Description
The literature review should clearly argue for the proposed research question. It should be themed appropriately and contain headings and subheadings.The review should be detailed, demonstrating breadth of reading and critical appraisal of other research studies relevant to the topic. The review should place this study in the context of previous studies and should include research research primarily sourced from Ireland or Western European countries that share a similar healthcare system.
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Research Question:
Midwives’ experiences of caring for women with FGM
First theme:
Midwives’ experiences
Second theme:
Midwives’ Knowledge of FGM (discuss lack of knowledge)
Third theme:
Impact on women’s care
Discuss the gap of research on FGM in Ireland
QUALITATIVE research
Design: DESCRIPTIVE
Data collection: IN-DEPTH INTERVIEWS (60-90 MINS), one-to-one, face-toface interviews will be conducted and semi-structured
Paradigm: NATURALIST
Sampling: NON-PROBABILITY SAMPLING (snowball or purposeful sample)
Population: MIDWIVES are the population of this research area
Sampling setting: through GATEKEEPER (hospital management)
Sub-heading: research study articles
•
Discuss how did you refine it down to and chose those articles instead
of others.
•
Why choose this author? (e.g. because Ali Et. Al, looks in-depth in
midwives experiences of fgm)
•
CRITIQUE AT LEAST 5 STUDIES
Try to be objective and sensitive throughout and discuss limitation. Add ethical
issues around the topic.
Research Proposal.
Word Limit: 5,500 Words ( +/- 10%)
Weighting: 100%
Presentation Guidelines:
•
A CA submission signed front sheet.
•
A title page containing your name, student number, the title of the
research proposal, the date of submission, module leader, supervisor
and word count.
•
A table of contents should be included
•
Acknowledgements can be included if students wish.
•
Abstract
•
Chapter 1. The literature review
•
Chapter 2. Methodology
•
References. (Words not included in word count). Use DKIT referencing
guidelines.http://www.dkit.ie/library/support/guide-harvardreferencing
•
Appendices: Include letters, completed ethics form, supplementary
material.
Abstract – approximately 300 single spaced words (words not included in
word count). Include an outline of the main parts of the proposal, following
the same order as the proposal.
Chapter 1. (3,000 words) Includes:
Introduction (rationale and background of proposed study, significance of
problem/issue), literature review, research questions, research hypothesis (if
appropriate), aims/objectives.
Introduction:
Give a brief outline (200 words) of the research problem/issue and why you
are interested in it. Variables to be examined, described, or explored should
be introduced.
A short description of the search strategy and key words used for the
literature review. Use databases such as PubMed,
CINAHL, PsycINFO, Embase, and Scopus. You may need to try several key
word combinations to get the literature you require. Include ‘Irish’ or ‘Ireland’
as one of your key words to identify research conducted in Ireland.
Literature Review
The literature review should clearly argue for the proposed research question.
It should be themed appropriately and contain headings and subheadings.The
review should be detailed, demonstrating breadth of reading and critical
appraisal of other research studies relevant to the topic. The review should
place this study in the context of previous studies and should include research
research primarily sourced from Ireland or Western European countries that
share a similar healthcare system.
Strengths and weaknesses of previous research should be identified. In
addition it is important to demonstrate how this study will improve on previous
research or add to the body of existing Irish Nursing/Midwifery knowledge on
the topic. The research question should be stated at the end of this chapter
alongside the aims and objectives of the proposed study.
Research Question or Hypothesis
The research questions should be interrogative i.e. posed as a question, not
as a statement. For example; what are women’s experiences of midwifery led
care’? What are nurse’s attitudes towards patients with mental health
problems? The question should be researchable, and relevant to Irish
nursing/midwifery
State the question(s) that needs to be answered. A hypothesis should identify
the independent and dependent variable if relevant.
For example; does an exercise prevention programme improve outcomes for
patients with chronic stable angina/mental health issues?
It is important to remember that the research question should be formulated in
the context of the literature review and it forms the basis of the design chosen
for the methodological section.
Aims / Objectives
These should be stated clearly. They highlight the purpose and expected
outcomes of the study. They should be realistic and achievable.
