SUPPORTING PARENTS

Mother’s experience of the support from a bereavement follow-up

intervention after the death of a child

Ida Nikkola, Marja Kaunonen and Anna Liisa Aho

Aims and objectives. To describe the mothers’ experience of the support they received in a bereavement follow-up intervention

after the death of a child and their experiences of the intervention programme. The intervention included three complementary

components: (1) a support package, (2) peer supporters’ contact with mothers and (3) health professionals’ contact with

mothers.

Background. Although several types of intervention have been targeted at grieving parents or mothers, there exists a lack of

knowledge of what kind of intervention is supportive and enhances the coping of parents after the death of a child.

Design. An intervention was implemented in two university-level hospitals in Southern Finland. The study participants were

grieving mothers (n = 86) whose child had died at the age of three or younger. The data were collected by using a structured

questionnaire within six months of the death of a child.

Methods. The data were analysed with descriptive statistical methods.

Results. The mothers felt that the support they received helped them in coping with the situation. Among the different forms of

received support, the mothers felt they received the most emotional support from peer supporters and health professionals. The

mothers considered the support intervention to be useful.

Conclusion. The collaborative support intervention between health professionals and peer supporters enabled versatile,

immediate and long-term support that helped the mothers cope after the death of a child.

Relevance to clinical practice. Health professionals should collaborate systematically with the third sector to provide support

for mothers after the death of their child. In addition to the support given in hospital, health professionals should arrange more

contacts and meetings with bereaved mothers on a long-term basis, after the mothers have left the hospital.

Key words: death of a child, intervention study, peer support, social support

Accepted for publication: 9 May 2012

Introduction

In 2010, 60,980 children were born alive in Finland. Every

year the number of stillborn children is about 200. In

addition, 140 children under one year of age die, most of

whom die during the first weeks after the birth. Annually,

about 20 children of one to three years of age die

(Statistics Finland 2011a,b). The death of a child is one

of the most painful crisis parents can experience during

their lives and, to cope, they need many types of informal

and professional support (Dyregrov 2004, Barrera et al.

2007, Cacciatore 2010).

Interventions for bereaved parents to help them to cope

have been developed and tested to some extent. The support

Authors: Ida Nikkola, MNSc, University of Tampere, School of

Health Sciences, Tampere; Marja Kaunonen, PhD, Professor,

University of Tampere, School of Health Sciences, Tampere;

Anna Liisa Aho, PhD, Senior Assistant Professor, University of

Tampere, School of Health Sciences, Tampere, Finland

Correspondence: Anna Liisa Aho, Senior Assistant Professor,

University of Tampere, School of Health Sciences, PO BOX 607,

FIN – 33014 Tampere, Finland. Telephone: +358 40 1901448

E-mail: anna.l.aho@uta.fi

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Journal of Clinical Nursing, 22, 1151–1162, doi: 10.1111/j.1365-2702.2012.04247.x 1151

interventions have been complex in their nature and imple-

mentation. Although parents have had a positive experience

of the support interventions, demonstrating their effect and

helpfulness has received less attention (Rowa-Dewar 2002,

Chambers & Chan 2004, Flenady & Wilson 2008, Harvey

et al. 2008).

The problem in intervention studies has been the method-

ological aspects; either the number of participants has been

low or there have been no control groups and intervening

factors have not been controlled. In addition, the complexity

of the interventions has caused uncertainty as to what kind of

support should be given, at what time and who should

provide the support in order for the intervention to truly help

in coping with the death of a child. This research describes

the mothers’ experiences of the support they received in a

bereavement follow-up intervention immediately after the

death of a child and their experiences of the intervention

programme. The accurate description of the intervention,

controlling the factors and measuring the different forms of

support received, provides new information on the imple-

mentation of interventions. The study is part of a broader

bereavement research project where a support intervention

for bereaved parents was developed and tested (Aho et al.

2010, 2011).

Background

The death of a child is one of the most stressful experiences in

mothers’ lives, and their coping may take a long time (Laakso

& Paunonen-Ilmonen 2002, Arnold & Gemma 2008, Cac-

ciatore 2010). Bereaved mothers may have thoughts of self-

harm, feelings of regret, guilt, despair and symptoms of

physical distress (Barr & Cacciatore 2008, Cacciatore 2010).

Mothers also have experience of personal growth, such as

greater forgiveness, empathy and hope after their child’s

death (Laakso & Paunonen-Ilmonen 2002, Lundquist et al.

2002).

Social support protects from the impact of stressful life

events (Kahn 1979), and it is also helpful for coping after

the death of a child (Hogan et al. 2001, Kreichbergs et al.

