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The Pain That Binds Us: Midwives' Experiences of Loss and Adverse
Outcomes Around the World
William McCoola; Mamie Guideraa; Morghan Stensona; Lindsay Dauphineea
a
School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA

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Copyright © Taylor & Francis Group, LLC
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DOI: 10.1080/07399330903134455

The Pain That Binds Us: Midwives’ Experiences

of Loss and Adverse Outcomes Around the
World

WILLIAM McCOOL, MAMIE GUIDERA, MORGHAN STENSON,

and LINDSAY DAUPHINEE
School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Although much has been written about helping women and their
families cope with loss related to childbearing, little exists in the
literature to guide and support the midwives who witness these
losses. We conducted qualitative interviews globally with 22 mid-
wives from nations located on six different continents to begin
exploring common themes of experiences and coping methods of
midwives involved in adverse perinatal outcomes. The concept of
critical incident stress (CIS) is presented as a framework for under-
standing practitioner reactions that occur after adverse outcomes.
Implications for practice, education, and continued research are
addressed.

From one country to another, the training, title, and practice of midwives
varies. Whether one is referred to as a traditional birth attendant in Guatemala
or a nurse midwife in the United States, the connotation is the same: one
who cares for and assists women in the birth process. In this article we ad-
dress midwives’ differing reactions to a universal experience: loss or adverse
outcomes in caring for women. As the World Health Organization (WHO)
becomes increasingly concerned with having a skilled birth attendant at ev-
ery birth, it is important to support midwives and acknowledge the difficulty
of their work. It is our hope that readers will get a glimpse of the impact
adverse outcomes have on midwives, by listening to their stories shared in
this article.

Received 30 September 2008; accepted 3 February 2009.

Address correspondence to Dr. William McCool, PhD, CNM, RN, School of Nursing,
University of Pennsylvania, Room 417, Fagin Hall, 418 Curie Boulevard, Philadelphia, PA
19104, USA. E-mail: mccoolwf@nursing.upenn.edu

1003
 1004 W. McCool et al.

BACKGROUND

Adverse outcomes, such as neonatal or maternal deaths, are as real an aspect

of midwifery practice as is the joy of birth. In developed nations, neonatal
death may induce fear of litigation. Midwives in developing nations risk
licensure retraction and loss of livelihood with each maternal death. Cur-
rently, 536,000 direct maternal deaths take place each year; 99% of these
occur in developing nations (WHO, UNICEF, UNFPA, & the World Bank,
2007). Perinatal mortality rates around the world range from single digits
to greater than 75 per 1,000 live births (WHO, 2006). While the statistics
measure mortality related to childbirth, these numbers do not quantify other
poor outcomes, or morbidities, that occur within the scope of midwifery
practice.
In the United States, Zeidenstein (1995) began the dialogue on mid-
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wives’ reactions to the death of a baby. She described diminished practitioner

confidence after such a loss. Until Zeidenstein’s initiation, the experience of
adverse outcomes in midwifery practice in the United States had received
little discussion or research in a professional forum. She encouraged mid-
wives to broach the topic of adverse outcomes in practice, provide support
for fellow professionals after loss, and teach midwifery students that loss is
inherent in midwifery practice.
Despite Zeidenstein’s call over a decade ago for acknowledgment in
the United States of the effects of adverse pregnancy outcomes on mid-
wives and their practice, the topic remains largely understudied. To date,
research regarding the effect of traumatic incidents in the health care work-
place generally has been limited to emergency and disaster medicine. The
term “critical incident” has been used to describe a traumatic event or situa-
tion faced by emergency or health care personnel that causes them to have
unusually strong emotional reactions (Macnab, Sun, & Lowe, 2003). Critical
incidents have been defined as disturbing events, well outside the sphere of
usual human experience, that overwhelm an individual’s usual coping and
adaptive responses. This definition certainly applies to the death of a woman
in labor, the death of a neonate, and other unexpected adverse outcomes
encountered in midwifery practice.
The resulting stress from critical incidents, often labeled as CIS, has been
described as “a normal response to an abnormal event” (Mezey & Robbins,
2001). Laws and Hawkins (1995) first put a name to CIS when studying
emergency workers’ responses to traumatic events. Critical incident stress
(CIS) typically is manifested as recurrent intrusive recollections of the event,
numbing of responsiveness, and myriad cognitive, physical, behavioral, and
emotional symptoms (Laws & Hawkins, 1995). The possible experiencing
of CIS by midwives following adverse pregnancy outcomes has not been
investigated.
 Midwives’ Experiences of Loss 1005

