Abstract
Background
The practice of allowing women to see their stillborn baby after pregnancy termination is clinically debated, yet little is known about its psychological implications in Chinese cultural settings. This study aimed to assess the association between visual contact with a stillborn baby and the risk of postpartum depression (PPD) and anxiety (PPA) among Chinese women.
Methods
This prospective cohort study recruited 202 women who underwent pregnancy termination due to stillbirth or a fetal anomaly between March 2022 and September 2023. Symptoms of depression and anxiety were assessed at baseline, and at 1 and 3 months following the termination using the Edinburgh Postnatal Depression Scale and the Generalized Anxiety Disorder Scale. Multivariable logistic regression was conducted to examine the association between seeing the stillborn baby and the risk of PPD and PPA, adjusting for potential confounders.
Results
There was no significant impact of seeing the stillborn baby on the PPD and PPA at 1 month after termination. At 3 months after termination, seeing the stillborn baby was emerged as a significant protective factor against PPD (OR 0.28, 95% CI 0.13–0.59) and PPA (OR 0.12, 95% CI 0.05–0.27). These associations remained significant after adjusting for confounders, with an adjusted OR of 0.18 (95% CI: 0.08–0.42) for PPD and 0.12 (95% CI: 0.05–0.29) for PPA.
Conclusions
Visual contact with the stillborn baby may act as a protective factor against PPD and PPA. These findings underscore the importance of healthcare professionals providing respectful and sensitive care that is tailored to women’s individual preferences during visual contact with the stillborn baby, with implications for improving clinical practice and guiding future research.
Keywords: Stillbirth, Fetal abnormality, Pregnancy termination, Postpartum depression, Postpartum anxiety, Perinatal bereavement care, Visual contact
Background
Stillbirth is defined as the intrauterine death of a fetus during the later stages of pregnancy, typically occurring at or beyond 28 weeks of gestation [1]. Nearly 2 million stillbirths occur globally each year, equating to approximately one every 16 s [2]. In 2021, the global stillbirth rate was estimated at 23.0 per 1,000 total births for pregnancies of 20 weeks’ gestation or more, and 16.1 per 1,000 when restricted to those at 28 weeks or later [3]. A multicenter study conducted in China reported a stillbirth rate of 13.25 per 1,000 births [4]. China ranked fourth globally in terms of the total number of stillbirths [5]. Fetal abnormalities, typically diagnosed after 14 weeks of gestation, are structural or functional disorders that arise during development and represent the leading cause of second- and third-trimester pregnancy termination [6]. The incidence of fetal abnormalities in China was approximately 12.72% [7], and about 60.7% of the pregnant women opted for therapeutic termination of pregnancy [8].
Termination of pregnancy has widespread and long-lasting negative impacts on women’s psychological well-being, physical health, family relationships, and social development [9]. Postpartum depression (PPD) and postpartum anxiety (PPA) are two of the most common psychological sequelae, with distinct prevalence patterns between the general Chinese postpartum population and the high-risk group of women who undergo pregnancy termination. In the general Chinese postpartum population, the prevalence of PPD varies from 11.5% to 25.8% [10, 11]. For PPA, population-based longitudinal studies indicate that the prevalence of comorbid anxiety and depression in the postpartum period is 13.24%, reflecting the high co-occurrence of these two conditions [12]. Notably, women who undergo pregnancy termination due to stillbirth or fetal abnormalities face a significantly higher risk of PPD and PPA compared to the general population. A cross-sectional study of 169 Chinese women who experienced pregnancy termination for fetal abnormalities found that the prevalence of PPA was 24.3% and PPD was as high as 50.3% [13]. Another study involving Chinese women with stillbirth or fetal malformation-induced abortion reported even higher rates, with 54.7% experiencing anxiety and 41.8% experiencing depression [14]. These elevated rates highlight the severe psychological vulnerability of this population, making the investigation of protective or risk factors particularly critical [15, 16].
Perinatal bereavement care refers to the care provided by interdisciplinary healthcare professionals to the bereaved parents considering their religious, secular, ethnic, social, cultural values, and personal preferences [17]. It involves providing comprehensive support and guidance to bereaved parents as they cope with the complex emotional and practical challenges surrounding both the birth and loss of their baby [18]. The delivery of high-quality, humanistic perinatal bereavement care by healthcare professionals is vital for alleviating women’s psychological trauma and restoring their confidence in future childbearing [19, 20].
Postmortem contact including seeing the stillborn baby is recognized as a crucial element of perinatal bereavement care. This process is brief and irreversible, and its significance is emphasized in international guidelines and expert consensus [18, 21, 22]. It serves an important function in the grieving process by supporting memory creation, meaning-making, and the maintenance of continuing bonds [23]. Parents seeing their stillborn baby may be beneficial to their bereavement adaptation [24, 25]. However, evidence suggests that seeing the stillborn baby postpartum may contribute to moderate to severe depressive symptoms [26]. A meta-analysis found that seeing a stillborn baby had no significant effect on women’s anxiety or depression [27]. The included studies have primarily been retrospective in nature. Cultural factors may also contribute to incongruent research conclusions. Research on this topic remains scarce in China. One study [28] developed a grief counseling program for women who underwent pregnancy termination due to fetal abnormalities, which included meeting the women’s needs to see their baby. Preliminary findings suggested that the intervention was potentially effective in alleviating grief symptoms. However, the study was limited by a small sample size, and the intervention encompassed multiple components beyond postmortem viewing. Therefore, the psychological impact of postmortem viewing on Chinese women remains insufficiently understood.
