The Critical Role of Fathers to Reduce Stillbirth in India
Repository Posting Date2017-07-05T20:04:28Z
Author DetailsLisa R. Roberts, DrPH, MSN, RN, FNP-BC, CHES; Susanne Montgomery
Lead Author Sigma AffliationGamma Alpha
Other Title(s)Interventions in Birth Outcomes
Level of EvidenceN/A
The purpose of this study was to explore how men and women experience stillbirth in India, and their respective needs, to inform locally sustainable interventions.
Millennium Development Goal 4, to reduce child mortality, cannot be achieved without reducing the world’s 3.3 million stillbirths (Yoshida et al., 2016). India has the highest number of stillbirths in the world (Blencowe et al., 2016). A confluence of medical and sociocultural factors contribute to the high stillbirth rate among poor, rural women in central India, and the effects are devastating. For women, fertility is correspondent to worth, yet social norms increasing the risks of stillbirth include: lifelong malnutrition due to girls/women receiving less food, of less quality, after males have been fed; young (due to early marriage) or advanced maternal age (as women continue trying to get pregnant with a boy child), lack of reproductive health choice/resources, and the quest for sons; maternal socioeconomic disadvantage as girls receive less education, are less likely to work in the formal workforce, and are unable to inherit property; short birth intervals and lack of antenatal care; and lack of skilled birth attendants due to lack of infrastructure in addition to women’s low general autonomy and specifically lack of health care decision making power (McClure et al., 2015). When stillbirth occurs, women in India and other low-middle income countries suffer perinatal grief that may persist for years, but is unrecognized, repressed, and untreated, resulting in mental health sequelae such as depression, anxiety, somatic symptoms, decreased functioning, and increased risk for domestic violence, stigma, and abandonment, or isolation (Burden et al., 2016; Lawn et al., 2016).
All too often multiple stillbirths occur in one family, as stillbirth begets stillbirth. In India’s patriarchal society with its strong son preference and deficient women’s autonomy, sex-selective abortion occurs, putting women at risk for future preterm birth—increasing the risk of poor infant outcomes, including stillbirth (Ahankari, Myles, Tata, & Fogarty, 2015; Bharadwaj & Lakdawala, 2013; Straus & Mickey, 2012). While few studies have explored how fathers experience grief after stillbirth, previous studies in the West indicate that fathers—unlike mothers, have increased psychological symptoms the more time elapses before another pregnancy (Cacciatore, Erlandsson, & Rådestad, 2013). In India, this tendency combined with social pressure to try to conceive a son soon after stillbirth, may actually cause men to unwittingly reduce their chances of fulfilling desired fertility expectations (Kozuki & Walker, 2013). Therefore, men’s perceptions and knowledge regarding maternal-child health and reproduction are important to achieving a reduction in stillbirth rates in India.
We used mixed-methods in two parallel studies; (a) evaluation of a short mindfulness-based pilot intervention which was culturally adapted and implemented in collaboration with local nurses, for women (n = 22) who had experienced stillbirth, and (b) formative work exploring men’s experiences with stillbirth using key informant interviews (n = 5) and structured interviews using a survey based on identified themes (n= 23).
Women who had experienced one to three stillbirths participated in the Mindfulness-based intervention (MBI), 6-week, and 12-month follow-up assessments. Anxiety and depression symptoms were significantly reduced, as measured by HSCL index (M = 2.17 (SD 0.60), M = 1.81 (SD 0.48), and M= 1.59 (0.47) respectively). Likewise, significant reductions in the perinatal grief index as well as the active grief, difficulty coping, and despair subscales were noted at each assessment over time. Mindfulness was positively correlated to resilience, and at 1 year, 95.4% of the participants were still practicing mindfulness skills. Women reported that mindfulness was useful in helping them feel calm, increased their sense of peace in mind and body despite stressors, and gave them positive energy making it easier to function in their roles despite never forgetting their stillborn babies.
Men (three who were fathers of stillborn babies) acknowledged their medical and reproductive decision making power matter-of-factly as well as the lack thereof for their wives, and while they saw it as a natural a right, they also experienced it as a burden. They often felt they lacked knowledge and readiness for decision-making. Wives were not allowed/encouraged to discuss their stillbirth and men accede societal expectations for fertility, pushing their wives to conceive again soon. If unsuccessful, or a son was not produced, a second wife was seen as a possible solution.
Of the 23 men who completed surveys, 18 had experienced stillbirth. These men, compared to those without a history of stillbirth, were significantly more likely to have anxiety or depressive symptoms and perceived lower social provision of support. They also had significantly more egalitarian attitudes towards women, though they were also more abusive of their wives. They reported a greater number of days as normal for women to grieve after stillbirth and employed greater use of positive religious coping, but still reported frustration with their wives crying or otherwise showing grief and wished their wives would just get on with life. Once aware of the MBI for women, men were supportive of the program.
Overall, men reported granting far greater autonomy to women than women themselves perceived. Additionally, men were more likely to report abusing their wives than women were to report being abused. There was, however, concordance of reports by both men and women that approximately half of the stillbirth deliveries had been conducted by unskilled birth attendants at home.
Our short, culturally adapted MBI was found to be effective in reducing perinatal grief and increasing resilience for poor village women in rural central India, with not only sustained but increased improvements at one year. However, men in the same villages were often unaware of the need or that the intervention had been offered. Fathers of stillborn babies had unmet needs for support, yet dealing with perinatal grief possibly provided an opportunity for them to gain new insight, experience personal growth and develop empathy resulting in the more egalitarian view towards women noted in our results. Providing support to fathers might reduce their increased propensity for abuse and symptoms of anxiety and depression, while increasing capacity for the positive changes in attitudes found towards their wives.
Miss-matched perceptions between men and women regarding women’s autonomy and abuse are opportunities for community engagement and discussion. The link between stillbirth and the low use of skilled birth attendants/facilities represents an opportunity for education and community-based intervention. Nurses, who interact with both genders and are knowledgeable of the cultural context are already positioned in the community. Local nurses are ideal collaborative partners for community engagement and with appropriate training and support can implement community-based interventions.
As Kofi Annan has said, “When women thrive, all of society benefits and succeeding generations are given a better start in life.” Clearly, if progress toward reducing stillbirths is to be made both men and women have to be involved in intervention efforts. In a patriarchal society like India, stillbirth studies should explore fathers’ perceptions, attitudes, and behaviors regarding stillbirth so that appropriate interventions can be developed for men, ultimately supporting women. While societal norms would require separate interventions, an effective intervention such as the pilot MBI for women is promising and may be adaptable for fathers too.