Kamuzu College of Nursing,
University of Malawi
Women’s Perceptions of Nurses’ Caring
Behaviours during Perinatal Loss in
Lilongwe, Malawi: An Exploratory
Study.
Andrew Simwaka, Winnie Chilemba
Background
• Perinatal loss, including early (between 20 and 28 weeks
gestation) and late (after 28 weeks) fetal deaths and
neonatal deaths within 28 days after birth (Miller, 2009) is
a devastating but common experience.
• Malawi’s perinatal mortality rate is amongst the highest in
the world; it was at 36 per 1,000 in 2004, down from 46 in
2000 (NSO and ORC Macro, 2005).
• Perinatal loss involves the loss of the hoped for, planned
for, and anticipated child, and a sense of failure to
become a parent ( Callister 2006; Capitulo, 2005; Hutti,
2005). This makes perinatal loss particularly traumatic.
Objective
The study examined women’s
perceptions of and satisfaction with
nursing care they received following
stillbirth and neonatal death in
Malawi
Methods
• a qualitative, exploratory study
• 20 women who had lost a child through
stillbirth or neonatal death in the past 2 years
• recruited through a mixture of purposive and
snowball sampling
• in 10 villages around a community hospital in
Lilongwe, Malawi
• semi-structured interviews
• Interviews tape-recorded and
transcribed verbatim
• Data analyzed using thematic
analysis
Results
Characteristics of women
• Age: ranged from 17 to 33 years (Mean = 20.4
years)
• Educational: from standard 2 (primary) to form 3
(n=2)
• Marital status: 19 married and one was single.
• Six had unplanned pregnancies.
• Parity: one to nine (Mean = 3.5, Mode = 3).
• Most women in petty trade like selling small scale
farm produce
Women’s experience of care received
Women referred to both positive and negative
episodes in terms of physical and psychological
aspects of care.
Physical aspects of care received
• Women’s interpretation of the quality of the care received
depended in part on the kind of physical or medical care
received.
They took good care of me because they gave me some
medicine and blood after I gave birth to a dead child.
(Interview 15)
Psychological impact of physical care
• If women felt that their physical needs were
looked after, this was likely to be beneficial
for their psychological well-being and overall
experience.
Responding to the Loss
• Perinatal loss is a traumatic experience
because it thwarts expectations; the hoped
for, planned for, and anticipated child is lost.
I was filled with sorrow because I was
expecting something, I was eagerly
waiting, and I was also happy that I would
have a baby. I was heart-broken…….
(interview 3)
• Three other women blamed it on the nurses’
negligence:
it is the nurse’s negligence because if she
had attended to me a way could have
been found to save my baby (interview 9)
• several women described feelings of
abandonment or not being supported
(Interview 11)
Lack of empathy and attention.
Several women found that nurses
• lacked warmth and sensitivity
• they felt they were cared for in a businesslike manner.
• nurses did not show any empathy by saying
words of encouragement or counselling them
following their stillbirth or neonatal death.
• All participants wanted the nurse’s attention
soon after experiencing perinatal loss and
they were disappointed when they were not
adequately attended to.
There is nothing that they were doing,
when the child died, they were just
walking about. (Interview 6)
Lack of explanations
• Twelve women said that the nurses did not
explain to them the possible causes of their
stillbirths and newborn deaths.
• Some mothers gave their own explanations as to
what may have caused their child’s death, such
as suffocation, God’s will or witchcraft and
these explanations themselves (e.g. witchcraft)
may have caused additional stress.
• nurses did not take their complaints seriously
and neglected them and their babies.
• However, five participants said that the death
of their (unborn) baby was God’s wish
(Interview 1)
Coping strategies in dealing with the loss
• belief in God and fate
• support received from significant others like
their spouse, parents, relatives, and
members of their (religious) community
Discussion
• The importance women attach to bearing
children in Malawi may have aggravated their
sense of loss
• Providing explanations to women
• Patient-centred care
Medicalisation of perinatal death:
• health professionals view perinatal death from a
medical perspective focusing on the
physiological factors only.
- loss as an emotional and symbolical event
(Frost et al 2007).
- institutionalized norms of dealing with
bereaved women
- depersonalisation and ‘mechanical’
interactions
• nurses’ attitudes and professional negligence,
• reluctant to critique health professionals
Limitations
• The sample was fairly homogenous; most
participants in this study had relatively little
education, were poor and belong to the Chewa
ethnic group predominantly found in central
Malawi.
• Use of other methods of data-collection such as
observations would have enabled triangulation
of findings and provide a more holistic
perspective of the child loss experience.
• Nevertheless, the findings add to a body of
knowledge about womens’ perceptions of
nursing care following perinatal loss
previously unexplored in Malawi.
Implications for practice
• Although follow-up research is desirable, nurses
must attend to the physical and medical needs
of women
• physically being with the bereaved woman
conveys emotional presence and connectedness
• acknowledge the meaning which women attach
to their pregnancies and the significance of the
baby to them in a society that highly values
childbearing.
• provision of explanations is likely to facilitate
coping as well as future use of maternity
services.
Conclusion
• Nurses in Malawi work in an environment with
limited human and financial resources, structural
interventions are needed to improve this
• need for nurses to change the way they care for
women experiencing perinatal loss.
• Well-thought through training and programmes
focused on promoting awareness and attitudinal
and institutional change need to be developed .
• more research of a larger scale to inform
development of effective strategies for
responding to such women.
• Research investigating health professionals’
and mens’ perspective of child loss will be
essential too as their views may differ from
those of women but will affect their loss
experience and the way it is dealt with.
References
• Frost J, Harriet B, Levitas R, Smith L,& Garcia 2007. The
loss of possibility: scientisation of death and the special
case of early miscarriage Sociology of Health&
Illness.29, 1003 – 1022
• Hutti, M.H.,2005 Social and professional support needs
of families after perinatal loss. Journal of Obstetric,
Gynecologic, and Neonatal Nursing 34; 630 - 638.
• Kok, B. C.de, Hussein, J. & Jeffery, P. 2010.
Introduction: Loss in childbearing in resource-poor
settings. Social Science and Medicine, 71(10), 17031710.
• Smith L, Frost J, Levitas R, Bradley H & Garcia J
2006 Women’s experiences of three early
miscarriage management options: a
qualitative study. British Journal of General
Practice. 198 - 205
Acknowledgement
• KCN for funding the research
• De kok Bregje for her useful comments