Elsevier

International Journal of Nursing Studies

Volume 160, December 2024, 104863
第 160 卷，2024 年 12 月，104863
International Journal of Nursing Studies

The influence of culture and spirituality on maternal grief following stillbirth in China: A qualitative study
文化和精神对中国死产后产妇悲痛的影响：定性研究

https://doi.org/10.1016/j.ijnurstu.2024.104863 IF: 7.5 Q1 B1Get rights and content  获取权利和内容
Under a Creative Commons license
采用知识共享许可协议
Open access  开放存取

Abstract  摘要

Background  背景介绍

Stillbirth is a unique phenomenon with various manifestations influenced by cultural contexts and spiritual beliefs. Chinese cultural and spiritual practices produce different post-stillbirth grief experiences for bereaved mothers in China. However, the majority of research on perinatal loss and grief has been conducted in Western cultures. In the Chinese cultural context, the post-stillbirth grief experience of bereaved mothers may differ from the types of Western bereavement examined in the dominant research.
死胎是一种独特的现象，受文化背景和精神信仰的影响，其表现形式多种多样。中国的文化和精神习俗为中国的丧母者带来了不同的死产后悲伤体验。然而，大多数关于围产期损失和悲伤的研究都是在西方文化中进行的。在中国文化背景下，丧亲母亲的死产后悲伤体验可能与主流研究中西方丧亲类型有所不同。

Objective  目标

This study investigated the influence of culture and spirituality on grieving mothers who had experienced a stillbirth in China.
本研究调查了文化和灵性对中国经历死产的悲伤母亲的影响。

Methods  方法

This qualitative study was grounded in an interpretivist constructionist epistemology. In-depth interviews were conducted with mothers who had experienced a stillbirth within the previous year. Thematic analysis was used to analyse the data.
这项定性研究以解释主义建构主义认识论为基础。研究人员对在过去一年中经历过死胎的母亲进行了深入访谈。采用主题分析法对数据进行分析。

Findings  调查结果

A total of 28 women were interviewed by trained interviewers. Three key themes were identified: 1) The influence of culture on grief expression, with four subthemes: restrained expressions of grief, unattainable mourning ceremonies, hospital policy as a barrier to grieving, and others-oriented self; 2) Cultural characteristics of post-stillbirth experiences, with four subthemes: paternalistic medical culture, “Kong yuezi”, embarrassment during postpartum visits, and cultural taboos on dealing with deceased babies' possessions; and 3) Finding significance in spiritual healing process, with four subthemes: seeking meaning in the event, accepting and reconciling with the event, reshaping beliefs and views about life and death, and achieving personal growth.
共有 28 名妇女接受了训练有素的访谈员的访谈。确定了三个关键主题1) 文化对悲伤表达的影响，包括四个次主题：克制的悲伤表达、无法实现的哀悼仪式、医院政策是悲伤的障碍，以及以他人为导向的自我；2) 死产后经历的文化特征，包括四个次主题：家长式医疗文化、"孔乙己"、产后探视时的尴尬，以及处理死婴的文化禁忌：2) 死胎后经历的文化特点，包括四个次主题：家长式医疗文化、"孔乙己"、产后探视时的尴尬、处理逝去婴儿遗物的文化禁忌；以及 3) 在精神康复过程中寻找意义，包括四个次主题：在事件中寻找意义、接受并与事件和解、重塑关于生与死的信念和观点、实现个人成长。

Conclusion  结论

Chinese culture and spirituality have different influences on bereaved mothers' expressions of grief and post-stillbirth healing. This research demonstrates specific aspects of spirituality that contribute to or hinder the grieving process and the different roles of Chinese culture and spirituality for individuals. The findings suggest the need for the development of culturally sensitive interventions and support systems to assist mothers in navigating grief and healing. Future studies could explore the roles of Chinese culture and spirituality over time in the different stages of grief and healing after stillbirth.
中国文化和灵性对失去亲人的母亲的悲伤表达和死胎后的康复有着不同的影响。这项研究展示了灵性的具体方面对悲伤过程的促进或阻碍作用，以及中国文化和灵性对个人的不同作用。研究结果表明，有必要开发具有文化敏感性的干预措施和支持系统，以帮助母亲度过悲伤和愈合过程。未来的研究可以探索中国文化和灵性在死产后不同阶段的悲伤和愈合中的作用。

Keywords  关键词

Culture
Spirituality
Stillbirth
Grief
Bereaved mother

文化精神死产悲伤失去亲人的母亲

What is already known  已知信息

  • •
    Culture and spirituality influence the stillbirth experience.
    文化和精神影响死产经历。
  • •
    The majority of research on stillbirth and grief has been conducted in Western cultures.
    有关死产和悲伤的研究大多是在西方文化中进行的。
  • •
    The approaches used by Chinese grieving mothers in the context of China exhibited notable differences from the dominant research in the Western context.
    中国悲伤母亲在中国背景下使用的方法与西方背景下的主流研究有着明显的不同。

What this paper adds  本文的补充内容

  • 1.
    Cultural and spiritual factors play various roles in the expression and experience of grief, and healing in the Chinese context.
    在中国，文化和精神因素在悲伤的表达和体验以及愈合方面发挥着不同的作用。
  • 2.
    The influences on expression of grief include restraint, the inability to hold a mourning ceremony, hospital policy barriers, and an others-oriented perspective.
    影响悲伤表达的因素包括克制、无法举行哀悼仪式、医院政策障碍以及他人导向的观点。
  • 3.
    Culture and spirituality can both help and hinder the grieving process.
    文化和精神既可以帮助哀悼过程，也可以阻碍哀悼过程。