Women’s decisions to see or not see their stillborn baby were shaped by their personal beliefs, emotional readiness, and prevailing social and cultural values [21, 29]. Perinatal bereavement care practice varies from country to country. It is reported that bereavement care practices occur significantly more frequently by women in high-income countries compared with women in middle-income countries [30], including opportunity to see and hold their baby (OR = 4.8, 95% CI 4.0-5.9). Cultural norms in low- and middle-income countries stigmatize the grieving process following the loss of a newborn, rendering it a taboo and culturally discouraged practice. Among Chinese women who undergo pregnancy termination, the desire to see the stillborn baby ranks as the most prominent among various forms of bereavement support involving infant contact [31]. However, in the Chinese cultural context, prevailing societal norms and traditional beliefs often discourage open expressions of grief following perinatal loss, thereby impeding parents from engaging in fundamental acts such as seeing their stillborn baby. In clinical settings, it remains common practice for nurses and midwives to avoid initiating discussions about postmortem contact, particularly visual contact, with the baby. Even when mothers explicitly express a wish to see their baby, healthcare professionals may rely on personal judgment to discourage such requests, often out of concern for potential psychological harm. As a result, parents’ needs and preferences regarding postmortem contact are frequently overlooked in practice, depriving them of an important component of perinatal bereavement care [32, 33]. Therefore, investigating how specific perinatal bereavement care practices, including whether or not the baby is seen, affect women’s mental health within particular cultural and contextual settings is especially important.
This study aims to investigate the psychological impact of seeing the stillborn baby on Chinese women undergoing pregnancy termination. Given China’s distinct cultural perspectives on death and bereavement, there has been a lack of empirical research in this area. The psychological consequences of postmortem contact, particularly the act of viewing the stillborn infant, among women experiencing pregnancy termination in the Chinese context had not been clearly established. To address this gap, a prospective longitudinal cohort design was employed to examine whether seeing the stillborn baby was associated with PPD and PPA. The findings contribute to the existing body of knowledge and offer important implications for clinical practice, supporting healthcare professionals in making informed decisions about whether and how to facilitate maternal contact with stillborn infants following pregnancy termination.
Methods
Study design and setting
This prospective observational cohort study was conducted at the Women’s Hospital, School of Medicine, Zhejiang University, located in Hangzhou, China. The hospital has a licensed capacity of 1,520 beds and records more than 20,000 deliveries annually. Ethical approval for the study was obtained from the Ethics Committee of the hospital prior to its initiation (IRB no.20210091).
Participants and sample size
Participants who underwent pregnancy termination at the study hospital between March 2022 and September 2023 were invited to participate. Inclusion criteria were: (1) age over 18 years; (2) gestational age of at least 14 weeks; and (3) termination of pregnancy due to stillbirth or diagnosed fetal abnormality. Exclusion criteria included the presence of severe postpartum complications, such as massive postpartum hemorrhage. The required sample size was estimated using G*Power. Based on a previous study [34], a two-tailed test with a significance level (α) of 0.05 and statistical power (1–β) of 0.80 was employed. The calculated effect size (Cohen’s h) was 0.40. The analysis indicated that a minimum total sample size of 150 participants would be required to detect a statistically significant difference between the two groups. The final sample of 202 participants exceeded this threshold, providing adequate power for the primary analysis.
Instruments
Edinburgh postnatal depression scale (EPDS)
We measured depressive symptoms using the Chinese version of the EPDS, originally developed by Cox et al. [35] and validated in Chinese populations by Lee et al. [36]. This widely utilized instrument is specifically designed for screening depression among pregnant and postpartum women [37, 38]. EPDS is a ten-item self-report questionnaire designed to assess depressive symptoms experienced over the past seven days. Each item is scored on a four-point scale ranging from 0 (no depressive symptoms) to 3 (severe depressive symptoms), yielding a total score between 0 and 30. Previous studies have identified a cut-off score of ≥ 11 as optimal for balancing sensitivity and specificity against diagnostic reference standards [39]. In the present study, a standardized EPDS score of 11 or above was used to indicate the presence of clinically relevant depressive symptoms.
Generalized anxiety disorder (GAD-7)
Anxiety symptoms were assessed using the Chinese version of the GAD-7 scale, originally developed by Spitzer et al. [40] and well-validated in Chinese populations by He et al. [41]. The scale comprises seven items, each rated on a four-point Likert scale from 0 to 3, yielding a total score ranging from 0 to 21. Higher scores reflect greater anxiety severity. In the original validation study conducted in primary care settings, the GAD-7 demonstrated excellent internal consistency (Cronbach’s α = 0.92), with sensitivity and specificity of 89.0% and 82.0%, respectively, at a cut-off score of 10 [40]. The Chinese version of the GAD-7 was translated and validated for use among general hospital outpatients in mainland China. In the present study, a cut-off score of ≥ 6 was used to indicate clinically significant anxiety, consistent with previous research in Chinese populations [42].
Data collection
Sociodemographic and obstetric information collected included age, gestational age, gravidity, parity, education level, religious affiliation, duration of marriage, and household income. These data were obtained through face-to-face interviews and review of medical records during participants’ hospitalization. Information on whether the participant saw the stillborn baby was collected after the pregnancy termination. Symptoms of depression and anxiety were assessed at three time points: baseline (prior to pregnancy termination), and at 1 month and 3 months post-termination, using electronic questionnaires (www.wjx.cn). Participants were informed of the study’s purpose, content, and the time required to complete the survey. Anonymity and confidentiality were ensured. A total of 221 eligible women were approached, and the present analysis includes a final sample of 202 participants who completed the questionnaires at all three time points with no missing data on the variables of interest. All participants provided written informed consent and were notified of their right to withdraw from the study at any time without consequence.
