Introduction

Perinatal loss, defined as the death of a baby during pregnancy, at the time of birth, or shortly after birth, has a profound impact on expecting parents [1–3]. In the United States (U.S.), the stillbirth ratio (loss before birth at ≥20 weeks’ gestation per 1,000 total births) was 5.73 per 1,000 with a total of 21,000 stillbirths reported in 2023 [4,5]. The World Health Organization (WHO) published a statement on respectful maternity care, including dignified maternal care for grieving parents [6]. Similarly, and more recently, the United Nations Interagency Group for Child Mortality Estimation (UNIGME) recommended providing the highest quality bereavement care by providing comprehensive and ongoing training and support to all members of the teams providing maternity care [7]. Despite these recommendations and guidelines, the needs of bereaved parents’ are frequently unmet [8–10].

Perinatal loss has a great effect on parents and has been cited to cause intense psychological distress [1]. A recent systematic review found that the most frequently reported symptoms after stillbirth were high rates of depressive symptoms, anxiety, post-traumatic stress, suicidal ideation, panic and phobia [11]. Psychological outcomes may also depend on the healthcare professionals’ ability to provide effective bereavement support, as it has been demonstrated that training and education are essential for both bereaved parents and their healthcare providers, fostering better communication, shared decision-making, and acknowledgement of parenthood [10].

Similarly, the effectiveness of the provision of bereavement care and support is vital for both long- and short-term psychological outcomes, as recently cited by qualitative focus groups and interviews with families who experienced a perinatal loss [10,12,13]. Recent research reported that healthcare workers are not specifically trained on bereavement care or processes to begin after the diagnosis is made. Therefore, psychological outcomes for parents experiencing loss may be impacted by the hospital staffs’ ability to provide effective bereavement support [14–17]. Nurses in the maternity and emergency settings have reported both lack of preparation and knowledge regarding how to care for bereaved parents and/or how to address the complex circumstances surrounding perinatal loss [18]. These complexities include helping the family start a normal grieving process, actualizing the loss, being able to acknowledge their grief as part of the healing process, and meeting the particular cultural and behavioral needs of each family [19].

Strategies and programs to improve knowledge, skills, and abilities of hospital staff in bereavement care provision have been implemented in recent years. The TEARDROP Program (Teaching, Excellent, pArent, peRinatal, Deaths-related, inteRactions, tO, Professionals), a perinatal bereavement care training program based in Ireland educates practitioners on the essential skills and workflow needed for providing high-quality patient and family-centered bereavement care. Program evaluation results indicated that before the trainings, participants had low levels of bereavement skills and knowledge; post-training, care satisfaction increased for bereaved parents and providers reported feeling well equipped in caring for grieving parents [20]. Similarly, online training courses and interventions to improve bereavement support care provision were implemented in the United Kingdom with results showing notable improvements from baseline in self-reported confidence and communication skills [21].

In Connecticut, where our hospital is located, the stillbirth rate was 4.53 per 1,000 live births in 2023, equating to 168 deaths [22]. Although stillbirth affects families across all races, ethnicities, and income levels, it disproportionately impacts minority populations, with longstanding disparities seen in infant mortality rates which have grown over the last century [23]. Connecticut legislature passed a law in 2023 allowing parents to spend at least 24 hours in the hospital with their babies as they grieve their loss [24] and while validated tools to measure outcomes are reported, there is relatively little evidence based research on provider competencies surrounding perinatal loss in diverse settings.

This quality improvement needs assessment presents the historical frequencies of perinatal loss, as well as the knowledge, attitudes and processes that staff currently utilize in managing patients who experience perinatal loss at our 305-bed Magnet^®- designated and Planetree certified community-based teaching hospital. 1,096 diagnoses of perinatal loss were identified at our hospital with a diagnosis code for stillbirth, miscarriage, neonatal/fetal demise, or an unplanned abortion from January 1st, 2021, to March 15th, 2024. To further understand the need for a perinatal bereavement program, this study aims to evaluate the staffs’ confidence in providing perinatal bereavement support. After completing the study, the questionnaire will be sent to all hospital staff, as well as piloting interventions to address any reported gaps in knowledge, skills or confidence.

