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Proof of Life Protocol: Pre-Twenty Week Loss and Grief

THE IMPACT OF A BEREAVEMENT INTERVENTION ON LEVELS OF GRIEF IN PREGNANT WOMEN WHO EXPERIENCE PRE-TWENTY WEEK LOSS. Proof of Life Protocol: Pre-Twenty Week Loss and Grief. Presented by: OLINDA PRUITT JOHNSON, PhD. RNC, CNS. Statement of the Problem.

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Proof of Life Protocol: Pre-Twenty Week Loss and Grief

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  1. THE IMPACT OF A BEREAVEMENT INTERVENTION ON LEVELS OF GRIEF IN PREGNANT WOMEN WHO EXPERIENCE PRE-TWENTY WEEK LOSS Proof of Life Protocol: Pre-Twenty Week Loss and Grief PRE-TWENTY WEEK LOSS AND GRIEF Presented by: OLINDA PRUITT JOHNSON, PhD. RNC, CNS

  2. Statement of the Problem The purpose of this research study was to evaluate the impact of implementing a bereavement intervention on levels of grief in women experiencing perinatal loss between the gestational ages of 12 to 19 weeks, and 6 days (or a fetus weighing less than 500 grams) compared to women who receive the usual standard of care following a perinatal loss PRE-TWENTY WEEK LOSS AND GRIEF

  3. Background • One in six pregnancies are lost before the 20th week • Losses can be devastating for woman and family • Society considers perinatal death a private affair ; actual impact goes underreported or under recognized • 12-31% of all conceptions terminate in early or late fetal death Craven and Wise(2000) • Abma & Henshaw (1999) reported a rate of spontaneous abortions (unplanned and unexpected) about 16% • Regardless of gestational age the loss of a pregnancy can be devastating and is associated with some level of grief, anxiety and or depression PRE-TWENTY WEEK LOSS AND GRIEF

  4. Background Over the last thirty years there has been remarkable improvements in caring for a loss greater that twenty weeks or over 500gms The care of perinatal loss under twenty weeks is focus on physical needs and minimal emotional or psychological interventions are provided Most care is provided in isolated ER’s Follow –up in Gyn Clinics verses Postpartum clinics PRE-TWENTY WEEK LOSS AND GRIEF

  5. A randomized controlled trial was conducted utilizing a two group posttest only design. N=40 Research Design PRE-TWENTY WEEK LOSS AND GRIEF

  6. For the purpose of this study,the Neuman System Model was utilized as the conceptual framework for women experiencing perinatal loss under twenty weeks gestation Theoretical Framework PRE-TWENTY WEEK LOSS AND GRIEF

  7. Betty Neuman Model PRE-TWENTY WEEK LOSS AND GRIEF

  8. Theoretical Framework The NSM model provides a solid theoretical foundation for this study. The primary stressor is perinatal loss. This perinatal loss causes a disruption in the FLD which are unable to contain the stress reaction which leads to a disruption in the client’s NLD. As a result, she is no longer in a homeostatic state and physical and psychological reactions to the perinatal loss (grief) are evident. The lines of resistance are activated to protect the client and at this point a secondary level of intervention is required to return her to a steady state. The clients’ ability to stop the reaction and return to homeostasis is dependent on her support systems and core resources as well as appropriate health care intervention. The use of a prescribed evidence-based, secondary nursing intervention should mitigate the degree of reaction (grief) to a stressor (early perinatal loss) and return or reconstitute the individual system to a stable state. PRE-TWENTY WEEK LOSS AND GRIEF

  9. Do women who experience early perinatal loss (12-20 weeks or less than 500 grams of fetal weight) and seek care at a county funded hospital and receive a perinatal bereavement intervention in the ER demonstrate decreased levels of perinatal grief at their two-week follow-up appointment, as compared to those women who are in the attention control group? Research Question/Hypothesis PRE-TWENTY WEEK LOSS AND GRIEF

  10. Setting • Subject acquisition, consent obtainment • and data collection occurred on the 2nd • floor of the Obstetrical Emergency Center (OBEC) • of Lyndon B. Johnson General Hospital, a county facility. The OBEC provides care for over 1,500 women with pregnancy complaints per month. One-third (500) are admitted to Labor and Delivery from the OBEC and an estimated forty (40) women per month are treated for pregnancy loss under twenty weeks in the OBEC. • The follow-up visit occurred in a private exam room in the Obstetric-Gynecology (Ob-Gyn) Clinic on the 2nd floor. PRE-TWENTY WEEK LOSS AND GRIEF

  11. Sample • The population of study were women experiencing pre-twenty week loss in a county obstetrical emergency center. The sample of 40 women, were divided evenly into an experimental and a control group, for this study. The sample size, for this study was based on an effect size of .57 using a power of .8 and an alpha of .05 for an independent student’s t-test (Cohen,1965). The effect size was determined from two meta-analysis studies that evaluated educational interventions for improvement of patient care (Driel & Keijser, 1995; Theis & Johnson 1995). These meta-analytical studies reported effect sizes that ranged from 0.46-0.57 for primary prevention and patient education. PRE-TWENTY WEEK LOSS AND GRIEF