Data analysis
All statistical analyses were conducted using SPSS version 21.0 (IBM Corp., Armonk, NY, USA). A two-sided P value of < 0.05 was considered statistically significant. The analysis was carried out in the following steps: (1) Baseline Comparison: Descriptive statistics (means and standard deviations for continuous variables; frequencies and proportions for categorical variables) were used to summarize participants’ baseline characteristics. Independent t-tests and chi-square tests were performed to compare characteristics between women who saw their stillborn baby and those who did not. (2) Identification of Potential Confounders: Variables independently associated with both the exposure (seeing the stillborn baby) and the outcomes (PPD and PPA) were identified using t-tests or chi-square tests, with a liberal threshold of P < 0.20 to screen for potential confounders. (3) Multivariable Analysis: Given that the primary study objective was to examine the association between exposure (seeing the stillborn baby) and the risk of clinically significant PPD/PPA (defined as the presence or absence of symptoms), logistic regression was the most appropriate analytical approach, as it is specifically designed to model dichotomous outcomes. This methodological choice aligns with the established framework in existing literature [43, 44]. Logistic regression analyses were conducted to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between visual contact with the stillborn baby and the risk of PPD and PPA at 1 and 3 months after termination. Both unadjusted and adjusted models were constructed. The adjusted models controlled for relevant confounding variables, including sociodemographic factors and pre-pregnancy psychological status.
Results
Baseline characteristics of participants
A total of 221 eligible women were recruited for this study. After excluding participants with invalid questionnaires or lost to follow-up, the final analysis included 202 women (91.40%). Among them, 48 participants (23.8%) reported having visual contact with the stillborn baby. Table 1 presents a comparison of the baseline characteristics between women who saw the stillborn baby and women who did not. A significant difference was observed between the two groups in terms of education level (P < 0.05); pairwise comparisons further indicated that the significant difference existed between the Senior college or below group and the University group (χ²=9.84, P = 0.0017), while no significant differences were found between the other two pairs of educational level groups. No statistically significant differences were found for the other variables examined (Table 1).
Table 1.
Demographic characteristics
| Variable | Women who had seen the stillborn baby | Women who had not seen the stillborn baby | |
|---|---|---|---|
| N(%) or mean ± SD | N(%) or mean ± SD | P-value | |
| Total | 48 (23.8) | 154 (76.2) | |
| Age (years) | 30.75 ± 2.82 | 29.88 ± 3.39 | 0.110 |
| Gestational age (weeks) | 22.96 ± 5.90 | 24.12 ± 6.03 | 0.244 |
| Gravidity | 0.170 | ||
| 1 | 22 (45.8) | 88 (57.1) | |
| ≥ 2 | 26 (54.2) | 66 (42.9) | |
| Parity | 0.062 | ||
| 0 | 26 (54.2) | 106 (68.8) | |
| ≥ 1 | 22 (45.8) | 48 (31.2) | |
| Education level | 0.006 | ||
| Senior college or below | 8 (16.7) | 6 (3.9) | |
| University | 34 (70.8) | 134 (87.0) | |
| Postgraduate or above | 6 (12.5) | 14 (9.1) | |
| Do you believe in a particular religion? | 0.388 | ||
| Yes | 2 (4.2) | 12 (7.8) | |
| No | 46 (95.8) | 142 (92.2) | |
| Years of marriage | 0.060 | ||
| < 2 years | 14 (29.2) | 74 (48.1) | |
| 2–5 years | 18 (37.5) | 42 (27.3) | |
| ≥ 5years | 16 (33.3) | 34 (22.1) | |
| Single and others | 0 (0.0) | 4 (2.6) | |
| Average monthly household income (yuan) | 0.360 | ||
| < 5000 | 6 (12.5) | 12 (7.8) | |
| 5001-10,000 | 14 (29.2) | 60 (39.0) | |
| > 10,000 | 28 (58.3) | 82 (53.2) | |
| Antenatal depression | 0.090 | ||
| No | 26 (54.2) | 62 (40.3) | |
| Yes | 22 (45.8) | 92 (59.7) | |
| Antenatal anxiety | 0.175 | ||
| No | 15 (31.2) | 65 (42.2) | |
| Yes | 33 (68.8) | 89 (57.8) | |
Association between seeing the stillborn baby and PPD
Figure 1 illustrates the changes in PPD scores across three time points (T1-T3) for women who did and did not see their stillborn baby. At 1 month post-termination, 49.5% of participants (n = 100) met the criteria for PPD. The prevalence was 50.0% (24/48) among women who had seen the stillborn baby and 49.4% (76/154) among those who had not. There was no statistically significant difference in PPD incidence between the two groups at this time point, in either the unadjusted or adjusted models (Table 2). At 3 months post-termination, 44.6% of participants (n = 90) met the criteria for PPD. Among women who had seen the stillborn baby, the prevalence was notably lower at 22.9% (11/48), compared to 51.3% (79/154) among those who had not. As shown in Table 2, visual contact with the stillborn baby was associated with a significantly lower risk of PPD at 3 months (OR = 0.28, 95% CI: 0.13–0.59). This association remained significant after adjusting for potential confounders, including age, gravidity, parity, years of marriage, and antenatal depression (adjusted OR = 0.18, 95% CI: 0.08–0.42).
