Primipara)
‘So, it was during the delivery that they placed the baby on me, and I noticed that the baby wasn't moving. I asked the nurse, and she informed me that my baby had been dead in my womb for three days, and I was not informed. Hmm, I felt very sad and disturbed.’(PPM 13, Nullipara)
Two participants (13.3%) found it particularly challenging to deliver a stillborn baby, citing the lack of hope and life in the fetus as their primary difficulty.
‘The labor process was incredibly painful because the fetus was not alive, and therefore there was no pressure from the baby to aid in the delivery. It was all my effort. I was in severe pain, unable to do anything for myself. When I asked for help, they said the only assistance they could provide was the infusion they had set up for me…’.(PPM 12, Nullipara)
Furthermore, culturally families prefer a particular sex (a male or female child) and when the preferred sex is dead, it increases the pain. This was emotionally distressing to two (13.3%) of the participants.
‘In fact, I didn’t know it was a male… so when they showed the sex to me, I was really sad and hurt…this is because they didn’t inform you about the sex of the baby at ANC… they will just tell you whatever sex the Lord grants just take it like that’. (PPM 4, First pregnancy)
‘My husband desired a daughter, so I felt hurt when they informed me that the baby upon delivery, as I was told by the doctor that I was expecting a female baby. According to the nurses, she did not move at birth, and despite their efforts, they were unable to revive her.’ (PPM 10, First pregnancy).
The spiritual experience of women with stillbirth
More than half of the women (53.3%) believed that they needed some sort of supernatural intervention. They appreciated the fact that health workers can only do the physical therefore there should be a pastor who will come in a critical moment to take care of the spiritual.
‘I believe that certain events occur beyond the ordinary, necessitating spiritual intervention. Perhaps through prayer, God guided them on how they were to care for me, which could have been beneficial.’(PPM 1, Multiple pregnancy).
There was no hospital-based spiritual support system established in the health facility for the women as narrated by the other seven (46.7%) participants.
‘If I had received support from a pastor during that time, it would have been beneficial… but that never happened. I was praying alone,’ she shared. Spiritual leaders, whether pastors, imams, or others, are crucial for women in bereavement’ (PPM 5, Multiple pregnancy)
Theme 3: substandard care for mothers coping with stillbirth
Poor communication by HCPs
When communication is hindered, it negatively impacts care. The findings indicated that some pregnant women, six (40%), were unable to express their experiences, and HCPs struggled to convey information to their clients effectively.
‘When she told me that the baby was breathing fast, that was all, the midwife did not say anything about it and she didn't tell me the complications associated with it, I didn't know what I was supposed to do about it. So when the baby passed on in utero I was devastated and in pain’ (PPM 11, Multiple pregnancy)
‘When you ask any question, they will not answer; instead, they tell you to wait. I informed the midwife that my baby was moving too much, and I was having difficulty breathing, so they should call the doctor. She did not pay attention. I called several times, and she responded that the doctor would come’ (PPM 10, First pregnancy).
Lack of urgency
There was a delay in the decision-making and also triaging of six (40%) of the patients. They did not give immediate attention to the life-threatening conditions as shown below.
‘I was aware that I wasn't feeling well, but the staff at my clinic assured me that they would manage since they had dealt with similar situations before. It wasn't until I reached full term that they referred me, perhaps causing the baby to die inside me’ (PPM 6, Multiple pregnancy)
‘I was aware that my condition was different because this was not my first pregnancy, and I recognized that the pain I was experiencing was unlike before. However, I was managed the same way as all the other women in labor’ (PPM 8, Second pregnancy)
Inadequate logistic
The findings revealed that the inability to diagnose the condition of the client immediately due to inadequate equipment or logistics affected the care some of the participants 3 (20%) received.
‘I was directed to an off-site location for a scan outside the hospital, which was distressing. Already exhausted and in pain, I was nearly struck by a car upon receiving the news. After obtaining the results, I was referred elsewhere because the clinic couldn't handle my case’ (PPM 4, First pregnancy).