2007, Arnold & Gemma 2008, White et al. 2008, Caccia-

tore 2010). Social support can be conceptualised in a

number of ways. Kahn (1979) identified three types of

social support: affirmation, affect and concrete aid. Affir-

mation refers to expressions of agreement, or acknowledge-

ment of the appropriateness, or suitability, of some act or

statement of another person. Affect refers to expressions of

liking, admiration, respect or love. Aid includes direct

assistance, such as the exchange of money, information and

time. Bereaved mothers receive social support in the form of

affirmation, such as information about the cause of death,

grief, differences in grief and its effects on coping (Dent

et al. 1996, Laakso & Paunonen-Ilmonen 2002, Dean et al.

2005, Ota 2006, Cacciatore 2010), in the form of affect,

such as listening, being available, grieving together and

answering questions (Malacrida 1999, McHaffie et al.

2001, Lundquist et al. 2002, Contro et al. 2004, Dean

et al. 2005) and in the form of concrete aid, such as helping

them deal with practical matters (Thuen 1997, Dean et al.

2005).

Several types of intervention have been targeted at grieving

parents after the death of a child (Cambers & Chan 2004,

Flenady & Wilson 2008, Harvey et al. 2008). Support for the

bereaved can take the form of professionally led, or peer led

support, either on a one-to-one or a group basis. Previous

studies have reported on group sessions for bereaved parents

(Heiney et al. 1995, DiMarco et al. 2001); small group

sessions focused on information giving, skill building and

emotional support (Murphy et al. 1998); contact with a

skilled grief worker, access to information and handouts for

the social network of the parents (Murray et al. 2000);

hospital-based pastoral care involving family contact, home/

funeral home visits, and educational meetings with parents

and their supporters at a restaurant (Oliver et al. 2001); and

a couples-based bereavement support programme that

included a sympathy card, a follow-up telephone call and a

group session for bereaved parents (Reilly-Smorawski et al.

2002). The efficacy of a parent bereavement programme is

quite weak, or even non-existent, although some studies have

reported that parents have a positive impression of them

(Murphy et al. 1998, DiMarco et al. 2001, Reilly-Smorawski

et al. 2002, Rowa-Dewar 2002, Cambers & Chan 2004,

Currier et al. 2008, Flenady & Wilson 2008, Harvey et al.

2008).

As indicated by Dyregrov (2004), bereaved parents need

many types of informal and professional support. Long-

term support from self-help groups, parental groups with

similar experience, and peers has been rated favourably by

mothers (Dent et al. 1996, Murphy et al. 1998, Laakso &

Paunonen-Ilmonen 2002, Reilly-Smorawski et al. 2002,

Kreichbergs et al. 2007). Bereaved mothers expect long-

term bereavement follow-up social support from health

professionals (Cook et al. 2002, Macdonald et al. 2005,

Saflund & Wredling 2006, Meert et al. 2007, Widger &

Picot 2008).

The importance of designing interventions for specific

subgroups of bereaved individuals has been acknowledged

(Currier et al. 2008). There is a lack of support-intervention

studies, especially with respect to the types of support

received, their effectiveness and helpfulness. According to

I Nikkola et al.

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1152 Journal of Clinical Nursing, 22, 1151–1162

the results from a study on fathers, the support intervention

encouraged fathers’ personal growth and they considered the

support intervention to help with their coping process. The

support intervention was also perceived to work well and be

well timed (Aho et al. 2010).

Aim & research question

The aim of the study was to describe the mother’s experience

of the support they received in a bereavement follow-up

intervention after the death of a child and their experiences of

the intervention programme. The research questions were as

follows:

1 What kind of support bereaved mothers did receive in the

bereavement follow-up intervention from health profes-

sionals and peer supporters after the death of a child?

2 What is the association between the background variables

(the attributes of the mother and deceased child, antici-

patory grief, participation in a bereavement support

group and the amount of support from health profes-

sionals and peer supporters) and the support received

from health professionals or peer supporters after the

death of a child?

3 What kind of experiences have the mothers had of the

intervention programme?

Methods

Description of the intervention

The bereavement follow-up intervention was guided by

theory but also by a synthesis of clinical and scientific

knowledge with a focus on the participant perspective and

clinical experience (Aho et al. 2010). The intervention

included three complementary components: (1) a support

package, (2) peer supporters’ contact with mothers and (3)

health professional’s contact with mothers.

The support package consisted of informational letters and

poems and stories about the loss of a child. The package was

tailored to each mother’s needs (e.g. information on sibling

grief was removed from the package if the family did not have

other children).

While in hospital, health professionals asked the bereaved

mothers whether they would consent to peer supporters’

contact and whether their contact information could be

passed on to the peer support association (Kapy ry, 2011,

Available at: http://www.kapy.fi/[accessed 4 October 2011]).

In addition to their previous own experience of the death of a

child, peer supporters were trained by professionals. (Aho

et al. 2010).

