Communication, Training, and Debriefing After Stillbirth in U.S. Hospitals: A National Survey.

Background: Stillbirth is a devastating event for families as well as hospital staff. Hospital practices around internal and external staff communication, debriefing, and training are unknown. Methods: We systematically sampled U.S. hospitals that provide obstetrical care. Staff knowledgeable of bereavement care on labor and delivery were invited to participate in an anonymous survey linked to hospital descriptors. We evaluated stillbirth communication, debriefing, and training for staff. Results: We received 289 usable surveys from 429 eligible staff (67% response). Most (94%) noted hospitals' marked rooms housing bereaved families, but only a third (37%) reported a marker on the paper or electronic medical record. Half of the hospitals had no standard debriefings post-loss, and 38% reported no perinatal loss training for labor and delivery nurses. Conclusions: Hospitals have significant variations and gaps in staff communication, support, and training, which are key aspects of respectful stillbirth care.

Gaps in Stillbirth Bereavement Care: A Cross-Sectional Survey of U.S. Hospitals by Birth Volume.

OBJECTIVES: The quality and scope of perinatal bereavement care in the United States has been evaluated by surveying bereaved parents, but little is known about how care varies across hospitals. We sought to survey clinicians about stillbirth bereavement care practices at U.S. hospitals and to evaluate care by hospital birth volume. METHODS: Using American Hospital Association data, we employed stratified random sampling to select 300 hospitals from all centers with at least 100 annual deliveries. Within each state, we divided all hospitals into size quartiles and randomly selected from each until we reached the goal number per state. We then identified a staff member knowledgeable about typical bereavement care on labor and delivery at each hospital and sent an on-line survey about care. We linked survey data with hospital characteristics and used summary statistics, Chi squared, and Fisher's Exact test to compare care by hospital birth volume. RESULTS: We reached an eligible respondent at 429/551 hospitals and 396 of the 429 (73%) agreed to participate. We received 289 usable surveys for an overall response rate of 67%. Only one third of hospitals (n = 96, 33%) reported staff protected time for perinatal bereavement care. Of 17 bereavement topics, just six were routinely offered by at least two-thirds of the hospitals. Financial limitations and staff shortages were the most commonly identified barriers to care and were most pronounced at small-volume hospitals. CONCLUSIONS FOR PRACTICE: This study offers a snapshot in bereavement care and identified important gaps for both large and small hospitals.

Online Support Groups for Perinatal Loss: A Pilot Feasibility Study for Women of Color.

We tested use of an online support group for women of color who had experienced stillbirth or early infant loss. We recruited recently bereaved mothers and asked them to participate in an existing online community for pregnancy and infant loss hosted on a commercial platform. Participants were asked to go online at least three times weekly for 6 weeks to read posts. Using a mixed-methods approach, we assessed attitudes toward online support, mental health, and experiences pre- and postintervention using written surveys and a brief phone interview. We used summary statistics for quantitative data and a deductive coding approach for qualitative data. Twenty participants completed the study. We found nonsignificant improvements in all four mental health domains (depression, post-traumatic stress disorder, moderate-severe generalized anxiety, and perinatal grief). Women reported the group allowed them to help others and feel less alone. They also reported that at times, posts could increase the intensity of their loss emotions. This study demonstrated feasibility to recruit, retain, and track participation in an online support group for perinatally-bereaved mothers of color. Although the study was not powered for outcome, all mental health measures showed nonsignificant improvements, suggesting value in further investigating online social support for improving women's mental health after perinatal loss. Clinical Trial Registration: Registered on clinicaltrials.gov [NCT04600076], October 19, 2020.

MOMSonLINE: Lessons Learned From a Feasibility RCT of Online Support for Mothers Bereaved by Perinatal Loss.

Online support groups are popular for peer support, particularly for uncommon or stigmatized topics including pregnancy and infant loss. We conducted a randomized, controlled, 6-week feasibility study of three groups: an anonymous BabyCenter.com loss support group, a closed Facebook loss group, or a control group. Intervention arm mothers were asked to sign on to their support sites for 6 weeks. Participants completed regular surveys, text message surveys after each log-in, and a final semistructured phone interview. Thirty women were randomized to each arm of the study. Women reported preference for anonymous groups and found it empowering to support others, although many noted an emotional cost to reading postings. Tracking usage online was a major issue despite multiple strategies to collect these data. This pilot demonstrated feasibility of a randomized trial for online perinatal support but noted a critical need for more reliable methods to track usage.