‘Although I was in labor and informed that my blood pressure was high, I was asked to sit in a wheelchair due to the unavailability of a bed’ (PPM 7, Nullipara)
Discussion
This study aimed to delve into the experiences of women who had experienced stillbirth at Shai Osudoku District Hospital. Participants shed light on factors that led to their babies’ deaths, such as delays in initiating interventions to prevent fetal demise. Additionally, instances where mothers refused admission were highlighted, leading to complications and ultimately, the loss of the baby. These findings emphasise the critical need for healthcare professionals to enforce measures like stringent monitoring and timely referrals to avert future occurrences. Furthermore, there is a pressing need to educate mothers, particularly those in rural areas, about the importance of antenatal services. It is worth noting that other authors have identified various causes of stillbirth, including placental tissue destruction, insufficiency and umbilical cord abnormalities.24 25
The women expressed profound sadness as a result of stillbirth, feeling the emotional pain of leaving the hospital ‘empty-handed’ without their anticipated baby. This shattered expectation of bringing a live baby home was particularly distressing for those who had specific preferences regarding the baby’s sex. There is a clear need for emotional support from healthcare staff, families and friends to assist these mothers in coping with the loss of their babies without facing complicated grieving processes. Additionally, midwives should receive training on how to sensitively deliver such news to mothers. In contrast, a separate study found that mothers maintain an ongoing relationship with their stillborn babies, highlighting the prolonged grieving experience endured by these mothers.26
Various spiritual support strategies were identified, including prayers, reading the Bible and using hospital-based spiritual support systems such as the chaplain. Participants highlighted the significance of these strategies in assisting them in navigating the challenges following stillbirth. This emphasises the importance of hospitals offering accessible and affordable spiritual support services for women coping with stillbirth. Moreover, there is a need for provisions to be made for mothers who are not Christians to ensure religious sensitivity and inclusivity. Although limited research has been conducted in this specific area, the use of counselling services and psychotherapy has been documented.27
Respondents reported negative experiences with certain healthcare professionals, particularly doctors and midwives, citing issues such as poor communication and inadequate care during admission. Participants expressed dissatisfaction with the lack of comforting communication from midwives, and some felt unfairly blamed for the death of their babies. This highlights the need for collaboration among healthcare staff, including administration, to ensure pregnant mothers receive quality care, which can significantly reduce stillbirth rates. Similar findings regarding inadequate care for mothers experiencing stillbirth and other complications during the COVID-19 pandemic were reported in another study.28
Additionally, a paternalistic approach by service providers, deciding when to inform women about the stillborn, rather than allowing immediate disclosure, was noted. This delay often occurred until the mother was perceived as emotionally stable or when her partner or relatives were present. Such cultural practices, hindering prompt notification, may impede the mother’s acceptance of the news. Providing firsthand information is crucial, and HCPs should offer support to women facing trauma.
The narratives shared were deeply distressing, underscoring the crucial significance of mothers’ and babies’ lives. While it appears that midwives and doctors are endeavouring to provide the best care possible, there is still room for improvement to mitigate stillbirth rates and ensure the delivery of healthy babies nationwide. Achieving this goal requires a collective effort from all professionals, including healthcare staff, administration and governmental and non-governmental organisations. It is imperative to allocate more expertise and resources towards providing standardised and accessible care for these mothers, thereby reducing the incidence of stillbirths and promoting maternal and infant health.
Conclusion
The findings of this study shed light on the myriad challenges faced by mothers following the loss of a stillbirth, emphasising the critical need for comprehensive support services to assist them in overcoming these hurdles. Moving forward, future research endeavours should focus on exploring coping strategies and developing targeted interventions to bolster the coping mechanisms of these mothers, thereby enhancing their overall well-being and resilience in the face of such devastating loss.
Strengths and limitations
This study’s small sample size and qualitative approach may limit the generalisability of findings. Conducted at a single district hospital, its transferability to other populations may be restricted. However, it is one of the first studies on this topic, guided by a theoretical framework and offering firsthand insights from women who experienced stillbirth.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. All supporting data for this manuscript have been made available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Ghana Health Service Ethical Review Board with a protocol number (GHS-ERC: 033/04/22). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We extend our sincere gratitude to all the mothers who participated in the interviews, despite enduring their profound loss. Additionally, we express our appreciation to the authors whose work has been referenced in this study.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors ON contributed to the conceptualisation, writing the manuscript, drafting the manuscript for publication and reviewing the manuscript. EAO contributed to the analysis, data interpretation, writing the manuscript and drafting the manuscript for publication. DR contributed to the writing of the manuscript, drafting the manuscript for publication and reviewing the manuscript. AM contributed to the analysis, data interpretation, writing the manuscript and drafting the manuscript for publication. All authors read and approved the final manuscript. ON, EAO, DR and AM accepted full responsibility for the finished work and/or the conduct of the study, had access to the data and controlled the decision to publish. The author responsible for content as the guaranter is ON.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests There are no competing interests for any author.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.