The peer supporters first made a telephone call to the

mothers (about a week after the death) and then scheduled

a home visit in accordance with the mothers’ wishes. The

overriding aim of the visit was to communicate compassion

and concern to the mothers. The visit consisted of paying

attention to the mothers, discussions with them, caring for

their other children and giving information. The health

professionals met the mothers in a scheduled meeting with

both parents within two to six weeks following the death.

The time varied because of hospital follow-up protocol for

the mother or depending on the availability of the

pathological cause of death. If the meeting was inconve-

nient for the parents, or not possible because of the nature

of the unit, either the nurse who was present at the time of

the death of the child in hospital or the child’s primary

nurse contacted the parents by telephone. The topics of the

call varied depending on the mothers’ needs but mainly

followed the written framework devised to guide the

intervention (Aho et al. 2010).

The purpose of the intervention programme was to provide

affirmation, affect and concrete aid for the grieving mothers

after leaving the hospital as a collaborative effort by health

professionals and peer supporters.

Study design and settings

The study was carried out in all Finnish University

hospitals (n = 5). Depending on the hospital in which the

child died or to which the dead child was taken, the

mothers were either assigned to an intervention group in

two university hospitals or to a control group that received

routine hospital care in three university hospitals immedi-

ately after the death of their child. All units of the

hospitals where a child might die or to which a dead child

might be taken (the intensive care unit, the maternity ward

and the emergency room) participated in the study. Only

the intervention group mothers were offered the interven-

tion. All parents were assigned the same treatment condi-

tions because of the ethically and emotionally sensitive

topics. There was a wide variation in routine follow-up

care in control hospitals by individual units to bereaved

parents. The units gave informational support mainly about

practical issues, such as organisation of memorial services

or bereavement support groups and peer support associa-

tion. Collaboration with peer supporters or a peer support

association was rare. A postdischarge contact was available

only in a few units. (Aho et al. 2010).

The implementation included the development of a pro-

gramme to be used in nursing practice, intervention training

for the practitioners involved and for peer supporters, and the

Supporting parents Mother’s experience of the support from a bereavement

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Journal of Clinical Nursing, 22, 1151–1162 1153

intervention implementation. A hands-on, practical action

plan, developed to aid the implementation, was included in

each unit’s project folder (Aho et al. 2010).

The data for the study were collected six months after the

child’s death. Owing to the research permission process, data

collection began in June 2006 and was finished in February

2010.

The Instrument

Social support provided by health professionals and peer

supporters

Social support provided by health professionals and peer

supporters after the death of a child was measured with an

instrument developed for this study based on Kahn (1979)

and previous studies (e.g., Dent et al. 1996, McHaffie et al.

2001, Samuelsson & Radesten 2001, Wood & Milo 2001,

Cook et al. 2002, Contro et al. 2004, McCreight 2004,

Dean et al. 2005, Aho et al. 2009). The summated rating

scale was developed specifically to be used in the interven-

tion group.

The support received from health professionals comprised

20 questions in three subscales: affect (7 items), affirmation

(8 items) and aid (5 items) (Table 3). The internal

consistency of the scale on the basis of Cronbach’s alpha

values was 0Æ87–0Æ92. The support received from peer

supporters comprised 16 questions in three subscales: affect

(6 items), affirmation (6 items) and aid (4 items) (Table 4).

The internal consistency of the scale on the basis of

Cronbach’s alpha values was 0Æ72–0Æ93. The mothers

evaluated the support received on a 6-point scale from

1 = ‘no support at all’ to 6 = ‘very much support’.

The instruments included the following questions: How

much did the support from health professionals (1 item)

and from peer supporters (1 item) help you in coping with

the grief? The mothers evaluated the support helping them

to cope on a 6-point scale from 1 = ‘not at all’ to 6 = ‘very

much’. In addition, the instrument involved the question:

Who supported you the most after leaving the hospital?

Mothers’ experiences of the intervention programme

Mothers’ experiences of the intervention programme were

assessed using an instrument based on this intervention pro-

gramme (Aho et al. 2010). The instrument included 15

questions about the implementation of the intervention, such

as the timing of the contact by health professionals and peer

supporters, the modes and number of contacts and the per-

sons who contacted the mothers. One question asked the

mothers to provide an opinion on whether the intervention

was worth continuing (1 = yes, 2 = no).