Materials and methods

Instrument

Due to a lack of questionnaires specifically designed to measure factors that impact providing bereavement support, The Australian College of Midwives developed the Perinatal Bereavement Care Confidence Scale (PBCCS) [25]. To understand the baseline bereavement knowledge, skills, self-awareness, and organizational support among staff working at our hospital, the study team adopted the validated PBCCS. Permission to utilize the questionnaire was requested and subsequently received on February 20th, 2024. The questionnaire required approximately 10 minutes to complete. Prior to participation, respondents provided informed consent, which outlined eligibility criteria and explained the study purpose and rationale.

The 43-item questionnaire is conceptually grounded in the literature with a panel of experts supporting the content validity of the PBCCS; Bereavement care knowledge (15 items, 3 subscales) skills (9 items, 2 subscales), self-awareness (8 items, 2 subscales), and organizational support (11 items, 2 subscales). The internal consistency ranges from 0.753 to 0.871 [25]. Items are rated on a Likert-based scale of 1–5 with 1 representing Strongly Disagree and 5 representing Strongly Agree. As the questionnaire was originally developed for midwives and nurses in Ireland, some items were not relevant to the current U.S. healthcare system, some were repetitive while others were related to confidence/awareness on the needs of bereaved parents expecting their next baby. A total of 14 questions were thus removed for the current research (Supplemental 1). To assess staff perceptions on our hospital’s practices, as well as barriers and facilitators in providing bereavement care, three items were added to the organizational support subscale (these are noted in Table 2).

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Table 2. PCBBS Survey Results by Subscale.

https://doi.org/10.1371/journal.pone.0347348.t002

The current study questionnaire included a total of 32 items: Bereavement care knowledge (12 items, 3 subscales), Bereavement care skills (7 items, 2 subscales), Self-awareness (7 items, 2 subscales), and Organizational support (6 items, 2 subscale). The range of scores for bereavement care knowledge (12 items) is 12–60; a score of 12 representing the least level of support knowledge and 60 representing the most. Score range was calculated in a similar way for the other subscales. To obtain the total bereavement support confidence score, the mean score for each survey item was calculated as well as for each subscale (score range of 32–160). As the authors who developed the original survey [25] determined scoring 80% or higher was considered having sufficient level of confidence, a score of 128 or higher (achieving 80%) for this research was determined as sufficient confidence.

Results

Participants

The survey was completed by 55 staff, out of which 46 had valid responses with a response rate of 83.64%. Most of the staff were female (n = 35, 89.74%) and belonged to age group of 30–39 years (43.59%) (Table 1). Most (48.72%) had high school or bachelor’s degree followed by Master’s or Doctorate degree (43.59%). More than half (51.28%) had been working at our hospital for four or less years. Almost 50% of respondents worked in L&D, 33.33% were from ED and 12.82% from Maternity. More than 70% of respondents reported that they had not received any formal education on perinatal bereavement as compared to 28.21% of staff who reported receiving either informal or some bereavement education (p = 0.006).

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Table 1. Respondent Demographics (n = 46).

https://doi.org/10.1371/journal.pone.0347348.t001

Table 2 shows the mean score of each survey item within each PBCCS subscale. The lowest average score of 3.09 was found for the knowledge survey item “I have been well prepared to provide perinatal bereavement support”. Similarly, the lowest average score (3.12) for self-awareness category was found for “I am aware of my personal resources for bereavement support”. For bereavement support skills, the lowest score (2.86) was found for the survey item: “I can easily respond to the needs of bereaved sibling when accompanying their parents” and for organizational support, the lowest score (2.90) was for the item: “I am aware of the passage of House Bill No. 6835 (Effective July 1, 2023) that requires our state’s hospitals to give parents of babies who pass at birth at least 24 hours to be with their stillborn child.”