Fig. 1.
Change in the PPD scores in the two groups at three time points (T1-T3)
Table 2.
Relationship between seeing the stillborn baby and PPD
| Exposure | Chi-sq test | Unadjusted | Adjusteda | Chi-sq test | Unadjusted | Adjustedb | ||
|---|---|---|---|---|---|---|---|---|
| 1-month PPD | P-value | OR (95% CI) | OR (95% CI) | 3-month PPD | P-value | OR (95% CI) | OR (95% CI) | |
| Seeing the stillborn baby | 0.937 | < 0.001 | ||||||
| No (N = 154) | 76 (49.4) | 1 [Reference] | 1 [Reference] | 79 (51.3) | 1 [Reference] | 1 [Reference] | ||
| Yes (N = 48) | 24 (50.0) | 1.03 [0.54, 1.96] | 0.97 [0.46, 2.05] | 11 (22.9) | 0.28 [0.13, 0.59] | 0.18 [0.08, 0.42] |
Abbreviations: CI Confidence interval, PPD Postpartum depression, OR Odds ratio
aAdjusted OR and 95% CI were generated after adjusting for gravity, parity, year of marriage and antenatal depression
bAdjusted OR and 95% CI were generated after adjusting for age, gravity, parity, year of marriage and antenatal depression
Association between seeing the stillborn baby and PPA
Figure 2 presents the trajectory of PPA scores across the three time points (T1-T3) for women who did and did not see their stillborn baby. At 1 month post-termination, 74.3% of participants (n = 150) exhibited symptoms of PPA. The prevalence was 72.9% (35/48) among women who had seen the stillborn baby and 74.7% (115/154) among those who had not. As shown in Table 3, there were no statistically significant differences in PPA outcomes between the two groups at this time point, in either the unadjusted or adjusted models. At 3 months post-termination, 52.0% of participants (n = 105) reported PPA symptoms. The prevalence was substantially lower among women who had seen the stillborn baby (16.7%, 8/48), compared to those who had not (63.0%, 97/154). In the unadjusted model, logistic regression analysis demonstrated a significantly reduced risk of PPA for women who had visual contact with their stillborn baby (OR = 0.12, 95% CI: 0.05–0.27). This association remained statistically significant after adjustment for education level and antenatal depression (adjusted OR = 0.12, 95% CI: 0.05–0.29).
Fig. 2.
Change in the PPA scores in the two groups at three time points (T1-T3)
Table 3.
Relationship between seeing the stillborn baby and PPA
| Exposure | Chi-sq test | Unadjusted | Adjusteda | Chi-sq test | Unadjusted | Adjustedb | ||
|---|---|---|---|---|---|---|---|---|
| 1-month PPA | P-value | OR (95% CI) | OR (95% CI) | 3-month PPA | P-value | OR (95% CI) | OR (95% CI) | |
| Seeing the stillborn baby | 0.808 | < 0.001 | ||||||
| No (N = 154) | 115 (74.7) | 1 [Reference] | 1 [Reference] | 97 (63.0) | 1 [Reference] | 1 [Reference] | ||
| Yes (N = 48) | 35 (72.9) | 0.91 [0.44, 1.90] | 1.05 [0.50, 2.23] | 8 (16.7) | 0.12 [0.05, 0.27] | 0.12 [0.05, 0.29] |
Abbreviations: CI Confidence interval, PPA Postpartum anxiety, OR Odds ratio
aAdjusted OR and 95% CI were generated after adjusting for antenatal depression and antenatal anxiety
bAdjusted OR and 95% CI were generated after adjusting for education level and antenatal depression
Discussion
In this prospective cohort study of women undergoing pregnancy termination in China, visual contact with the stillborn baby was identified as a significant protective factor against PPD and PPA at 3 months post-termination. Women who saw their stillborn baby had significantly lower odds of developing PPD and PPA compared to those who did not. However, no statistically significant differences were observed between the two groups at 1 month following termination. The analysis, based on longitudinal data collected at three time points, offers novel insights into the temporal dynamics of the association between postmortem contact and psychological well-being. These findings contribute to the existing literature by addressing a key knowledge gap regarding the impact of seeing the baby after stillbirth on maternal mental health, an area where previous evidence has been inconsistent. The results are particularly meaningful within the Chinese cultural context, where expressions of perinatal grief are often constrained. This study provides valuable evidence to inform culturally sensitive bereavement care practices.
Our results found that seeing the stillborn baby had no significant effect on PPD and PPA at 1 month after termination (T1). This finding was consistent with a previous meta-analysis [27], and can be further interpreted by considering the temporal dynamics of the grieving process and the unique context of the puerperium period in Chinese culture. As documented in previous research [45], grief levels among women with pregnancy loss typically follow a trajectory of “rising then declining”, peaking at approximately 1 month after childbirth loss. At T1, all participants were in the puerperium period; influenced by the traditional Chinese custom of “confinement” (Zuo Yue Zi), women were primarily resting at home, and their attention had shifted from the clinical environment of termination to introspection and rumination about the loss [46]. This stage is characterized by intense, universal grief symptoms, potentially leading to a ceiling effect where both groups (women who saw their stillborn baby and those who did not) exhibited high levels of PPD and PPA, which may thus result in no significant difference between the two groups at the T1 time point.
