abstract: The stillbirth of a wanted baby is a devastating and life altering experience that happens more than 26,000 times each year in the United States, but the impacts and implications of this loss on families is rarely discussed in public spaces. While another kind of pregnancy ending, abortion, dominates political discourse about reproduction, the absence of talk about stillbirth prevention or support in those same contexts is worthy of further investigation. This project explores stillbirth as a communication phenomenon and draws upon narrative, performance and rhetorical articulations of testimony to extend our understanding of how narratives of stillbirth circulate in current conditions of discourse. A model for viewing how dominant and counter narratives circulate is explained (Narrative Loop Model) and a new model for illuminating the unique functions of testimony is given (Testimonial Loop Model). This dissertation employs performance and rhetorical methods to explore testimonies of stillbirth, both naturally occurring and solicited through interviews, in order to create several performance texts that put pregnancy-ending narratives in conversation with each other on stage. Analysis of the performance text and choices, as well as reflection on the embodied performance experience and member checking, yielded several findings. The discovery of somatic sentience and its influence on performance ethnography is discussed. Themes of relationality and temporality were found in the performance of testimonies of stillbirth. The implications of these findings add to the communication discipline’s understanding of how and why stillbirth testimony may circulate, its impact on conditions of discourse for pregnancy ending and its potential use as/in intervention, support, and advocacy. Ethical considerations and limitations are addressed. / Dissertation/Thesis / Doctoral Dissertation Communication Studies 2015

Submitted by Simone Souza (simonecgsouza@hotmail.com) on 2017-10-18T11:55:40Z No. of bitstreams: 1 DISS_2014_Gustavo de Sousa e Silva.pdf: 1487784 bytes, checksum: 4186b95c575710ea6c22f3194977f150 (MD5) / Approved for entry into archive by Jordan (jordanbiblio@gmail.com) on 2017-11-07T15:23:51Z (GMT) No. of bitstreams: 1 DISS_2014_Gustavo de Sousa e Silva.pdf: 1487784 bytes, checksum: 4186b95c575710ea6c22f3194977f150 (MD5) / Made available in DSpace on 2017-11-07T15:23:51Z (GMT). No. of bitstreams: 1 DISS_2014_Gustavo de Sousa e Silva.pdf: 1487784 bytes, checksum: 4186b95c575710ea6c22f3194977f150 (MD5) Previous issue date: 2014-02-19 / CAPES / Falhas reprodutivas em suínos são muitas vezes um problema de diagnóstico difícil. O objetivo do trabalho foi identificar potenciais fatores de riscos (infecciosos / não infecciosos) correlacionados com a ocorrência de leitões natimortos em duas granjas comerciais de suínos situadas na região centro-oeste do Brasil. Os dados foram coletados a partir do acompanhamento de 96 fêmeas suínas com natimorto (casos) e 96 fêmeas sem natimortos (controles). Os potenciais fatores de risco foram incluídos no modelo de regressão logística multivariada e alguns dados foram categorizados: parição (1, 2, 3-6 e > 6), momento do parto (durante o dia ou noite: entre 6:00h-20:00h e as 20:00h-06:00h, respectivamente) e de duração do parto (< 2hs, 2- 4hs e > 4hs). A variável dependente foi definida como a presença de pelo menos um leitão natimorto na leitegada (sim ou não). No melhor modelo final duas variáveis oferecidas para a análise multivariada foram significativamente associadas com a presença de natimortos nas granjas, dessas o tamanho total da leitegada (p = 0,01) e peso médio ao nascer (p = 0,03). O PCV2 foi detectado em 29,1% das leitegadas. Nenhuma infecção de PPV ou leptospirose foi identificada sugerindo um impacto menor sobre a doença reprodutiva. / Reproductive failure in swine herds is often difficult to diagnose. Our aim was to identify the potential risk factors (infectious/non-infectious) for stillborn piglets in two commercial swine farms situated in midwestern region of Brazil. Data were collected from 96 sows that produced stillborn piglets (cases) and 96 sows that did not (controls). The potential risk factors were included in the multivariable logistic model as categories: parity (1, 2, 3–6 and >6), moment of farrowing (during day or night: between 6:00–20:00 and 20:00–6:00, respectively) and duration of parturition (<2 h, 2-4 h and >4 h). The dependent variable was defined as the presence of at least one stillborn piglet in a given litter (yes or no). In the best fit model, two variables from the multivariable analysis, total litter size (p= 0.01), and average birth weight (p=0.03), were significantly associated with the presence of stillborn piglets at the farms examined in this study. PCV2 was detected in 29.1% of the litters. Neither PPV nor Leptospirosis infections were identified in this study, suggesting that they have a minor impact on reproductive disease.