Independent of the discussion of the CIS, a few investigators have ex-

plored midwives’ reactions to adverse outcomes. Gardner (1999) surveyed
nurses and midwives in the United States, England, and Japan after they had
experienced a perinatal death. Midwives consistently emphasized a need for
increased awareness and preparation in their training for such events; sup-
port and mentoring from senior midwives; and improved communication
skills regarding adverse outcomes. In all three cultures, midwives stated a
need for increased preparation related to the processing of their own grief
and that of the women who suffer loss.
Similar sentiments were echoed in Mander’s (2001) study of 36 mid-
wives in the United Kingdom, all of whom had experienced a maternal
death. Midwives’ responses to maternal death were comparable with those
of emergency personnel encountering a large-scale disaster (Mander, 2001).
Midwives experienced intrusive thoughts and feelings of unpreparedness.
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Mander identified a need for cultural change among midwives and proposed
that midwifery education facilitate that change and eliminate the taboo sur-
rounding maternal death.
In the United States, the current litigious environment in both obstetrics
and midwifery has increased the importance of understanding the impact of
adverse outcomes in practice. Coping with malpractice litigation is a com-
plex process that leaves practitioners struggling to regain a sense of mastery
in, and control of, their practice (American College of Obstetricians and Gy-
necologists [ACOG], 2005). Although exact numbers of midwives who will
be sued during their lifetime remains unknown, McCool, Guidera, Hakala,
and Delaney (2007) discovered that 25% of U.S. midwives completing a
national survey on midwifery practice and litigation reported having been
named in a lawsuit at least once. The number of obstetricians who will be
sued during their lifetime hovers close to 90% (ACOG, 2006). Of course, risk
of litigation is not solely an American phenomenon. The Royal College of
Midwives survey of more than 2,000 midwives and obstetricians in Scotland
described defensive practices that result from perinatal loss and subsequent
litigation (Symon, 2000). Increased rates of cesarean section deliveries, use
of monitoring and testing, and rates of induction of labor were examples of
such defensive practices.
Our investigation reports data on midwives’ professional and personal
experiences following adverse pregnancy outcomes. Information was gath-
ered from midwives practicing on six different continents, with the intent of
answering two major research questions:

1. Do midwives globally undergo common experiences following adverse

outcomes in practice?
2. Are the experiences of midwives following adverse outcomes similar to
documented symptoms of CIS?
 1006 W. McCool et al.

METHODS

We collected data between 2004 and 2007, conducting qualitative interviews

of 12 U.S. midwives and 10 midwives from other nations located on six
different continents. All midwives had participated at some point in their
careers in births that resulted in the serious morbidity or mortality of a
newborn or mother.
A purposeful sampling technique was used to access midwives who
had at least 5 years of active practice experience, and who self-identified
as having been involved in a health care experience that resulted in an
adverse outcome. “Adverse outcomes” were identified as less-than-optimal or
unexpected health outcomes that occurred with a client receiving midwifery
care. Through self-identification and networking, a convenience sample of 34
midwives who had been involved in adverse pregnancy outcomes became
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known to the investigators and were approached for possible interview. A