Table 3 presents the total mean sum score for each PBCCS subscale along with the score range. Results showed low levels of bereavement support knowledge (46.45 ± 13.04), bereavement support skills (23.07 ± 7.31), self-awareness (24.85 ± 7.54) and organizational support (21.73 ± 6.08). The total mean sum score of 116 showed an inadequate level of confidence among the staff.

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Table 3. PBCCS Subscale Results and Total Mean Scores.

https://doi.org/10.1371/journal.pone.0347348.t003

Scores for each PBCCS subscale between departments showed significant differences in mean score for self-awareness (p = 0.02). The mean score for ED staff was 3.17 while those working in L&D scored 3.83 for this subscale (Table 4).

No significant differences were found in other PBCCS subscales between the departments. Those reporting having a formal education were more likely to have greater self-awareness (p = 0.001) and bereavement support skills (4.23) as compared to those who did not (3.39) (Table 5).

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Table 4. PBCCS Subscale Results by Department.

https://doi.org/10.1371/journal.pone.0347348.t004

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Table 5. Sub-Analysis on Formal Bereavement Education.

https://doi.org/10.1371/journal.pone.0347348.t005

The survey also included the option for participants to submit comments or suggestions. A total of nine responses were received. One participant noted, “Nurses have done an excellent job with the perinatal loss committee; more education and support is needed for residents and attendings.” Another emphasized the widespread training: “Everyone that has any patient contact should be educated on this topic.” Two respondents specifically highlighted the need for training focused on grief, and another noting formal policies on training and workflow are limited. Another comment noted that the hospital has one Cuddle Cot, as well as a bereavement committee responsible for staff and patient education, hosting a memorial each year for patients and their families who experienced perinatal loss. They noted: “this is so helpful to staff and patients in taking care of patients with perinatal loss.” The retrospective chart review identified 1,096 patients who had a visit or diagnosis code for stillbirth, miscarriage, neonatal/fetal demise, or an unplanned abortion from January 1^st, 2021, to March 15^th, 2024.

Discussion

This quality improvement project needs assessment reported on the knowledge, attitudes, and processes that staff currently utilize in managing patients who experience perinatal loss at our community-based teaching hospital. The validated PBCCS [25] was utilized to survey staff employed in the ED, L&D, and Maternity Unit as frontline staff experiencing perinatal loss and grieving parents. Our results indicated that a significant number of responders did not have formal education on perinatal bereavement support, highlighting a need for further education. Staff felt ill-equipped to provide perinatal bereavement support as a result. The survey results also highlighted that staff did not know how to respond to the needs of bereaved siblings and that they were not aware of personal resources available for bereavement support. Overall, from the assessment, the staff showed inadequate levels of confidence, with the highest scores for confidence in the L&D staff and lowest in the ED staff. Importantly, when staff did receive formal education on perinatal bereavement support, they experienced a significant increase in self-awareness when compared to those that did not.

Our findings underscore the critical need for structured education and resource availability to support frontline staff managing patients and families experiencing perinatal loss. The lack of formal education among a significant proportion of respondents likely contributes to the reported feelings of being ill-equipped to provide appropriate bereavement care. This is consistent with a recently published scoping review, which highlights that healthcare professionals with specialized training in perinatal bereavement exhibit greater confidence and competence in addressing the emotional and psychological needs of grieving families [26]. The disparity in confidence levels between L&D and ED staff further suggests the importance of tailoring educational interventions to the unique demands of each clinical setting.