1. Introduction  1.导言

According to data from the World Health Organization, nearly 2 million stillbirths in late pregnancy occur worldwide every year (WHO, n.d.-b). China, which accounts for approximately one-fifth of the global population, had a stillbirth rate of approximately 4.9 per 1000 births in 2021 (WHO, n.d.-a). This makes China the fourth highest country in the world in terms of the number of stillbirths (Zhu et al., 2021). Despite the devastating impact on parental mental health and the significant direct and indirect costs associated with stillbirths, this public health concern has largely been overlooked in discussions and debates for an extended period (Blencowe et al., 2016; Heazell et al., 2016).
根据世界卫生组织的数据，全世界每年有近 200 万例孕晚期死胎（世卫组织，注：b）。占全球人口约五分之一的中国，2021 年的死胎率约为每 1000 名新生儿中有 4.9 个死胎（WHO, n.d.-a）。这使得中国成为世界上死胎数量第四高的国家（Zhu 等人，2021 年）。尽管死胎对父母的心理健康造成了破坏性的影响，而且与死胎相关的直接和间接成本巨大，但在很长一段时间内，这一公共卫生问题在讨论和辩论中基本上被忽视了（Blencowe 等人，2016 年；Heazell 等人，2016 年）。
The loss associated with stillbirth is a typically sudden, unexpected, and in many cases, inexplicable making it one of the most emotionally distressing circumstances of grief (Chambers and Chan, 2000). There is a distinction between the grief experienced following stillbirth and other types of loss. The abrupt emotional shift from joy and happiness in anticipation of the baby's arrival to mourning over the baby's death is devastating for a family (Bennett et al., 2008; Kelley and Trinidad, 2012). Pregnant women and their families experience psychological trauma and unpleasant feelings, including depression, self-blame, and long-term grief, which are frequently ignored by society (Cacciatore and Thieleman, 2019; Shakespeare et al., 2019; Mills et al., 2021). Stillbirth disrupts parents' natural order of life and raises uncertainty about the future, including subsequent pregnancy and parenting expectations. Expressing grief may involve addressing the physical experiences, such as labour and delivery, which are less prominent in other forms of grief. Women who experience stillbirth may need to navigate changes in their physiological condition and engage in postpartum recovery, aspects that may not be as conspicuous in alternative forms of loss. Stillbirth grief is more likely to lead to complicated grief, a prolonged and intense mourning period that can negatively affect both psychological and physical well-being (Kersting and Wagner, 2012; Shear, 2015; Kustanti et al., 2021). This grief can extend beyond six months and, in extreme cases, even persist for several years (Prigerson et al., 1995; Maercker and Lalor, 2012; Lawn et al., 2016).
与死胎相关的损失通常是突然的、意料之外的，在许多情况下是无法解释的，这使其成为最令人痛苦的悲伤情绪之一（Chambers 和 Chan，2000 年）。死产后的悲伤与其他类型的丧亲之痛是有区别的。从期待婴儿到来的喜悦和幸福到对婴儿死亡的哀悼，这种突然的情绪转变对一个家庭来说是毁灭性的（Bennett 等人，2008 年；Kelley 和 Trinidad，2012 年）。孕妇及其家人会经历心理创伤和不愉快的感受，包括抑郁、自责和长期悲伤，而这些往往被社会所忽视（Cacciatore 和 Thieleman，2019 年；Shakespeare 等人，2019 年；Mills 等人，2021 年）。死产扰乱了父母的自然生活秩序，并引发了对未来的不确定性，包括对以后怀孕和养育子女的期望。表达悲痛可能会涉及到身体上的经历，如分娩和生产，这在其他形式的悲痛中不太突出。经历死产的妇女可能需要应对其生理状况的变化并参与产后恢复，而这些方面在其他形式的丧亲中可能并不明显。死胎的悲伤更有可能导致复杂的悲伤，这是一个漫长而强烈的哀悼期，会对心理和生理健康产生负面影响（Kersting 和 Wagner，2012；Shear，2015；Kustanti 等人，2021）。这种悲伤可能会持续六个月以上，在极端情况下甚至会持续数年（Prigerson 等人，1995 年；Maercker 和 Lalor，2012 年；Lawn 等人，2016 年）。
Scholars (Stroebe et al., 2007; Allahdadian and Irajpour, 2015) have indicated that the comprehension of life and death can be approached from either scientific perspectives or through the lenses of philosophy and spirituality. Following a stillbirth, mothers employ various strategies, such as crying and engaging in conversations, to navigate their grief. Additionally, cultural rituals and spirituality serve as avenues for seeking comfort (Covington and Burns, 2006). A systematic review highlighted the positive impact of religious and spiritual beliefs on the grieving process, with 94 % of individuals reporting such benefits (Becker et al., 2007). Culture and spirituality are recognised as potentially pivotal contextual elements in the grieving process and are predominantly conceptualised as metaphysical constructs and behaviours driven by metaphysical forces. Within this framework, metaphysical drivers refer to all-encompassing forces or influences that transcend the material realm and mould cultural and spiritual dynamics. These drivers include philosophical underpinnings, belief systems, and intangible elements, which act as guiding principles for the manifestation of cultural and spiritual expressions. “Culture” (Culture, n.d.) refers to the intrinsic nature of shared values, beliefs, and practices within a society, and “spirituality” (Taylor, 2003; WHO，n.d.-c) pertains to an individual's inner sense of purpose and meaning. They are both structures through which members of a society organise their thoughts and actions; thus, they affect the way people cope with the emotional effects of stillbirth. Spirituality is an essential framework that helps people make sense of their experiences and find inner peace and harmony during challenging times (Fisher, 2011). As a belief system, religion can be a part of spirituality, but spirituality can exist independently and does not require religious views.
学者们（Stroebe 等人，2007 年；Allahdadian 和 Irajpour，2015 年）指出，对生与死的理解既可以从科学的角度出发，也可以从哲学和灵性的角度出发。死产后，母亲们会采用各种策略（如哭泣和交谈）来化解悲伤。此外，文化仪式和灵性也是寻求安慰的途径（Covington 和 Burns，2006 年）。一项系统性综述强调了宗教和精神信仰对悲伤过程的积极影响，94% 的人报告了这种益处（Becker 等人，2007 年）。文化和灵性被认为是哀伤过程中潜在的关键环境因素，主要被概念化为由形而上学力量驱动的形而上学建构和行为。在此框架内，形而上学驱动力指的是超越物质领域并塑造文化和精神动态的全方位力量或影响。这些驱动力包括哲学基础、信仰体系和无形要素，它们是文化和精神表现形式的指导原则。"文化"（Culture, n.d.）指的是社会中共同价值观、信仰和习俗的内在本质，而 "精神"（Taylor, 2003; WHO, n.d.-c）指的是个人的内在目的和意义感。它们都是社会成员组织思想和行动的结构；因此，它们会影响人们应对死产情绪影响的方式。灵性是一个重要的框架，可帮助人们理解自己的经历，并在充满挑战的时期找到内心的平静与和谐（Fisher，2011 年）。 作为一种信仰体系，宗教可以是灵性的一部分，但灵性可以独立存在，并不需要宗教观点。
Reactions to death and manifestations of grief vary enormously across cultures and spiritual beliefs, with each culture defining its own bereavement traditions and rituals (Hebert, 1998; Markin and Zilcha-Mano, 2018; Ayebare et al., 2021; Li et al., 2016; Roberts et al., 2012). Most medical literature in the Western context emphasises taking photographs of deceased babies, keeping mementos, and holding memorial services in order to generate memories and maintain contact with the baby, in addition to encouraging grievers to express their emotions and share their experiences (York and Stichler, 1985; Shorey et al., 2017; Nuzum et al., 2017). These cultures may differ from cultures that are less expressive, such as Chinese cultures. In our previous study, we discovered that the majority of Chinese bereaved mothers were unwilling to retain mementos, create memories, or express their emotions (Liu et al., 2021). Some studies on the manifestations of grief between Western countries and China have illustrated a similar phenomenon (Pressman and Bonanno, 2007; Xiu et al., 2016). Despite these variations, there is a paucity of research on the cultural and spiritual influences on mothers' grieving process after stillbirth in the Chinese context. The purpose of this descriptive qualitative study is to investigate the impact of culture and spirituality on the grieving process of mothers who have experienced stillbirth within the Chinese context.
不同文化和精神信仰对死亡的反应和悲伤的表现大相径庭，每种文化都有自己的丧亲传统和仪式（Hebert，1998；Markin 和 Zilcha-Mano，2018；Ayebare 等人，2021；Li 等人，2016；Roberts 等人，2012）。西方背景下的大多数医学文献都强调为逝去的婴儿拍照、保留纪念品和举行追悼会，以便产生回忆并与婴儿保持联系，此外还鼓励悲伤者表达情感和分享经历（York 和 Stichler，1985 年；Shorey 等人，2017 年；Nuzum 等人，2017 年）。这些文化可能与表达能力较弱的文化（如中国文化）有所不同。在我们之前的研究中，我们发现大多数中国丧亲母亲不愿意保留纪念品、创造回忆或表达情感（Liu 等人，2021 年）。一些关于中西方悲伤表现的研究也说明了类似的现象（Pressman 和 Bonanno，2007 年；Xiu 等人，2016 年）。尽管存在这些差异，但在中国背景下，有关文化和精神因素对母亲死产后悲伤过程的影响的研究还很少。本描述性定性研究旨在调查文化和灵性对中国背景下经历死产的母亲的悲伤过程的影响。