  12. Table 1 Frequencies of Selected Demographic Characteristics broken down by group PRE-TWENTY WEEK LOSS AND GRIEF

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  15. Instruments • Perinatal Grief Scale • (measures grief in women who experience loss) • Translated 22 languages • 33 Items • Total Score 0f 33-165 • Higher score =more grief • Alpha = .96 • Lasker& Toedter (1989) • Our Study • Alpha =.96 • Homogenous groups PRE-TWENTY WEEK LOSS AND GRIEF

  16. Bereavement Intervention • Medical Professional Guidelines: • Providing care for the family experiencing perinatal loss, neonatal death ,SIDS or other Infant deaths. (Not used in previous research) • Follow-up telephone call 1 week after loss. PRE-TWENTY WEEK LOSS AND GRIEF

  17. Bereavement Protocol • 1. Evaluate clients level of need. • 2.Offer and encourage discussion of pregnancy and loss experience. • 3. Notify chaplain regardless of gestational age • 4. Naming ceremony • 5. Baptize (if possible) • 6. Memory box : Review contents with family Includes list of support web sites. • 7. Note pad for writing a letter to the unborn • 8. Self address envelope MEMORY BOX CONTENTS BLANKET/SMALL GOWN CAMERA STUFF ANNIMAL BRACELETS DATE /TIME Copy of Lab(Beta HcG) PRE-TWENTY WEEK LOSS AND GRIEF

  18. Treatment of Data • Data was be analyzed using the Statistical Package for the Social Sciences 15.0 (SPSS) Data from the demographic questionnaire was analyzed using descriptive statistics of frequencies and percentages with means and standard deviations being calculated for all interval and ratio level data. • A Student’s t-test for independent groups was used to answer the research question: whether exposure to a bereavement intervention would have impact levels of grief (total score on PGS: (33-165) in pregnant women who experience pre- twenty week loss. Higher score the greater the grief. PRE-TWENTY WEEK LOSS AND GRIEF

  19. Results • Total PGS scores indicated no significant differences between the two groups on overall levels of grieving (t=2.518 p=.065) • Examination of 3 subsets of the grieving process reveals no differences in the active grief processes or coping processes for the 2 groups • There were significant differences in the levels of despair between the 2 groups (t=38 p=.000) • Despair, is complex form of grieving that is seen when coping mechanisms fail to ameliorate the grief reaction • The experimental group displayed significant lower levels of despair PRE-TWENTY WEEK LOSS AND GRIEF

  20. Conclusion • The study concluded that the bereavement intervention was effective in ameliorating the degree of the grief reaction as measured by levels of despair in low income, women experiencing an early pregnancy loss. PRE-TWENTY WEEK LOSS AND GRIEF

  21. Impact on Clinical Practice • Utilization of a bereavement intervention on all women experiencing loss regardless of gestational age • Inclusion of the women in decision making on what level of care is needed to help them resolve grief after loss • A bereavement assessment has been added to the screening tool in the electronic medical record at the institution PRE-TWENTY WEEK LOSS AND GRIEF

  22. This study needs to be replicated using a larger and more diverse sample of women including those with varying socioeconomic status receiving care at private as well as public institutions. • Future studies need to measure grief at several points after the pregnancy loss to better explore the grief process over time and to examine the relationships between active grief, coping, and despair. Future Studies PRE-TWENTY WEEK LOSS AND GRIEF

  23. Proof of Life • Follow up on all women • The participation in the study validated the pregnancy • Staff felt more open to discuss the loss in the follow up clinic (Change appointments PP Clinic visit) • Registry to report loss >20 weeks /500grams PRE-TWENTY WEEK LOSS AND GRIEF

  24. References References • Craven,D.,&Wise,L.A.(2000). The epidemiology of recurrent pregnancy loss. Seminars in Reproductive Medicine,18,331-339 • Ventura,S,.Mosher,W., Curtain,S., Abma,J., &Henshaw,S.(1999) Highlights of Trends in Pregnancies and Pregnancies Rates by Outcome: Estimates of the United States, 1976-96. National Vital Statistics Reports; 47(29) PRE-TWENTY WEEK LOSS AND GRIEF

  25. WEB SITES FOR SUPPORT • A Place to Remember • Babyloss.com (U.K.) • Brief Encounters • Born Still but Still Born • Center for Loss in Multiple Birth, Inc. • The Compassionate Friends • Gentle Birth (loss resources from a midwifery perspective) • Hygeia Foundation & Institute for Perinatal Loss and Bereavement • Infants Remembered in Silence • M.E.N.D. (Mommies Enduring Neonatal Death) • MISS Foundation • Pregnancy.org: Dealing with Childbearing Complications • Pregnancy and Infant Loss.org • Pregnancy Loss and Infant Death Alliance • SANDS Stillbirth and Neonatal Death Society (Australia) • SANDS Stillbirth and Neonatal Death Society (England) • SHARE Pregnancy and Infant Loss Support • StorkNet: Pregnancy/Infant Loss PRE-TWENTY WEEK LOSS AND GRIEF

  26. QUESTIONS PRE-TWENTY WEEK LOSS AND GRIEF

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