Several years ago an excellent editorial appeared in JNM called “Bereavement: Who Counsels the Counselor?” (1). The author remained anonymous to protect the identity of the client. This need for anonymity was real and allowed the author to express her feelings freely. In the several years since that editorial, few mechanisms of support have been developed to assist a midwife with the grief and complex emotions that accompany fetal or neonatal loss.
Twelve-step self-help programs such as Alcoholics Anonymous, Al-Anon, and Overeaters Anonymous coined the phrase, “We are only as sick as our secrets.” The atmosphere of secrecy that surrounds the emotions of newborn death discourages healing and promotes ill health for both the midwife and the profession. Senior midwives must mentor junior midwives along these difficult trails. This can only be done, however, if senior midwives have paid proper homage to their own healing process. Some senior midwives may be perceived as emotionally unavailable, threatened, and frightened by their own experiences with perinatal death; too often junior midwives find that they have simply joined a club of secrecy and shame. They may feel some comfort in networking with others who live with pain and shame; but, clearly, healing cannot take place without some therapeutic intervention. Historically, this is reminiscent of the secrecy and shame that surrounded childbirth. Certified nurse-midwives (CNMs) know well that education, support, and the sharing of experience are the ingredients that transform childbirth into an experience of empowerment. The profession needs to apply these tools to the subject of newborn deaths.
I was a midwife for almost 6 years before I experienced my first bad outcome. More than a year later, it is still a haunting experience. Although my professional life continues to be filled with many joyful births, it does not take much to rekindle the vivid nightmares of that experience and to relive the acid adrenalin nausea of impending disaster that overwhelmed me as the CNM responsible for the care of this woman and her new baby. The enormity of my responsibility is awesome. We all know in our heads that some births will not have happy endings, no matter what we do. We, as midwives, know that science cannot explain all phenomena; nature has rules that she follows which we may never understand. We cannot control the power of nature, life, sickness, birth, and death. Yet, guilt and regrets linger over clinical decisions and judgments made and “funny feelings” or instincts not adhered to. At such times, collegial offerings of empathetic kindness are vital to facilitate the midwife's healing process.
After a fetal or newborn death, diminished self-esteem and a depressed sense of confidence are to be expected. The clinical jitters set in and any woman who presents with a clinical ingredient reminiscent of the clinical mixture from the unfavorable past experience will be evaluated fully. In reality, this is probably a positive result unless the midwife is no longer willing to trust his or her own clinical judgment. If the midwife is so scared that s/he begins searching for disease, then clinical support and supervision by an available and acknowledged senior CNM consult may be necessary for a period of time.
I have spoken to many midwives during my own grieving/healing process. Each response has been a gift. Usually, the midwife has a similar story to tell. When s/he does, unfinished business from the original trauma comes up. I have been told of crying alone in the middle of the night, nightmares of grotesque dead and dying fetuses, and recurrent unwarranted clinical fears. Food and other substance disorders may unconsciously be used to numb overpowering feelings. Some midwives have actually left the profession as a result of unresolved dead baby experiences. It would be worthwhile to investigate physical and emotional illnesses associated with unresolved midwife grief. It would also be worthwhile to explore with physician colleagues how they resolve their feelings of grief when they encounter death. Studies have shown that defendant physicians in medical malpractice litigation cases experience a wide range of distressing emotions and increased stress that may disrupt their personal lives, their families, their relations with patients, and medical practices. Attorneys and claims adjusters tell physicians to speak to no one about any aspect of a case; the American College of Obstetricians and Gynecologists notes that literal adherence to this vow of silence may lead to “isolation, increased stress, and dysfunctional behavior” (2). The College suggests peer and professional counseling as well as support groups to help with this situation.
Midwives have found creative ways to facilitate personal integration of their negative experiences. Some have intensified spiritual experiences including belief in reincarnation. One midwife went for a session with an American Indian medicine man who told her she was filled with “dead baby spirits” and gave her suggestions for healing. Psychotherapy, meditation, dream analysis, and hypnosis have been very helpful for some. Creative outlets such as writing and painting help others. Meditative time alone as well as time spent with friends and family have helped heal the wounded sense of self.
Having direct responsibility in the case of a newborn death is a daunting experience. It has the potential to be humbling and empowering as our role takes perspective in the light of these natural forces: humbling in the sense that birth and death take their appropriate place in life transformation and empowering because we are given the opportunity to integrate this experience into our being. If the accompanying despair and soul-searching elicited by the unexpected tragedy is respected and allowed expression, the result will be personal empowerment: increased clinical vision and astuteness, increased confidence, increased empathy, and increased ability to love and to receive love.
My deepest concern is that the midwifery profession has not implemented mechanisms to facilitate the integration of bad outcomes. The term “bad outcome” denotes a value that has a punitive attitude, eg, the “bad child,” “bad behavior,” “bad baby.” These are adjectives of shame. They assume an ability to control outcome. The euphemism bad outcome implies collective feelings of guilt and inability to express depth of feeling, pain, and confusion that the tragedy entails. I propose that we eliminate the term “bad outcome” from our midwifery vernacular and more openly refer to neonatal or fetal death (as the case may be). The integration of newborn death experiences into our lives is a personal and internal process; it also includes public exposure. Many times the personal process and public exposure interact.