2. Methods  2.方法

2.1. Study design  2.1.研究设计

This study is a component of a larger research programme that employed a longitudinal qualitative study to illuminate the specific roles and trajectory of bereaved mother's grief experiences at distinct stages following stillbirth. The larger research project is approximately three years long. This qualitative study is an original study, grounded in an interpretivist constructionist epistemology that serves as an exploratory study preceding the larger research. According to constructionists, individual experiences create reality and knowledge. This paradigm recognises multiple truths and views knowledge as constructed rather than discovered. It emphasises the influence of individual experiences whilst considering larger social, cultural, and economic contexts (Levers, 2013). Participants were recruited for this study independently from the larger research programme. In-depth interviews with 28 mothers who had a stillbirth before the past year were conducted by two trained researchers. The first author was the main interviewer, and had 12 years of experience in maternal health education, and the other author was the assistant interviewer. Inductive thematic analysis was performed whilst reviewing the interview transcripts. Themes were identified. Ongoing reflections about possible biases were discussed throughout the research process.
本研究是一项大型研究计划的组成部分，该计划采用纵向定性研究的方法，以阐明死产后丧亲母亲在不同阶段的具体角色和悲伤经历轨迹。该大型研究项目为期约三年。这项定性研究是一项原创性研究，以解释主义建构主义认识论为基础，是大型研究之前的一项探索性研究。建构主义认为，个人经验创造了现实和知识。这种范式承认多重真理，认为知识是建构出来的，而不是发现出来的。它强调个人经历的影响，同时考虑到更大的社会、文化和经济背景（Levers，2013 年）。本研究的参与者是独立于更大的研究计划之外招募的。两位训练有素的研究人员对 28 位在过去一年前有过死产的母亲进行了深入访谈。第一位作者是主访谈员，拥有 12 年的孕产妇健康教育经验，另一位作者是助理访谈员。在审阅访谈记录时进行了归纳式主题分析。确定了主题。在整个研究过程中，对可能存在的偏见不断进行反思。

2.2. Setting  2.2.设置

The investigation was conducted at a 1120-bed provincial public hospital, which is the largest hospital for maternal and child health in Hangzhou, Zhejiang Province. The city in which the hospital is located is a modern city with a large migrant population originating from various regions throughout China. In 2020, the hospital had seven maternity wards, with an annual birth volume of more than 20,000 babies. In the previous year, 83 primiparous women gave birth to stillborn babies.
调查在一家拥有 1120 张床位的省级公立医院进行，该医院是浙江省杭州市最大的妇幼保健院。医院所在城市是一座现代化城市，拥有大量来自全国各地的流动人口。2020 年，医院有 7 个产房，年分娩量超过 2 万名婴儿。上一年，有 83 名初产妇生下死胎。