total of 22 individuals agreed to participate in the investigation.
In the U.S. interviews, attempts were made to include participants
who were (a) midwives of varying cultural backgrounds, (b) midwives
who worked with individuals from varying cultural backgrounds, and (c)
midwives who worked in a variety of birth settings. Participants included
midwives of Caucasian American (n = 10), African American (n = 1), and
Latino backgrounds (n = 1), who were working with populations of Cau-
casian American, African American, Latina American, Amish/Mennonite, and
Native American women. The midwives worked in hospital (n = 7), birth
center (n = 3) and home birth (n = 2) settings. One interviewee was a certi-
fied professional midwife (CPM), and the remainder (n = 11) were certified
nurse–midwives (CNM).
Internationally, the primary focus of convenience sampling was to locate
at least one midwife from each of the six habitable continents in order to
gather initial data from midwives working in diverse geographical regions
across the world. The 10 midwives interviewed were from North America
outside of the United States (n = 1), South America (n = 2), Asia (n = 2),
Australia (n = 1), Europe (n = 2), and Africa (n = 2).
The design of the investigation received approval from the Institutional
Review Board at the University of Pennsylvania. Participants signed a written
informed consent and were interviewed at a venue of their choice. We con-
ducted all of the interviews, which lasted 1 to 2 hours, and all participants
gave permission to be videotaped during the interview. This phenomenolog-
ical method of data collection involving videotaped face-to-face interviews
with individual midwives was used to explore the personal and professional
effects of adverse outcomes on midwives, how they have coped with these
outcomes, and to what extent they felt successful in doing so.
Recognizing that there has been limited information gathered to date on
the investigated topic, we utilized a qualitative approach to data collection.
 Midwives’ Experiences of Loss 1007

Five open-ended questions, using principals described in Streubert and Car-

penter’s book (2006), were developed exploring the nature of adverse out-
comes in which individual midwives were involved, and the methods by
which they coped. Review of the developed questions was accomplished
by three experienced researchers familiar with phenomenological methods
and midwifery practice, and after minor adjustments to language, the five
questions to be asked of participants were established. They included the
following: “What was the adverse outcome? Tell the story of what hap-
pened”, “What was helpful to you in coping with this outcome, and what
was not?”, “What were the personal or professional consequences of this
adverse outcome?”
We began data analysis during taped interviews, with the interviewer
interpreting participants’ descriptions so as to ask clarifying questions as they
were deemed necessary, as promoted in a phenomenological approach to
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investigation (Streubert & Carpenter, 2006). Following each interview, con-

versations were transcribed and also translated as needed. An analysis of
content was achieved by our two principal investigators, who independently
described common themes found in each conversation, and reached con-
sensus regarding those themes that were identifiable.

RESULTS

Not surprisingly, midwives’ and their patients’ responses to adverse outcomes

in practice varied by culture; by national policies, mores, or traditions related
to adverse health outcomes; and by geographical location. Several common
themes, however, emerged within two distinct groups: midwives practicing
in developed nations and those practicing in developing nations.

Developed Nations
In developed nations, midwives’ primary concerns centered on litigation,
including the prevalence of, potential for, fear of lawsuits. In addition, the
need for personal healing after an adverse outcome frequently was cited as
a concern.
Litigation. Clearly, a common outcome of an adverse pregnancy out-
come in developed nations is subsequent litigation related to the outcome.
All interviewees from developed nations were aware of potential litigation.
The amount of lawsuits concerning pregnancy outcomes, however, varied
by culture and customs. One hospital midwife from Norway shared the fol-
lowing:

When a baby dies in our country, the focus is not on responsibility or

blame, it’s on feelings. A mother and father can stay as long as they want
 1008 W. McCool et al.

at the hospital. There is no litigation, and a midwife loses her job only
if there was negligence. After discharge, a midwife or doctor visits the
home . . . to talk, counsel, start the healing.

In the United States, the threat of a lawsuit after an adverse outcome was
both an expressed fear and a reality. One hospital midwife shared his story:

I had a patient who experienced a placental abruption in labor several

years ago. Although I knew I had not done anything clinically wrong, I
feared that there would be a lawsuit, so I took copious notes to help me
remember the clinical facts. Sure enough, the case came to trial several
years later; the jury found in my favor. A student studying midwifery
should accept today, that one day they will be sued for a poor outcome
in practice.
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Another birth center midwife from the United States shared her story:

I was involved in the resuscitation of a baby who did poorly at birth. I

had not delivered the baby but was seeing clients at the birth center for
office hours and offered my assistance when a resuscitation was needed.
I visited the mother and baby in the neonatal intensive care unit and
she thanked me for saving her baby’s life. I was shocked when several
months later I was named in a lawsuit. . . . I couldn’t eat or sleep. The
case was eventually settled. It was about money, and it was about blame.