Prenatal Point-of-Care Tobacco Screening and Clinical Relationships.

PURPOSE: Up to one-third of female smokers with Medicaid deny tobacco use during pregnancy. Point-of-care urine tests for cotinine, a tobacco metabolite, can help to identify women who may benefit from cessation counseling. We sought to evaluate patient and clinician perspectives about using such tests during prenatal care to identify smokers, with particular focus on the impact of testing on clinical relationships and the potential for tobacco cessation. METHODS: We conducted 19 individual interviews and 4 focus groups with 40 pregnant or postpartum women covered by Medicaid who smoked before or during pregnancy. Patients also took the urine cotinine test and received sample results. Interviews were conducted with 20 health care practitioners. We analyzed the transcripts using an inductive approach and developed a model of how prenatal testing for cotinine could affect the patient-clinician relationship. RESULTS: Patients were more likely than clinicians to believe that testing could encourage discussions on tobacco cessation but emphasized that the clinician's approach to testing was critical. Clinicians feared that testing would negatively affect relationships. CONCLUSIONS: Despite having reservations, low-income patients had a surprisingly favorable view of using point-of-care urine testing to promote smoking cessation during pregnancy, which could increase the availability of cessation resources to women who do not disclose their tobacco use to clinicians.

Are participants in face-to-face and internet support groups the same? Comparison of demographics and depression levels among women bereaved by stillbirth.

Support groups can help individuals cope with difficult health situations but have been understudied for women with perinatal bereavement. An early study suggested those using internet support groups had high rates of positive depression screens, raising the question whether these users were more symptomatic than those in similar face-to-face support groups. We therefore conducted two convenience sample surveys of women bereaved by perinatal loss, one looking at use of online support groups and the other in-person support groups. The surveys identified demographics, use of peer support, potential confounders, and current depression symptoms using the Edinburgh Postnatal Depression Scale (EPDS). Four hundred sixteen women from 18 internet groups and 60 women from 13 in-person groups met inclusion criteria. Participants in both groups were predominantly Caucasian, highly educated, and had private insurance. Severe depression symptoms were similar in the two groups despite the different modalities. Women in both face-to-face or internet groups for pregnancy and perinatal loss demonstrated similar scores on depression screens. Women of color, poor, and less-educated women were starkly underrepresented in both types of groups, raising questions about knowledge of support options, barriers to use, preferences for bereavement support, and optimization of groups for a broader population.

Depression and Posttraumatic Stress Symptoms After Perinatal Loss in a Population-Based Sample.

INTRODUCTION: Perinatal loss is often a traumatic outcome for families. While there are limited data about depressive outcomes in small populations, information about depression and posttraumatic stress disorder among large racially and economically diverse populations is sparse. METHODS: We collaborated with the Michigan Department of Community Health to conduct a longitudinal survey of bereaved mothers with stillbirth or infant death under 28 days of life and live-birth (control) mothers in Michigan. The study assessed 9-month mental health outcomes including self-reported symptoms of depression and posttraumatic stress disorder along with information about demographics, pregnancy and loss experience, social support, and past and present mental health and treatment. RESULTS: Of 1400 women contacted by the State of Michigan, 609 completed surveys and were eligible to participate for a 44% response rate (377 bereaved mothers and 232 control mothers with live births). In multivariable analysis, bereaved women had nearly 4-fold higher odds of having a positive screen for depression and 7-fold higher odds of a positive screen for post-traumatic stress disorder after controlling for demographic and personal risk variables. A minority of screen-positive women were receiving any type of psychiatric treatment. CONCLUSION: This is the largest epidemiologically based study to date to measure the psychological impact of perinatal loss. Nine months after a loss, bereaved women showed high levels of distress with limited rates of treatment. Symptoms need to be monitored over time for persisting disorder and further research should identify women at highest risk for poor outcomes.

Anxiety disorders and obsessive compulsive disorder 9 months after perinatal loss.