2.3. Participants and recruitment
2.3.参与者和招募

The recruitment process was conducted through the hospital information system, including the use of electronic medical records and the identification of eligible participants by hospital staff. A purposeful sampling approach (Benoot et al., 2016) was employed using stratified sampling and maximum variation sampling. This study adopted participants' ancestral origins as the basis for sampling. The electronic medical record contains details about their information of ancestral original cities. We divided China into five major regions: East, West, South, North, and Central. This classification was crucial in ensuring geographic cultural diversity, facilitating the inclusion of perspectives from diverse regional contexts that reflect the wide-ranging religious beliefs and cultural practices across China (Tang et al., 2023). To capture a diverse range of experiences, multidimensional sampling was conducted, deliberately including participants with varying religious beliefs, gestational ages, ages and levels of education in this study. After the identification of cases through the hospital information system, the researchers explained the purpose and significance of the study to potential participants over the phone and obtained verbal consent from the participants. Women who agreed to participate were then connected with the researcher through WeChat (a common app that is mostly used as an alternative to phone calls in China), which was used for conducting the interviews and follow-up communication. The method of interviews by telephone, WeChat, or in person was chosen based on participants' preferences. Data saturation was reached after 28 participants were interviewed. A total of 41 potential participants were contacted during the study, and 13 declined due to discomfort about reliving their grief experience. Of the 28 participants, 6 were interviewed via telephone, 17 by WeChat, and 5 were interviewed in person. In-person interviews were conducted with COVID precautions in place. All participants, their family members and the caregivers in the maternity wards were Chinese. They shared the same cultural background, and their experiences and perspectives were mainly shaped by Chinese culture. The inclusion and exclusion criteria were as follows.
招募过程通过医院信息系统进行，包括使用电子病历和由医院员工识别符合条件的参与者。采用分层抽样和最大变异抽样的有目的抽样方法（Benoot 等人，2016 年）。本研究将参与者的祖籍作为抽样的基础。电子病历中包含了他们祖籍城市的详细信息。我们将中国划分为五大区域：东、西、南、北、中。这种划分对于确保地域文化的多样性至关重要，有利于纳入来自不同地区的观点，反映中国各地广泛的宗教信仰和文化习俗（Tang 等，2023 年）。为了捕捉不同的经验，本研究进行了多维度抽样，特意将不同宗教信仰、孕龄、年龄和受教育程度的参与者纳入本研究。通过医院信息系统确定病例后，研究人员通过电话向潜在参与者解释了本研究的目的和意义，并获得了参与者的口头同意。同意参与的妇女随后通过微信（中国人常用的替代电话的应用程序）与研究人员取得联系，并通过微信进行访谈和后续沟通。根据参与者的偏好选择电话、微信或当面访谈的方式。在对 28 名参与者进行访谈后，数据达到饱和。 研究期间共联系了 41 位潜在参与者，其中 13 位因不愿意重述自己的悲伤经历而拒绝接受采访。在 28 名参与者中，6 人通过电话接受了访谈，17 人通过微信接受了访谈，5 人接受了当面访谈。面谈时采取了 COVID 预防措施。所有参与者、其家庭成员和产房护理人员均为中国人。他们具有相同的文化背景，其经历和观点主要受中国文化影响。纳入和排除标准如下。

2.3.1. Inclusion criteria
2.3.1.纳入标准

The inclusion criteria were as follows: primiparous women who were diagnosed as pregnant and gave birth before the past year, with a diagnosis of “stillbirth”, or “intrauterine foetal death”; or women who underwent termination of their pregnancy at the research hospital with a foetal gestational age ≥ 24 weeks; women aged ≥ 20 years, and women who could communicate in spoken and written Mandarin Chinese. The 24-week gestational age limit was chosen because at the study hospital at that time, the youngest infant to survive a premature birth had a gestational age of 24 weeks. Moreover, the stillbirth rate estimates in the data from the China Labour and Delivery Survey were based on a 24-week gestational age (Zhu et al., 2021).
纳入标准如下：过去一年前确诊怀孕并分娩的初产妇，诊断为 "死胎 "或 "胎死宫内"；或在研究医院终止妊娠的妇女，胎龄≥24 周；年龄≥20 岁，能用普通话进行口头和书面交流的妇女。之所以选择 24 周的胎龄限制，是因为在当时的研究医院中，最小的早产儿存活胎龄为 24 周。此外，中国分娩调查数据中的死胎率也是基于 24 周胎龄估算的（Zhu 等人，2021 年）。

2.3.2. Exclusion criteria
2.3.2.排除标准

The study excluded participants who had taken part in or were currently participating in other clinical research or psychological interventions. Additionally, individuals with a history of prior mental illness or a current mental health disorder were excluded. We employed two main pathways to exclude participants with mental health disorder. Initially, when searching the hospital E-system, women with a recorded history of mental disorders were excluded. The second pathway involved self-report. Before the phone interview, the researcher inquired whether candidates had a history of mental health disorders or were currently undergoing mental health treatment. A positive response led to their exclusion.
这项研究排除了曾经或正在参与其他临床研究或心理干预的参与者。此外，曾患精神疾病或目前患有精神疾病的人也被排除在外。我们主要通过两种途径来排除患有精神疾病的参与者。首先，在搜索医院电子系统时，排除有精神障碍病史记录的女性。第二种途径是自我报告。在电话访谈前，研究人员会询问受访者是否有精神疾病史或正在接受精神疾病治疗。如果回答是肯定的，则将其排除在外。

2.4. Ethical approval and consent
2.4.伦理批准和同意

Institutional ethics approval for the study was obtained from Women's Hospital School of Medicine Zhejiang University (Approval number PRO2020-1002) in October 2020. Participants provided their consent in-person or online through WeChat or by telephone prior to the interview. Participants were able to decline to answer any questions and withdraw from the study at any time up to the time of data analysis. All participant-related data were de-identified, encrypted, and kept by the researcher. Only research team members had access to the data.
本研究于 2020 年 10 月获得浙江大学医学院附属女子医院的机构伦理批准（批准号 PRO2020-1002）。参与者在访谈前通过微信或电话当面或在线表示同意。在数据分析之前，参与者可以随时拒绝回答任何问题并退出研究。所有与参与者相关的数据都被去标识化、加密，并由研究人员保存。只有研究小组成员可以访问这些数据。

