RECALLING
HER experience of delivering stillborn twin babies in the 1970s, one
woman noted that she was never asked if she wanted to see her babies and
that the nurses 'took them away very quickly.' She continued:
I regretted that I didn’t ask to see them. I think they believed that what you didn't see … you wouldn’t miss them. A few days later the matron came down to see me and asked me to fill out applications for birth and death certificates. When I said I needed to make arrangements for the funeral the matron said, ‘Oh, don’t you know, there won't be any funeral.’ She told me that the babies had been disposed of. When I asked what did that mean, she said, ‘you don't want to know.’ Apparently I was one week gestation off what was considered ‘human life’……… a bit bizarre. [And] that was it. Later I did ask a nurse and was told that they put them in the hospital incinerator.
It was a momentous day in the early 1990s, then, that the then-chaplain of the King Edward Memorial Hospital for Women, the Reverend Robert Anderson, took possession of an extraordinary item - the first cremator designed specifically for miscarried babies. This unique creation was the culmination of a lengthy design collaboration between Reverend Anderson and a firm in London, an expensive shipping fee, and an equally costly customs charge. It was with a sense of bittersweet satisfaction, that Reverend Anderson was present to oversee the first cremation of an individual stillborn baby, and from that point forward, he recalled that he felt able to answer grieving parents' queries as to their baby's cremation with sincerity and credibility.
As
an ordained Anglican minister, Robert Anderson had been appointed as
the inaugural chaplain in 1987 in an agreement between the hospital and
the Perth Diocese of the Anglican Church (the then-rector of Shenton
Park Anglican Church had acted as chaplain prior to this). Rev'd
Anderson came to the position assuming that most of his time would be
spent counselling patients on the oncology and gynaecology wards; he
was, frankly, astonished to discover the frequency of miscarriage and
perinatal death, and the depth of grief that many women and their
families felt after such a loss.
I didn’t come to the position with an idea of what I wanted to do … The first
dimension was gradually realising almost overwhelmingly the extent of pregnancy
or baby loss. And wondering what did I, as a white male Anglican priest would ever
have to offer in that context. And that was disconcerting in some ways and very
very quickly I realised that I had no resources, and limited knowledge about that.
Shortly after his appointment Reverend Anderson found he was principally occupied in
taking small ceremonies for babies in the chapel – particularly for babies under twenty
weeks gestation, who were still labelled by the hospital as ‘non-viable foetuses’ and who
legally required no formal burial. This caused some censure amongst some other staff
working at the hospital, who had begun to accept the practice of parents viewing so-called
‘viable’ foetuses but who felt that memorial services for miscarried babies was perhaps
going ‘too far’.
At the heart of these shifts in the care of bereaved women was the concept of holistic care. Whilst midwives since the mid 1970s had been suggesting that members of the profession should extend their care to the emotional needs of the patient, the 1990s saw several studies which affirmed the anecdotal evidence. This research suggested that this type of care, with the core value of the individualised approach, would produce the best outcome for the patient, whether the pregnancy had ended with a live baby or a stillborn baby.[i]
Whereas in the past parents’ questions about reasons why their infants had died were deflected or ignored, deemed as ‘undesirable’ knowledge, some staff began to believe that parents had every right to have these questions answered satisfactorily and truthfully. The manifestation of a culture of silence from decades past was a fear of procedures such as autopsy, and it was a matter of concern to many hospital directors that most parents refused a post mortem, afraid as to what would be done to their child. The various Human Tissue Acts in respective state legislation meant that autopsies could only be performed on the deceased with the consent of the next of kin, and many parents chose not to give their consent. At King Eddies, some staff felt it was important to demystify the concept of the autopsy - and so the idea of plain language reports was born. The plain language report was driven largely at KEMH by the conviction that parents deserved to be informed in an understandable manner as to any reasons – if known – why their baby had died. Simon Knowles, a perinatal pathologist at KEMH in the 1990s, believed that autopsy was vital in acknowledging the value of that individual child:
A post-mortem is worthwhile both for the caregivers and for the parents, quite apart from the amount of medical help it provides. It reinforces the existence of the infant as an individual in his or her own right and helps to underline the fact that the medical attendants consider the baby (and the family) sufficiently important to deserve a full and caring investigation.[ii]
Parents also began to embrace the funeral service believing it to be an empowering ritual that would help them properly say farewell to their baby. Shortly after his appointment as chaplain, Revd Anderson found he was principally occupied in taking small ceremonies for babies in the chapel – particularly for babies under twenty weeks gestation, who were still labelled by the hospital as ‘non-viable foetuses’ and who legally required no formal burial. This caused some censure amongst some other staff working at the hospital, who had begun to accept the practice of parents viewing so-called ‘viable’ foetuses but who felt that memorial services for miscarried babies was perhaps going ‘too far’.