Background variables

The background variables (Table 1) used were age, marital

status, education, vocational education, employment, health,

having a living child, gender and age of the deceased child,

anticipatory grief, reason of death and participation in a

bereavement support group. The amount of support from

health professionals (1 item) and peer supporters (1 item)

Table 1 Demographic statistics of participants

Demographic n (%)

Age (years) (n = 85)

23–29 19 (22)

30–39 58 (68)

40–43 8 (9)

Marital status (n = 85)

Marriage 56 (66)

Common law marriage 28 (33)

Education (n = 85)

Comprehensive school 23 (27)

High school 62 (73)

Vocational education (n = 82)

No education 3 (4)

Vocational education 17 (21)

College or polytechnic degree 34 (42)

University degree 28 (34)

Employment (n = 85)

Employed 59 (69)

Not employed/working 13 (15)

Housewife 13 (15)

Health (n = 84)

Satisfactory or poor 31 (37)

Quite good 44 (52)

Very good 9 (11)

Has a living child (n = 86)

No 35 (41)

Yes 51 (59)

Gender of the deceased child (n = 86)

Female 39 (46)

Male 45 (54)

Stillbirth (n = 86)

Yes 62 (72)

No 24 (28)

Gestational age of stillborn children (n = 84)

20–36 weeks 43 (71)

37–42 weeks 18 (29)

Age of deceased child (n = 86)

Less than a day 7 (29)

1–7 days 10 (42)

Over 7 days 7 (29)

Anticipatory grief (n = 83)

No advance warning 52 (63)

Advance warning 31 (37)

Reason of death (n = 72)

Illness 56 (78)

Accident 16 (22)

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1154 Journal of Clinical Nursing, 22, 1151–1162

after leaving the hospital was measured in both groups on a

6-point scale from 1 = ‘no support at all’ to 6 = ‘very much

support’.

Ethical considerations

Research involving bereaved persons is sensitive and

requires careful ethical consideration (Harvey et al. 2008).

Approval to undertake research and intervention was

obtained from the Ethics Committee of the Pirkanmaa

Hospital District, the Finnish Ministry of Social Affairs and

Health and all the Finnish Hospital Districts. Permission

was also obtained from the Hospital Districts. Mothers

received both verbal and written information about the

intervention and the study, and informed consent was

obtained. A letter of information was enclosed with the

questionnaire and sent out to the participants six months

after the child’s death. The letter contained information

about the study, assured the respondents of confidentiality

and voluntariness of participation and encouraged them to

contact the researcher with any further questions about the

study. When carrying out the research, the ethical guide-

lines of the Declaration of Helsinki were adhered to

(World Medical Association 2011). Mothers’ decisions not

to participate in the study or intervention were respected,

and no follow-up letters were sent. In this study, the peer

supporters who implemented the intervention had over two

years from the death of their own child, and they also had

received the training from professionals to support. They

are also provided mentoring when needed.

Data analysis

A statistical analysis was carried out using SPSSSPSS Win 18.0 (SPSS

Inc., Chicago, IL, USA). The results are presented in the form

of frequencies and percentages. The sum variables normal

distribution was assessed with the Kolmogorov–Smirnov test.

When the data were not normally distributed, non-parametric

tests were used; the Mann–Whitney test was used for

dichotomous variables, and the Kruskal–Wallis test was used

for categorical variables. The alpha level for statistical

significance was set a priori at .05 (Polit & Beck 2008).

Results

Participants

The study participants were grieving mothers whose child

had died at the age of three years or younger (including

perinatal deaths at 22 weeks of gestation or foetuses over

500 g). The mothers mean age was 33Æ2 years (range 23–43).

Two-thirds (66%) of the mothers were married. Altogether

73% of the mothers had a high school education. Almost half

(42%) of the mothers had a college or polytechnic degree and

one-third (34%) a university degree. Most of (69%) the

mothers were employed. Over half (52%) of mothers

considered their health to be quite good and 37% considered

their health to be satisfactory or poor. Altogether, 59% of the

mothers had a living child. Totally, 54% of the deceased

children were male. Of the deceased children, 72% were

stillborn and the gestational weeks of the stillborn children

were 36 or less in 71% of the cases. The deceased child’s age

was over seven days in only 29% of the cases. Over half

(63%) of the mothers received no advance warning before the

child’s death. The reason for the child’s death was illness in

78% of the cases (Table 1).

The mothers’ experience of the support received in a

bereavement follow-up intervention from health

professionals and peer supporters

The mothers had received a moderate amount of affect from

health professionals (Md = 4Æ00), somewhat less affirmation

(Md = 3Æ62) and the least aid (Md = 3Æ00) (Table 2). With

regard to the types of affect, half of the mothers (50%) felt

that the health professionals respected and valued them

much/very much after the death of their child. However,

27% of the mothers felt that the people providing support

did not share memories of their child with them at all

(Table 3). Half (49%) of the mothers felt that they received

much/very much affirmation support for information mak-

ing decisions on issues regarding the child’s death. In total,

15% of the mothers felt that they did not receive any

guidance from the health professional involved to seek

Table 2 Mothers’ experience of support received from health pro-

fessionals and peer supporters in the intervention group (n = 6)

Supporter/type of

support Median Q1 Q3

Cronbach¢salpha

Health professionals

Affect 4Æ00 3Æ25 4Æ86 0Æ924

Affirmation 3Æ62 3Æ00 4Æ62 0Æ919

Aid 3Æ00 2Æ20 4Æ40 0Æ868

Peer supporters

Affect 4Æ58 3Æ84 5Æ00 0Æ929

Affirmation 3Æ50 2Æ67 4Æ17 0Æ833

Aid 2Æ50 2Æ00 3Æ25 0Æ717

The values are mean scores on a 6-point scale (1 = no support all,

6 = very much support). Each form of support has the min value of

on 1 and a max value of 6.