Chapter 2. (2,500 words)
Research methodology
Include a rationale for the decisions about the research process and discuss
the strengths and limitations of choices made where appropriate. Use the
following headings as a guide and apply the principles specifically to your
study.
Paradigmatic / philosophical issues
The choice of design is informed and guided by a world view which shares
value systems and beliefs (e.g. Positivism (quantitative research), or
Interpretivism (qualitative research) etc.) This short introductory section
provides an opportunity for the student to discuss some of the relevant
underlying assumptions which influenced their choice of paradigm (why did
you choose quantitative or qualitative research to address this research
question?). Focus your attention on explaining a single paradigm.
Research Design
Outline and discuss the rationale for the choice of research design for the
proposed study. The design should be appropriate for the question. State
clearly what the design is (e.g. Survey, experiment, or qualitative descriptive
design) and give a rationale for using this design.
Population/Sample/ Sampling design
Describe the population . Describe the sample (i.e. size and members) and
sampling design giving a rationale for your choices. State inclusion / exclusion
criteria and rationale for these choices in the context of the proposed study.
Explain how the sample will be accessed. e.g. through a third
party/gatekeeper, online groups, via Facebook Instagram following DkIT
social media management policies.
https://www.dkit.ie/about-dkit/policies-and-guidelines/it-policies.html
Data Collection (Instrument)
How, where and when will be data be collected. (E.g. questionnaire or
interview). Give rationale for choices made. Describe the data collection
instrument to be used e.g. survey or interview questions. Discuss the issues
around data collection and the questions to be asked.
Place a copy of the instrument in the appendix. (Please reference if it is
sourced from another study)
Pilot Study
Describe the approach to be used for the pilot study and discuss the size of
the pilot sample. State that a pilot study will be done and why it should be
done. With an interview/focus group schedule what types of amendments
might be needed. Where, when, and how will it be done?
Ethical Considerations
Discuss the relevant ethical considerations related to the proposed study in
the main body of the work. Outline how the rights of subjects will be upheld in
this study. Indicate the essential ethical principles that must be upheld and
then state how you might uphold them. Develop a short letter to an
appropriate ethics committee to seek permission to carry out the study and
include this in the appendix (participant’s letter, consent form and ethics form).
DkIT ethics forms to be completed and put in the appendix available
@http://www.dkit.ie/health-science/research/research-ethics.
Data Analysis
How will the data be analysed?
• For quantitative research highlight the statistical description and tests
to be used.
• For qualitative research give clear guidelines on how the data will be
managed and then analysed.
• State the computer package to be used to manage the data e.g.
(SPSS/NVivo).
• Ensure that each step of the analysis phase is highlighted
demonstrating that all the research questions will be answered.
Validity & Reliability (Quantitative)
How will validity and reliability be achieved? (refer to pilot study)
Robustness/ Rigour or trustworthiness of the study (Qualitative)
How will trustworthiness of the study be achieved?
Proposed Outcomes of the study and dissemination of findings
What outcomes are expected from this study and how will findings be
disseminated? These should be linked to the aims and objectives.
•
•
•
The nature of the report that will be written up.
Benefits and limitations of the study.
Make recommendations for further research and how this study might
inform nursing and midwifery practice.
Reference List:
Harvard System of referencing must be used throughout the document.
The guide is available@http://www.dkit.ie/library/support/guide-harvardreferencing
References should be up to date (within the past five years). They should
refer to the professional bodies such as the NMBI, to provide professional
contextual information. References should also include national government
and local policy documents, systematic reviews (e.g. Cochrane Reviews)
where appropriate. Research conducted in Ireland should be included.
Academic Integrity
It is important to familiarise yourself with the dkit academic integrity policy
available @ https://www.dkit.ie/about-dkit/policies-and-guidelines/academicpolicies/student-centred-learning-teaching-and-assessment/academicintegrity-policy-and-procedures.pdf
Please submit your assignment into the research proposal module on Moodle
prior to. This assignment contains a ‘turnitin’ element where you can check
your originality index prior to your final submission The index can take several
hours to generate therefore ensure you have allowed sufficient time for
complete submission. Please include a signed front sheet. Please check your
originality index and be aware of self-plagiarism i.e. using work for which you
have already received credit. Please be aware that Turnitin has the capability
to detect any irregularities that may suggest the use of generative artificial
intelligence tools (e.g. ChatGPT), even if they are not apparent to you.
