Birth is a wonder and each baby is God perfect creation. Pregnancy is often a time of great expectation for the future (Podder Pottal, 2014). Perinatal bereavement care (PBC) refers to the comprehensive and integrative components of care provided by nurses and multidisciplinary staff in the physical, psychological, emotional, and spiritual domains, following perinatal loss (Kim Kim, 2022). Based on these the current study aimed to assess the knowledge, attitude factors associated with attitude regarding perinatal bereavement care among the nursing personnel.
Stillbirths are a significant public health issue, affecting over 7,000 families globally every day (Altijani et al, 2018). Globally in 2019, an estimated 2.0 million babies were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13.9 stillbirths per 1000 total births (Qian et al, 2022). In context of India, stillbirths in urban areas of Bhopal (Madhya Pradesh) were reported second highest in country according to the Civil Registration System report, based on year 2013. The Annual Report on Vital Statistics of India based on CRS 2019 depicts the total stillbirth rate of Madhya Pradesh at 10,017 out of which 5460 were from rural areas and 4557 from urban areas. Data show that Bhind leads with a total of 3171 stillbirths in state. The rural areas of Bhind district accounts for 1671 male stillbirth and 1395 female stillbirth which shows a significant rise in the rates. There is research evidence that a significant portion of the information, support, and treatment choices offered to women who suffer perinatal loss are provided by nurses and midwives. The degree of grief is lessened for bereaved families when there is congruence between the care they anticipate and the care they actually receive (Qian et al, 2022)
Need of the study
the paucity of research on perinatal bereavement care in central India, especially concerning nursing cadre, the present study endeavoured to assess the knowledge, attitudes and associated factors attitude among the nursing personnel in Madhya Pradesh, regarding perinatal bereavement care. This study sought to establish a baseline dataset as a foundation for informed strategies to guide improvement in bereavement care services in the region of Madhya Pradesh.
Review of Literature
Perinatal death can negatively affect women and men not just physically and emotionally but also long-term economic and psychosocial wellbeing. A study from Delhi revealed that stillbirth and child death have long-term psychosomatic, social and economic impacts on parents, which are usually overlooked. Sociocultural, appropriate bereavement support for the parents are needed to reduce the impacts (Das et al, 2021). Gopichandran et al (2018) showed that there was a perception among the women and their families that their health system provides poor quality of services and reported the discourteous and insensitive behaviour of health care providers (HCP).
Ravaldi et al (2018) in her study discovered a measurable gap between the standards of care and practices currently used in Italy. The reported lack of confidence and capability among nursing and midwifery professionals in providing perinatal bereavement care, made it necessary to conduct the present study particularly in Indian hospital settings, specifically in the region of Madhya Pradesh with high stillbirth rates (Armour, 2019). A descriptive correlational survey conducted by Eunhui Kimet et al (2022) revealed that hospital policies should be established and providing training programme for nurses related to perinatal bereavement care could positively affect attitudes of nursing personnel. Similarly, Ravaldi et al (2018) assessed the current practices of health care providers for women experiencing a stillbirth and to explore their needs for training to better support bereaved families. It was found that as per international guidelines there is a measurable gap between the standards of care and practices currently used in Italy. An exploratory study conducted in Pune to determine knowledge and attitude of nursing personnel regarding PBC concluded that the most of nursing personnel have positive attitude and average knowledge about PBC; they also identified that the hospital administration should provide positive environment to motivate the nursing personnel and update their knowledge and practice (Podder Pottal, 2014). A similar study conducted by Mohamed et al revealed that nurses had insufficient knowledge, highly positive attitude about implementing PBC concluding that preceptorship supervision and educational programme related to bereavement counselling should be introduced to increase the quality of care for bereaved parent along with increased confidence of nursing personnel. Chan al (2009) in their study explored nurses attitudes towards perinatal bereavement care and sought to identify factors associated with such attitude. They concluded that midwives, who have positive attitude with religious beliefs, understand the importance of hospital policy and who are provided with the training sessions had significantly more positive attitude towards PBC.