Supporting parents Mother’s experience of the support from a bereavement

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Journal of Clinical Nursing, 22, 1151–1162 1155

Table 4 Social support received by mothers (n = 86) from peer supporters after the death of their child

Not at all

n (%)

Very little/little

n (%)

Moderate

n (%)

Much/very much

n (%)

Affect

Discussed/pondered on the event with me 4 (5) 1 (1) 27 (31) 43 (50)

Encouraged me to talk and/or express my emotions 3 (3) 10 (12) 26 (30) 36 (42)

Empathised/shared emotions with me 2 (2) 9 (10) 21 (24) 43 (50)

Respected and valued me 2 (2) 10 (12) 17 (20) 46 (53)

Showed interested in my coping 3 (3) 10 (12) 21 (24) 41 (48)

Gave me hope of coping 2 (2) 13 (15) 21 (24) 38 (44)

Affirmation

Gave information on grief and coping methods 3 (3) 13 (15) 27 (31) 32 (37)

Encouraged to participate in peer groups 3 (3) 7 (8) 25 (29) 39 (45)

Guided me to meet health professionals 30 (35) 23 (27) 15 (17) 7 (8)

Guided me to seek professional support/help 26 (30) 22 (26) 15 (17) 11 (13)

Gave information according to personal needs 7 (8) 26 (30) 20 (23) 21 (24)

Gave information on who to contact in need of support 17 (20) 16 (19) 18 (21) 24 (28)

Aid

Gave me their time 4 (5) 6 (7) 20 (23) 45 (52)

Helped with taking care of matters after the child’s death 29 (34) 31 (36) 9 (10) 6 (7)

Instructed me on where to seek concrete help 31 (36) 36 (42) 5 (6) 3 (3)

Gave me help 58 (67) 13 (15) 0 (0) 2 (2)

Table 3 Support received by mothers (n = 86) from health professionals after the death of their child

Not at all

n (%)

Very little/little

n (%)

Moderate

n (%)

Much/very much

n (%)

Affect

Empathised/shared emotions with me 6 (7) 16 (19) 26 (30) 37 (43)

Respected me and valued me 3 (3) 17 (20) 21 (24) 43 (50)

Shared memories of the child with me 23 (27) 30 (35) 15 (17) 17 (20)

Encouraged me to talk and/or express my emotions 11 (13) 20 (23) 22 (26) 32 (37)

Gave me hope of coping 7 (8) 23 (27) 25 (29) 29 (34)

Discussed/pondered on the event with me 6 (7) 22 (26) 26 (30) 32 (37)

Gave the opportunity to discuss unclear matters 7 (8) 18 (21) 24 (28) 36 (42)

Affirmation

Evaluated my coping 10 (12) 27 (31) 20 (23) 28 (33)

Encouraged to participate in peer groups 8 (9) 27 (31) 22 (26) 27 (31)

Guided me to seek professional support/help 13 (15) 30 (35) 20 (23) 22 (26)

Gave information on grief and coping methods 12 (14) 28 (33) 27 (31) 19 (22)

Gave information on matters related to the child’s death 7 (8) 17 (20) 19 (22) 42 (49)

Gave information on reactions to the death of a child 8 (9) 24 (28) 26 (30) 28 (33)

Gave information on who to contact in need of support 10 (12) 23 (27) 23 (27) 30 (35)

Gave information based on personal records 8 (9) 24 (28) 27 (31) 27 (31)

Aid

Gave help (e.g. filling in forms) 25 (29) 30 (35) 7 (8) 23 (27)

Gave me their time 6 (7) 16 (19) 24 (28) 38 (44)

Helped with taking care of matters after the child’s death 26 (30) 28 (33) 11 (13) 20 (23)

Instructed me on where to seek concrete help 28 (33) 26 (30) 16 (19) 15 (17)

Arranged sick leave and/or medication for me according to my needs 17 (20) 27 (30) 12 (14) 27 (31)

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1156 Journal of Clinical Nursing, 22, 1151–1162

professional support or help. Almost half of the mothers

(44%) felt that they received much/very much concrete aid

in the form of time from the health professional after the

death of their child. Almost a third of the mothers (29%)

felt that they did not receive any support from the health

professionals in filling in forms.

