Framework for Bereavement Care After Perinatal Loss: Affected Parents’ Perspective and Healthcare Providers’ Perspective at Kenyatta National Hospital, 2020. A Descriptive Cross-sectional Study

Abstract

Background: Within a year of a loss of pregnancy, about 20% of mothers develop some form of psychological disorder, with anxiety and depression being the commonest. If the disorders are not managed, progression to serious psychiatric disorders such as postpartum psychosis disorder (PPD) has been reported. PPD afflicts 1-2/1000 women of a childbearing age in the first two to four weeks following an unsuccessful pregnancy and can affect the future pregnancies of bereaved mothers and relationships with infants. To prevent such outcomes, support for bereaved mothers after a perinatal loss, which includes delivery of bad news with sensitivity, provision of a private space for mourning, and referrals for psychological support are some components of bereavement care. However, whether healthcare workers at Kenyatta National Hospital (KNH) adhere to these standards is not understood as the framework for bereavement care after perinatal loss has not been evaluated. Moreover, the bereavement care experience of patients has not be evaluated in this setting. We used the Donabedian model to evaluate its structure, processes, and outcomes in this health facility. Broad Objective: To evaluate the framework for bereavement care after perinatal loss at Kenyatta National Hospital as perceived by the affected parents and health care providers. Methodology: This was a mixed methods study at KNH maternity unit. Seventy-three (73) parents who had experienced a stillbirth were recruited consecutively as they were identified at KNH, a bereavement care experiences questionnaires completed, and the participants offered the opportunity to participate in parent/couple in-depth interviews or a Focus group discussion scheduled on a later date. After consenting, a pretested questionnaire was used to capture the socio-demographics of the parents and healthcare providers, reproductive characteristics of women such as parity, any obstetrics complication, characteristics of infants such as the gestation at birth, sex, and cause of death. Bereavement care structure and process was also evaluated. The perceptions of parents on intrapartum care and the postpartum care offered during labor and delivery was also captured and a focused group discussion scheduled with 7 randomly chosen parents. Five couples (10 parents) took part in in-depth interviews (IDIs). The In-depth interviews and focus group discussion (FGDs) were conducted using semi-structured interview guide and moderated by the research assistant. Healthcare workers (65) who were randomly recruited also completed an observational checklist on best bereavement care practices and key informant interviews moderated and recorded by the principal investigator (PI) for ease of reference. Quantitative data was analyzed using Microsoft Excel. Frequency-distributions and proportions have been used to explain demographic and reproductive characteristics. IDIs and FGDs recordings were transcribed and data analyzed using content analysis to arrive at themes. Dedoose version 8.0.35 was used for qualitative data analysis while STATA Version 15 was used for quantitative analysis. Findings: Of the 73 parents recruited, 71 (97%) were female, while 75% had post primary education. Most were Christian (97%), employed (49.0%), and received antenatal care (ANC) (96%). The median (interquartile range) number of contacts reported to be 4 (3-5). Only 34% had pregnancy complications, mostly hypertensive disease in pregnancy (54.0%). Overall, 56.8%, 41.3% and 34.8% reported positive bereavement care experiences in the antepartum, intrapartum, and postnatal periods respectively. In most cases, the loss of a child was not communicated effectively by health care workers (HCWs). counseling was necessary yet lacking, while families, especially spouses were not engaged in bereavement care. In most cases, a conducive environment for mourning loss was lacking. Of the 65 HCWs interviewed, 66% were female and 63% were nurses in the maternity unit. Only 17% had received training on bereavement care with only 44.3% were adhering to the best practices of bereavement care on how to handle patients who experience perinatal loss. Around 94%...............................................................................