After a fetal or neonatal death, the medical chart needs to be thoroughly reviewed by the midwife and clinical director to determine adherence to accepted protocols, accurate documentation, clarity of charting, and completeness. Were clinical protocols followed throughout? Was appropriate follow-up done throughout? Was charting clear? Does it accurately reflect prenatal care? Does it specifically reflect the actual incident and the events leading up to it? The chart is a legal document. Has it been reviewed by a medical law expert? Does the CNM need to keep in writing the events of the incident in a file at home? If CNMs have soul-searching questions about their clinical judgments, speed of their responses to adverse situations, sequence of performing emergency skills, or simply guilt, sorrow, anger, and regret that an event has occurred—how can they express them? If they keep a journal and write all of these feelings down, is that journal a legal document? Can it be subpoenaed? The complexity of the issues for midwives include having to maintain a legal defensive response and still find a safe harbor for natural human ponderings and critical self-examination.
It can be both threatening and painful for most midwives to listen to their colleagues questioning their own clinical judgment and skill performance, especially if the listener has been the midwife involved in a prior fetal death incident. One's own haunting nightmares seem to reopen at the same doorway that had previously been closed, even locked. The experience seems to be a nightmare recurrence rather than a stream that flows. For the midwife, it's like being stuck in transition. It seems likely that midwives do not receive appropriate emotional supervision for the integration of a tragic clinical experience. How do we carry our responses to the next woman in labor who has fresh excitement for the hope of birth? We may feel anger at this happy, naive mother for not realizing the daunting responsibility the CNM undertakes for the mother and newborn. We might convey our anxiety about the outcome of this birth to the mother and, in so doing, inadvertently increase her own fears.
Everyone is affected by a fetal/newborn death. We know that the emotional impact on the midwife who had primary responsibility for the birth is great. There is also a powerful impact on CNM colleagues, staff, and clients. As the involved midwife is reviewing the events and his/her own management decisions, so is everyone else who is peripherally involved. CNM colleagues may be so thrown into their own personally unresolved neonatal death memories, that they are rendered unable to be constructive. Some CNMs may need to acknowledge possible flaws in their own management. A flaw in management can be defined as a judgment error including an instinct not followed—a mistake that in most other professional fields might only require a minor adjustment to correct. Stakes are much higher in the midwifery profession, however. Flaws can only be corrected the next time. How does the responsible CNM live with his or her flaws? How do we live with each other's flaws? How do physicians and other health care providers overcome their professional deficits?
In many CNM practices, clients have their own communications network that may be facilitated by childbirth class participation and waiting room conversation. Often, clients get the information surrounding the fetal death informally from each other. The information may or may not be accurate. How do the CNMs and health care provider colleagues handle this? What information can be shared? Who should our clients' questions be referred to?
CNMs should have some understanding of the process of grieving from the well-known writings of Kubler-Ross; in addition, most midwifery education programs provide information on bereavement counseling of the client. Nevertheless, midwives may not be the appropriate professionals to provide follow-up counseling for a particular family, especially in situations in which the midwife triggers painful memories that are better expressed to a midwife unassociated with the event or if the midwife senses she is being blamed. Regular follow-up with the family is invaluable; this may simply be check-in telephone calls, referrals, and meetings with the family.
The danger for the CNM in follow-up is knowing when his or her role as bereavement counselor/referral agent/facilitator must end or change. Some grieving new mothers and families bond with the attending midwife as a form of transference and this is far beyond the scope of midwifery practice. CNMs are not psychotherapists and, thus, have not been trained in psychic detachment. If this transference is going on, it may be unconsciously mutual. The midwife is also getting unconscious needs met in this type of relationship. Unconscious needs include self-punishment if one feels guilty for the incident (even if no guilt is clinically warranted), over-identification with the grieving mother as if the lost baby were one's own lost internal or external child, or a need to avoid one's own painful feelings because of fear/terror. CNM colleagues must be aware that the involved midwife is also in a grieving process, whether s/he expresses it or not.
The grief of a midwife includes loss of opportunity for a healthy baby, loss of the baby, loss of self-confidence (clinically and personally), feelings of isolation, and fears for the future including legal liability and loss of licensure. These fears may or may not be based on reality, but they are still real feelings and must be addressed. As midwives, we must address our own limitations and fears in order to be better care providers for ourselves, our clients, and our colleagues.
Like obstetricians, midwives must live with the knowledge that fetal/newborn deaths will happen again. As a profession, we must prepare ourselves for these horrific events and be prepared to facilitate a healing process, and it is imperative that we begin now. We need more skills and more help. Implications for the future include the following:
- 1The American College of Nurse-Midwives could sponsor continuing education workshops to focus on the unique needs of CNM professional grief. The results of these workshops could be used to develop protocols for CNM practices that address professional needs in the grieving process. Preliminary findings could also identify research questions for further investigation.
- 2Educational programs need to include in their curricula content on the grieving midwife and the healing process. Currently, the modular curriculum includes bereavement counseling for the client, but this is not adequate.
- 3CNMs must develop mechanisms to facilitate and to evaluate the healing experience. In one practice, a workshop retreat facilitated by a midwife-friendly psychotherapist was held to provide a safe environment for the entire CNM staff to explore their personal and interactive responses to the newborn death experience. Part of healing is the open acknowledgment of the seriousness of the event.
- 4Collegial sharing of bereavement processes with other health care professionals, eg, obstetricians and perinatologists, might increase awareness through mutual respect and understanding.
To facilitate breaking the silence of newborn loss, the Journal of Nurse-Midwifery urges the development of a nationally based support group that focuses on the bereavement needs of the professional CNM. This support network should be easily accessible and a safe haven. Through sharing our personal experiences, renewed hope can be born.