The peer supporters provided a lot of affect (Md = 4Æ58),

less affirmation (Md = 3Æ50) and aid the least (Md = 2Æ50)

(Table 2). Regarding affect, over half of the mothers (53%)

received much/very much respect and were valued by peer

supporters after the death of their child. Half of the

mothers (50%) reported that the peer supporters discussed

the death and shared emotions with them much/very much.

With regard to affirmation, almost half of the mothers

(45%) felt that the peer supporters encouraged them much/

very much to participate in the peer groups. A little over

one-third of the mothers (35%) did not receive any

guidance from peer supporters to meet health professionals.

Regarding aid, the mothers felt that peer supporters gave

them time (52% of all support types), whereas 67% of the

mothers felt that they did not receive any concrete help.

(Table 4).

The connection of background variables to the support

received from the intervention

The mother’s age has a statistically significant association

(p = 0Æ009) with social support received from health profes-

sionals (Table 5). Mothers of the age of 30–39 (Md = 4Æ15)

received the most social support. There was a statistically

significant association between the health status of the

mother and the received support from health professionals

(p = 0Æ020). Mothers who perceived their health to be very

good reported having received the most (Md = 4Æ46) social

support. There was no linear association between other

background variables (Table 1) and social support from

health professionals or from peer supporters.

The mothers’ experiences of the intervention programme

In total 37% of the mothers reported that the support

provided by health professionals was of much/very much help

in coping and 21% rated it as moderately helpful (Table 6).

Only 10% reported that it was not helpful in coping.

Correspondingly, 34% of the mothers felt that the support

provided by peer supporters was much or very much help in

coping, and 23% rated it as moderately helpful. Support

from peer supporters was not helpful in coping for 9% of the

mothers.

The mothers reported that the most important support

person after leaving the hospital was the hospital chaplain

(20%), followed by the public health nurse (19%) and the

nurse/primary nurse (14%). The mothers reported that a

social worker (1%) and a genetics doctor (1%) provided the

least amount of support (Table 7).

Most (87%) mothers reported that the contact by health

professionals (two to six weeks after the death of the child)

was well timed. When asked about the best possible time for

the contact, seven mothers (8%) suggested an earlier date,

two or three days after the child’s death. Health professionals

contacted the mothers mostly by telephone (71%) and once

(31%), two or three times (32%) or four or more times

(37%) after the mothers had left the hospital (Table 8). The

number of the contacts by health professionals had a

statistically significant association with the mothers’ experi-

ence of social support from health professionals (p = 0Æ040).

Mothers who were contacted by health professionals only

once reported receiving less support (Md = 3Æ15), as did

mothers who were contacted twice or three times

(Md = 3Æ90), and mothers contacted four or more times

reported having received a moderate amount of (Md = 4Æ20)

social support.

In total, 81% of the mothers met health professionals after

leaving the hospital. Of the mothers, 92% perceived the

timing of the meeting as appropriate. Health professionals

met the mothers 1–30 times, in most cases once (43%), twice

(23%) or three or more (34%) times. The mothers mostly

Table 6 Helpfulness of the support received from health profes-

sionals and peer supporters for the coping of mothers

Supporter and

support

received

(n = 86)

Not at

all

n %

Very

little/little

n %

Moderate

n %

Much/very

much

n %

From health professionals 9 (10) 27 (31) 18 (21) 32 (37)

From peer supporter 8 (9) 17 (20) 20 (23) 29 (34)

The amount of helpfulness of the support is measured on a 6-point

scale (1 = not at all, 6 = very much).

Table 5 Social support received from health professionals

Median Q1 Q3 p

Age

20–29 years 3Æ18 2Æ50 4Æ10 0Æ009

30–39 years 4Æ15 3Æ25 4Æ60

40–59 years 3Æ10 2Æ46 3Æ44

Health

Satisfactory or poor 3Æ15 2Æ50 4Æ21 0Æ02

Quite good 3Æ98 3Æ11 4Æ41

Very good 4Æ46 3Æ48 5Æ38

Supporting parents Mother’s experience of the support from a bereavement

� 2013 Blackwell Publishing Ltd

Journal of Clinical Nursing, 22, 1151–1162 1157

(63%) met a nurse/primary nurse, but also a public health

nurse (61%), the hospital chaplain (46%) and the doctor who

treated the child (46%) (Table 7). The number of the

meetings with health professionals had a statistically signif-

icant association with the mothers’ experience of social

support from health professionals (p = 0Æ012) (Table 9).

Mothers who met health professionals only once (Md = 3Æ95)

or twice (Md = 3Æ20) got less support and mothers who met

health professionals three or more times got a moderate

amount of (Md = 4Æ22) social support.

Of the mothers, 83% felt that the first contact (seven days

after the death) by peer supporters was timely. An earlier date

was suggested by 10% of the mothers and 7% of the mothers

suggested a later date, ranging from two weeks to six months.