Bakgrund: Enligt studier kan möten med föräldrar som föder barn som inte lever framkalla sorg, skuld och stress hos vårdpersonal och stöd är något som efterfrågas. Trots behovet finns begränsad forskning om vilket typ av stöd som behövs. Syfte: Syftet med studien var att identifiera barnmorskors och undersköterskors behov av stöd samt vilket typ av stöd de behöver vid möten med föräldrar som föder barn som inte lever. Metod: Åtta barnmorskor och fem undersköterskor fördelade i tre fokusgrupper intervjuades på en mellanstor förlossningsavdelning i Mellansverige. Semistrukturerade frågor ställdes utifrån en intervjuguide. Analysmetoden var kvalitativ innehållsanalys. Resultat: Ett tema och fem kategorier identifierades. Temat var: Viljan att göra gott. Kategorierna var: Kollegialt stöd, Verksamhetsstöd, Utbildning, Handledning och Reflektion samt Att vara oerfaren. Slutsats: Behovet av stöd varierade men samtliga deltagare ansåg att de fanns för varandra som stöd samt upplevde behov av kontinuitet i möten med föräldrarna och någon typ av utbildning. Fasta handledningstillfällen där deltagarna kunde träffas tvärprofessionellt önskades. Deltagare med lång erfarenhet av förlossningsvård kände sig tryggare i möten med föräldrar som föder barn som inte lever, än de med kortare erfarenhet. Klinisk tillämpbarhet: Studien skulle kunna leda till att stöd implementeras i verksamheten, vilket på sikt kan leda till att drabbade föräldrar får ett bättre bemötande. / Background: According to research health professionals are feeling grief, guilt and stress when they meet parents giving birth to stillborn babies. They are in need of support but research about what kind of support is limited. Aim: To identify midwives’ and assistant nurses’ need of support and what kind of support they need meeting parents giving birth to stillborn babies. Method: Eight midwives and five assistant nurses were interviewed and distributed in three focus groups. They were asked semi-structured questions based on a questionnaire. The analysis method was qualitative content analysis. Results: One theme and five categories were identified. The theme was: The will to do good. The categories were: Collegial support, Education, Support from the hospital management, Tutorial and Reflection and To be inexperienced. Conclusion: The need of support varied but all participants considered they were there for each other as a support and a need of continuity and education in their meetings with parents. They also wished for tutorials with regular occasions where they could meet with different professions in a group. Those participants with longer experience from childbirth care felt more secure in their meetings with parents giving birth to stillborn babies, compared with those with shorter experience. Clinical application: The study could lead to support being implemented in maternity units, which in the end could lead to better treatment for the affected parents.

No description available.