In 3 months after termination, seeing the stillborn baby was considered as a protective factor for PPD and PPA in our study. These results suggest that seeing the stillborn baby, at the very least, does not lead to negative psychological outcomes. The benefits of seeing the stillborn baby for PPD and PPA become more pronounced during an extended postpartum period. Psychological benefits of seeing the stillborn baby on reducing PPD and PPA was also confirmed in a study [26]. However, it was inconsistent with previous finding that behaviours promoting contact with the stillborn infant were associated with worse psychological outcome [34]. The inconsistent findings may be resulted from many factors, such as culture differences, behaviours and attitudes of health care professionals during the process, the time of seeing the baby, the gestational age and appearance of the stillborn baby and physical environment [27]. Specifically, the positive psychological effects of seeing the stillborn baby are more likely to be realized when the process takes place in an appropriate physical environment and is supported by compassionate, humanistic care provided by trained healthcare professionals [27].
In our study, seeing the stillborn baby emerged as a protective factor against PPD and PPA, potentially because it strengthens the bereaved parents’ roles as a parent. This act holds significant meaning in the grieving process, as it facilitates memory-making, supports the reconstruction of meaning, and fosters continuing emotional bonds [23], which are associated with more positive bereavement adaptation [25]. A respectful, flexible system that involves bereaved parents in their baby’s perinatal death review and responds to their individual needs is essential. Healthcare professionals have a crucial role in supporting and enabling parents to actively participate in normal parenting practices [47, 48]. Therefore, actions should be taken to standardized clinical practice. The formulation of unified procedures and principles is of paramount importance, as it not only affects maternal psychological outcomes but also contributes to improved satisfaction with perinatal bereavement care [49].
In China, death remains a cultural taboo. On the one hand, women who do not receive sufficient information, emotional support, or guidance from healthcare professionals are less likely to engage in contact with their stillborn baby [50]. Parents may initially feel emotionally unready, apprehensive, or anxious about encountering their baby, including uncertainties around how to approach, touch, or hold the infant. Some women expressed concern about the baby’s possibly distressing appearance after delivery [31], which contributed to fears of psychological harm. This obstacle constituted a primary factor hindering the mothers from seeing their baby. On the other hand, many healthcare professionals lack familiarity with the principles of respectful bereavement care [51]. Some research conducted in China have suggested that healthcare providers should advise women not to see the stillborn baby without considering and asking the individual preferences of the mothers [52]. A disconnect often exists between parental preferences and healthcare providers’ perceptions regarding appropriate post-loss support [53]. Therefore, it is essential to prioritize women’s choices in perinatal bereavement care, rather than relying on the subjective assumptions of healthcare providers. Engaging parents in culturally sensitive, informed discussions about the potential benefits and challenges of seeing their stillborn baby helps support autonomous, well-considered decision-making [18]. Healthcare professionals should take time to understand parents’ individual preferences, concerns, and uncertainties, and provide tailored guidance, emotional support, and appropriate preparation for postmortem contact and parenting activities [21, 54]. Cultivating a well-trained and competent healthcare workforce is important to facilitating appropriate postmortem contact. It is recommended that bereavement support training programs tailored to the Chinese sociocultural context be implemented [28, 55], enabling healthcare professionals to build awareness, empathy, and competence in providing this form of care.
During the process of seeing stillborn baby, healthcare professionals who treat contact with a stillborn baby as a normal and meaningful part of care, similar to contact with a live-born infant, can help parents feel more at ease, comfortable, and less fearful during their contact with the baby [56]. A previous study suggested that the first 30 min following birth present a precious opportunity for parents to establish connection with their babies, as this is when the infants are in their tender and cozy state [57]. It is recommended that the fetus undergo gentle cleaning after delivery, and that arrangements be made promptly to allow the mother or family members to view the baby [26]. To minimize potential visual distress caused by the presence of blood, the use of disposable care pads to wrap the fetal body is advised [28]. The availability of private, undisturbed spaces for perinatal bereavement care is essential, as postpartum hospital rooms often do not provide an appropriate setting for parents to spend time with their stillborn baby [58]. Beyond simply viewing the baby, healthcare professionals can further support the grieving process by facilitating additional forms of postmortem contact, such as encouraging parents to bathe, dress, read to, or sing to their baby [54]. These actions provide a structured and meaningful opportunity for emotional connection and farewell [54].
Strengths and limitations
Despite an extensive literature review, no prior studies were identified that specifically examined the association between seeing the stillborn baby and the occurrence of PPD or PPA among Chinese women using a prospective cohort design. Given the pivotal role of cultural factors in bereavement care, this study contributes valuable evidence to the literature on the relationship between seeing the stillborn baby and the psychological well-being of women undergoing pregnancy termination in China, thereby offering important implications for both research and clinical practice. Potential confounders were carefully considered, and appropriate statistical methods were employed to adjust for variables that could influence the observed associations.
This study has several limitations. First, self-reported instruments were used to assess symptoms of PPD and PPA. While the EPDS and GAD-7 are widely used and validated screening tools, they are not diagnostic measures. The use of clinical diagnostic interviews could provide a more comprehensive and accurate assessment of psychological outcomes. Second, the study was conducted at a single hospital, which may limit the generalizability of the findings to broader populations of Chinese women. Future studies should adopt multi-center designs to improve the external validity of the results. Third, follow-up assessments were limited to three months post-termination. The long-term psychological impact of seeing the stillborn baby, including potential effects during subsequent pregnancies, remains unclear. Future research should consider extended follow-up periods to better understand the enduring influence of postmortem contact on maternal mental health.