In half of the cases (50%), peer supporters contacted the

mothers both by telephone and a home visit/meeting, but

some only made telephone contact (30%). The number of

contacts by peer supporters ranged from 1–25 times. Peer

supporters contacted the mothers once (15%), 2–3 times

(40%) and 4 or more times (45%) Most mothers (97%)

favoured the continuation of contact by peer supporters.

The number of the contacts by peer supporters had a

statistically significant association with the mothers’ expe-

rience of social support from peer supporters (p = 0Æ027)

(Table 8). Mothers who were contacted by peer supporters

only once reported getting less support (Md = 3Æ01), and

mothers contacted 2–3 times by peer supporters also

reported getting less (Md = 3Æ60) support. Mothers con-

tacted four or more times were the most satisfied

(Md = 3Æ92) regarding the received support from peer

supporters (Table 8).

Discussion

The mothers received affect the most, a moderate amount

of affirmation, and little aid, both from health professionals

and peer supporters, after leaving the hospital. The mothers

received more affect from peer supporters than from health

professionals. The results confirmed the results of Dyre-

grov’s (2004) and Lundquist et al.’s (2002) studies. In

contrast, the mothers received more affirmation from peer

supporters than from health professionals, as did fathers’

according to Aho et al. (2011). According to Laakso and

Paunonen-Ilmonen’s (2002), the study mothers did not

always receive up to date information from health profes-

sionals after the death of the child. The results on the

support received by fathers and mothers indicate that the

parents receive different amounts of support from health

professionals and peer supporters (Aho et al. 2011).

Mothers who perceived their health status to be very good

received most social support from health professionals after

the death of a child. It was not possible to determine in the

study whether the mother’s health was already good or

whether the support received from the health professionals

enhanced it. Mothers who estimated their health to be poor

reported having received the least support. This result

supports a similar result from the study on fathers. Fathers

with the poorest health also had the strongest grief reactions

(Aho et al. 2011,.) In earlier intervention studies, it has been

noticed that parents in risk groups, for instance socially

isolated parents, benefit the most from interventions (Murphy

et al. 1998, Murray et al. 2000). Dyregrov (2004) has

Table 8 Mothers’ experiences of social support in the intervention

programme and association to the received social support

n (%) Md p

The number of

contacts by health

professionals

1 23 (31) 3Æ15 0Æ040

2–3 24 (32) 3Æ90

4 or more 27 (37) 4Æ20

The number of

meetings with

health professionals

1 30 (43) 3Æ95 0Æ012

2 16 (23) 3Æ20

3 or more 24 (34) 4Æ22

The number of contacts

by peer supporter

1 10 (15) 3Æ01 0Æ027

2–3 28 (40) 3Æ60

4 or more 31 (45) 3Æ92

The differences regarding the support received with respect to the

number of contacts and meetings were tested with the Kruskal–Wallis

H-test. p = 0Æ05 level

Table 7 Health professional giving the most support to mothers and

type of support

Supporter

Gave the

most support

n (%)

Contacted

the mother

n (%)

Met the

mother

n (%)

Hospital chaplain 17 (20) 25 (31) 46 (57)

Public health nurse 16 (19) 36 (46) 49 (61)

Nurse/primary nurse 12 (14) 43 (54) 51 (63)

Psychologist 11 (13) 5 (6) 17 (21)

Psychiatrist 3 (4) 3 (4) 13 (16)

Doctor who cared

for the child

2 (2) 22 (28) 37 (46)

Social worker 1 (1) 9 (11) 31 (38)

Genetics doctor 1 (1) 6 (8) 7 (9)

Pathologist 0 (0) 3 (4) 5 (6)

I Nikkola et al.

� 2013 Blackwell Publishing Ltd

1158 Journal of Clinical Nursing, 22, 1151–1162

mentioned that if the bereaved retain their emotional

expressions, they may not allow themselves to receive

emotional support.

Over half of the mothers reported that the support from

health professionals and from peer supporters helped them at

least moderately with coping after the death of a child.

According to Aho et al. (2011), fathers felt even more often

that the support received from health professionals helped

them cope. In earlier studies, the support received from health

professionals has also had a positive effect on the coping of

mothers after the death of their child (Murphy et al. 1998 &

Murray et al. 2000, Kreichbergs et al. 2007). However, this

study has shown what type of support should be given, what

kind of person should provide the support and how it should

be timed in order for the support to help the mothers cope

after the death of their child.

