The final sample consisted of 445 female midwives, mean age 35.1 (SD 9.9), mean working years 11.2 (SD 10.2). Distribution of age and working years in tertiles and number of stillbirths assisted are reported in Table 1
. The type of professional settings where participants were currently working at the time of the interview is reported in Table 2
(multiple answers allowed) and show that midwives working in birthing rooms assisted significantly more stillbirths than the others, while those working in private practices assisted fewer events. Fig. 1
shows geographical distribution of the sample: participants answered from all Italian regions, although the vast majority of respondents (375, 82.4%) were working in hospitals located in the regions of Lombardy, Piedmont, Veneto, Emilia Romagna, Sardinia and Puglia. Only 152 midwives (34.2 %) reported that in their setting a specific protocol for the management of perinatal loss was available, and only 149 (33.4%) reported having attended specific training on perinatal loss in the past. With regard to stillbirth management, Table 3
presents emotions (a), attitudes (b) and behaviours (c) of midwives according to years of work. 384 midwives (86.3%) reported talking with someone about loss events they had to manage, in particular with other midwives (373, 83.8%), obstetricians (173, 38.9%), or their own relatives (268, 60.2%). Many midwives reported the need to receive training and support for the management of stillbirth: midwives working for less than five years referred more need for periodic debriefing meetings and were less likely to have attended specific courses on perinatal loss management (Table 4
). Participants were also asked to complete a questionnaire assessing their knowledge of 78 recommended interventions in case of stillbirth, extracted from several international guidelines with the same procedure described in Ravaldi et al. 2018 [
- Ravaldi C.
- Levi M.
- Angeli E.
- et al.
Stillbirth and perinatal care: Are professionals trained to address parents’ needs?.
]. According to their answers (reported in Supplementary Table), each subject was graded in three classes of knowledge, divided low (correct answer to <40 items), medium (41−50 items), and high (>50 items). Results reported in Table 5
show that knowledge of guidelines tends to increase (although not at a significant level) with working years and after having assisted more events, while it is significantly higher in participants who attended specific training courses on perinatal loss management. Midwives who reported having attended specific training courses on stillbirth in the past scored significantly higher in the guidelines test (61.7 ± 6.2 vs 58.4 ± 6.0; p < 0.01). Midwives were also asked to rate on a Likert scale, from 0 (easy) to 5 (very hard), how difficult it is to perform some of the tasks needed when assisting women during stillbirth (Fig. 2
, panel A). The hardest task was “communicating the diagnosis of death” (4.6 ± 0.7; p < 0.01), followed by “presence during the meeting with the baby” (3.9 ± 0.9; p < 0.01). “Collecting mementos” was considered the least difficult task (3.3 ± 1.0; p < 0.01). Caring for the stillborn baby was considered significantly less hard by midwives working for more than 15 years (3.8 ± 0.6 vs 3.7 ± 0.6 vs 3.6 ± 0.6, p < 0.05; Fig. 2
panel B) and by those who had assisted more than 10 bereaved mothers (3.8 ± 0.6 vs 3.8 ± 0.5 vs 3.5 ± 0.6, p < 0.01; Fig. 2
panel C). Results of psychometric tests are reported in Tables 6
(MBI) and 7
(IES-R): 109 midwives (24.5%) reported high IES-R scores, suggesting significant symptoms of PTSD related to stillbirth events; with reference to professional burnout, high levels of emotional exhaustion, depersonalisation and reduced personal accomplishment MBI subscales were scored, respectively, by 12 (2.9%), 24 (5.9%) and 155 (37.9%) respondents. Emotional exhaustion and reduced personal accomplishment were significantly higher in midwives working for more than five years. Scores for emotional exhaustion and depersonalisation subscales of MBI significantly correlated with those of IES-R, while this was not true for reduced personal accomplishment subscale (Fig. 3
). When addressing which factors were able to independently predict high levels of burnout in a multivariate analysis, we found that working for more than five years increased the risk of emotional exhaustion (OR 2.6, CI 1.7–4.0) and reduced personal accomplishment (OR 1.8, CI 1.2–2.8), and a good level of knowledge of guidelines reduced the risk of having low personal accomplishment (OR 0.3, CI 0.1 – 0.6). In addition, high IES-R scores significantly predicted high levels of all burnout domains: emotional exhaustion (OR 2.7, CI 1.6–4.7), depersonalisation (OR 2.0, CI 1.2–3.5), and reduced personal accomplishment (OR 1.7, CI 1.0–3.0). With exclusive regard to the subscale emotional exhaustion, also subclinical scores of IES-R were significantly and independently associated with higher levels of burnout (OR 2.2, CI 1.3–3.7). The number of stillbirths assisted was instead not associated with burnout levels. A forest plot graphically showing results of the multivariate analysis is reported in Fig. 4
. Finally, several emotions reported during stillbirth care were independently associated with high levels of IES subscales in a multivariate analysis (Table 8
Table 1Main characteristics of the sample.
Table 2Place of work according to number of stillbirths assisted; * significant differences between midwives who assisted fewer or more than 5 stillbirths.
Table 3Emotions (a), attitudes (b) and behaviours (c) of Italian midwives with regard to stillbirth care, according to years of work; * significant differences between midwives working for less or more than 5 years.
Table 4Need for support and professional updating according to years of work. In bold, significant differences between midwives working for less or more than 5 years.
Table 5Knowledge of guidelines (number of items from 0 to 78) according to years of work, number of stillbirths assisted or attendance of courses on perinatal loss; * significant differences versus midwives who never attended courses on perinatal loss.
Table 6Results of psychometric evaluation – Maslach Burnout Inventory according to years of work; * significant differences between midwives working since less or more than 5 years.
Table 7Results of psychometric evaluation – Impact of Event Scale according to years of work; * significant differences between midwives working since less or more than 5 years.
Table 8Items significantly associated with high levels of Impact of Event Scale total score and subscales.