BREAKING BAD NEWS

As a House Officer, while on call we had a lady rushed into theatre for an emergency CS due to foetal bradycardia diagnosed on the CTG (i.e. the heart rate of the baby was reading about 80bts/min when a normal heart rate for a baby in the womb should be between 110 to 160bts/min). It turns out that the CTG (an out-of-date model compared to what is used in UK and the developed world) had been picking up the mother’s pulse and we delivered a macerated foetus (i.e. the baby had been dead for a while and was already decomposing – sorry for the graphic details).
It was left to the consultant paediatrician to leave the theatre and tell the father how a baby would not be coming out and why (the mother was under general anaesthesia and so was unaware of what had occurred).
Different guidelines on the management of pregnancy loss suggest that the most senior member of the team should break the news to the woman/couple wherever possible.
However, this raises a question for more junior doctors on the frontline of care. If, for example, you are the Medical Officer on NYSC (national service in Nigeria) posting and you are the first and only person most patients would see, how do you effectively deliver bad news? What qualifies you to deliver bad news? Can empathy only be gained with experience? Is that why the more senior health professionals should deliver bad news? If yes, does this mean that we will inevitably bungle up the delivery of bad news until we learn how to do it properly?
Personally, I was always uncomfortable with miscarriage and pregnancy loss. I am ashamed to admit that when I went in to see the mother the next day on my House Officer ward round, I could not look her in the eye, I did not offer my condolences for her loss; I just said, “good morning” and checked her vital signs. It wasn’t till I had experienced a loss myself and conducted the survey that I realised how lonely and scary such an experience could be. Empathy can really go a long way to make a difference in such instances.
While preparing for my PLAB exams (in order to be registered with the General Medical Council in the UK), breaking bad news was one of the skills I had to learn. It is also a module in BMJ Learning for continuing professional development. This is a topic that was never discussed while I was in medical school in Nigeria.
I don’t claim to know the answers to the who, how, when or why of the delivery of bad news. But I know that no matter what level you are at as a medical student, doctor, nurse or midwife, “I’m so sorry for your loss” is easy to say: there’s no law against that.

THE DISENFRANCHISED GRIEF OF PREGNANCY LOSS

Disenfranchised grief is defined as grief that is not socially supported, either because the relationship with the person lost is not recognised, the loss itself is not recognised or the griever is not recognised1. In the case of pregnancy loss, it is usually that the loss is not recognised making it difficult to grieve properly.
Across sub-Saharan Africa, death is traditionally perceived as the process by which a person becomes an ancestor2. With pregnancy loss, there was no opportunity for the foetus to become a person, not to talk of an ancestor; this makes it very difficult for a typical woman or couple to come to terms with what exactly has been lost and how to mourn that loss.
The mourning practices of Nigerians in particular stem from a religious perspective, due to Nigeria’s triple heritage of Christianity, Islam and Traditional religions1. There is, however, no mourning practice for a pregnancy loss. A change to this should be considered as it has been reported that unacknowledged loss and a lack of grief rituals for the loss can challenge healing after pregnancy loss3.
In Nigeria, obituaries and memorials are used to celebrate a person’s life achievements and position in society2; it is an opportunity to list out all the family members that will miss that person. After a miscarriage, there are people that are affected by the loss, people who already loved this tiny foetus and were dreaming of the day the child would be born and the changes he/she would bring to their lives. But the very nature of first trimester loss is that there is a sense that one has lost someone so loved but has nothing to show for it; there is no actual visible person to mourn.
There is a need for an accepted approach to the process of dealing with a pregnancy loss. Without this, there is the risk that the accompanying grief, which goes unacknowledged, may be too much for the woman to bear, especially if she does not have the essential social support or the empowerment that comes from education to deal with it in her own way.

REFERENCES
1. Eyetsemitan F, “Cultural interpretation of dying and death in a Non-Western society: the case of Nigeria”, Online Readings in Psychology and Culture, Unit 14, Chapter 1. ©International Association for Cross-Cultural Psychology, 2002.
2. “Death, Mourning and Ancestors”, accessed from http://www.novelguide.com/a/discover/aes_01/aes_01_00107.html on 29/04/11
3. Douglas K I, Fox J R, “Tears of blood: understating and creatively intervening in the grief of miscarriage”, Compelling Counselling Interventions: VISTAS 2009, pp89-100, ©American Counselling Association, 2009.