An interesting result of interviewing midwives working in developed

nations was that concerns about litigation appeared affected by the subcul-
tural group with which midwives worked, suggesting an interaction effect
between the culture of a midwife’s clientele and the anxiety felt by the mid-
wife about potential litigation following an adverse outcome. An American
midwife working in home birth with the Amish/Mennonite community stated
the following:

There are no lawsuits when there is a poor birth outcome in this com-
munity. Disabled children are called special people and considered a gift
from God. If a baby dies, the community comes together to support the
family, not to blame the midwife.

An African American midwife practicing in the United States described

African American women as more resilient in the face of loss as a function
of maternal–child health disparities, decreased expectations for a “perfect
birth,” and faith-based coping mechanisms:

Infant mortality is higher among African American women. We tend to

deal with loss in an internal way, or within the family. The church and
 Midwives’ Experiences of Loss 1009

spirituality [are] what sustain the Black woman; historically, faith is the
cornerstone that gets us through. In addition, the cultures with which I
have worked don’t expect the perfect birth. If it doesn’t happen, they
accept it more readily.

It is important to note here that while working with women who do not
expect everything to proceed perfectly may assuage some of the midwife’s
fears of litigation, it is as yet unclear whether such subdued expectations
match the reality of litigation actually occurring. The midwife’s fear of liti-
gation when working with certain subcultures appears diminished. Whether
litigation itself is lower amongst these subgroups in developed nations re-
mains unclear.
Personal healing. Just as powerful a feeling as the fear of litigation that
exists for midwives in developed nations is the desire for personal healing
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following an adverse outcome. As has been demonstrated in CIS model

analyses of adverse outcomes in the health care field (Mitchell, Sakraiden,
& Kameg, 2003), it is vital for any practitioner to move beyond the strong
emotions that result from being involved in an unexpected outcome so that
the individual can heal personally and can continue to offer optimal care.
The midwives interviewed seem to clearly understand this. A home birth
midwife described her need for personal healing after the death of a baby:

I transferred a baby to the hospital after the mother’s membranes ruptured

and showed thick meconium. The baby was eventually delivered by
cesarean section, and died several days later from meconium aspiration.
I was devastated. I visited the mother, went to funeral, but I needed
to process my feelings over and over. Talking to midwife friends, who
understood, was most helpful. I lost my confidence in myself for a while,
and carried my nervousness about safety to the next birth. . . . It’s a grief
that I still carry with me, but, eventually, one learns again to trust birth.

Interestingly, the possible interaction effect between the subculture of

the group with whom the midwife works and the fear of lawsuits that the
midwife may have did not seem to exist with regard to the personal emo-
tions the midwife was likely to experience following an adverse outcome.
A Colombian-born midwife working in the United States with a predomi-
nantly Central American population explained that, although women who
experience adverse pregnancy outcomes may sue involved midwives, the
women have the potential to become pregnant again, and when they do,
their personal sense of loss appears tempered:

If a woman has a bad outcome, she may sue, but she’ll be pregnant again
in 3 to 6 months. The healing comes when she has another baby; the
circle is complete . . . for both the woman, and her midwife.
 1010 W. McCool et al.

An interviewed midwife who works largely with Native American women

echoed the same sentiment:

You know, we are taught not to say, “You can have another baby,” but,
in reality, much of the grief goes away when the woman has another
baby. It is always sad, for both a woman and the midwife caring for her,
when a baby dies. But when the woman comes back a year or so later,
and has another baby, some kind of healing takes place.

Developing Nations
Midwives practicing in developing countries differed in their primary con-
cerns regarding adverse outcomes in practice. Their concerns seemed to
be focused on matters of loss of livelihood, fear of public exposure, and
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continual need for the development of preventative measures.

Loss of livelihood. While midwives in developed nations are at risk of
litigation, and the subsequent result of alteration or discontinuation of clinical
practice, midwives in developing nations also face the potential loss of their
professional practice due to government involvement or public humiliation.
With regard to loss of livelihood, a Midwife in Guatemala explained:

It is easy to get a license to be a midwife in Guatemala, but also easy

to have it taken away. Almost all women deliver at home; we are not
supposed to deliver complicated women at home—first-time mothers,
breech, twins. If you do, and lose a mother or a baby, you will lose your
license, your income, your work. . . . Women are fearful of the hospital.
Even when I tell them it is best, they are stubborn. Women fear they will
die in the hospital, and feel it is better to die at home . . . or they may
not have transportation.