2.5. Data collection  2.5.数据收集

The data were collected between October 2020 and May 2021. We used a broad question to encourage the participants to describe their experiences: “Could you please share with me how you felt and how you coped with the situation after experiencing a stillbirth?” Subsequent interview questions focused on the influence of culture and spirituality on mothers' grief. A semi-structured interview guide (Price, 2002) was developed to explore the influence of culture and spirituality on the bereaved mothers after stillbirth in China. A sample item of the interview guide was, “Could you describe how any cultural or spiritual beliefs may have influenced your experience with stillbirth and grief?” Examples of probes to further explore this question were included: Could you describe any rituals or customs related to stillbirth and grief in your culture or religion? Have you sought support or guidance from any cultural or spiritual resources in your grieving process? Can you explain more about any challenges or conflicts you have experienced related to your cultural or spiritual beliefs? The interview guide questions related to cultural and spiritual influences on grief were drawn from studies conducted by our research team and the literature. Participants were encouraged to fully and openly share their experiences without interruptions, and the interviewer created a safe, open and comfortable environment for sharing (Fraser, 2004). Demographic data were collected before the interviews. Thirty-three interviews were conducted with the 28 participants. The interview methods and the locations of the in-person interviews were determined by the participants. We conducted one supplementary interview with each of the five participants, all of whom opted for interviews via WeChat. The purpose of these supplementary interviews was to uncover previously undiscovered information and to confirm themes. For instance, in the interviews, one mother expressed reluctance to discuss her experiences during postpartum confinement, emphasising that she prioritised the feelings of her family and friends over her own grief. During the previous interviews, there were two other mothers echoed similar sentiments. Initially, we attributed their hesitancy sharing to passive cultural suppression. However, our sensitivity to thematic patterns led us to identify a distinct theme: ‘the Others-oriented self’. Subsequently, we conducted supplementary interviews with these two mothers. The insights gleaned from these interviews deepened our understanding of their behaviours and cultural influences, providing additional support the theme of ‘the Others-oriented self’.
数据收集时间为 2020 年 10 月至 2021 年 5 月。我们使用了一个宽泛的问题来鼓励参与者描述他们的经历："能否请您与我分享一下您在经历死产后的感受以及您是如何应对这种情况的？随后的访谈问题侧重于文化和精神对母亲悲伤的影响。为了探究文化和灵性对中国死胎母亲的影响，我们制定了一个半结构化访谈指南（Price，2002 年）。访谈指南的一个样本项目是："您能否描述一下文化或精神信仰是如何影响您的死产和悲伤经历的？为进一步探究这一问题，访谈指南中还包括了一些探究示例：您能否描述在您的文化或宗教中与死产和悲伤有关的任何仪式或习俗？在您的悲伤过程中，您是否寻求过任何文化或精神资源的支持或指导？您能否进一步解释您在文化或精神信仰方面遇到的任何挑战或冲突？与文化和精神对悲伤的影响有关的访谈指南问题来自我们研究团队进行的研究和文献。我们鼓励参与者在不受干扰的情况下充分、坦诚地分享他们的经历，访谈者为他们创造了一个安全、开放和舒适的分享环境（Fraser, 2004）。访谈前收集了人口统计学数据。对 28 名参与者进行了 33 次访谈。访谈方法和面谈地点由参与者决定。我们对五名参与者各进行了一次补充访谈，他们都选择了通过微信进行访谈。 这些补充访谈的目的是发掘以前未被发现的信息并确认主题。例如，在访谈中，一位母亲表示不愿意讨论她在产后分娩期间的经历，强调她优先考虑家人和朋友的感受，而不是自己的悲伤。在之前的访谈中，也有两位母亲表达了类似的观点。起初，我们将她们不愿分享的原因归结为被动的文化压制。然而，我们对主题模式的敏感性使我们发现了一个独特的主题："面向他人的自我"。随后，我们对这两位母亲进行了补充访谈。从这些访谈中获得的启示加深了我们对她们的行为和文化影响的理解，为 "面向他人的自我 "这一主题提供了更多支持。
The interviews were audio recorded and lasted between 24 and 193 min, with a mean of 66 min. The recordings were transcribed verbatim into a Word document as soon as possible by iFLYTEK digital translation software. Pauses, voice and tone, special emotional performance, and special body language were noted in the transcript by the interviewer. Two researchers replayed the recordings for verification and reviewed the transcriptions. The demographic information of the interviewees was entered into a standardised datasheet and sorted in Excel 2003.
访谈进行了录音，持续时间从 24 分钟到 193 分钟不等，平均为 66 分钟。录音由 iFLYTEK 数字翻译软件尽快逐字转录到 Word 文档中。访谈者在笔录中注明了停顿、语音和语调、特殊情绪表现和特殊肢体语言。两名研究人员重放录音进行核实，并审阅记录稿。受访者的人口统计学信息被输入标准数据表，并在 Excel 2003 中进行分类。

2.6. Data analysis  2.6.数据分析

The data were analysed through thematic analysis (Braun and Clarke, 2012) assisted by NVivo 12.0 software. The researchers reread the transcripts line by line, taking note of their initial thoughts. The initial codes were generated by grouping notes about commonalities found in the transcripts. Meaningful thoughts were classified and encoded. Associated themes were extracted. The extracted data were grouped according to overall themes using the collected codes for interpretive analysis. The identified themes were reviewed, analysed, and refined, and some themes with significant similarities were merged. These codes were reviewed and classified into subthemes according to similarities, differences, relationships, and patterns. The characteristics of each theme were improved by reanalysing a subset of representative themes (Saldaña, 2021).
在 NVivo 12.0 软件的辅助下，通过主题分析法（Braun 和 Clarke，2012 年）对数据进行了分析。研究人员逐行重读记录誊本，记下他们最初的想法。最初的代码是通过对记录誊本中发现的共同点进行分组而产生的。对有意义的想法进行了分类和编码。提取相关主题。根据总体主题对提取的数据进行分组，使用收集到的代码进行解释性分析。对确定的主题进行审查、分析和完善，并将一些具有显著相似性的主题合并。根据相似性、差异性、关系和模式，对这些代码进行审查并将其归类为次主题。通过重新分析具有代表性的主题子集，改进了每个主题的特征（Saldaña，2021 年）。

