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

Education and training for healthcare professionals

Education, training, and support are critical enablers for best practice care following perinatal death. This includes formal educational initiatives and informal debriefing and sharing of experiences with colleagues. Studies show opportunities for professional development and training enable healthcare professionals to build confidence and knowledge to feel more equipped to deliver care,19,23-28 build self-awareness of their own needs,29,30 and to feel supported in their role by their workplace.31-33 This supports workforce capacity and sustainability.4,34,35

Healthcare professionals have a major role in helping parents to make decisions that minimise regret and avoid missed opportunities.6,7,36 Inappropriate or insensitive care can disempower parents. This can make an already potentially traumatic event worse for bereaved parents.17 Healthcare professionals must be prepared for a wide range of responses that may not reflect their own values or expectations.26 Providing perinatal loss care is a stressful and challenging area of practice for many healthcare professionals and they require skills to support parents, including knowing where and how to seek their own support, and the ability to develop resilience to ensure the longevity of their career and to avoid burnout. Providing appropriate and high quality perinatal loss care requires healthcare professionals to understand the law, policy, practices, and clinical care standards related to reporting perinatal deaths. This is particularly pertinent for termination of pregnancy for medical reasons.

Healthcare professionals play a central role across the continuum of care from the moment of bad news, through birth and postpartum, and into future pregnancies.8

Healthcare professionals often report feeling underprepared to provide perinatal loss care,37 and may require support to address gaps in their knowledge, experience, or training. Some seek mentoring and exposure to real-life experiences with support from experienced healthcare professionals.37 Healthcare professionals’ perceptions may contribute to low autopsy rates, which have been steadily decreasing across many high-income country settings.38,39 This may be because of perceived lack of qualifications and training to discuss autopsy with parents, a desire to avoid uncomfortable discussion, and fear of adding stress and burden on bereaved parents and families/whānau. Further, healthcare professionals may underestimate the value of investigations such as perinatal autopsy.40 Training for staff in developing a rapport with parents and addressing emotional distress may help to overcome barriers to consent for an autopsy.28 It is also important for healthcare professionals to be aware of and understand cultural, religious, or spiritual influences on decision making around investigations, such as need for burial to occur within a specified time and for the baby’s body to remain intact.41 Having a dedicated role/service within maternal and newborn services can help services ensure optimal care in investigation of perinatal deaths. Ideally, this role/service would include training for staff to meet the needs of parents and families/whānau regarding options for postmortem investigations.  

In Australia, the National Stillbirth Action and Implementation Plan (the Plan) proposes the development and implementation of a national evidence-based, culturally safe education program for care around stillbirth and neonatal death.42 IMPROVE is a national educational program based on the PSANZ/Stillbirth CRE Clinical Practice Guideline for Care Around Stillbirth and Neonatal Death.43 The Plan also recommends undergraduate education in stillbirth prevention and management.

Healthcare professionals in Australia and Aotearoa New Zealand can access online training resources to learn how to provide culturally responsive best practice care. The WellMob website contains resources for non-Indigenous health workers in Australia. Developed by Aboriginal and Torres Strait Islander people, the WellMob training resources can help health workers understand cultural identity, grief and Sorry Business, appropriate language use, the impact of trauma and intergenerational trauma, and other social and emotional wellbeing topics. The Australian Refugee Health Practice Guide contains information to support healthcare professionals to take a trauma-informed approach to care for women of refugee background. In Aotearoa New Zealand, healthcare professionals can complete Working with Māori e-learning modules to learn how to provide respectful health care that includes parent-centred decision making. The modules are endorsed by the Royal New Zealand College of General Practitioners.

IMPROVE is offered as a face-to-face workshop and is based on the SCORPIO (Structured, Clinical, Objective Referenced, Problem-based, Integrated and Organised) educational model designed for skills training. This workshop involves small groups of learners rotating between six interactive learning stations that are each facilitated by an experienced educator. IMPROVE workshops have been run in Canada, Fiji, Spain, United Kingdom, the Netherlands, and Vietnam, with content updated to align with the local context. Evaluations of the IMPROVE workshops conducted between May 2012 and May 2015 found high levels of satisfaction with the workshop and increased confidence following completion of the workshop.44 The IMPROVE educational program is also available as an e-learning module in Australia and Aotearoa New Zealand. Like the face-to-face workshop, this online training package of six courses is designed to support healthcare professionals respond to women and families/whānau who have experienced stillbirth, conduct and better understand perinatal autopsy and mortality reviews, and communicate findings with bereaved parents. The e-learning component of IMPROVE was launched in December 2019 and recently evaluated by 1,339 participants (1,074 midwives [80.2%]) in Australia and Aotearoa New Zealand.45 Most participants evaluated the program as helpful and useful (94.7%), engaging (90.9%), and likely to lead to change in their clinical practice (80.7%).

In Australia, other educational training programs include the Stillbirth Investigations and Bereavement Care education program, ISLA Grief and Loss training for maternity services. Miracle Babies Foundation deliver The Butterfly Initiative course to provide guidance to healthcare professionals in providing bereavement support to families/whānau who experience the loss of a baby in a multiple pregnancy. InUTERO provides healthcare professional education for stillbirth awareness for prevention.46,47 The Perinatal Training Centre provides a relationship-based training program for perinatal loss.

In Aotearoa New Zealand, VCA – Vicki Culling Associates provides education and training for perinatal and infant loss and range of resources for whānau. VCA also provides a Baby Loss Directory of support organisations and services.

Consensus-based recommendation 8.8

All healthcare professionals should be aware of and familiar with the law, policy, practices, and clinical care standards related to reporting stillbirths and neonatal deaths.

Evidence-based recommendation 8.9

Evidence quality: Moderate confidence

Maternal and newborn services should make available specific professional development opportunities in care around stillbirth and neonatal death to all staff. The Improving Perinatal Mortality Review and Outcomes Via Education (IMPROVE) educational program has been well received by healthcare professionals across Australia.

Consensus-based recommendation 8.10

Organisations must provide and maintain effective cultural education for all healthcare professionals particularly non-Indigenous health professionals. Education must include:

  • cultural awareness and understanding of diversity within and between cultural groups
  • understanding of implicit biases and ongoing racism for some population groups
  • impact of colonisation for some populations, particularly Aboriginal and Torres Strait Islander communities in Australia and Māori communities in Aotearoa New Zealand
  • awareness of history of trauma and loss, and previous negative experiences with health services particularly:
    • intergenerational trauma among Aboriginal and Torres Strait Islander families
    • complex trauma among women of refugee background
  • acknowledge the importance of each cultural group’s vital support systems such as kinship and community care for Aboriginal and Torres Strait Islander families.
Approach to care
Supporting healthcare professional wellbeing
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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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