Conclusion
This prospective cohort study among Chinese women undergoing pregnancy termination provides evidence that visual contact with the stillborn baby may serve as a protective factor against PPD and PPA. These findings underscore the importance of respectful, sensitive, and individualized bereavement care. Healthcare professionals should offer appropriate guidance and support to accommodate women’s preferences regarding contact with their stillborn baby. Such practices have the potential to improve the quality of the perinatal bereavement experience and reduce the risk of adverse psychological outcomes, thereby offering important implications for both future research and clinical practice in the field.
Acknowledgements
We express our sincere gratitude to the individuals who participated in the study.
Abbreviations
- PPD
Postpartum depression
- PPA
Postpartum anxiety
- EPDS
Edinburgh Postnatal Depression Scale
- GAD
Generalized Anxiety Disorder
- OR
Odds ratios
- CI
Confidence intervals
Authors’ contributions
Jialu Qian: Conceptualization, Investigation, Formal analysis, Data Curation, Writing-Original DraftMengye Yang: Conceptualization, Formal analysis, Writing-Review & EditingMan Wang: Data Curation, Writing - Review & Editing.Shiwen Sun: Investigation, Formal analysis, Supervision, Writing-Review & Editing.Xiaoyan Yu: Conceptualization, Supervision, Writing-Review & Editing.
Funding
This research was supported by the following grants: the General Project of Philosophy and Social Science Research in Jiangsu Universities (Grant No. 2025SJYB0235), the General Program of Basic Science (Natural Science) Research in Universities of Jiangsu Province (Grant No. 25KJB320007), the General Project of Humanities and Social Sciences Research, Ministry of Education (Grant No. 25YJC630109).
Data availability
The data used to support the findings of this study are available from the corresponding author upon request.
Declarations
Ethics approval and consent to participate
The study protocol was approved by the Ethics Committee of the Women’s Hospital, School of Medicine, Zhejiang University (IRB no.20210091).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Jialu Qian and Mengye Yang are the joint first authors, who contributed equally to the manuscript.
Shiwen Sun and Xiaoyan Yu contributed equally as corresponding authors.
Contributor Information
Shiwen Sun, Email: sunsw@zju.edu.cn.
Xiaoyan Yu, Email: yuxy@zju.edu.cn.
References
- 1.WHO. Stillbirth. In., vol. 2026.
- 2.WHO. One stillbirth occurs every 16 seconds, according to first ever joint UN estimates. In., vol. 2025.
- 3.Global regional. and national stillbirths at 20 weeks’ gestation or longer in 204 countries and territories, 1990–2021: findings from the Global Burden of Disease Study 2021. LANCET 2024, 404(10466):1955–1988. [DOI] [PMC free article] [PubMed]
- 4.Zhu J, Zhang J, Xia H, Ge J, Ye X, Guo B, Liu M, Dai L, Zhang L, Chen L, et al. Stillbirths in China: a nationwide survey. BJOG-INT J OBSTET GY. 2021;128(1):67–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, Hogan D, Shiekh S, Qureshi ZU, You D, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. LANCET GLOB HEALTH. 2016;4(2):e98–108. [DOI] [PubMed] [Google Scholar]
- 6.Yinli Z, Xinhua W, Can L, Xionghu W, Yingxian Z. Analysis of the causes of labor induction in the second and third trimesters of 4400 pregnant women. Chin J Woman Child Health. 2022;33(07):72–8. [Google Scholar]
- 7.Ruiqing L. Prevalence of fetal malformation and related influencing factors in pregnant women with second child demand from the perspective of eugenics. J Snake. 2018;30(04):588–90. [Google Scholar]
- 8.Feng S, Zhang C, Yue X, Teng W. Analysis of Factors for Fetal Induction and Distribution Characteristics of Fetal Malformations in 478 Cases in Gansu Area. 中国妇产科临床杂志 2022, 23(02):179–180.
- 9.Mørk S, Hvidtjørn D, Möller S, Henriksen TB, O’Connor M, Bonanno GA. Grief trajectories after loss in pregnancy and during the neonatal period. J PSYCHIATR RES. 2023;168:293–9. [DOI] [PubMed] [Google Scholar]
- 10.Peng S, Lai X, Du Y, Meng L, Gan Y, Zhang X. Prevalence and risk factors of postpartum depression in China: A hospital-based cross-sectional study. J AFFECT DISORDERS. 2021;282:1096–100. [DOI] [PubMed] [Google Scholar]
- 11.Zhang C, Duan C, Liu H, Xu H, Li C, Fan J, Li H, Li X, Guo Y, Wang Y, et al. Prevalence and related factors of antenatal depression in 11 provinces and cities of China: a 100,000 population-based study. SCI BULL. 2025;70(18):2953–8. [DOI] [PubMed] [Google Scholar]
- 12.Xu J, Xiao Y, Li F, Cui Y, Shi C, Shi J, Yu C, Qi S, Lu C, Li G, et al. Prevalence and impact of parental co-morbid anxiety and depression during the first 2 years postpartum in China. J AFFECT DISORDERS. 2025;374:63–71. [DOI] [PubMed] [Google Scholar]
- 13.Sun SW, Hao YP, Qian JL, Wang F, Sun YP, Yu XY. Incidence and predictors of paternal anxiety and depression following fetal abnormalities requiring pregnancy termination: a cross-sectional study in China. BMC Pregnancy Childbirth. 2022;22(1):440. [DOI] [PMC free article] [PubMed]
