Perinatal loss includes loss due to miscarriage, ectopic pregnancy, termination of pregnancy, stillbirth, and neonatal death. It is a devastating experience which, for some families, can have a significant impact on mental health.
Global prevalence rates of perinatal loss are estimated to be around 30%. In the UK, registration data from 2018 indicates that 1 in every 150 births results in stillbirth or neonatal death, while 1 in 4 pregnancies end in miscarriage. Grief due to perinatal loss is complex and highly personal and may involve experiences of loss of parenthood status and reproductive story, loss of self, feelings of biological failure, and fears of stigma related to the loss. Death at this time is often not acknowledged in the same way as loss at other times of life, making it hard for families to gain support or feel that their grief is legitimate. Indeed, for some, the experience of ‘giving birth to death’ can feel like a taboo subject, creating social isolation at a time when support is so important. Furthermore, for a substantial number of stillbirths, there is no recognised cause of death, which makes it hard to create any meaning or narrative around the experience. These factors can impact the development of mental health disorders for grieving parents and, indeed, reports of symptoms of depression and anxiety following loss are common (Gold et al, 2014; 2016).
In the UK, the NHS Long Term Plan (LTP, 2019), which sets out the priorities for the health service over the next 10 years, included ambitions to reduce stillbirth and neonatal mortality alongside several priorities for perinatal mental health services. Amongst these was the provision of ‘maternity outreach clinics’ – since renamed Maternal Mental Health Services (MMHS) – which are specifically intended to support families who suffer perinatal loss (as well as birth trauma and fear of childbirth). This is an important step forward for our health service and provides recognition of the enormous impact that loss can have and the need for specialist support.
To provide evidence-based interventions for women, research is needed which can identify the most promising interventions to support good family outcomes. The current paper is a global review of psychosocial interventions for perinatal loss and, as such, provides a useful contribution to this (Shaohua & Shorey, 2021). It aims to “evaluate the effectiveness of psychosocial interventions in reducing depression, anxiety, and grief among parents after perinatal loss”.
Death in the perinatal period is often not acknowledged in the same way as loss at other times of life, making it hard for families to gain support or feel that their grief is legitimate.
Methods
The authors used the PRISMA guidelines for their review, searching key databases, reference lists, grey literature and specialised target journals. They used search terms related to perinatal loss and mental health. To be included, papers had to report randomised controlled trials (RCTs) of psychosocial interventions for heterosexual parents who had experienced any type of perinatal loss and were less than two years postpartum. Outcomes included depression, anxiety and/or grief, and were principally self-report questionnaire measures.
After duplicates were removed and full texts screened, 17 papers were identified that met the criteria. These papers were assessed for quality using the Cochrane Collaboration’s tool for risk of bias.
The authors used meta-analysis to explore the impact of psychosocial interventions on the three outcomes. This means that the results of different studies are pooled together to determine overall trends and give a more robust finding than individual studies. One limitation of this is that some studies don’t report enough detail about their findings to be included. Where this was the case, the authors used a narrative synthesis.
The authors also used subgroup analyses to explore the impact of different features of interventions on parental mental health. This included number of sessions, type of loss, delivery method, and healthcare professional.
Results
Interventions took a variety of formats, including individual, group, couple and family based. They included psychological approaches (e.g. cognitive behavioural therapy), psychoeducation, bereavement interventions (e.g. memorial services) and supportive interventions (e.g. peer support).
Twelve studies included symptoms of depression as an outcome and eight included anxiety. There was a statistically significant reduction in symptoms for both outcomes, with a small effect size (d = 0.46 and d=0.34 respectively).
Seven trials included grief as an outcome and there was a significant reduction in symptoms following an intervention, with a medium effect size (d=0.51).
Due to variability in the studies in terms of features of the intervention, the authors undertook subgroup analyses. They found no differences in outcomes whether the interventions were delivered face to face or technology assisted, no differences based on the number of sessions, and no differences based on the profession of the person delivering the intervention. There were some small differences depending on the type of loss, with impacts being lower in interventions that targeted parents who had experienced miscarriage compared with interventions that targeted loss through termination of pregnancy or mixed types of loss.