A Honduran midwife reported, “All births are at home. A midwife can go to

jail if she has a poor outcome. That is what the ministry of health says, but I
have never known that to happen to a midwife.”
Public exposure. In addition to the possibility of government interven-
tion following an adverse outcome, there can be a risk of public exposure
of the event through the media by the woman’s family, thus defaming the
midwife and her skills as a means of retribution or humiliation. A Dominican
midwife detailed the significance of public exposure:

I had a patient die in the delivery room; she was preeclamptic. I felt
terrible, depressed, and impotent. I couldn’t go into that delivery room
for days, but there was no blame. Here, nobody sues. Here, families go to
the radio station, the television programs, the mass media, and tell what
happens. They express themselves, tell their feelings, but a journalist only
 Midwives’ Experiences of Loss 1011

reports one voice—without hearing our version. A lot of times, we are

not to blame. . . . Who wants their patient to die?
You don’t lose your job when a woman dies, but you feel so sad and
possibly humiliated or exposed to the mass media. If a patient shows up
with her baby dead—and that often happens—there is no problem. If
the baby dies in the delivery room, that is a different story.

Prevention of adverse outcomes. Finally, the responses of interviewed

midwives from developing nations accentuated the importance in their minds
of preventing adverse outcomes from the start, and the frustration in many
cases of not being able to do so. One Tanzanian midwife explained the focus
of prevention:

We have much perinatal loss due to HIV, delays in getting transporta-

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tion to the hospital, prolonged labor, ruptured uterus due to prolonged

labor. . . . again, waiting too long at home before arriving at the hospital,
hemorrhaging, and preeclampsia. Midwives feel very bad because often
the reason for adverse outcomes could have been prevented. Feelings
are not typically shared, [but] mostly internalized in this country.
How do we respond? It becomes an administration issue—What
could be done in the future to prevent adverse outcomes? Training staff,
community education to raise awareness and stress the importance of
obtaining prenatal care, methods to improve transportation. Litigation is
not an issue. If someone is prosecuted, it is due to criminal reasons. Very
rarely do civil lawsuits exist.

It is clear from midwives’ comments in both developed and developing

nations that involvement in an adverse outcome generates fear and anxiety
regarding employment and livelihood. However, while midwives in devel-
oped nations concentrated on concerns related to litigation, malpractice rates,
and personal healing, midwives in developing nations emphasized fears re-
lated to losing their livelihood, public exposure, and the ongoing need for
prevention of adverse outcomes.

DISCUSSION

Based on our qualitative interviews, we learned that the responses of the

midwives from developed nations to perinatal loss ranged from sadness
to fear to changes in practice. It is interesting to note that their primary
emotional concerns focused on personal healing from experiencing adverse
outcomes and coping with litigation. In contrast, we found that midwives
from developing nations were more emotionally concerned with prevention
of an adverse outcome. Diminished access to care, due to such matters as
lack of transportation or undereducation/training of birth attendants, was
 1012 W. McCool et al.