Currently there is no test to accurately predict stillbirth. It is proposed that better identification of placental disease in utero may aid stillbirth prediction and prevention. Pregnancies complicated by reduced fetal movement (RFM) have increased risk of stillbirth. We hypothesised that RFM is a symptom of placental dysfunction associated with adverse pregnancy outcome (APO) and that this placental abnormality can be detected antenatally and used to identify fetuses at highest-risk of APO. We tested this hypothesis by: 1) comparison of ex vivo placental structure and function between APO RFM pregnancies and their normal outcome RFM counterparts, 2) comparison of in utero estimates of placental size, vascularity, vascular and endocrine functions obtained from placental ultrasound, Doppler waveform analysis and maternal circulating placentally-derived hormone concentrations, to their ex vivo correlates and 3) examination of the predictive potential of placental biomarkers at the time of RFM.Ex vivo placentas from APO RFM pregnancies, compared to normal outcome RFM counterparts, were smaller (diameter, area, weight and volume, p<0.0001), less vascular (vessel number and density, p≤0.002), with arteries that were less responsive to sodium nitroprusside (p<0.05), and with aberrant endocrine function (reduced tissue content and/or release of human chorionic gonadotrophin (hCG), human placental lactogen (hPL) and soluble fms-like Tyrosine Kinase-1 (sFlt-1), p<0.03). Placental volume (PV) ex vivo correlated with sonographic estimated PV (p<0.004), hPL, hCG and placental growth factor (PlGF) concentrations in the maternal circulation (p<0.03). Ex vivo villous vessel number and density correlated with Doppler impedance at the umbilical artery free-loop (UAD-F, p=0.02) and intraplacental arteries (p<0.0001) respectively, whilst UAD-F impedance correlated with arterial thromboxane sensitivity (p<0.04). Examination of placental structure and function at the time of presentation with RFM identified 15 independently-predictive biomarkers. Three potential predictive models, incorporating measures of placental size (PlGF), endocrine function (sFlt-1), arterial thromboxane sensitivity and villous vascularity (UAD-F), were proposed. Using these models, sensitivity for APO was improved from 8.9% with baseline care (assessment of fetal size and gestation) to up to 37.5% at a fixed specificity of 99% (p<0.05). This series of studies shows that antenatal placental examination is possible and improves identification of pregnancies at highest risk of stillbirth in a high-risk population by up to 29%. Therefore such tests merit further development to prospectively assess their ability to predict and prevent stillbirth itself.

The human health impacts of anthropogenic climate change continue to intensify. Perhaps most concerning is the rapid rise in ambient temperature, with 10 of the hottest years ever recorded having occurred over the last 15 years (IPCC, 2018; NASA, 2019). A robust literature has accumulated characterizing an extensive list of adverse health effects of heat exposure, identifying a number of groups particularly vulnerable (Ebi et al., 2018). The most recent group identified as highly vulnerable to heat exposure is expectant mothers (Bekkar et al., 2020; Chersich et al., 2020). A consistent relationship has been observed between increased ambient temperature and adverse pregnancy events, including increase in preterm delivery (PTD), small for gestational age, and stillbirth (Bekkar et al., 2020; Chersich et al., 2020) . Utilizing birth records and fetal death records from 2000-2004, we carried out two case-crossover studies assessing the impact of ambient temperature on preterm delivery and stillbirth across the contiguous United States, where 1 in 10 births results in a preterm delivery and 1 in 160 births results in a stillborn fetus. Our aim was to assess how increased temperature, singularly and in combination with air pollution exposure, impacts the odds of experiencing a preterm delivery or stillbirth (Aims 1 and 2). Our third aim, performed with a case-control study, expanded on the exploration of air pollution exposure, examining how traffic related air pollution (measured by maternal residential proximity to major roadways) impacts placental-associated stillbirth (Aim 3). We identified significantly increased odds of preterm delivery and stillbirth associated with a 10-degree Fahrenheit increase in average apparent temperature in the week preceding delivery for babies delivered in the warm season (May – October) and the meteorological summer (June – August). These increases were strongest in the Southern half of the United States and modified by maternal race/ethnicity for both preterm delivery and stillbirth. The increased odds were independent of air pollution exposure (ozone and PM2.5), which had no impact on the odds of preterm delivery or stillbirth. Furthermore, we did not observe a meaningful increase in overall odds of placental-associated stillbirth with increased proximity of the maternal residence to major roads. These studies contribute to the growing literature on the vulnerability of pregnant women to heat exposure and enhance the understanding of environmental risk factors of preterm birth and stillbirth, a chronically understudied health outcome. / 2023-05-14T00:00:00Z