3. Findings  3.研究结果

3.1. Participant demographics
3.1.参与者人口统计

Twenty-eight participants were interviewed from 16 ancestral cities across eight provinces. Twelve were from six cities in the East region, seven were from four cities in the South region, four were from two cities in the West region, three are from two cities in the North region, and two are from two cities in the Central region. Twelve stillbirths occurred during the first wave of the COVID-19 pandemic, which lasted from January to May 2020. During this period, there were no COVID-19 cases in the research city, and there was no special isolation policy for the maternity wards in the hospital. In this study, none of the mothers reported that COVID-19 magnified their grief reactions. Table 1 shows the demographic and loss-related characteristics.
来自八个省份 16 个祖籍城市的 28 名参与者接受了访谈。其中 12 人来自东部地区的 6 个城市，7 人来自南部地区的 4 个城市，4 人来自西部地区的 2 个城市，3 人来自北部地区的 2 个城市，2 人来自中部地区的 2 个城市。在 2020 年 1 月至 5 月 COVID-19 大流行的第一波期间，有 12 例死胎。在此期间，研究城市没有出现 COVID-19 病例，医院的产房也没有特殊的隔离政策。在本研究中，没有一位母亲表示 COVID-19 加剧了她们的悲伤反应。表 1 显示了人口统计学特征和与损失相关的特征。

Table 1. Demographic and loss-related characteristics (n = 28).
表 1.人口统计学特征和损失相关特征（n = 28）。

Demographic characteristics
人口特征		Parameters  参数
n (valid%) or mean ± SD  n（有效百分比）或平均值 ± SD
Age, years, mean ± SD  年龄（岁），平均值 ± SD32.96 ± 4.97  32.96 ± 4.97
Educational level  教育水平
 Secondary school  中学4 (11.2)
 Junior college  大专8 (28.6)
 Undergraduate  本科生11 (39.3)
 Postgraduate or above  研究生或以上5 (17.9)
Marital status  婚姻状况
 Single  单人0
 Married  已婚28 (100)
 Separated, divorced, or widowed
分居、离婚或丧偶		0
Religious affiliation  宗教信仰
 Buddhism  佛教5 (17.9)
 Catholicism  天主教1 (3.6)
 Christianity  基督教1 (3.6)
 Other religion  其他宗教0
 No religion  无宗教信仰21 (75.0)
Gestational age (weeks)  胎龄（周）
 24–27  24-275 (17.9)
 28–31  28-3112 (42.9)
 32–36  32-367 (25.0)
 37 +4 (11.2)
Intended pregnancy  计划怀孕
 Yes  是21 (75.0)
 No  没有7 (25.0)
Previous bereavement experience
有过丧亲经历
 Yes  是6 (21.4)
 No  没有22 (78.6)
Subsequent pregnancies  后续怀孕
 Yes  是5 (17.86)
 No  没有23 (82.14)

3.2. Thematic analysis  3.2.专题分析

The themes extracted during the analysis are outlined in Fig. 1. Three major themes were identified: 1) the influence of culture on grief expression, 2) the cultural characteristics of the post-stillbirth experience, and 3) finding significance in spiritual healing processes.
图 1 列出了分析过程中提取的主题。确定了三大主题：1) 文化对悲伤表达的影响；2) 死产后经历的文化特征；3) 在精神治疗过程中寻找意义。
Fig. 1
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Fig. 1. The influence of culture and spirituality on maternal grief following stillbirth in China.
图 1.中国死产后文化和精神对产妇悲痛的影响。