Generative artificial intelligence (AI) tools cannot be used in this assessment
task. In this assessment, you must not use generative artificial intelligence
(AI) (ChatGPT, ChatSonic, Bing Chat, Lex, DALL-E 2, or other tools) to
generate any materials or content in relation to the assessment task.
The DkIT Academic Integrity Policy and Procedures,
https://www.dkit.ie/about-dkit/policies-andguidelines/academic-policies.html)
states the following: “Using generative artificial intelligence tools (e.g.
ChatGPT) in an assessment unless explicitly permitted to do so and with
proper acknowledgement, is a form of plagiarism”.
Please check with your supervisor if they also require a hard copy of the
proposal.
A student is permitted to submit an assessment item 10% over or under the
stated word limit. If the word limit exceeds 10% the content will not be read
by the examiner. This means that the examiner will not include any work after
the maximum word limit has been reached within the allocation of marks.
Appendices
Appendices must be referred to in the text. Appendix 1, 11,111. Examples of
appendices are:
1 Realistic Study Plan detailing
a) Time Scale: A detailed time frame for the study. Assume the study will
be done over an 18-month period. Outline each stage of the study
assigning time frames to each.
b) Resources: What will be the resource implications for this study i.e.
funding etc.
c) Budgetary implications: include a detailed realistic budget for the study.
Think about the following:
o Travel (researcher & subjects/participants)
o Consultant’s fees (Statistician), Secretarial help
o Equipment (tape recorders), Stationary, Photocopying.
2 Research instrument/data collection tool
(Interview schedule or questionnaire) Please remember to reference.
3 Communication with stakeholders
• Letter to the Director of Nursing/Midwifery to gain access where
appropriate.
• Letter/email to participants inviting them to participate.
• Include a consent form where appropriate
• Dkit Ethics form.
• Participation letter
• Letter to relevant ethics committees.
Supervision.
Each student is allocated a total of 3.5 hours with their supervisors and supervision
can take place individually or in groups as organised by the supervisor. All students
must agree an appropriate topic for the research proposal with their supervisor. A
current nursing/midwifery issues relevant to practice is appropriate. It is the
responsibility of the student to contact the supervisor and negotiate appointment times
or dates while in College and on Clinical Placement. It is also the student’s
responsibility to ensure that the supervisor has sufficient time to read drafts of
completed work before visits. A limited number of drafts will be reviewed.
Students should not submit the proposal without it being reviewed by the
supervisor. In the event of this happening the Head of Department along with the
module leader and supervisor may request that the student participate in a Viva Voce
where they will be expected to discuss, elaborate and defend the submitted proposal.
Reading List
Cluett, E.R. and Bluff, R. (2006). Principles and Practice of Research in
Midwifery. London: Churchill Livingstone, Elsevier.
Diagnostic and statistical manual of mental disorders (DSM-5) (2013),
Arlington, VA, American Psychiatric Association.
Ellis, P. (2016). Understanding Research for Nursing Students (Transforming
Nursing Practice Series.) 3rd ed. London: Sage.
Gray, J.R., Grove, S.K. and Sutherland, S. (2016). The Practice of Nursing
Research: Appraisal, Synthesis, and Generation of Evidence. 8th ed. St Louis,
Missouri: Elsevier.
Grove, S.K. and Gray, J.R. (2014). Understanding Nursing Research: Building
and Evidence-Based Practice. 6th ed. St Louis, Missouri: Elsevier Saunders.
Hart, C. (2001). Doing a Literature Search. A Comprehensive Guide for the
Social Sciences (Sage Study Skills Series). London: Sage.
Kabacoff, R.I. and Girden, E.R. (2010). Evaluating Research Articles from Start
to Finish (Volume 3). 3rd ed. London: Sage.
Kellar, S.P. and Kelvin, E. (2012). Munro’s Statistical Methods for Health Care
Research. 6th ed. London: Wolters Kluwer/ Lippincott Williams & Wilkins.
LoBiondo-Wood, G. and Haber, J. (2009). Nursing Research: Methods and
Critical Appraisal for Evidence-Based Practice. 7th ed. St Louis, Missouri:
Mosby, Elsevier.