An important aspect of perinatal loss management is addressing the needs of the entire family unit, including bereaved siblings. For families, coping with this loss highly depends on social and emotional support and this support can play a vital role in helping the families cope with grief and helps them navigate the healing process [27]. Haghighi et al. found individualized counseling directly after receiving the news can significantly aid in emotional recovery, underscoring the need for tailored psychological interventions [28]. The findings of Stanhope et al. further emphasize the need for external support systems in mitigating adverse postpartum health outcomes, highlighting how social and professional support influence recovery trajectories. Support can come from healthcare professionals, support groups, community organizations, family and friends [3]. Current staff knowledge and awareness in this area were notably insufficient, reflecting gaps identified in previous literature.

According to Limbo and Kobler [29], comprehensive family-centered care, which considers the emotional needs of siblings and extended family, is crucial for holistic bereavement support. However, our findings reveal that this critical component is often overlooked, reinforcing the necessity of nursing-targeted training programs to include not just the parents, but the whole family to ensure the provision of family-centered care. Importantly, our study identified that formal education not only improved staff confidence but also enhanced self-awareness, a key component in delivering empathetic care. These findings align with research by Johnson and Esplen et al., demonstrating the use of high-fidelity simulation, both reporting significant improvements in nursing and emergency staff knowledge, emotional resilience and the ability to establish therapeutic connections with patients [30,31].

To address these challenges, institutions should consider implementing evidence-based educational programs, such as perinatal bereavement workshops and simulation training, which have been shown to improve staff preparedness and patient outcomes [32]. Furthermore, ensuring access to institutional resources, including mental health services for staff and bereavement care pathways for families, could help bridge the identified gaps. Collaborative approaches that involve nursing, social workers, mental health professionals, and chaplaincy services may further enrich the support network for grieving families and staff alike. Most of the surveyors on the open comments agreed that information, formal training, an in service for bereavement, education and more staff member that can be part of the bereavement committees is the best way to promote confidence and increasing the comfort level in providing care.

Evidence-based programs augmenting the clinical environment for grieving parents have been reported by patients and hospital staff as crucial [11,14,15]. In addition to targeted hospital-wide education, leaders should prioritize the implementation of bereavement suites; located external to the maternity unit, this designated area provides a private, supportive care environment that offers resources and case management for those experiencing a loss. At our hospital, we are exploring the opportunity to create a bereavement suite to aid families via the provision of a supportive environment that is respectful, resource-driven, and family-centered.

Limitations of this study include assessing rates and perceptions at one community hospital and was limited to three departments. It is unclear whether the baseline knowledge of the current staff could have been impacted by study analysis and results due to the type of hospital, location, and size. Compared to the other hospitals in the area that are composed of many hospitals joined into one healthcare organization, these results could have varied if more staff or hospitals were included in this study. In addition, the validity and reliability scores were not re-evaluated for the modified scale, as the survey was originally developed to evaluate bereavement confidence, competencies, and skills among midwives in Ireland, rather than among acute care hospital staff in the U.S. who also care for patients experiencing perinatal loss. The intent of the current cross-sectional study was not to re-validate or evaluate the instrument for acute care hospital staff, but rather to use the existing tool pragmatically to assess staff confidence, competencies, and perceived skills within our specific clinical context.

This study is the first on the topic which will set the stage for additional research on understanding the existing state of bereavement care in hospitals in our state to assess the impact of such interventions on both provider confidence and patient outcomes. Additionally, exploring cultural and contextual variations in bereavement care practices could provide valuable insights for developing inclusive and effective support systems; especially due to the unpredictable maternal and child healthcare policy, program funding, and political environments we are currently experiencing [33].

Conclusion

Perinatal loss is a profound and multifaceted life event, leaving a lasting impact on families and healthcare providers across the world. This global burden highlights both the challenges and the opportunities to strengthen bereavement care provision to better support the grieving and healing process for this at risk population. This quality improvement project highlights critical gaps in education, confidence, and resource awareness among frontline staff managing perinatal loss in a community-based teaching hospital. The findings underscore the pressing need for structured training programs and institutional resources to equip staff with the necessary skills to provide compassionate and effective bereavement support.

Supporting information