Thesis (Ph.D. (Psychology)) -- University of Limpopo, 2022 / The psychological impact of perinatal death in the form of bereavement has been widely researched especially from the western perspective. The aim of this study was to establish the help-seeking pathways by mothers bereaved through perinatal death from the African perspective. The qualitative research paradigm in particular the phenomenological approach was adopted for the study. Phenomenology is described as an approach that focuses on the study of the lived experiences of individuals within their world. The application of this approach included personal interviews of 20 mothers who have experienced perinatal death at Doctor George Mukhari hospital in Gauteng province. The aim was to establish the help-seeking pathways they adopted to relief their distress, in terms of how they managed their bereavement and the help that they sought to relief their emotional distress. The findings of the study indicated that mothers lacked knowledge about what precipitated the onset of sudden symptoms such as early rupture of membrane, bleeding, lack of foetal movement which finally led to perinatal death. This lack of knowledge led mothers to attribute the cause of perinatal death to various reasons and conclusions such as distance decay, bad roads that delayed their arrival timeously at the hospital for their babies to be saved. Some cited lack of sense of urgency from the medical personnel and shortage of staff, especially doctors. However, they perceived positive social support from their families, spouses and medical professionals as one of the factors that contributed to their level of calmness and ability to bear the pain of loss. However, participants sought alternative help to facilitate clear understanding about what could have caused their babies to die, also how to manage their grief and how to deal with their subsequent pregnancies. Most of the participants benefited from the various healing pathways they chose. There is a need for healthcare system and community support to be more responsive to the plight of bereaved mothers, in reducing the stigma and the self-blame by bereaved mothers by offering support through counseling center. The findings reaffirm that despite the great studies taken in reducing perinatal deaths, there is a need for collaboration between the modern healthcare system and the traditional healthcare practitioners. Furthermore, emphasis v is needed on the preventative measures and training of healthcare practitioners within the maternal and child healthcare system to further reduce the alarming increase of prenatal deaths

Problem to be addressed: Stillbirth is a major public health problem. The stillbirth burden is on a par with newborn deaths. The stillbirth rate measures not only a substantial portion of the global and national burden of mortality, but also equity and quality of care for women’s and children’s health. Reducing the numbers of these deaths requires an understanding of why they occur, yet approximately one-third of stillbirths are unexplained, even in settings with high-quality autopsy and placental examination, while deaths considered to be explained are usually ascribed to single, proximal causes. An important limiting factor for efforts to reduce the large and inequitable stillbirth burden has been insufficient research into conditions that could inform prevention strategies and reduce inequity.1 2 Substantial evidence exists for associations between structural racism, maternal stress, and adverse pregnancy outcomes, yet research focusing on stillbirth is sparse, particularly at the ends of the causal spectrum—macro-level structural conditions and mechanisms. Several studies have called for research on possible biological mechanisms by which racism, racism-related stress, and stillbirth may be associated, including epigenetic mechanisms.3-6 The most recent review of causes of racial disparities in stillbirth rates in the U.S. recommended that researchers take a multi-domain approach, considering not just individual-level risk factors, which have been relatively well-studied, but also upstream factors such as institutional racism, and biological mechanisms such as epigenetic modification. The objective of this dissertation was to explore evidence that could help to explain persistent racial disparities in stillbirth. The specific aims were: 1. To review the literature on racial disparity in stillbirth rates; 2. To assess whether structural racism can help to explain racial disparity in stillbirth rates in New York City; and 3. To assess whether maternal stress is associated with stillbirth, whether stress is associated with methylation of stress-related genes, whether methylation is associated with stillbirth, and whether there is evidence that methylation of stress-related genes mediates associations between stress and stillbirth. Materials and methods used: For Aim 1, we carried out a scoping review of the literature in five databases (PubMed, Scopus, Cinahl, Embase, PsycInfo) to identify all reports including stillbirth rates stratified by race in the U.S., mapping exposures and effect modifiers (“domains of analysis”) and authors’ comments on racial disparity in stillbirths (“domains of explanation”) into one of eight domains (race, genetic, fetal, maternal, family, community, healthcare system, and structural). We defined Stillbirth