When Silence Speaks: How Midwives Turn Stillbirth Grief Into Healing Care

Every year, roughly 1.9 million families around the world receive the devastating news that their baby has been stillborn, according to the World Health Organization. Behind each of those losses stands a team of clinicians who must simultaneously care for a deceased infant, support a shattered family and manage their own emotional turmoil. A new phenomenological study published in Nursing Open offers an unusually intimate window into that hidden dimension of maternity care, following ten midwives and obstetric nurses in Macao as they described, in their own words, what it feels like to stand beside a grieving mother when a life that was expected never arrives. The findings reveal a striking psychological journey in which silence, often dismissed as a failure of communication, can become either a shield of fear or a profound therapeutic tool.

The research team, based at Kiang Wu Nursing College of Macau and Kiang Wu Nursing Hospital, chose a qualitative phenomenological design precisely because the subjective experience of grief care cannot be captured by surveys or outcome metrics. Between March and September 2023, the primary researcher, herself a midwife with eight years of experience at the participating hospital, conducted semi-structured in-depth interviews with six midwives and four obstetric nurses, all women aged between 26 and 44 years. Each participant had provided direct care to stillbirth cases, and pregnant clinicians were deliberately excluded to avoid causing psychological distress. Interviews lasted between 50 and 80 minutes, with an average of 61 minutes, and were structured around McClelland’s STAR model, which guides narrators through the Situation, Task, Action and Result of an experience in chronological order. Nonverbal cues such as pauses, tone changes and facial expressions were documented alongside the transcripts, and the data were analysed using Colaizzi’s seven-step phenomenological method with support from NVivo 12 software.

The setting matters as much as the method. Macao, one of China’s two Special Administrative Regions, records between 7 and 16 stillbirths annually among approximately 680,000 residents, a rate of 1.2 to 3.5 per 1,000 live births. The participating hospital, which handles 59.4 percent of local deliveries and has offered obstetric services for more than a century, established a Bereavement Support Team in 2017. Composed of obstetric, maternal and paediatric nurses, the team receives quarterly training through case discussions, experience sharing and evidence-based workshops, and its members are prioritised for stillbirth cases. Yet because stillbirths are unpredictable and staffing is limited, non-team clinicians are frequently drawn into grief care without the same preparation, creating a natural contrast between trained and untrained responses that runs through the study’s findings.

The analysis yielded 19 categories clustered into three major themes. The first, ‘Caught Up in Multiple Emotions’, describes the immediate emotional impact of stillbirth care. Participants could vividly recall nearly every case they had encountered, and even the most senior clinicians reported persistent distress. One midwife with more than two decades in the delivery room explained that despite witnessing numerous stillbirths, she steps into the mother’s shoes, offering constant reassurance while feeling overwhelmed with grief inside, because a life has been lost. The visual impact of a stillborn infant emerged as a particularly potent stressor. A midwife with three years of experience recounted her first encounter, describing a baby that was purple, dark, tiny, limp and slightly swollen, and admitting she felt scared when she touched the body while wrapping it in a blanket alone. Others recalled colleagues avoiding the ward entirely, reluctant to enter unless specifically asked to help.

Fear of blame compounded the emotional burden. One nurse with eight years of experience described detecting no foetal heartbeat in a 40-week pregnant patient during an independent night shift just over a year into her career. She was terrified of what responsibility she might bear and had no idea what to do. The colleague who had handed over that shift ultimately resigned, unable to function under the accumulating pressure. This medico-legal anxiety, the researchers note, interacts with cultural context: in Chinese communities, public discussion of death remains taboo, and stillbirths are often concealed due to stigma, which can silence both bereaved families and the professionals caring for them. The result is a clinical environment in which nurses may fear that any inappropriate wording, delayed explanation or perceived lack of empathy could be interpreted as negligence.

The second theme, ‘Silent Companionship’, captures the study’s most conceptually interesting finding: silence in grief care is not a single behaviour but two fundamentally different ones. ‘Passive silence’ arose from unpreparedness and fear. Novice clinicians who had received no specialised bereavement training during their internships described feeling at a loss when alone with a mother who had lost her baby, not knowing what to do or say. Others worried that saying the wrong thing might deepen the family’s grief and cause misunderstandings, so quiet presence became a self-protective default, a way of avoiding conflict rather than offering care. The researchers link this pattern to Benner’s novice-to-expert model, in which inexperienced nurses rigidly follow rules and rely on conservative error-avoidance strategies, temporarily sidestepping conflict but missing critical opportunities to provide emotional support.