Three studies did not have sufficient data to be included in the meta-analysis and so were summarised separately. Two of these studies reported non-significant findings for couple-based counselling, while one reported reductions in depression and grief for individual counselling.
An important finding was that the overall quality of evidence for all three outcomes was low. Many studies had small sample sizes and showed risk of bias, for example, poor randomisation and blinding. This means that the significant findings should be interpreted with caution.
Parents who received psychosocial treatment for perinatal loss had overall significant reductions in symptoms of depression, anxiety, and grief.
Conclusions
It is heartening that there are a variety of interventions for perinatal loss being offered and tested, and that there is some evidence of positive impacts on parental mental health. Nevertheless, as is often the case, the main conclusion is that we need better quality evidence to ensure that resources are being targeted in ways that benefit families the most.
Better quality evidence is needed to identify the most beneficial interventions for families.
Strengths and limitations
The review had a clearly focused question and used broad search terms across multiple databases, increasing the likelihood that all relevant studies were captured. A standardised quality assessment tool was used, and the use of meta-analysis allowed an objective appraisal of the evidence with increased power to detect effects.
The key limitation of this review is the low overall quality of the included studies and the variability and heterogeneity in terms of interventions, population, and time of measurement. This makes it hard to draw conclusions from the results about the most promising interventions for parental mental health following perinatal loss. Nevertheless, this is an important area of study and hopefully, the review will stimulate further research which can overcome some of the limitations.
The findings must be treated with caution due to the low overall quality and heterogeneity of the included studies in this review.
Implications for practice
As with any clinical population, the most effective intervention is prevention. While not all perinatal loss can be prevented, the NHS Long Term Plan aims to reduce rates of stillbirth and neonatal death by improving timely access to specialist care (for more details see here).
Alongside this, while grief is a natural reaction to experiencing loss, symptoms of depression and anxiety may be mitigated by improved community support. Overcoming the taboo and encouraging open conversations about loss can reduce isolation and allow families to acknowledge the impact. This can reduce stigma or shame, enhance peer support from others with similar experiences, and provide a language to talk about what’s happened to process the experience. This type of support is currently being offered by organisations such as SANDS (Stillbirth and Neonatal Death) and the Miscarriage Association. Widening this support to include health services and other community contexts may further improve outcomes for families and reduce the likelihood of developing mental health difficulties.
Where parents do need additional psychological input, it remains important to build evidence of the most effective ways to support parents following a loss so that resources can be targeted effectively. Therefore, the hope is that the new Maternal Mental Health Services are evidence-generating, recording details of interventions and collecting outcomes so that they can contribute towards improvements in services over time.
Improved community support following a perinatal loss can reduce the likelihood of grief developing into parental mental health problems.
Statement of interests
There are no conflicts of interest.
Links
Primary paper
Shaohua, L. & Shorey, S. (2021) Psychosocial interventions on psychological outcomes of parents with perinatal loss: A systematic review and meta-analysis, International Journal of Nursing Studies, 117, 103871. https://doi.org/10.1016/j.ijnurstu.2021.103871
Other references
NHS England. (2019). The NHS Long Term Plan. Retrieved from www.longtermplan.nhs.uk
Gold, K.J., Leon, I., Boggs, M.E., Sen, A., 2016. Depression and posttraumatic stress symptoms after perinatal loss in a population-based sample. J. Womens Health (Larchmt) 25 (3), 263–269. https://doi.org/10.1089/jwh.2015.5284
Gold, K.J., Boggs, M.E., Muzik, M., Sen, A., 2014. Anxiety disorders and obsessive compulsive disorder 9 months after perinatal loss. Gen Hosp Psychiatry 36 (6), 650–654. https://doi.org/10.1016/j.genhosppsych.2014.09.008
https://www.miscarriageassociation.org.uk/
Photo credits
- Photo by Sylwia Bartyzel on Unsplash
- Photo by Angel Luciano on Unsplash