3.2.1. The influence of culture on grief expression
3.2.1.文化对悲伤表达的影响

3.2.1.1. Restrained expressions of grief
3.2.1.1.克制地表达悲伤
The participants indicated that they were pressured by family members to accept the belief that expressions of grief could be harmful to their lost babies, their families, or even themselves. These individuals stated that their families invoked taboo customs as a justification to dissuade them from openly expressing their thoughts and emotions.
参与者表示，他们受到家人的压力，不得不接受这样的观点，即表达悲伤可能会对他们失去的婴儿、家人甚至自己造成伤害。这些人表示，他们的家人以禁忌习俗为理由，劝阻他们不要公开表达自己的想法和情感。
“… I couldn't help crying all the time. My mother-in-law said it was not good to cry all day, that this would keep the baby's soul attached and make it difficult to be reincarnated to the next life.”
"......我忍不住一直哭。婆婆说，整天哭不好，会让孩子的灵魂留恋，难以投胎转世"。
(M10, no religion)  (M10，无宗教信仰）
Some participants reported that upon returning home from the hospital, family members purposefully refrained from discussing the stillbirth. Their husbands and other relatives avoided addressing the loss and behaved as though it had never occurred. This lack of acknowledgement deprived them of the chance to express their grief, forced them to hide their emotions in the presence of their families and restricted their expressions of grief.
一些参与者报告说，从医院回家后，家人故意不谈论死产。她们的丈夫和其他亲属避免谈及丧子之痛，表现得就像这一切从未发生过一样。这种不承认的态度剥夺了她们表达悲伤的机会，迫使她们在家人面前隐藏自己的情绪，并限制了她们对悲伤的表达。
“After I was discharged from the hospital and returned home, my husband didn't mention the loss, like it had never happened. I didn't dare to talk about it.”
"我出院回家后，丈夫对我的丧子之痛绝口不提，就像从来没有发生过一样。我不敢谈起这件事"。
(M1, no religion)  (M1，无宗教信仰）
3.2.1.2. Unattainable mourning ceremony
3.2.1.2.无法实现的哀悼仪式
Almost all participants expressed uncertainty about how to handle their babies' remains and were perplexed about the appropriateness of arranging a funeral for a stillborn baby. In Chinese culture, the issue of conducting a funeral ceremony for a deceased baby has seldom been addressed, and if planned, there are few traditional social and religious customs to follow. Participants who shared this experience described it as tragic and emotionally devastating for a family when a young person passed away before an older relative, let alone the death of a stillborn baby. To avoid cultural taboos, they could only leave the baby's body at the hospital.
几乎所有参与者都对如何处理婴儿遗体表示不确定，并对为死产婴儿安排葬礼是否合适感到困惑。在中国文化中，为已故婴儿举行葬礼的问题很少被提及，即使计划举行葬礼，也很少有传统的社会和宗教习俗可循。分享了这一经历的参与者描述说，如果一个年轻人先于年长的亲属去世，这对一个家庭来说是悲惨的，在情感上是毁灭性的，更不用说死产婴儿的死亡了。为了避免文化禁忌，他们只能将婴儿的遗体留在医院。
“You can't have a funeral. It seems to be a bit taboo. People say it's taboo to have a funeral for children who weren't even born and that the family would encounter bad luck if they did so.”
"你不能举行葬礼。好像有点忌讳。人们说，为还没出生的孩子举行葬礼是禁忌，如果这样做，家人会遭遇厄运。"
(M10, no religion)  (M10，无宗教信仰）
“We couldn't hold a funeral for the baby. [As the saying goes], ‘Grey hair should not send black hair away.’ [If it happened], this is not allowed [have a funeral for babies], right?”
"我们不能为孩子举行葬礼。[俗话说'白发人送黑发人'。[如果发生了]，这是不允许的[为婴儿举行葬礼]，对吗？
(M29, Buddhism)  (M29，佛教)
In this study, only two participants reported asking the hospital staff if they could bring their stillborn babies home, and neither of them actually took the baby's body out of the hospital. The participants indicated that they were instructed that the baby's body would be left at the hospital for disposal. Although there are no explicit rules against taking deceased newborns home for burial, none of the mothers in this study opted to do so. These findings indicate that the recommended practice in Western bereavement care guidelines, which encourage a funeral as a method of post-stillbirth healing, did not seem to be feasible for Chinese mothers.
在本研究中，只有两名参与者询问医院工作人员是否可以将死产婴儿带回家，而这两名参与者都没有将婴儿尸体带出医院。参与者表示，他们得到的指示是将婴儿尸体留在医院处理。虽然没有明文规定禁止将死亡的新生儿带回家安葬，但本研究中没有一位母亲选择这样做。这些结果表明，西方丧亲护理指南中建议的做法，即鼓励将葬礼作为死产后康复的一种方法，对中国母亲来说似乎并不可行。
“I asked the midwives and they said my baby would be put in the freezer and then the hospital would dispose of it according to protocol.”
"我问了助产士，她们说我的孩子会被放进冰柜，然后医院会按照协议处理掉"。
(M3, Catholicism)  (M3，天主教）
“I never thought of holding a funeral. The hospital wouldn't let us take the baby home.”
"我从没想过要举行葬礼医院不让我们把孩子带回家"
(M27, no religion)  (M27，无宗教信仰）
3.2.1.3. Hospital policy as a barrier
3.2.1.3.医院政策是一个障碍
All of the respondents expressed dissatisfaction with the hospital's lack of a policy on the provision of individual rooms or designated areas for women following foetal demise. All participants were accommodated in shared rooms with mothers who had live infants rather than being housed in individual rooms within the maternity ward. Some women were placed in a delivery room alongside other mothers during labour, and the cries of the newborns occasionally reminded them of their own losses. The participants found that they struggled to articulate their sorrow or talk about their loss whilst sharing a room with elated women who were commemorating their deliveries. This became a barrier to the expression of grief following stillbirth.
所有受访者都对医院缺乏为胎儿夭折后的产妇提供单独房间或指定区域的政策表示不满。所有受访者都被安置在与有活产儿的母亲共用的房间，而不是产科病房内的单独房间。一些产妇在分娩时被安置在产房，与其他产妇住在一起，新生儿的哭声偶尔会让她们想起自己的损失。参与者发现，当她们与那些为自己的分娩而欢欣鼓舞的妇女同处一室时，她们很难表达自己的悲伤或谈论自己的损失。这成为死产后表达悲伤的障碍。
“I was placed in a ward with a mother who had given birth. There was a newborn baby in the bed right next to mine…I felt that I was so useless.”
"我被安排在一间病房，和一位产妇住在一起。我的病床旁边就躺着一个新生儿......我觉得自己太没用了。
(M1, no religion)  (M1，无宗教信仰）
“I wanted to move [to another room], but there was no special room for [mothers of stillborn babies] on the ward”
"我想搬到另一间病房，但病房里没有专门的[死产婴儿母亲]房间"。
(M24, no religion)  (M24，无宗教信仰）
3.2.1.4. Others-oriented self
3.2.1.4.面向他人的自我
Some participants stated that they were more concerned about the emotions of their husbands and family members than about their own. They feared that expressing their grief would cause discomfort to others, generate an unnecessary emotional load, and cultivate negative feelings. They preferred to conceal their emotions and pretend that the loss did not impact them significantly or that they had already overcome it. This phenomenon is referred to as the “others-oriented self,” sometimes known as a relational orientation or social orientation (Ho, 1995). Chinese culture prioritises the emotions and sentiments of individuals in their surroundings more than other cultures (Yang, 1995).
一些参与者表示，与自己的情绪相比，她们更关心丈夫和家人的情绪。他们担心表达自己的悲伤会给他人带来不适，造成不必要的情绪负担，并滋生负面情绪。她们宁愿隐藏自己的情绪，假装失去亲人对自己的影响不大，或者假装自己已经克服了失去亲人的痛苦。这种现象被称为 "他人导向的自我"，有时也被称为关系导向或社会导向（Ho，1995）。与其他文化相比，中国文化更重视周围人的情绪和情感（Yang，1995）。
“I always thought about my mother—how she worked so hard to take care of me and did not get a good result in the end. I have to be careful when I am sad. …I feel I must do better for my mother and my family.”
"我总是想起我的母亲--她是如何辛辛苦苦地照顾我，最终却没有得到一个好结果。当我伤心时，我必须小心翼翼。......我觉得我必须为母亲和家人做得更好"。
(M10, no religion)  (M10，无宗教信仰）
“I don't dare to cry in front of [relatives who come to visit]. Their families are doing fine. Showing such emotions would definitely upset them… I should restrain myself.”
"我不敢在 [前来探望的亲戚] 面前哭泣。他们的家人都很好。表现出这种情绪肯定会让他们难过......我应该克制自己。
(M17, Buddhism)  (M17, 佛教)