Disparity Ratios (SDRs) as the ratio of the stillbirth rate in a racial/ethnic minority group to the stillbirth rate in white individuals. Selected SDRs were extracted from each report, as were all SDRs for Black/white comparisons. For Aim 2, we modelled associations between four measures of structural racism and stillbirth in all non-Hispanic (NH) Black and white singleton births in New York City between 2009 and 2018. Exposures were four Public Use Microdata Area (PUMA)-level measures of structural racism (Indices of Dissimilarity, Isolation, and Concentration at the Extremes (ICE), and an Educational Inequity Ratio) constructed from U.S. Census American Community Survey data. Using multilevel logistic regression, we first tested for interaction between race and structural racism in relation to stillbirth. For structural racism measures that interacted with race, we estimated odds ratios for stillbirth separately in 221,925 NH Black and 325,058 NH white births. Race-specific models were further stratified by maternal age. For Aim 3, we assessed associations between maternal stressors and stillbirth in 183 non-anomalous full-term singleton births (63 stillbirths and 120 livebirths) from the U.S. Stillbirth Collaborative Research Network. Measuring maternal stress with two hypothesized stressors, an Index of Significant Life Events and an Index of Disadvantage, we assessed associations between maternal stressors and stillbirth in our sample, and then whether maternal stressors and stillbirth were associated with differential methylation of 1,191 CpGs on five stress-related genes (BDNF, FKBP5, HSD11B2, IGF2, and NR3C1). Finally, we assessed whether methylation mediates associations between stressors and stillbirth. Conclusions reached: For Aim 1, we found 95 reports presenting stillbirth rates stratified by race/ethnicity in the U.S. We found evidence of increased risk of stillbirth in Black as compared to white births in the majority of the 83 reports with the necessary data. Among the 1143 Black-white SDRs that we extracted, the median SDR was 1.67, with 74% of SDRs showing evidence of disparity. Family and community factors, healthcare system factors, and structural factors were commonly used as domains of explanation (20-38% of reports), but rarely (family/community, structural, 4-5%) or never (healthcare system) used in analysis. The most commonly used domains of analysis—fetal and maternal factors including gestational age, maternal age, education, and prenatal care—do not appear able to explain the observed racial disparities. Gaps in the literature include a paucity of studies examining the possible role of health system, community, and structural factors in Black-white disparity in stillbirth rates, and limited data on other types of racial disparities in stillbirth rates, including Hispanic and Native American births. For Aim 2, we found that structural racism as measured by ICE and Isolation was associated with stillbirth in NH Black but not NH white mothers. This would seem consistent with our hypothesis that structural racism may help to explain racial disparity in stillbirth rates; however, the associations we observed were not in the expected direction. Specifically, NH Black mothers living in PUMAs with a high concentration of privilege had 90% greater odds of stillbirth in comparison to those living in PUMAs with a high concentration of disadvantage (ICE quintile 5 vs 1), and NH Black mothers living in PUMAs that were the most isolated had 40% lower odds of stillbirth in comparison to those living in PUMAs that were the least isolated (Isolation tertile 3 vs 1). We suggest that while the measures we used (ICE and Isolation) do help to explain the Black-white disparity in stillbirth rates, our results raise questions about the way these measures operationalize structural racism, meriting further investigation. For Aim 3, we found that having two or more vs no items in the Index of Disadvantage (“Disadvantage”) was associated with more than fourfold greater odds of stillbirth (95% CI 1.58, 12.93). We found no association between the Index of Significant Life Events and stillbirth. We found that 32 out of 1,191 CpGs on five stress-related genes were differentially methylated with respect to stillbirth, and six CpGs were differentially methylated with respect to Disadvantage. Methylation at two CpGs on IGF2 and one on HSD11B2 (cg02097792, cg12283393, and cg19413291, respectively) mediated the association between Disadvantage and stillbirth. Research on causes is a critical component of stillbirth prevention and reducing the inequitable distribution of this public health burden. Limited understanding of causes at both “ends of the spectrum”, from upstream distal factors to mechanisms, has likely contributed to slow progress on prevention.7 8 This dissertation contributes to science and public health by providing researchers with data to support new lines of inquiry, e.g., into associations between structural racism and stillbirth, and for methylation as a mechanism of effect, that should help to improve our understanding of causes. Our research may also support health policy makers who now have additional data to illustrate the adverse health outcomes of structural racism in the U.S. Finally, it may help the parents and other family members of stillborn babies who continually seek to understand “why”.