Many cemeteries around the country had responded to pressure – usually through groups such as SANDS – and the advice of hospital social workers to provide an area appropriate for the interment of stillborn children or neonatal deaths. For example, after nearly a decade of discussion and planning, the Metropolitan Cemetery Board of Western Australia [MCB] had opened the Infants Butterfly Garden in the early 1990s which was a private area within Karrakatta Cemetery dedicated to babies dying before birth or shortly afterwards, and provided for the interment of ashes with a range of memorial options such as butterfly plaques and wind sculptures symbolising ‘the spirit of the child’. Pinnaroo Valley Memorial Park, also operated by the MCB, also became a popular choice for bereaved parents from the 1990s. Funeral costs, however, could be prohibitive – and so the Rose Garden was conceived.
Claire, for example, initially wanted to have her daughter cremated and interred in a cemetery, the cost was prohibitive and the idea of a tiny coffin was difficult to bear. I did one of their little rose garden services they have at King Edward. I guess at the time, it was like, such a big decision, cause I was thinking cremation, but then we found out it was going to cost at least five hundred bucks, and I couldn’t stand the thought of having a tiny little coffin, so when they told me about the memorial garden, and how they have all the babies for that month, they have the service, and everyone gets to scatter ashes under the rose bush and you can go and visit – that sounded nice to me. Like a little baby heaven. So I went with that. And I’ve gone back several times, I used to go back every year, they’ve got a little gazebo now, and reflect, but I haven’t been for a few years now.
One midwife commented that ‘It was seen to be a
midwife’s responsibility to separate a baby from the mother, to protect the mother and their
family from what was basically a sad event, but something that they would get over as soon
as they walked out the door’.
Oral history shows that a number of staff were becoming very aware that miscarriage and stillbirth were tremendously significant events.
However, times were a-changing . The ‘swinging sixties and seventies’ wrought more than the sexual revolution; it also brought new ideas and attitudes towards grief, loss and bereavement, as well as novel approaches to healthcare. Internationally, the work of health professionals such as Elisabeth Kubler-Ross and John Bowlby challenged the stoicism of former generations. Kubler-Ross’ seminal work, for example, introduced nursing and social work students to the idea that there were ‘stages’ of grief, and that grief could be ‘healing and appropriate’. Psychologist John Bowlby promulgated ‘attachment theory’: bonds, he argued, were developed between mother and infant and there were consequences for the breaking of these bonds. It was this theory in particular that led to a questioning of the forced removal of babies at birth from unmarried women, a social change which gave social workers the opportunity to focus on other areas in the hospital, such as miscarriage and pregnancy loss.
Patient-centred care, the questioning of the way unmarried women were treated, forced adoption practices, fathers’ rights during labour and the postnatal period, further education for nurses and midwives, Ros Denny vanguard in this area, professionalizing nursing. Longstanding Matron, Rosalind Denny, was instrumental in establishing the King Edward Chapel . Individual staff members recognizing that the stoic response was not appropriate, and oftentimes, harmful, but with plenty of opposition and springing from personal compassion and not training. Emphasis on further nursing education nationally, led by funeral directors and social workers, increased understanding of the impact of miscarriage and perinatal death. The appointment of the Reverend Robert Anderson was a key moment in the history of King Eddies.
Rosemary Keenan: I didn’t like doing that job [of taking deceased babies to parents] but I could see what it meant for the families and … that was another lesson that Ros Denny taught me, was that whatever the mothers need or want, uou should try and give it to them.’
At King Eddies, the fomenting waters of change were stirred by a number of staff members: Professor Patrick Giles, the head of obstetrics and gynaecology at King Eddies, and himself a bereaved parent, observed women’s grief after miscarriage, and put forth the idea that women should not be sedated, as was the custom, after miscarriage. Miscarriage, he argued in a major medical journal, was not something to be brushed off, but would have a profound effect on a woman – physically, emotionally and mentally. Rosemary Keenan, midwife and nurse administrator at King Eddies in the 1970s and 1980s,
These ideas landed at KEMH in the early 1970s. In 1970, the head of obstetrics and gynaecology at KEMH (himself a bereaved parent), Professor Patrick Giles, became interested in the possible emotional impact of perinatal death, which he suspected would show similarities to the psychosomatic reactions often seen after the death of an older child or an adult. Writing for a major medical journal, Professor Giles (himself a bereaved father), wrote that pregnancy loss was a major life event that would almost certainly have a profound effect on a woman, physically, metally and emotionally. ‘Besides feeling empty, sad and physically exhausted, the woman who has lost a baby in the perinatal period may feel that she is to blame, that she is a failure, and that it may recur in future pregnancies.’[i] Contrary to accepted care, Professor Giles suggested that women should not be sedated, and that autopsies be conducted to ‘relieve fear, misconception and guilt.’