- 14.Liu L, Jie L, Qi X, Cui H, Liu Y, Jiang Y, Zheng C. Correlation Analysis of Psychological Characteristics and Social and Family Support of Pregnant Women after Fetal Death and Fetal Malformation. Chin Prim Health Care. 2020;34(02):36–8. [Google Scholar]
- 15.Lamon L, De Hert M, Detraux J, Hompes T. Depression and post-traumatic stress disorder after perinatal loss in fathers: A systematic review. EUR PSYCHIAT. 2022;65(1):e72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Mainali A, Infanti JJ, Thapa SB, Jacobsen GW, Larose TL. Anxiety and depression in pregnant women who have experienced a previous perinatal loss: a case-cohort study from Scandinavia. BMC PREGNANCY CHILDB. 2023;23(1):111. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Kalu FA, Larkin P, Coughlan B. Development, validation and reliability testing of‘Perinatal Bereavement Care Confidence Scale (PBCCS)’. WOMEN BIRTH. 2020;33(4):e311–9. [DOI] [PubMed] [Google Scholar]
- 18.Boyle FM, Horey D, Middleton PF, Flenady V. Clinical practice guidelines for perinatal bereavement care — An overview. WOMEN BIRTH. 2020;33(2):107–10. [DOI] [PubMed] [Google Scholar]
- 19.de Andrade Alvarenga W, DeMontigny F, Zeghiche S, Verdon C, Castanheira Nascimento L. Experience of hope: An exploratory research with bereaved mothers following perinatal death. WOMEN BIRTH. 2021;34(4):e426–34. [DOI] [PubMed] [Google Scholar]
- 20.Caro-Costa R, Alcaide-Leyva JM, García-Luque L, Alcaraz-Clariana S, Guzmán-García JM. Jiménez-Mérida MDR: Healing Through Humanized Care: Lessons from a Patient-Centered Perinatal Loss Protocol. HEALTHCARE-BASEL. 2025;13(3):242. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Care Around Stillbirth and Neonatal Death (CASaND) Clinical Practice Guideline. In., vol. 2025; 2024.
- 22.Shakespeare C, Merriel A, Bakhbakhi D, Blencowe H, Boyle FM, Flenady V, Gold K, Horey D, Lynch M, Mills TA, et al. The RESPECT Study for consensus on global bereavement care after stillbirth. INT J GYNECOL OBSTET. 2020;149(2):137–47. [DOI] [PubMed] [Google Scholar]
- 23.Cassidy RP. Care quality following intrauterine death in Spanish hospitals: results from an online survey. Bmc Pregnancy Childbirth. 2018;18(1):22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Kingdon C, Givens JL, O’Donnell E, Turner M. Seeing and Holding Baby: Systematic Review of Clinical Management and Parental Outcomes After Stillbirth. BIRTH-ISS PERINAT C. 2015;42(3):206–18. [DOI] [PubMed] [Google Scholar]
- 25.Jones EE, Crawley R, Brierley-Jones L, Kenny C. Continuing bonds following stillbirth: protective and risk factors associated with parental bereavement adaptation. J REPROD INFANT PSYC. 2023;41(1):93–109. [DOI] [PubMed] [Google Scholar]
- 26.Arocha PR, Range LM. Events surrounding stillbirth and their effect on symptoms of depression among mothers. DEATH STUD. 2021;45(7):573–7. [DOI] [PubMed] [Google Scholar]
- 27.Sun S, Qian J, Wang F, Tian Y, Sun Y, Zheng Q, Yu X. Impact of contact with the baby following stillbirth on parental mental health and well-being: a systematic review and meta-analysis. Int J Nurs Pract. 2023;29(6):e13146. [DOI] [PubMed]
- 28.Liu L, Wang W, Sun S, Qian J, Yu X. Construction and application of a grief counseling programme for women undergoing pregnancy termination due to fetal anomaly. Chin J Nurs. 2022;57(24):2964–71. [Google Scholar]
- 29.Sun JC, Rei W, Sheu SJ. Seeing or not seeing: Taiwan’s parents’ experiences during stillbirth. INT J NURS STUD. 2014;51(8):1153–9. [DOI] [PubMed] [Google Scholar]
- 30.Horey D, Boyle FM, Cassidy J, Cassidy PR, Erwich J, Gold KJ, Gross MM, Heazell A, Leisher SH, Murphy M, et al. Parents’ experiences of care offered after stillbirth: An international online survey of high and middle-income countries. BIRTH-ISS PERINAT C. 2021;48(3):366–74. [DOI] [PubMed] [Google Scholar]
- 31.Lu L, Qiong Z, Jialu Q, Mengwei W, Yaping S, Xiaoyan Y. A qualitative study on the needs of grief counseling for women with fetal abnormalities induced labor. Chin J Nurs. 2021;56(10):1509–15. [Google Scholar]
- 32.Qian J, Wang W, Sun S, Wu M, Liu L, Sun Y, Yu X. Exploring interactions between women who have experienced pregnancy loss and obstetric nursing staff: a descriptive qualitative study in China. BMC PREGNANCY CHILDB. 2022;22(1):450. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Wang J, Chen X, Huang R. Ethical Dilemmas and Reflection on Clinical Nursing of Stillbirth. Chin Med Ethics. 2017;10(11):1347–50. [Google Scholar]
- 34.Hughes P, Turton P, Hopper E, Evans CD. Assessment of guidelines for good practice in psychosocial care of mothers after stillbirth: a cohort study. Lancet. 2002;360(9327):114–8. [DOI] [PubMed] [Google Scholar]
- 35.Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. BRIT J PSYCHIAT. 1987;150:782–6. [DOI] [PubMed] [Google Scholar]
- 36.Lee DT, Yip SK, Chiu HF, Leung TY, Chan KP, Chau IO, Leung HC, Chung TK. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. BRIT J PSYCHIAT. 1998;172:433–7. [DOI] [PubMed] [Google Scholar]
