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The experience of stillbirth

Stillbirth has a significant impact on parents, health professionals and wider society and yet related research, policy and practice remains low-profile internationally. Worldwide, the stillbirth rate in 2015 was 18.4 stillbirths per 1000 total births1 (Lawn et al., 2016). This rate varied considerably from country to country, although the majority of stillbirths (98%) occurred in lowand middle-income countries (LMIC). In high-income countries (HIC) the rate varied from 1.3 to 8.8 per 1000 births. The experience of stillbirths produces an under-recognised burden on health and well-being and there is an opportunity for psychology to provide leadership in supporting families and healthcare professionals through this experience. The role of psychology is not only evident because of the support needed for the estimated 4.2 million women who are living with depression associated with previous stillbirth (Heazell, Slassakos, & Blencowe et al. for the Lancet Ending Preventable Stillbirths Series study group, with the Lancet Ending Preventable Stillbirths investigator group, 2016), but also because even a brief overview shows many opportunities for psychosocial intervention. The majority of stillbirths in HIC occur in the antepartum period and may be associated with preventable lifestyle factors such as obesity and smoking (Flenady, Wojcieszek, & Middleton et al. for the Lancet Ending Preventable Stillbirths study group & The Lancet Stillbirths in High-Income Countries Investigator Group, 2016). Social disadvantage also plays a role. In the UK, women who are pregnant and live in socially deprived areas are 50% more likely to experience a stillbirth or neonatal death compared to women who live in less socially deprived areas (Manktelow et al., 2016). Ultimately, the most challenging psychosocial problem is addressing the grief of parents which is largely hidden. In a systematic review of the psychosocial impact of stillbirth by Burden et al. (2016), a key theme identified in the meta-summary was feeling isolated and stigmatised as the experience of being a parent without a child was not recognised by society. Fathers especially reported feeling left out and marginalised by their experience. In higher-income settings, approaches to supporting women following a stillbirth changed considerably during the 1990s when the approach of directly addressing the grieving process began to be addressed. A population-based survey by Radestad, Steineck, Nordin, and Sjogren (1996) in Sweden raised awareness of the importance of immediate sensitive management in preventing psychological complications after stillbirth. The findings highlighted the importance of promoting a quiet, supportive environment after the birth of the baby directly when a mother is supported to engage with her baby in whatever way she wants rather than being prescriptive about procedure and activity. Radestad et al. (1996) also raised concerns that the then relatively new approach of confronting the grieving process may raise problems if staff are inflexible in the application of care protocols. This concern is still very pertinent 20 years later. A systematic review which aimed to provide evidence to help understand and improve care after stillbirth found that maternity care staff identified a number of emotional, knowledge and system-based barriers to providing effective care (Ellis et al., 2016). These included not enough time, complexity of paperwork, being emotionally overwhelmed, the need for coping strategies such as avoidance and a lack of knowledge of cultural and social differences around the grieving process. Staff reported a lack of confidence in supporting bereaved parents, and while some reported the