Varje år sker 2,6 miljoner dödfödslar världen över. Av 1000 födda barn föds tre till fyra barn döda (en stilla födsel), i Sverige varje år. Att ett barn dör intrauterint eller under förlossningen kan ha många orsaker, ungefär 90 procent av alla dödfödda barn dör intrauterint i Sverige. Inom mödrahälsovården arbetar barnmorskor med att identifiera riskfaktorer som kan leda till negativt graviditetsutfall både för barnet och kvinnan. Frånvaro av fosterrörelser kan ge misstankar om att barnet har dött i livmodern, om hjärtljud hos fostret inte kan registreras konfirmeras misstanken. Ett barn som föds stilla är förenat med långvarig och djup sorg. Barnmorskors medverkan, attityder och förhållningssätt är viktiga och värdefulla vid en stilla födsel och det krävs stor kunskap och engagemang från barnmorskorna. Barnmorskorna ska se till alla människors lika värde och arbetar för att ge kvalitativ och respektfull vård. Syftet med denna litteraturöversikt var att belysa barnmorskors upplevelser av att bistå en stilla födsel. Med ökad kunskap och förståelse kunna ge barnmorskor vägledning att hantera dessa händelser i sin profession. En allmän litteraturöversikt där 16 vetenskapliga artiklar kvalitetsgranskades och inkluderades i resultatet. En analys genomfördes av utvalda kvalitativa artiklar i sex steg. Tre kategorier identifierades: En svår situation, Känsla av otrygghet och I mötet med föräldrarna, med totalt åtta underkategorier. Underkategorierna som framkom var: Svårigheter med att bistå, Strategier, Emotionellt och mentalt påverkad, Bristande kunskap och kompetens, Kollegialt stöd, Ge stöd i sorg - attityder och förhållningssätt, Ärofullt och givande samt Behandla barnet med respekt. Barnmorskors upplevelser av att bistå en stilla födsel var individuellt och berodde till stor del av tidigare erfarenheter. En stilla födsel medförde många starka känslor vilket bidrog till att barnmorskor upplevde det svårt att stödja familjer i sorg. Tillgängligheten av stöd från kollegor var av stor betydelse för hur barnmorskor hanterade sina känslor och situationen. Behovet att tydliga riktlinjer i vården vid en stilla födsel upplevdes vara stort. / Every year 2,6 million stillbirths occur worldwide. Out of 1000 born children three to four children are stillborn (a still birth), in Sweden every year. The reason why a child dies intrauterine or during childbirth can depend on many different factors, about 90 percent of all stillborn children die intrauterine in Sweden. In maternal health care midwives work to identify risk factors that can lead to negative pregnancy outcomes in both the child and the pregnant woman. Absence of fetal movements may give rise to suspicions that the child has died in the womb, if the fetal heartbeat can not be registered, the suspicion is confirmed. A child who is born still iss associated with prolonged and deep grief. Midwives' involvement, attitudes and approach is important and valuable, and great knowledge and commitment is required from the midwife in a stillbirth. The midwives’ must ensure the equal value of all people and work to provide qualitative and respectful care. The aim of this literature review was to illuminate midwives' experience of assisting a stillbirth. With increased knowledge and understanding, be able to give midwives guidance to deal with these events in their profession. A general literature review where 16 scientific articles were quality reviewed and included in the result. An analysis was performed of selected qualitative articles in six steps. Three categories were identified: A difficult situation, A feeling of insecurity and In the meeting with the parents, with a total of eight subcategories. The subcategories that emerged were: Difficulties with assisting, Strategies, Emotionally and mentally affected, Lack of knowledge and competence, Collegial support, Giving support in grief - attitudes and approach, Honorable and rewarding and Treat the child with respect. Midwives' experiences of assisting a stillbirth were individual and were largely due to previous experiences. A stillbirth brought many strong emotions, which contributed to midwives finding it difficult to support families in grief. The availability of support from colleagues was of great importance for how midwives handled their emotions and situations. The need for clear guidelines in care during a stillbirth was perceived to be great.

No description available.