- 37.Matthey S, Henshaw C, Elliott S, Barnett B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: implications for clinical and research practice. ARCH WOMEN MENT HLTH. 2006;9(6):309–15. [DOI] [PubMed] [Google Scholar]
- 38.Schwarze CE, Lerche V, Wallwiener S, Pauen S. Partnership quality and maternal depressive symptoms in the transition to parenthood: a prospective cohort study. BMC PREGNANCY CHILDB. 2024;24(1):664. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Levis B, Negeri Z, Sun Y, Benedetti A, Thombs BD. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data. BMJ-BRIT MED J. 2020;371:m4022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. [DOI] [PubMed] [Google Scholar]
- 41.He X, Li C, Qian J, Cui H, Wu W. Reliability and validity of a generalized anxiety disorder scale in general hospital outpatients. Shanghai Archives Psychiatry. 2010;22(04):200–3. [Google Scholar]
- 42.Jiang L, Zhu S, Peng Z, Yang D. Analysis of results of mental health survey in pregnant women in Shenzhen with PHQ-9 and GAD-7. Chin J Woman Child Health Res. 2022;32(08):1172–7. [Google Scholar]
- 43.Huang X, Zhang L, Zhang C, Li J, Li C. Postpartum depression in Northeastern China: a cross-sectional study 6 weeks after giving birth. FRONT PUBLIC HEALTH. 2025;13:1570654. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Gravensteen IK, Jacobsen E, Sandset PM, Helgadottir LB, Rådestad I, Sandvik L, Ekeberg Ø. Anxiety, depression and relationship satisfaction in the pregnancy following stillbirth and after the birth of a live-born baby: a prospective study. BMC PREGNANCY CHILDB. 2018;18(1):41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Liu L. Research on the construction and application of bereavement care programme for women undergoing pregnancy termination for fetal anomaly. Hangzhou: Zhejiang University; 2022. [Google Scholar]
- 46.Qian J, Sun S, Yang M, Zhou X, Wu M, Yu X. Psychological trajectories of Chinese women undergoing pregnancy termination for foetal abnormality: A descriptive qualitative study using expressive writing. J CLIN NURS. 2020;29(19–20):3667–78. [DOI] [PubMed] [Google Scholar]
- 47.Thornton R, Nicholson P, Harms L. Being a Parent: Findings from a Grounded Theory of Memory-Making in Neonatal End-of-Life Care. J PEDIATR NURS. 2021;61:51–8. [DOI] [PubMed] [Google Scholar]
- 48.Thornton R, Nicholson P, Harms L. Scoping review of memory making in bereavement care for parents after the death of a newborn. J Obstet Gynecol Neonatal Nurs. 2019;48(3):351–60. [DOI] [PubMed]
- 49.Hennegan JM, Henderson J, Redshaw M. Contact with the baby following stillbirth and parental mental health and well-being: a systematic review. BMJ OPEN. 2015;5(11):e8616. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Rådestad I, Surkan PJ, Steineck G, Cnattingius S, Onelöv E, Dickman PW. Long-term outcomes for mothers who have or have not held their stillborn baby. MIDWIFERY. 2009;25(4):422–9. [DOI] [PubMed] [Google Scholar]
- 51.Qian J, Chen S, Jevitt C, Sun S, Wang M, Yu X. Experiences of obstetric nurses and midwives receiving a perinatal bereavement care training programme: A qualitative study. FRONT MED-LAUSANNE 2023, 10. [DOI] [PMC free article] [PubMed]
- 52.Yan S. Analysis of the influence of grief care on depression in pregnant women with pregnancy termination for fetal abnormality. China Health Care Nutr. 2017;027(033):204–5. [Google Scholar]
- 53.Christou A, Alam A, Hofiani S, Mubasher A, Rasooly MH, Rashidi MK, Raynes-Greenow C. I should have seen her face at least once’: parent’s and healthcare providers’ experiences and practices of care after stillbirth in Kabul province, Afghanistan. J PERINATOL. 2021;41(9):2182–95. [DOI] [PubMed] [Google Scholar]
- 54.Thornton R, Nicholson P, Harms L. Scoping Review of Memory Making in Bereavement Care for Parents After the Death of a Newborn. JOGNN-J OBST GYN NEO. 2019;48(3):351–60. [DOI] [PubMed] [Google Scholar]
- 55.Qian J, Sun S, Wang M, Liu L, Yu X. Effectiveness of the implementation of a perinatal bereavement care training programme on nurses and midwives: protocol for a mixed-method study. BMJ OPEN. 2022;12(8):e59660. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Koopmans L, Wilson T, Cacciatore J, Flenady V. Support for mothers, fathers and families after perinatal death. COCHRANE DB SYST REV. 2013;2013(6):CD452. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Rådestad I, Christoffersen L. Helping a woman meet her stillborn baby while it is soft and warm. Br J Midwifery. 2008;16(9):588–91. [Google Scholar]
- 58.Zheng Q, Yin X, Liu L, Jevitt C, Fu D, Sun Y, Yu X. The influence of culture and spirituality on maternal grief following stillbirth in China: A qualitative study. INT J NURS STUD. 2024;160:104863. [DOI] [PubMed] [Google Scholar]
Associated Data
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Data Availability Statement
The data used to support the findings of this study are available from the corresponding author upon request.