cited in the interviews of midwives from developing nations as a cause of

perinatal loss. Additionally, these midwives stated that while the threat of
litigation rarely was present, loss of licensure and public exposure were of
significant concern.
The responses of interviewed and surveyed midwives to perinatal loss
varied with regard to the sources of fear and anxiety. All responses contained
some component of CIS, however, including the reported sense of guilt and
a change in midwives’ practices. The consistent, global reports of responses
to perinatal losses, ranging from sadness to depression, sometimes motivat-
ing departure from the profession, reflected typical symptoms of CIS. The
concept of CIS as it applies to the midwifery profession, however, has yet to
be described or studied.
Critical incidents have been defined as events that cause an individual to
experience strong emotions that contribute to impairment of daily function-
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ing (Laws & Hawkins, 1995). Clearly, adverse perinatal outcomes, such as
maternal death during labor or loss of a baby, could be classified as critical
incidents, which can result in ineffective coping and maladaptive responses.
The qualitative responses to the interviews conducted for our investigation
suggested that midwives are experiencing a range of CIS symptoms and
have a demonstrable need for a set of skills to assist them in coping both
professionally and personally. The manifestation and course of CIS within
the scope of midwifery practice will require further investigation in order to
develop an appropriately tailored composite of coping skills for this subset
of health care professionals.
We will gain more insight into the effect of adverse pregnancy out-
comes on midwifery practice worldwide from information gathered from a
national survey of U.S. midwives (McCool et al., 2007), as well as from our
forthcoming analyses of communications with National Health Ministries and
midwifery organizations in 98 countries globally regarding the ramifications
of experiencing adverse outcomes in practice. Additionally, further research
is needed to identify individual, cultural, and societal factors that contribute
to midwives’ abilities to cope effectively and to continue to practice after
experiencing loss. The relation of adverse outcomes to CIS needs to be in-
vestigated with regards to midwifery practice, and subsequently addressed
within the midwifery profession.
Midwives throughout the world need support following unexpected,
adverse incidents that occur in practice. In one of the interviews, a mid-
wife practicing in the United States articulated the need for personal and
professional attention to the issue of perinatal loss:
Midwives need to break the silence about their experiences with adverse
outcomes in childbirth, and describe the guilt, shame, grief, and other
tumultuous feelings of those who attend a birth that ends in tragedy.
Midwives know well that education, support, and the sharing of experi-
ence are the ingredients that transform childbirth into an experience of
 Midwives’ Experiences of Loss 1013

empowerment. The profession needs to apply these tools to the subject

of death.

The lack of acknowledgment of the role played by adverse outcomes in

midwifery practice exists across the globe, and for the health of individual
midwives and the broader profession itself, this needs to be addressed.
Although midwives’ experience of loss or adverse outcome varies by culture,
it is a common and painful experience that binds midwives around the world.

REFERENCES

American College of Obstetricians and Gynecologists (ACOG). (2005). Coping with

the stress of medical professional liability litigation. ACOG Committee Opinion
Downloaded By: [Open University Library] At: 05:36 1 December 2010

No. 30. 105(2), 453–454.

American College of Obstetricians and Gynecologists (ACOG). (2006). Survey of
professional liability. Washington, DC: Author.
Gardner, J. M. (1999). Perinatal death: Uncovering the needs of midwives and nurses
and exploring helpful interventions in the United States, England, and Japan.
Journal of Transcultural Nursing, 10, 120–130.
Laws, T., & Hawkins, C. (1995). Critical incident stress. A normal response to an
abnormal situation. Australian Nursing Journal, 2(7), 32–34.
Macnab, A., Sun, C., & Lowe, J. (2003). Randomized controlled trial of three levels
of critical incident stress intervention. Prehospital and Disaster Medicine, 18,
367–371.
Mander, R. (2001). The midwife’s ultimate paradox: A UK study of the death of a
mother. Midwifery, 17, 248–258.
McCool, W., Guidera, M., Hakala, S., & Delaney, E. (2007). The role of litigation
in midwifery practice in the United States: Results from a nationwide survey of
certified nurse-midwives/certified midwives. Journal of Midwifery and Women’s
Health, 52, 458–464.
Mezey, G., & Robbins, I. (2001). Usefulness and validity of post-traumatic stress
disorder as a psychiatric category. British Medical Journal, 323, 561–563.
Mitchell, A., Sakraiden, T., & Kameg, C. (2003). Critical incident stress debriefing:
Implications for best practice. Disaster Management and Response, 1(2), 46–51.
Streubert, H., & Carpenter, D. (2006). Qualitative research in nursing: Advancing
the humanistic imperative (4th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.
Symon, A. (2000). Litigation and defensive clinical practice: Quantifying the problem.
Midwifery, 16(1), 8–14.
World Health Organization (WHO). (2006). Neonatal and perinatal mortality: Coun-
try, regional and global estimates. Retrieved July 23, 2008, from http://www.
who.int/reproductivehealth/docs/neonatal perinatal mortality/text.pdf
World Health Organization (WHO), UNICEF, UNFPA, & the World Bank. (2007). Ma-
ternal Mortality in 2005. Retrieved July 23, 2008, from http://www.unfpa.org/
upload/lib pub file/717 filename mm2005.pdf
Zeidenstein, L. (1995). Breaking the silence: Finding a voice for loss. Journal of
Nurse-Midwifery, 40, 317–319.