Parahoo, K. (2014). Nursing Research: Principles, Process and Issues. 3rd
ed. Basingstoke: Palgrave.
Polit, D.F., and Beck, C.T. (2003). Nursing Research: Generating and
Assessing Evidence for Nursing Practice. 10th ed. London: Wolters Kluwer
Punch, K.F. (2016). Developing Effective Research Proposals. 3rd ed. London:
Sage
Rebar, C.R., Gersch, C.J., Macnee, C.L. and McCabe, S. (2011).
Understanding Nursing Research: Using Research in Evidence-Based Practice
(Rebar, Understanding Nursing Research). 3rd ed. London: Wolters Kluwer/
Lippincott Williams & Wilkins.
Web Resources
http://health.gov.ie/
http://health.gov.ie/publications-research/publications/
http://www.dohc.ie/publications/research_strategy_for_nursing and
midwifery_and_midwifery_in_ireland.html
http://ww2.dkit.ie/library/electronic_resources
http://pregnancy.cochrane.org/
http://community.cochrane.org/cochrane-reviews
http://www.hseland.ie/dash/
https://inmoprofessional.ie/Library (if you are a member of the INMO)
http://0-web.b.ebscohost.com.dkitlibs.dkit.ie/ebma/detail/detail?sid=e28aff666b48-4fde-98 (nursing research e book)
http://dkit.ie.libguides.com/dkithealth
For Mental health
https://www.mhcirl.ie/
https://www.mentalhealthireland.ie/
https://www.hse.ie/eng/services/list/4/mental-health-services/nosp/
https://www.mhe-sme.org/
https://www.nmbi.ie/Publications/Standards-and-Guidance scroll down to
ethical conduct in research guide
Journals
Subject journal for your area of interest.
Health Education Research
Health Services Management Research
NT Research
Nurse Researcher
Journal of advanced Nursing
Research in Nursing and Midwifery and Health
Journal of Advanced Nursing
Midwifery
BMC pregnancy and childbirth.
Women and Birth
International Journal of Childbirth
The Practicing midwife
Mental health
Issues in Mental Health Nursing
Journal of Mental health and Psychiatric Nursing
Psychiatric Quarterly
Journal of Adolescent Health
Current Psychology
Evidence Based Nursing
Nurse Researcher
Nurse Education Today
Nurse Education in Practice
Journal of Prescribing Practice
What are women’s
experiences of pregnancy
after perinatal loss (stillbirth
and neonatal death) in the
Republic of Ireland?
BSc Hons Midwifery Research Proposal
Module Leader and Supervisor:
Word Count: 6050
Chapter 1: 3300
Chapter 2: 2750
Contents
Title and Subtitle
Page Number
Acknowledgements
3
Abstract
4
Chapter One: Literature Review
5-10
1.
2.
3.
4.
5.
6.
7.
Introduction
The Process of Grief
Shifting Emotions
Relief and Reassurance
The Research Question
Aim
Objectives
5
5-6
6-8
8-9
10
10
10
Chapter Two: Methodology
11-15
1. Paradigmatic Issues
2. Research Design
3. Sample and Sampling design
4. Inclusion and Exclusion Criteria
5. Data Collection
6. Pilot Study
7. Ethical Considerations
8. Data Analysis
9. Rigor of the study
10. Proposed Outcomes
11. Dissemination of findings
12. Strengths and Limitations
13. Recommendations for Future Research
11
11
11
12
12
12
13
13-14
14
15
15
15
15
References
16-19
Appendices
20-39
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
20
21
22
23
24
25
26
27-37
38
39
Letter to Ethics Committees
Letter to Directors of Midwifery
Letter to Clinical Midwife Specialists in Bereavement
Participants Information Leaflet
Consent Form
Interview Schedule
Braun and Clarke Framework
Ethical Approval Application Form
Gant Chart – scheduled timeline of events
Proposed costs and budgeting
1
Abstract
Background
In Ireland, over two hundred and fifty families are affected by stillbirth or neonatal death each year.
