Holding a stillborn baby: does the existing evidence help us provide guidance?

In Australia, stillbirth is defined as the loss of a fetus of at least 20 weeks’ gestation, or 400 g birth weight if gestational age is unknown. Every year in Australia there are 1750 stillbirths.1 Several studies have reported that stillbirth, regardless of how it is managed, can have long-lasting detrimental psychological effects on the mother. Factors such as young maternal age, more recent loss and lower education level result in greater anxiety and depression in mothers after experiencing a stillbirth.2 Post-traumatic stress disorder (PTSD) has also been reported in higher levels in mothers following a stillbirth.3 Furthermore, various factors in immediate management following a stillbirth can impact on outcomes for the parents; these include the contentious issue of parental contact with a stillborn child.

Before the 1980s in Australia, parents of stillborn children were not permitted to see the baby and were advised to quickly conceive again.4 However, since a shift in dogma, the majority of current guidelines recommend that parents be encouraged to see and hold their dead child. The American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and United Kingdom Royal College of Obstetricians and Gynaecologists all consider parental contact with the stillborn child to be “good practice”. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists endorses the guidelines laid out by the Perinatal Society of Australia and New Zealand regarding the management of stillbirths, which recommend parents be informed that they can hold, undress and bath the baby, and that staff should offer to assist parents in these processes.5

According to the literature, the effects of holding the stillborn child are uncertain. The main concerns regarding current recommendations stem from data suggesting that higher levels of depression and PTSD occurred in pregnant women if they had held their stillborn child.3 The number of studies assessing the effects of holding a stillborn child is limited, with most being reported by two major research groups from England and Sweden (Box). It is important to note that the available research has been conducted in developed countries, and that reported findings may not necessarily retain relevance for other cultures or developing nations.

In follow-up cohort studies, 52%–68% of women were reported to have held their stillborn child.3,6-7 Interestingly, in a more recent large-scale survey conducted in 2004–2005, 90% of women had held their stillborn child,2 reflecting the shift to “good practice” dogma.

In subsequent pregnancy, one study found that women who experienced PTSD during this time continued to have symptoms of PTSD 7 years on;6 and higher levels of anxiety during subsequent pregnancies have been reported in mothers who had held their stillborn baby, but symptoms did not persist.2 Infant attachment disorganisation was reported to be more likely following maternal symptoms of anxiety and depression during pregnancy and when a mother had held her stillborn child in a prior pregnancy.3 Partnership breakdown has been found to be significantly greater among parents who had held their stillborn child, as well as being associated with maternal PTSD and perceived lack of support from the partner at the time of stillbirth.6 It is possible that there is a complex and unmeasured interplay between baseline psychological symptoms, partnership instability and the choice to hold the stillborn child, which may have biased these findings.

Data on the effects of holding the stillborn child specific to Australian practice are scarce. One study included parents of babies stillborn between 1984 and 1986 in Australia and supports the more recent evidence that subsequent pregnancy causes a tendency towards increased anxiety symptoms in those who had seen or held their prior stillborn child.4 Also in the 1980s, an examination of the maternal grieving response after perinatal death in Australia showed poorer health and greater social adjustment problems among those with low perceived support from health professionals, and in those who saw but did not hold the baby.9

The studies evaluating the effects of holding a stillborn baby are not directly comparable, with differing study populations, tools and outcome measures. There are possible inherent differences between those who elect to hold their child versus those who do not, but a randomised controlled trial in order to account for these differences may be considered unethical. Overall, despite conflicting evidence, it appears that the negative symptoms experienced after holding a stillborn child are transient, and mostly exacerbated by subsequent pregnancy, which would understandably be a stressor for the mother. There does not appear to be clear evidence of a benefit for parents in holding a stillborn child, so it would seem that the most appropriate approach, given the available evidence, would be to support the parents to make their own choice.

Most studies have evaluated the effects that contact with the stillborn child had on the psychological disposition of the mother. Very few studies included the effects on the father or the siblings of the stillborn child — no quantitative and long-term data are available.

A 12-year prospective study on parental choices following prenatal mortality in the United States found that most parents stated that they wanted contact with their child, information and ongoing support.10 The authors of the report recommended providing information and allowing choice for all possible interventions following stillbirth, rather than a strict protocol.10 Persuasion of a reluctant parent may add to the trauma of the experience and consequent adverse psychological outcomes; conversely, mothers who actively chose to see their baby have been shown to have lower symptoms of depression.2 It has been reported that most parents make the choice expected of them regarding seeing and holding their stillborn child,3 so providing unbiased options is essential. Furthermore, seeing and holding the child, but not for as long as the mother wished, led to higher rates of depressive symptoms,2,8 highlighting the need to allow parents to spend as much time with their stillborn child as they wish.

While it has been reported that pregnancy within 5 months of a stillbirth resulted in higher anxiety levels,4 not conceiving again within 3 years was associated with higher rates of depression.8 It is advisable that parents do not rush immediately into a further pregnancy, as was recommended 30 years ago. That subsequent pregnancies appear to be a stressor for transient reactivation of depression and anxiety symptoms2,4,6 should not deter parents from trying to conceive again, but it does suggest that there could be benefit in clinicians providing additional counselling support to mothers during pregnancies subsequent to a stillbirth. There are also not-for-profit organisations such as SANDS (Stillbirth and Neonatal Death Support) that offer one-to-one or group support for parents, informative publications and educational services.1

Until further evidence brings greater certainty, all parents should be immediately offered balanced advice to help them choose whether or not to see and hold their stillborn baby, and, subsequently, made aware of the support that is available to them.