OBJECTIVE: Perinatal loss (stillbirth after 20 weeks of gestational age or infant death in the first month) impacts one to two infants per hundred live births in the United States and can be a devastating experience for parents. We assessed prevalence of anxiety disorders and obsessive compulsive disorder (OCD) among bereaved and live-birth mothers. METHODS: We collaborated with the Michigan Department of Community Health to survey Michigan mothers with perinatal death or live birth. We measured symptoms of generalized anxiety disorder, social phobia, panic disorder and OCD using validated written self-report screens and collected data on maternal demographics, psychiatric history, social support and intimate partner violence. RESULTS: A total 609/1400 mothers (44%) participated, returning surveys 9 months postdelivery. Two hundred thirty-two mothers had live birth, and 377 had perinatal loss. In unadjusted analyses, bereaved mothers had higher odds of all four disorders. In logistic regression adjusted for covariates, bereaved mothers still had higher odds of moderate-severe generalized anxiety disorder [odds ratio (OR): 2.39, confidence interval (CI): 1.10-5.18, P = .028] and social phobia (OR: 2.32, CI: 1.52-3.54, P < .0005) but not panic disorder or OCD. CONCLUSION: Bereaved mothers struggle with clinically significant anxiety disorders in the first year after perinatal loss; improved identification and treatment are essential to improve mental health for this vulnerable population.

Assessment of "fresh" versus "macerated" as accurate markers of time since intrauterine fetal demise in low-income countries.

OBJECTIVE: To compare provider assessment of fetal maceration with death-to-delivery interval to evaluate the reliability of appearance as a proxy for time of death. METHODS: Cohort chart abstraction was performed for all stillbirth deliveries at or above 28 weeks of gestation during a 1-year period in a teaching hospital in Ghana. RESULTS: Of 470 stillborn infants, 337 had adequate data for analysis. Of 47 fetuses alive on admission with death-to-delivery intervals estimated to be less than 8 hours (expected to be reported as fresh), 14 (30%) were actually reported as macerated. Of 94 cases in which the fetus was deceased on admission with death-to-delivery interval of more than 8 hours (expected to be macerated), 17 (18%) were described as fresh. CONCLUSION: Provider description of fetal appearance may be an unreliable indicator for time since fetal death. The findings have significant implications for stillbirth prevention and assessment.

Internet message boards for pregnancy loss: who's on-line and why?

BACKGROUND: Pregnancy loss is common, but its significance is often minimized by family, friends, and the community, leaving bereaved parents with unmet need for support. This study sought to describe demographics, usage patterns, and perceived benefits for women participating in Internet pregnancy loss support groups. METHODS: We requested permission to post an anonymous Internet survey on large and active United States Internet message boards for women with miscarriages and stillbirths. The study purposefully oversampled stillbirth sites and included both closed- and open-ended questions. The University of Michigan Institutional Review Board approved the study. Closed-ended questions were summarized and evaluated with bivariate analysis. We performed a qualitative analysis of open-ended data using an iterative coding process to identify key themes. RESULTS: Of 62 sites queried, 15 granted permission to post the survey on 18 different message boards. We collected 1,039 surveys, of which 1,006 were complete and eligible for analysis. Women were typically white, well educated, and frequent users. They noted message boards helped them to feel less isolated in their loss and grief and they appreciated unique aspects of Internet communication such as convenience, access, anonymity, and privacy. Pregnancy loss message boards are an important aspect of support for many bereaved mothers. African-American women seem to be substantially underrepresented on-line despite being at higher risk for stillbirth. CONCLUSION: Internet message boards serve a unique function in providing support for women with miscarriage and stillbirth. The benefits are often significantly different from those encountered in traditional face-to-face bereavement support.

Dose escalation of a curcuminoid formulation.

BACKGROUND: Curcumin is the major yellow pigment extracted from turmeric, a commonly-used spice in India and Southeast Asia that has broad anticarcinogenic and cancer chemopreventive potential. However, few systematic studies of curcumin's pharmacology and toxicology in humans have been performed. METHODS: A dose escalation study was conducted to determine the maximum tolerated dose and safety of a single dose of standardized powder extract, uniformly milled curcumin (C3 Complextrade mark, Sabinsa Corporation). Healthy volunteers were administered escalating doses from 500 to 12,000 mg. RESULTS: Seven of twenty-four subjects (30%) experienced only minimal toxicity that did not appear to be dose-related. No curcumin was detected in the serum of subjects administered 500, 1,000, 2,000, 4,000, 6,000 or 8,000 mg. Low levels of curcumin were detected in two subjects administered 10,000 or 12,000 mg. CONCLUSION: The tolerance of curcumin in high single oral doses appears to be excellent. Given that achieving systemic bioavailability of curcumin or its metabolites may not be essential for colorectal cancer chemoprevention, these findings warrant further investigation for its utility as a long-term chemopreventive agent.