Grief

When a Baby Dies: Reflections on Perinatal Bereavement Care

How to think about caregiving re: parental bonding, grief, & holding the baby.

Posted Mar 24, 2019

If you are a caregiver who is unfamiliar with or new to the world of perinatal bereavement, like many of us at first, you may feel bewildered by modern standards of care. A lot of what is considered gold standard might be seen as strange, morbid, misguided, or confusing. You may even notice that some of your colleagues are dismissive or put off by this work. Indeed, this work is not for the faint of heart, nor the judgmental. Still, even if we are drawn to this work, we tend to hold fast to preconceived ideas and myths about bonding, death, dying, dead bodies, grief, mourning, and effective parent support. This series of posts attempts to clear the decks and put forth a comprehensive way to think about perinatal bereavement care in terms of why bereaved parents want what they want and how to support their efforts to fulfill their own desires. When you can think clearly about these 2 key issues, you can boost your ability to integrate sound practices and intentionally provide the care you actually want to provide to grieving parents. Welcome to this sacred work.

A Short History

Birth and death collide when a baby dies during pregnancy, birth, or shortly thereafter.  This is frightening, complicated terrain, and unfortunately, we haven’t always done a great job of navigating it with parents. That's because, into the mid-1900s, as birth and death were shifted from home to hospital, traditional wisdom and mourning rituals were discarded in favor of this conventional medical wisdom: "Parents shouldn't grieve for a baby they’ve never really gotten to know." It followed that parents should be spared from seeing their babies, lest the vision deepen their bond and lead to an intense or lengthy mourning period. Doctors and nurses were generally trained to whisk away dead and dying babies after birth and to encourage parents to “move on and have another.” Of course, caregivers meant well, in that they wanted to protect parents from unnecessary grief and suffering. Unfortunately, there was little awareness that they were doing more harm than good. And during this era of “medical professionals know best,” parents were not consulted nor seen as able to determine what would actually be beneficial for themselves.

The Missing Link: Understanding Bonding

This “whisking away” practice was based on the false premise that parents don’t bond with their babies until after birth. Starting in the 1960s, this myth was challenged by two pioneering researchers, pediatricians Marshall Klaus and John Kennel, who observed parenting distress and disorders resulting from separating parents from sick newborns who needed intensive care.

Klaus and Kennel established that bonding is a natural, biological process, consisting of nurturing behaviors and feelings of devotion, largely resulting from the hormones that come with pregnancy and birth. This biological process prepares parents to physically, mentally, and emotionally devote themselves to the care of their new baby. Indeed, parents can start to invest in this child as soon as they start trying to conceive, or when they first discover they’re pregnant. Their devotion continues to deepen with joyfully anticipated experiences like hearing the heartbeat, viewing ultrasound images, and feeling intrauterine movement. Parental bonding grows throughout pregnancy, and especially for mothers, can be well developed before birth. Bonding continues with a “sensitive period” at birth, where close contact helps to strengthen parents’ attunement and willingness to nurture their new baby. Contact also helps satisfy those strong feelings of devotion, allowing parents to express their biologically-primed devotion and parenting drives, which also improves outcomes for babies.

As a result of these findings, hospitals starting changing maternity, newborn, and newborn intensive care practices. New policies included encouraging labor support by doula, the father’s presence, breastfeeding ASAP after birth, rooming in, and skin-to-skin contact between parents and infant.

But what about parents whose babies are dying or dead?

It's only natural to wonder whether these bond-promoting policies apply to bereaved parents.

  • Doesn’t spending time with their babies strengthen their bond and render grief more intensely painful?
  • Can we short-circuit the parent’s bond, feelings of devotion, and parenting drives?
  • Doesn’t separating parents from their babies protect them from painful memories, such as witnessing dying and death?
  • Isn’t it morbid and strange for parents to spend time with their dying or dead babies?
  • Isn’t it a kindness to keep dying or deceased babies away from parents?

In an extension of their work, Kennell and Klaus observed that when a baby dies, the parental bond doesn’t break. Since then, research has shown that parental devotion doesn’t evaporate when parents are denied contact with their baby after birth or advised to “forget about this child and have another.” Instead, when parents are denied and prodded to “move on,” they feel bereft, misunderstood, abandoned, lost, and disenfranchised, which only leads to a deeper despair.

So, contrary to conventional thinking, whisking away babies does not protect parents from pain. Instead, this actually creates unnecessary grief and suffering by deepening the parents' sense of loss. How? By trying to deny the undeniable instead of honoring it. Separation essentially

  • contradicts the biologically-based parenting drive;
  • invalidates parents’ natural desire to see, hold, and take care of their baby’s body;
  • undermines parents’ need to meet their baby, in order to make this baby real, to affirm this little life, and to know for whom they grieve;
  • denies parents the therapeutic benefits of expressing their love and devotion in tangible, physical ways;
  • deprives parents of the chance to create cherished memories and gather keepsakes;
  • withholds the comfort parents can reap from memories and keepsakes as they mourn;
  • robs parents of the only opportunity they get to lean into their roles as parents to this child;
  • disrupts the social support that could be offered by friend and relatives who could meet the baby, witness the parents’ devotion, and understand their grief;
  • strips parents of their right to determine for themselves whether, how, when, and where they can spend time with their baby;
  • adds to their feelings of grief, despair, and lack of control.

In contrast, parents can benefit enormously when the undeniable is acknowledged and the philosophy of care becomes precious little should come between parents and their babies after birth AND the parent knows best.  What does this look like in practice? The caregiver establishes a warm rapport and has an ongoing compassionate conversation with parents about their baby, their feelings, and what experiences and rituals would be meaningful to them-- perhaps offering unbiased information about what other parents have found meaningful-- and then the caregiver follows the parents' lead, without judgment. This kind of care trusts the parents' competence, reinforces their self-determination, honors their roles as mother or father, validates their grief, affirms their baby’s importance, and supports them in fulfilling their desires to nurture their baby as much as possible. And parents can feel gratitude where they might have otherwise felt regret.

The next post looks at how to reframe the suffering we witness in parents, and the value of accompanying them through their suffering rather than jumping in to protect them.

References

Black BP, Wright PM, Limbo, R. Perinatal and Pediatric Bereavement in Nursing and Other Health Professions. New York: Springer Publishing, 2015.

Davis, DL. Empty Cradle, Broken Heart: Surviving the Death of Your Baby (3rd ed). Golden, CO: Fulcrum, 2016,

Klaus MH, Kennell JH, Klaus, PH. Bonding: Building the Foundations of Secure Attachment and Independence (rev ed). New York: Da Capo Lifelong Books, 1996.

Leon I. Helping Families Cope with Perinatal Death. Chapter 81 in Glob Lib Womens Med, 2008. https://www.glowm.com/resources/glowm/cd/pages/v6/v6c081.html?SESSID=fq3h4kl3dk5g8878qiq13f51f1

Peppers L, Knapp R: Motherhood and Mourning: Perinatal Death. New York, Praeger, 1980.