Material and Methods
This hospital-based descriptive cross-sectional study was conducted from September to November 2022. The protocol was approved by Institutional Human Ethical Committee, Post Graduate Research, AIIMS Bhopal. Formal permission to conduct the study was obtained from the administration of chosen tertiary care hospital. The setting for data collection was selected from Obstetrics Gynaecology (OBG) units, labour room, paediatrics units, NICUs and ICUs of tertiary care hospital, Bhopal. The study participants were the nursing officers working in obstetrics gynaecology and paediatrics units, ICU NICU of selected hospital. Samples were selected through non-probability convenient sampling. Informed consent was obtained from the participants who were willing to participate in the study voluntarily without incentives. The sample size was determined with the help of earlier studies (Podder Pottal, 2014) with the assumption of 95 percent confidence interval (CI), 5 percent margin of error, which yielded the sample size to be 207. Non-probability convenient sampling technique was used to select the participants. Data was collected through a valid structured knowledge questionnaire, 5-point Likert scale dichotomous scale. The tool was validated by experts from field of obstetrics gynaecology, and psychiatry. The tool showed high value of Scale-Content Validity Item/Average (S-CVI/Ave=0.97). The reliability of this tool was obtained by establishing test retest method, Pearson correlation (r)=0.819 for questionnaire and internal consistency calculated using Cronbach alpha method that came out to be 0.812 0.813 for attitude scale and dichotomous scale. Hence the tool was found to be reliable. Participants who satisfied the inclusion criteria were asked to fill the questionnaire by the primary investigator at the time of data collection.
Results
Statistical analysis was done using statistical software SPSS18. The co-relation between knowledge and attitude of nursing personnel was calculated using Karl Pearson co-relation. Socio-demographic characteristics of nursing personnel Among 207 nursing personnel, all completed questionnaire. More than half (61%) of nursing personnel were in the age-group of 21-30 years and 58 percent had completed BSc nursing, 57 percent nursing personnel had total work experience of less than 5 years of work experience, 35 percent had 1-3 years experience in maternity ward.
The data in Fig 1 represents knowledge level of the nursing personnel. Among all nursing personnel (n=207), 45 (21.7%) had good knowledge regarding perinatal bereavement care while one 62 (78.3%) had average knowledge and none of them had poor knowledge regarding perinatal bereavement care.
The attitude of nursing personnel regarding perinatal bereavement care shows (Fig 2) that the majority of the nursing personnel (73.4%) had positive attitude regarding perinatal bereavement care while remaining (26.6%) nursing personnel were found to have neutral attitude regarding perinatal bereavement care.
Influencing factors associated with attitude among nursing personnel regarding perinatal bereavement care To identify the factors associated with attitude, item-wise analysis was done in which responses of nursing personnel to each question were arranged in frequency and percentage. Based on the maximum and minimum percentage of responses of nursing personnel to the questions high influencing, average influencing factors and low influencing factors among nursing personnel regarding perinatal bereavement care were further categorised as depicted in Table 1.
The factors associated with attitude of nursing personnel regarding perinatal bereavement care were (Table 1): high influencing factors-personal perinatal grieving experience, history of any other grieving experience, existing hospital policy, regular training/continuing Nursing Education and traditional beliefs/ values followed by average influencing factors as gender, socioeconomic status of bereaved parent, parity, attitude of colleagues and lack of interest in patient care. Personal conflicts and years of experience in maternity ward were found to be the low influencing factors among nursing personnel regarding.
The co-relation coefficient was found to be 0.495 at p 0.001, which indicates that there is positive relationship between knowledge and attitude of nursing personnel regarding perinatal bereavement care (Table 2). Association of knowledge scores and demographic variables of nursing personnel The chi-square value revealed significant association (p 0.05) between the knowledge score level and demographic variables namely total work experience of nursing personnel (p=0.039), years of experience in maternity ward (p=0.005), experience of personal loss (p=0.005) and past experience in handling grieving parents (p=0.001). Association of attitude and demographic variables of nursing personnel The chi-square value showed that there is a significance association between the attitude and demographic variables namely age of nursing personnel (p=0.039), years of experience in maternity ward (p=0.030), past experience in handling grieving parents (p=0.001) and experience of personal loss (p=0.013).
Discussion
The finding of the present study related to knowledge level of nursing personnel regarding perinatal bereavement care revealed that majority of the nursing personnel had average knowledge regarding perinatal bereavement care (78.3%) and some of the nursing personnel had good knowledge regarding perinatal bereavement care (21.7%) and none of them had poor knowledge regarding perinatal bereavement care. Similar to the findings of a study of Maharashtra (Podder Pottal, 2014), the current study findings are in contradiction to few other studies revealing poor knowledge (Mohamed et al, 2015; Raddi et al, 2009).