‘Proactive silence’, by contrast, is a deliberate clinical technique. Experienced clinicians, particularly Bereavement Support Team members, observed that families in deep sorrow are often unable to absorb words of consolation, so they created a pressure-free space in which families could grieve privately and begin psychological self-healing. One nurse described crouching beside a grieving mother’s bed, telling her simply ‘I’m here with you’, wiping her tears, stroking her head and gently patting her shoulder in silence. The approach proved effective; some mothers expressed gratitude months later for the companionship and encouragement they had received. The distinction resonates with research on compassionate versus awkward silence: the same absence of words can either heighten discomfort or create a reassuring environment, depending on the body language, eye contact and intentionality that accompany it.

The third theme, ‘Growing Through Grief-Care’, charts how clinicians transformed painful encounters into professional growth through two sub-themes: control of environment and control of emotions. Environmentally, experienced teams learned to arrange private rooms, keep bereaved mothers away from women who had just given birth, since the sound of healthy newborns crying intensifies distress, and fulfil specific family wishes such as seeing or dressing the baby, writing cards, taking handprints or spending private time with the infant. Emotionally, participants developed two distinct coping mechanisms. Some practised ’emotional distancing’, consciously limiting involvement to prevent exhaustion, with one midwife explaining that assigning only one or two staff members to stay with the family maintains composure, because an overwhelmed caregiver cannot care effectively. Others moved in the opposite direction, toward what the authors call ’empathic sublimation’. One midwife described her evolution from secretly hiding her tears to openly weeping with mothers, holding them and crying together before talking, an emotional exchange she now considers a genuinely good experience that brings clinicians closer to families.

The researchers interpret this trajectory through Lazarus and Folkman’s stress and coping model, in which intense initial stress responses give way to appraisal and problem-focused or emotion-focused strategies, and through Tedeschi and Calhoun’s theory of post-traumatic growth, in which enduring trauma can enhance personal strength, empathy and interpersonal skill. The study’s authors argue that the progression from passive silence to therapeutic presence, and from emotional suppression to authentic empathy, exemplifies the maturation of nursing from mechanical execution to humanistic care. Notably, they found that even nurses with five years of experience had not yet developed reliable emotional management in stillbirth care, suggesting the learning curve is steeper than in many other clinical domains and that experience alone cannot be relied upon to produce competent grief caregivers.

The practical implications are concrete. The authors recommend that grief care be embedded in routine obstetric protocols rather than left to individual experience, with clear guidance on privacy, memory-making opportunities such as photographs and mementos, and protection from exposure to routine maternity environments. Bereavement training should explicitly teach the difference between fearful and therapeutic silence, using simulation, case discussion, mentorship and post-event debriefing, including debriefing that specifically addresses the visual impact of stillborn infants, which can trigger fear and intrusive memories. The study’s limitations, a small sample from a single hospital and reliance on retrospective recall, mean the findings require broader replication, but the core message is clear: supporting bereaved families and supporting the clinicians who care for them are not separate goals but a single, bidirectional system, and institutions that invest in both stand to transform one of medicine’s most quietly traumatic encounters into an experience of shared humanity and measurable healing.

Subject of Research: Midwives' and obstetric nurses' lived experiences of providing grief care to families after stillbirth

Article Title: Grief Care Experiences of Midwives and Obstetric Nurses Following Stillbirth: A Phenomenological Study

Article References: Liao, Y., Xu, J., Mao, A., & Tan, X. (2026). Grief Care Experiences of Midwives and Obstetric Nurses Following Stillbirth: A Phenomenological Study. Nursing Open, 13(10), Article e70889. https://doi.org/10.1002/nop2.70889

Image Credits: AI Generated

DOI: 10.1002/nop2.70889

Keywords: stillbirth, midwives, obstetric nurses, grief care, perinatal bereavement, phenomenology, qualitative research, silence, empathy, Macao, nursing, post-traumatic growth