title: From grief, guilt pain and stigma to hope and pride - a systematic review and meta-analysis of mixed-method research of the psychosocial impact of stillbirth.
abstract: BACKGROUND
  Despite improvements in maternity healthcare services over the last few decades, more than 2.7 million babies worldwide are stillborn each year. The global health agenda is silent about stillbirth, perhaps, in part, because its wider impact has not been systematically analysed or understood before now across the world. Our study aimed to systematically review, evaluate and summarise the current evidence regarding the psychosocial impact of stillbirth to parents and their families, with the aim of improving guidance in bereavement care worldwide.
  
  
  METHODS
  Systematic review and meta-summary (quantitative aggregation of qualitative findings) of quantitative, qualitative, and mixed-methods studies. All languages and countries were included.
  
  
  RESULTS
  Two thousand, six hundred and nineteen abstracts were identified; 144 studies were included. Frequency effect sizes (FES %) were calculated for each theme, as a measure of their prevalence in the literature. Themes ranged from negative psychological symptoms post bereavement (77 · 1) and in subsequent pregnancies (27 · 1), to disenfranchised grief (31 · 2), and incongruent grief (28 · 5), There was also impact on siblings (23 · 6) and on the wider family (2 · 8). They included mixed-feelings about decisions made when the baby died (12 · 5), avoidance of memories (13 · 2), anxiety over other children (7 · 6), chronic pain and fatigue (6 · 9), and a different approach to the use of healthcare services (6 · 9). Some themes were particularly prominent in studies of fathers; grief suppression (avoidance)(18 · 1), employment difficulties, financial debt (5 · 6), and increased substance use (4 · 2). Others found in studies specific to mothers included altered body image (3 · 5) and impact on quality of life (2 · 1). Counter-intuitively, Some themes had mixed connotations. These included parental pride in the baby (5 · 6), motivation for engagement in healthcare improvement (4 · 2) and changed approaches to life and death, self-esteem, and own identity (25 · 7). In studies from low/middle income countries, stigmatisation (13 · 2) and pressure to prioritise or delay conception (9) were especially prevalent.
  
  
  CONCLUSIONS
  Experiencing the birth of a stillborn child is a life-changing event. The focus of the consequences may vary with parent gender and country. Stillbirth can have devastating psychological, physical and social costs, with ongoing effects on interpersonal relationships and subsequently born children. However, parents who experience the tragedy of stillbirth can develop resilience and new life-skills and capacities. Future research should focus on developing interventions that may reduce the psychosocial cost of stillbirth.
authors.affiliation: NIHR Clinical Lecturer in Obstetrics and Gynaecology, University of Bristol, School of Social & Community Medicine, Obstetrics and Gynaecology, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK. christyburden@hotmail.com.
authors.forename: Christy
authors.initials: C
authors.lastname: Burden
authors.affiliation: Primary Care Librarian, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK. stephanie_bradley@hotmail.co.uk.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Bradley
authors.affiliation: International Stillbirth Alliance, London, UKᅟ. storey.claire@yahoo.com.
authors.forename: Claire
authors.initials: C
authors.lastname: Storey
authors.affiliation: Specialist Registrar, Obstetrics & Gynaecology, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK. hills.alison@googlemail.com.
authors.forename: Alison
authors.initials: A
authors.lastname: Ellis
authors.affiliation: Maternal & Fetal Health Research Centre, Institute of Human Development, University of Manchester, Manchester, UK. Alexander.Heazell@manchester.ac.uk.|St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK. Alexander.Heazell@manchester.ac.uk.
authors.forename: Alexander E P
authors.initials: AE
authors.lastname: Heazell
authors.affiliation: School of Health, University of Central Lancashire, Brook Building, Lancashire, PR1 2HE, UK. SDowne@uclan.ac.uk.
authors.forename: Soo
authors.initials: S
authors.lastname: Downe
authors.affiliation: School of Social Work, Arizona State University, Phoenix, AZ, USA. jcaccia@me.com.
authors.forename: Joanne
authors.initials: J
authors.lastname: Cacciatore
authors.affiliation: Obstetrics and Gynaecology, University of Bristol, School of Social & Community Medicine, Obstetrics and Gynaecology, Southmead Hospital, Westbury on Trym, Bristol, BS10 5NB, UK. jsiasakos@me.com.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Siassakos
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D005220:Fathers / Q000523:psychology; D005260:Female; D006117:Grief; D006167:Guilt; D065026:Hope; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D009035:Mothers / Q000523:psychology; D011247:Pregnancy; D036301:Qualitative Research; D011788:Quality of Life; D057545:Social Stigma; D050497:Stillbirth / Q000523:psychology*