Most women conceive soon after and the impact of this perinatal loss will extend into subsequent
pregnancies. This may be an emotionally challenging time as well as one of increased obstetric,
psychological and social risk, requiring high quality care and support. Despite this, pregnancy after
perinatal loss is an overlooked area of research in Ireland. Therefore this study aims to gain a greater
insight into women’s experiences, expectations and needs and determine how maternity services are
addressing these.
Aims and Objectives
The aim of this research is to explore the experience of pregnancy subsequent to perinatal loss for
women in Irish maternity services to include:
–
Identifying feelings and emotions experienced during pregnancy after loss
Discerning women’s expectations and perceptions of current care provision
Discovering facilitators of and barriers to positive experiences
Design
A qualitative descriptive design will be used.
Sample
Ten mothers who have had a baby following on from a stillbirth or neonatal death will be purposively
sampled. Two recruitment strategies will be employed; potential participants will be highlighted from
an online maternity record database and an advertisement will be placed on relevant perinatal loss
charity webpages. A clinical midwife specialist in bereavement will act as a gatekeeper.
Data Collection
In-depth, one-to-one, face-to-face interviews will be conducted. A semi-structured schedule will be
used and debriefing sessions will be available to access.
Findings and Implications for Practice
Revealing the untold lived experience of women in Irish maternity services may allow healthcare
professionals to understand and empathise with them in a new way. Factors that contributed to
positive experiences will reinforce good practice and barriers and challenges to this may be
addressed in the clinical area. Findings will also establish at an organisational level what is working
well and areas that require improvement. It is hoped that this study could inform the development of
new roles and delivery of specialist services.
2
Chapter 1: The Literature Review
Introduction
Perinatal loss (PL) encompasses the death of a term baby before delivery, stillbirth (SB) or neonatal
death (NND), within four weeks postpartum (Health Service Executive (HSE) 2016). This type of
pregnancy loss is a profoundly painful experience that over 250 couples endure in Ireland each year
(Central Statistics Office 2022). Parents bereaved in such a way say it is impossible to ‘move on’ from
grieving their lost baby and will instead ‘move forward’, which largely involves trying for a new baby.
Meaney et al. (2017) discovered that Irish mothers reflect on the possibility of becoming pregnant
again immediately. Approximately 86% of women are successful within the first year and a half of
their infant’s passing (Mills et al. 2016).
Subsequent pregnancies are often complex. From an obstetric point of view, there is an increased
risk of recurrence (Lamont et al. 2015) and other adverse outcomes. These include; pre-eclampsia,
abruption, prematurity and operative intervention (Black et al. 2008). Pregnancies may also be
complicated by anxiety and depression which can compromise the woman’s wellbeing, quality of life,
and have consequences on the whole family unit (Thomas et al. 2021).
Alarmingly, a national survey of 138 maternity units across the United Kingdom (UK) revealed that
only 40% had written formal guidelines for such high risk pregnancies (Mills et al. 2016). Within these,
monitoring and surveillance of fetal wellbeing were consistently emphasised, whilst emotional and
psychological support measures for maternal wellbeing were consistently absent. Seventy seven
percent of women in the same study felt that the care they received required improvement.
In Ireland, maternity bereavement care remains a massively overlooked area of research, with the
first survey of women’s experiences commencing only in September 2022. The results remain
unpublished, however, are likely to focus around the time of the PL as support in subsequent
pregnancies is yet to be acknowledged in or addressed by countrywide policy documents. The
National Maternity Strategy (Department of Health (DOH) 2016) and HSE Bereavement Guidelines
(2016) offer many directives which centre around the immediate period after a loss but fail to provide
recommendations for care during consecutive pregnancies. In the lack of standardized guidance,
quality of care is likely to differ depending on individual experience, expertise and attitudes of
midwives and healthcare professionals.
Pregnancy after PL is therefore a prevalent and pressing issue within Irish maternity services that
requires investigation. Moreover, the voice of Irish mothers is largely absent in the literature. For that
reason, this research proposal aims to explore women’s experience of pregnancy subsequent to PL in
the Republic of Ireland. A literature review was performed in order to gain a greater understanding of
the subject. Three recurring themes were identified and existing research will be discussed under
these headings; the process of grief, shifting emotions and relief and reassurance.