The present study revealed that most of the nursing personnel (73.4%) have positive attitude towards perinatal bereavement care. Similar findings were reported in few studies from India (Podder Pottal, 2014; Raddi et al, 2009), Egypt (Mohamed et al, 2015) and Hong Kong (Chan et al,2015). Current study revealed that high influencing factors associated with attitude regarding perinatal bereavement care of nursing personnel were: personal perinatal grieving experience, history of any other grieving experience, existing hospital policy, regular training/CNE, traditional beliefs values. Similar findings were reported in studies from Korea and Hong Kong (Kim Kim, 2022; Chan et al, 2015). The co-relation of knowledge and attitude of nursing personnel regarding perinatal bereavement care showed that there is positive relationship between knowledge and attitude of nursing personnel regarding perinatal bereavement care. These results were supported by a study of Mohamed et al (2015) also by Chan et al, (2015) but are in contradiction to two studies from Maharashtra and Karnataka (Podder Pottal, 2014; Raddi et al, 2009).
In terms of the association between the knowledge score level and socio demographic variables, this study revealed that total work experience of nursing personnel, years of experience in maternity ward, experience of personal loss and experience in handling grieving parents were found to be significant (p=0.05). Similar findings were obtained in studies by Fatemeh Mousavi et al, (2014) in Pune city and Mohamed Aziza et al (2015) in Egypt.
The finding of current study in terms of the association between the attitude and socio demographic variables is also supported by other similar studies from Egypt and Singapore but contradictory to the findings of a study in Maharashtra exhibiting that attitude has no significant association with demographic variable.
Limitations
The study did not include any private health centres, also the researcher faced difficulty in getting permission from other hospitals for conducting study. The participants were drawn from the government health care centres, which may not be generalisable to all health care centres. Administration of self-reported questionnaire and unwillingness of nursing officers to take part in the study due to work load were other weaknesses of the study.
Recommendations future directions
Similar study can be carried out on a large scale in the tertiary care hospital to assess the knowledge and attitude of other health care professionals regarding perinatal bereavement care. A similar study can be undertaken with women to assess their satisfaction regarding perinatal bereavement care.
Nursing Implications
This study suggests that by improving knowledge and attitude of nursing personnel regarding perinatal bereavement care, the quality of nursing services rendered in clinical setting can be improved. Also, certain Standard Operating Procedure/ Hospital policy regarding care of parents undergoing perinatal bereavement can also be formulated to provide quality maternity services in regular continuing nursing education / training programme for nursing personnel on perinatal bereavement care. Incorporation of perinatal bereavement care in nursing curricula can also be inculcated. The study findings empower nurses by enhancing nursers's skills and understanding of perinatal bereavement care. By implementing these findings, healthcare settings can create a supportive environment that addresses the emotional and psychological needs of parents, leading to improved patient satisfaction, higher-quality care, and ultimately, better outcomes for families dealing with perinatal loss.
Acknowledgment I thank my guide and co-guide for their guidance and all the nursing officers who took time from their busy schedules to fill the questionnaires. I also like to convey my gratitude to the research review board and ethical committee of the institute for their constructive feedback and timely approval.
Conclusion
Perinatal loss is a psychologically trauPerinatal loss is a psychologically traumatic event and parents bear excruciating sorrowfulness following the death of a baby. Majority of nursing personnel have average knowledge regarding perinatal bereavement care but the majority of nursing personnel have positive attitude toward perinatal bereavement care. There is significant positive correlation between knowledge and attitude regarding perinatal bereavement care among nursing personnel working in maternity ward of selected hospitals of Bhopal. Also there is association between knowledge and attitude with selected demographic variables of the nursing personnel Based on the findings of this study, it is obvious that there is need for strengthening nurses working in selected hospital with in-service education in the arena of perinatal loss and bereavement care for demonstrating compassionate, comprehensive and considerate care. Better collaboration of Hospital and Nursing administration is required for development and implementation of counselling training in perinatal bereavement care as a component of in-service education programmes for the nurses and also for formulating Standard Operating Procedure regarding care of parents undergoing perinatal bereavement. These change needs to be incorporated to ensure persistant bereavement care for the individuals and their families.
Keywords: Knowledge, Attitude, Perinatal bereavement care.