For the majority of the mothers, the time of contact and

meetings with health professionals was well timed. The

number of the contacts or meetings had a statistically

significant association with the mothers’ experience of

social support from health professionals. The bigger the

number of contacts, the more support the mothers felt that

they had received. Although the purpose of the support

intervention was to have the primary nurse or doctor who

cared for child contact or meet the parents, the results

show that nearly half of the mothers were contacted by a

nurse and a third of the mothers were also contacted by

the hospital chaplain and the child’s doctor. After leaving

the hospital, the mothers most often met their primary

nurse, a health worker or the hospital chaplain. Despite

several contacts and meetings with health professionals, the

mothers felt that the hospital chaplain and a health worker

gave the most support. The results differ from the

experiences of fathers, as only 6% of the fathers were

contacted by a public health nurse, whereas the respective

figure for mothers was 61%. Mothers were significantly

more often in contact with a social worker, and fathers

were more often in contact with the child’s doctor.

However, fathers were mostly contacted and met by a

nurse/primary nurse, who was also perceived as the person

who provided the most support. (Aho et al. 2011). In

Finland, most of the young children who die die in a

hospital or at least after the death they are taken to a

hospital. After the death, the parents normally stay at the

hospital for only a few hours; however, the mothers of a

stillborn child may stay longer at the hospital. Previously,

there has not been systematic multiprofessional collabora-

tion to support grieving mothers and fathers.

Most of the mothers reported that the timing of the peer

supporter’s first contact was mostly timely. The more often

the peer supporters contacted the mothers, the more the

mothers received support from the peer supporters. A study

related to fathers gave similar results (Aho et al. 2011). In

earlier studies, the parents have perceived peer support to be

good and helpful in grief work (Dent et al. 1996, Murphy

et al. 1998, Laakso & Paunonen-Ilmonen 2002, Reilly-

Smorawski et al. 2002, Kreichbergs et al. 2007,.) In this

research, 97% of the mothers favoured the continuation of

contact by peer supporters following the death of a child.

Of the fathers, 99% favoured the continuation of contact by

peer supporters after the death of a child. (Aho et al. 2011).

The mothers felt that with the intervention, they received

versatile support both from health professionals and from

peer supporters immediately after the death of their child, as

well as on a long-term basis.

The results indicate that greater number of health profes-

sionals’ contacts was perceived as helpful for mothers as well

as fathers (Aho et al. 2011); thus, there is a need for

additional resources for health professionals to increase the

number of contacts. These study results describe the mothers

experience from support six months after the death of a child;

however, the support intervention continued for a longer

period. In the future, it would be interesting to continue the

follow-up period.

This study added new knowledge about the collaboration

intervention between health professionals and peer support-

ers when supporting grieving mothers, especially what kind

of support and when implemented support mothers experi-

ence positively.

Conclusion

As the mothers require a lot of support in many forms,

especially affect, collaboration between health professionals

and peer supporters should be systematically implemented

immediately after the parents have left the hospital, as well as

over a longer period. Based on the experiences reported by

mothers, the support intervention helped them cope after the

death of their child. According to the results, grieving parents

should be offered several contacts and meetings systemati-

cally after the death of their child, both by health profes-

sionals and by peer supporters.

Validity and reliability

The instrument for measuring social support used in this

study was developed for this research project. The instru-

ment has been used in a study on fathers’ grief, and it was

shown to work well (Aho et al. 2011). The reliability of

the instrument was also evaluated in this study with the

Supporting parents Mother’s experience of the support from a bereavement

� 2013 Blackwell Publishing Ltd

Journal of Clinical Nursing, 22, 1151–1162 1159

Cronbach’s alpha coefficient with values ranging from 0Æ72

to 0Æ93. The alpha values of the instrument were good, as

a value of 0Æ70 for the coefficient is generally considered

acceptable (Burns & Grove 2005). The study aimed to

control intervening variables broadly with factors that have

been shown in earlier studies to be variables related to grief

(Jordan & Neimeyer 2003, Flemming et al. 2008,.) The

low number of participants (N = 86) may weaken the

validity of the study and the generalisability of the results.

The research forms were not coded, and participants who

did not return them were not contacted again because of

the sensitivity of the topic (Stroebe et al. 2003). The

intervention was carried out in the same form for all

participants in the intervention group and the form was not

changed during the study (Currier et al. 2008).

Relevance to clinical practice

The support intervention for mothers after the death of their

child worked well in practice, and it was also well timed.

Both immediate and long-term versatile support were suc-

cessfully provided to the parents. Health professionals should

collaborate systematically with the third sector to help

parents in their grief. In the future, more contacts and

meetings after the parents have left the hospital should be

added in the support intervention programme. The support

intervention collaboration between health professionals and

peer supporters can be used in supporting and helping

grieving mothers and also fathers (Aho et al., in press). To

increase collaboration, health care management should allo-

cate resources to developing support for parents after they

leave the hospital.

Acknowledgments

We wish to thank the mothers who participated in the

intervention and in the study.

Contributions

Study design: IN, MK, ALA; data analysis: IN, MK, ALA and

manuscript preparation: IN, MK, ALA.

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