The Process Of Grief
The extraordinary grief connected to the death of a baby is so unimaginable that it has attracted much
attention in research. The intensity of sadness and suffering is thought to be attributed to the fact that
PL encompasses every type of grief. The loss of a child is also the loss of reality, the loss of hopes
and dreams, the loss of innocence around pregnancy and the loss of identity (Caelli et al. 2002). This
grief may be lifelong and can therefore extend into and be complicated by a subsequent pregnancy
(Côté-Arsenault and Morrison-Beedy 2001).
The significance of grief in SB and NND was not considered, nor was it documented in early literature
(Lewis 1976; Lewis and Page 1978). Bereavement care reflected this lack of understanding.
Preventing parents from seeing their baby was at one time standard practice, supported by Hughes et
al’s controversial study (2002) which suggested such action reduced the incidence of anxiety,
3
depression and post-traumatic stress disorder (PTSD). This has largely been discredited on the
grounds of validity concerns (Üstündağ-Budak et al. 2015). The opposite practice of encouraging
parents to see, hold and remember their baby is now accepted, as the value of memory making is
well established in research (Meredith et al. 2017). A pioneering study conducted by paediatricians
Kennel et al (1970) finally acknowledged grief as a remarkable reaction to PL. Later, the findings of
Lin and Lasker (1996) identified numerous emerging patterns in parents which illustrated the
multifaceted, especial, disseminating nature of the grieving process.
Practices have improved considerably in light of this. Yet, the magnitude of such a loss still goes
unappreciated by family, friends and worryingly, healthcare professionals (Meredith et al. 2017).
Parents describe a stigma in society surrounding the death of a baby, which culminates in a lack of
support from those closest to them. This is deduced in the literature as disenfranchised grief (Heazell
et al. 2019). Meaney et al (2017) and Caelli et al (2002) both report that where the provision of
comfort is attempted, it is often through the use insensitive platitudes and hurtful remarks, based on
the myth that another baby will ‘cure’ or help them to ‘get over’ their grief. A metasynthesis directed by
Mills et al. (2014) demonstrates that this can result in women feeling further isolated and alone at
what is already an incredibly vulnerable time and without this support, the grieving process may
become prolonged.
Grief is further compounded by the fact that mothers and fathers may have conflicting aspirations
about conceiving again (Caelli et al. 2002; Murphy et al. 2021; Meaney et al. 2017; Meredith et al.
2017). Whilst mothers immediately reflect on the possibility, as a means to escape the grieving
process, fathers struggle to consider future pregnancy in light of the loss. This reluctance and at
times, refusal was likened by some women in Meaney et al’s study (2017) to grieving their future baby
which causes guilt, anger, resentment and conflict in the relationship. Five Irish fathers and ten
mothers were recruited for this research which perhaps presents an outsized sample for
phenomenology. It also creates inequity between genders when a clear aim of the study is to
represent the voice of fathers. Some interviews lasted only 35 minutes, whereas phenomenological
data collection usually takes a minimum of 60. Perhaps a qualitative descriptive design would have
been more suitable to this research.
Further phenomenological research in Ireland was more appropriately carried out by Murphy et al
(2021) and the findings resonate with those of Meaney et al’s study (2017). Dyadic interviews of eight
couples, collectively willing to participate, found a yearning to get pregnant almost immediately after
the index loss amongst the women. Men often acted as gatekeepers in the decision, expressing a
desire to wait. Both studies suggested that men often had to set aside their own feelings in order to
support their spouse through the grief and some partners viewed subsequent pregnancy as a means
to ameliorate this. The difficult decision left many grieving the loss of communication and intimacy
between them in the relationship. Yet, others worked together to negotiate the journey to pregnancy
again alongside the process of grief, despite their differences.
Shifting Emotions
Becoming pregnant after loss is a poignant occasion, and an overwhelmingly happy time for most.
Many women discuss the colossal sense of relief they feel, that they no longer have to experience the
heartache that comes with each monthly menstrual period. It brings new light into their lives and hope
finally enters the home again (Meaney et al. 2017; Murphy et al. 2021). However, these feelings of
respite are often fleeting. It has been suggested that when a baby dies, everything a person knows to
be true dies with it. It can change the woman personally, alter her life drastically and taint her outlook
on future pregnancies. In the newfound knowledge that pregnancy does not always end the way it is
supposed to, joy can be swiftly robbed, replaced quickly by anxiety that this precious baby too may
not survive (Mills et al. 2014).