Despite these radical suggestions, cultural change often comes slowly. In the 1980s at KEMH, the work of a Canadian clinical psychologist began to pave the way for a flurry of changes in the way that pregnancy loss was treated at King Eddies. Margaret Nicol, along with Dr Jeffrey Tompkin, set out to try and understand maternal grief following the death of a baby either in utero or shortly after birth. Adopting Madison and Walker’s 1967 general health questionnaire used to assess the health of recent widows into the Mother-Infant questionnaire, Nicol and a small band of KEMH staff interviewed 110 women who had experienced some form of perinatal loss in the 3 years preceding the study, in various hospitals around the Perth metropolitan area. Based on these interviews, Nicol came to the mighty conclusion that:
The pattern of health deterioration in bereaved mothers is very similar to the two major studies on the effects of bereavement in women after the death of their husband. It may therefore be concluded that the loss of a baby can have as severe effects on the mental and physical health of a woman as the loss of a husband.[ii]
In her professionally influential book Loss of a Baby, Nicol suggested that miscarriage and perinatal loss are extremely complex life events – not, as was previously thought, a ‘sad event’ that could be resolved by simply having another child. A woman faced multiple losses, she argued, following the loss of a pregnancy: the death of their own dreams and hopes for the unborn baby, the thwarting of her perception of self as a mother, and the complication of relationships. The most significant issue, however, said Ms Nicol, was that the baby itself was likely already ‘deeply known and loved’:
To others, this baby may be only an unknown child. To the mother, her baby is deeply known and loved. The mother has many links to the baby’s past and through the future. She often intuitively knows her baby well, through all the memories and daydreams she has had of her child.[iii]
Of course, Margaret Nicol’s work didn’t occur in a vacuum; it was part of a wider efforts to educate nurses and midwives of the need to treat all patients with compassion and dignity – to treat the whole person, not just the physical condition. Nursing education in the past had emphasised an aloof approach to patients and had placed little, if any, emphasis on individuality, but the late 1970s and early 1980s marked a new trend in nursing and midwifery care. On the national stage, The National Body of Midwives was formed in 1978; the professional body sought to utilize the work of people like Marg Nicol, as well as the professional experience of those who on a day to day basis were involved with death, dying and bereavement – even from within a maternity hospital.
Changing social attitudes towards ex nuptial birth, meant that social workers freer to focus attention on other issues within the hospital – starting in the neonatal unit and then shifting outwards – SANDS
Consumer-focused health: first formal appointment of a chaplain
A veritable flurry of changes: plain language reports; training for staff including those in regional areas (Roadshow); formalising of policies regarding miscarried and stillborn babies; the first foetal cremator.
At KEMH, the first hospital chaplain was appointed in 1987 in an agreement between the hospital and the Perth Diocese of the Anglican Church. There had been a previous, informal arrangement between the hospital and the-then minister of St Matthew’s Anglican Church in Shenton Park, the Revd. David Seccombe. The first official hospital appointee, the Reverend Robert Anderson, started his chaplaincy in December 1987. Robert remembers that he came to the position assuming that most of his time would be spent counselling patients on the oncology and gynaecology wards. He was soon astonished to discover the frequency of baby death and miscarriage and the depth of grief that many women felt after such a loss. In response, Robert’s ministry became focused around the care of bereaved women and their families - although he remembers that he felt it a great challenge to discover what he could bring to the role, as a ‘white male Anglican priest’:
I didn’t come to the position with an idea of what I wanted to do … The first dimension was gradually realising almost overwhelmingly the extent of pregnancy or baby loss. And wondering what did I, as a white male Anglican priest would ever have to offer in that context. And that was disconcerting in some ways and very very quickly I realised that I had no resources, and limited knowledge about that.
Several hospital staff members all recalled that it was becoming increasingly clear to those in charge at the hospital that policies needed to be formalised. Although he felt that he was not principally responsible for such changes, the appointment of Revd Anderson likely acted as a catalyst for the formalising of these changes that individual staff members had been working quietly to achieve for some years.
[i] Patrick Giles, ‘Emotional impact of stillbirth’, Australia and New Zealand Journal of Obstetrics and Gynaecology, vol. 10, 1970, p. 209
[ii] Margaret Nicol, Loss of a Baby: Understanding Maternal Grief (Bantam) Sydney, 1989
[iii] Nicol, Loss of a Baby, p.15
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