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Care Around Stillbirth and Neonatal Death (CASaND) Clinical Practice Guideline

Social and emotional support

The experience of pregnancies after perinatal loss can be stressful and cause anxiety. Many parents will experience mixed emotions and conflict between their desire for another baby and fear of potential adverse outcomes.4,6,48

It is important to avoid making assumptions about how parents will grieve or the support they will need in a subsequent pregnancy.

Parents who have previously experienced the death of a baby are at increased risk for anxiety, depression, and posttraumatic stress in subsequent pregnancies and into the postpartum period.6,49,50 Grief, anxiety, fear, vulnerability, stress, guilt, and worry are common and may be heightened at certain points in pregnancy and as the birth approaches.5,9,11,33,51 Parents may continue to experience disenfranchised grief, societal stigma, and feelings of shame and guilt in their subsequent pregnancies.52,53 This can greatly affect parents’ coping and decision making around care planning.

It is important to acknowledge and manage parents’ anxiety in subsequent pregnancies. For example, parents may have a strong desire to monitor their baby’s movements at home using heart rate monitoring equipment or may seek reassurance through increased interactions with healthcare professionals and services.4,7,11,54 However, resulting feelings of relief and reassurance may be short lived.5,11 For other parents, avoiding interactions with healthcare professionals following sub-optimal care in their previous pregnancy may need to be addressed. The need for reassurance may increase at certain points in pregnancy such as at the gestational age when the previous baby died. It is essential that health care professionals discuss and anticipate these points in pregnancy and after birth, so that appropriate support and referrals can be offered.51,55 Specialised antenatal education classes for pregnancy after loss may provide parents with a safe space to discuss concerns and worries and provide access to further support and appropriate referrals.11 As subsequent pregnancies can be filled with fear and anxiety, pregnancy may not be enjoyable or celebrated. Connecting with others through peer support can be particularly helpful in countering social isolation.11,31Journaling (for example through diaries)56 and relaxation strategies may also be beneficial for coping with pregnancy-related anxiety and fear.56

It is essential to consider all those affected by each perinatal loss. Feelings of loss and grief are experienced by fathers/partners, who also need validation and support. It may be beneficial to take a family-centred approach by including partners, siblings, and grandparents in appointments, teaching sessions, and discussions about fears and concerns including opportunities for questions 24,52

These emotional reactions seemed to carry over into the subsequent pregnancy with partners having “difficulty trusting that things would be all right” and feeling “stressed and hypervigilant.”24

Some parents may refrain from or have difficulty forming a bond and attachment with the baby during pregnancy due to fear of further loss.54 This may present as parents not giving their baby a name, not preparing practically for their baby, and/or not attending medical appointments.48,51,57,58 Healthcare professionals should ask parents about their preparations for the baby and acknowledge the unique challenges of pregnancy and parenting after previous loss.11 Parents may also benefit from open discussions with health care professionals about the possible stresses that may be experienced postpartum, including delayed parent attachment with their baby, and breastfeeding and parenting challenges.4,54

Women with a history of stillbirth are at increased risk for adverse pregnancy and mental health outcomes including longer-term parenting difficulties.59 Psychological distress increases the risk of poor pregnancy outcomes and longer-term parenting difficulties.59 However, access to support during subsequent pregnancies is generally offered less than other types of care such as additional antenatal appointments.9,10 It is important to identify parents experiencing complex or intense grief responses who may benefit from professional follow-up and support after perinatal loss.60 However, there is little evidence to support the use of mental health screening tools in pregnancies following loss. It is important that all parents receive information and referral to professional support services (such as counsellors, psychologists) with expertise in perinatal mental health.

All parents should be provided with information on local support groups and a list of resources specific to subsequent pregnancies.51,59,61 Peer support is valued by many families and may counteract social isolation and normalise certain experiences in subsequent pregnancies.11

Red Nose and Bears of Hope provide a range of support options, including professional grief counselling and peer support. The Pink Elephants Support Network provides peer support programs (including Peer Support Live Chat), emotional support resources for parents following early pregnancy loss, including workplace programs to better support parents returning to work. In Aotearoa New Zealand, parents and families/whānau who experience perinatal loss can receive support from a range of support groups, organisations, and resources (see Baby Loss Directory). 

National perinatal emotional support and mental health is available through PANDA, ForWhen, and Gidget Foundation Australia. The Centre of Perinatal Excellence has an online directory that can be filtered by location to show perinatal mental health services in Australia. The Centre for Perinatal Psychology provides a national directory of psychologists with expertise in counselling and support around perinatal loss. The Perinatal Loss Centre also maintains a therapist register to enhance access to counselling support across Australia.

Evidence-based recommendation 5.14

Evidence quality: Moderate confidence

Engage parents in open discussions about the challenges of pregnancy and parenting after loss by:

  • anticipating and supporting parents through points in pregnancy and after birth that may be particularly distressing, such as pregnancy milestones and certain settings
  • acknowledging the mixed emotions relating to the joy of having a baby and the ongoing grief of previous loss 
  • asking about preparations for the baby to help identify and support parents who may experience impediments to parenting such as delayed attachment and bonding.

Evidence-based recommendation 5.15

Evidence quality: Moderate confidence

Ask parents about their social and emotional wellbeing and support needs at all antenatal and postnatal care appointments, in addition to routine mental health screening. Appropriately refer to support services where needed.

  • Provide information on how to access outpatient peer support, professional counselling and psychology services and other local and national perinatal mental health and parenting support services.
Management of a subsequent pregnancy
Section 5 references
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Western Pacific Regional Office of the International Stillbirth Alliance
Coordinating Centre, Stillbirth and Neonatal Death Alliance, Perinatal Society of Australia and New Zealand

Level 3, Aubigny Place
Mater Research Institute
Raymond Terrace,
South Brisbane QLD 4101
The University of Queensland Faculty of Medicine

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