4
Living with those thoughts for nine months was retrospectively described as ‘hell’ by one mother in a
focus group conducted by Côté-Arsenault and Morrison-Beedy (2001). Findings from another focus
group based study discerned that enjoyment and excitement was experienced; however fear
prevented them from stepping into the happiness of pregnancy with both feet. These shifting emotions
were captivated by the metaphor ‘one foot in; one foot out’ (Cote-Arsenault and Marshall 2000). The
women across both studies shared a fear of recurrent loss and recounted being plagued by constant
worry throughout their pregnancy.
Cote-Arsenault has lead much of the investigative efforts into women’s experiences during pregnancy
after loss in the United States and observed a prevalent phenomenon called emotional cushioning in
undertaking such research. It is since a well-documented coping mechanism particular to the
circumstance of pregnancy after loss, whereby women avoid antenatal attachment to their baby
(Meredith et al. 2017; Mills et al. 2014; Côté-Arsenault and Morrison-Beedy 2001). Driven by the fear
described, women suppress emotional investment as a form of self-protection and an attempt to
reclaim some control over what is otherwise an incredibly uncertain time (Côté-Arsenault and Donato
2011). This is a suggested contributing factor to the predominance of disrupted infant bonding and
consequential parenting difficulties detailed in the literature (Blackmore et al. 2011; Warland et al.
2011).
Some women report feeling safe and secure in their pregnancy, and many mothers learn to
appreciate each day because the future is so precarious (Meredith et al. 2017). But for others, the
uncertainty is overwhelming, which prompts unrelenting requests for obstetric intervention (Mills et al.
2014). This is apparent in the work of Roseingrave et al. (2022) into Irish health service utilization,
where the rates of induction and caesarean section, were found to be significantly higher in
pregnancies after loss. Furthermore, two thirds of preterm birth amongst the cohort was iatrogenic. In
these cases, there is a genuine maternal misconception that the baby is ‘safer out than in’. And yet,
one in four of the infants included in the study were transferred to the neonatal intensive care unit,
which is almost double that of the general obstetric population (Roseingrave et al. 2022).
Since fear is an emerging theme across all of the literature reviewed (Meredith et al. 2017; Mills et al.
2014; Côté-Arsenault and Morrison-Beedy 2001; Caelli et al. 2002; Côté-Arsenault and Donato 2011;
O’Leary 2005; Murphy et al. 2021; Meaney et al. 2017), it is not surprising that heightened levels of
anxiety and depressive symptoms in these pregnancies are well documented (Debackere et al. 2008).
Thomas et al. (2021) collected data using a Psychometric Questionnaire in conjunction with
measuring cortisol levels throughout pregnancy by means of hair samples. Self-reported symptoms
were highest during the first half of pregnancy and lowest postnatally, and hair cortisol followed same
downward trend as the pregnancy progressed. The safe arrival of a healthy baby was considered a
causative factor for this reduction in anxiety, stress and depression. Remarkably, the reverse order
was observed by Duffy et al. (2018) in their study of cortisol levels in uncomplicated pregnancies.
Having said that, Blackmore et al (2011) found no evidence to suggest that depression and anxiety
related conditions are resolved by the birth of a live baby and symptoms tend to persist long after the
postnatal period of subsequent pregnancies.
Whilst such amplified anxiety makes it difficult to get through each day, there are particular times
during the pregnancy women report as increasingly challenging (Meredith et al. 2017). The lead up to
routine antenatal appointments are generally associated with additional stress and any reassurance
surrounding baby’s safety is short-lived (Mills et al. 2014). Ultrasound scans too are met with intense
apprehension. Again they may yield a brief period of relief, however these interactions can quickly
become a traumatic experience, triggering flashbacks and causing parents to relive events related to
their baby’s death (O’Leary 2005; Mills et al. 2014; Graham et al. 2021). Indeed PTSD symptoms are
reported amongst 25-33.3% of pregnant women who have suffered a PL (Engelhard et al. 2001;
Horesh et al. 2018). Emotions are also heightened as the time of the