3.2.2. Cultural characteristics of the post-stillbirth experience
3.2.2.死产后经历的文化特点

3.2.2.1. Paternalistic medical culture
3.2.2.1.家长式医疗文化
The findings of this study revealed that healthcare professionals impose paternalistic decision-making on women following a stillbirth that coexisted with the passive decision-making of these women. The participants noted that healthcare professionals informed them about what was deemed appropriate without actively involving them in the decision-making process, as if the decisions were best for them. The respondents noted, for instance, that they were not asked if they wanted to see or hold their baby. Furthermore, the recognised authority of the medical staff led them to believe that these recommended decisions were the most suitable options. Consequently, they silently accepted these decisions and refrained from questioning or objecting to them.
本研究的结果表明，医护人员对死产妇女实施家长式决策，与这些妇女的被动决策并存。受访者指出，医护人员向她们告知了被认为适当的决策，却没有让她们主动参与决策过程，似乎这些决策对她们来说是最好的。例如，受访者指出，她们没有被问及是否想看看或抱抱自己的孩子。此外，医务人员公认的权威使他们相信这些建议的决定是最合适的选择。因此，他们默默地接受了这些决定，没有提出质疑或反对。
“The doctor said it would be better for me not to see [the baby].”
"医生说最好不要让我看到 [孩子]"。
(M1, no religion)  (M1，无宗教信仰）
“The midwife said don't look. There is nothing for you to see. It will only cause more grief and trauma. After saying that, they took the baby away.”
"助产士说不要看。没什么好看的。这只会给你带来更多的悲伤和创伤。说完，他们就把孩子抱走了"。
(M16, no religion)  (M16，无宗教信仰）
Some women lacked awareness of proactive involvement in medical decision-making. They acquiesced to the advice provided by the healthcare practitioners. They stated that they were unaware of the possibility of requesting to see their baby, holding their baby, taking photos or keeping a memento. The participants demonstrated a limited understanding of the aforementioned alternatives. The culture of medical authority consistently reinforced the belief that they should listen to and follow all hospital rules. They assumed that the hospital would have standardised procedures, and their understanding was that following the established process was sufficient.
一些妇女缺乏主动参与医疗决策的意识。她们默认了医护人员的建议。她们表示不知道可以要求看自己的孩子、抱孩子、拍照或留念。参与者对上述替代方案的理解十分有限。医疗权威文化不断强化他们的信念，即他们应该听从并遵守医院的所有规定。他们认为，医院会有标准化的程序，他们的理解是，遵循既定的程序就足够了。
“Could I ask the nurse to take a picture of her and ask for a footprint? I didn't know I could make such a request. No one talked about that. It never even occurred to us…”
"我能让护士给她拍张照片，然后要一个脚印吗？我不知道可以提出这样的要求。没人说过这个。我们甚至从来没有想过......"
(M3, Catholicism)  (M3，天主教）
3.2.2.2. Kong yuezi – empty postpartum confinement
3.2.2.2.孔悦子--产后空腹分娩
In this study, some mothers utilised the terms “kong” and “kong yuezi” to characterise the period following the loss of a baby. In traditional Chinese culture, there is a customary postpartum confinement and recovery phase known as “to sit the month” (Chinese pronunciation: zuo yuezi), during which newly delivered mothers are expected to remain at home for a duration of 30–42 days. The character “kong,” which translates to “empty” in Chinese, represents not only the loss of an infant but also the severed connection between the mother and her child. It encapsulates the emptiness, desolation, isolation, and absence of support that the women felt. Some women reported instances of inadequate suppression of lactation. They said that when milk secretion began, they experienced intense emotional despair. Their full breasts and leaking milk reminded them that they should be nurturing a newborn, yet their postpartum confinement period was “empty.” Without a baby to feed, their milk became purposeless, leaving them with a sense of helplessness.
在本研究中，一些母亲用 "坐月子 "和 "坐月子 "来形容失去婴儿后的阶段。在中国传统文化中，产后有一个称为 "坐月子 "的习惯性产后恢复阶段。空 "字在汉语中译为 "空虚"，不仅代表失去婴儿，也代表母亲与孩子之间的联系被切断。它概括了妇女所感受到的空虚、荒凉、孤立和缺乏支持。一些妇女报告了抑制泌乳不足的情况。她们说，当乳汁开始分泌时，她们经历了强烈的情感绝望。丰满的乳房和渗出的乳汁提醒她们本应哺育一个新生儿，但产后的产褥期却是 "空虚 "的。没有婴儿喂养，她们的乳汁变得毫无目的，让她们感到无助。
“I thought about how other babies were drinking milk in their mothers' arms at this time, but my arms were empty. Some mothers worry about not having enough milk to feed their babies. Now I had milk, but no baby to feed. As soon as I thought of this, I completely broke down and cried.”
"我想到其他婴儿此时都在母亲怀里喝奶，而我的怀里却空空如也。有些母亲担心没有足够的奶水喂养婴儿。现在我有奶水，却没有孩子可以喂。一想到这些，我就彻底崩溃了，哭了起来"。
(M8, no religion)  (M8，无宗教信仰）
Some participants noted that the conventional postpartum confinement protocol was designed for mothers who had delivered a living infant, implying that the traditional confinement rules were not applicable to postpartum mothers without a living child. For these individuals, the experience of “kong yuezi”, or being passive in participating in traditional postpartum practices, intensified their grief and magnified their sentiments regarding their deceased babies.
一些与会者指出，传统的产后分娩规程是为分娩过活婴的母亲设计的，这意味着传统的分娩规则不适用于没有活婴的产后母亲。对这些人来说，"坐月子 "的经历，或被动参与传统产后习俗的经历，加剧了她们的悲痛，放大了她们对逝去婴儿的情感。
“I was not allowed to open the curtain or turn on the light [during the postpartum confinement]. The room was so dark. It was the same as my mood at that time. I captioned the post ‘kong yuezi’.”
"[产后禁闭期间]不允许我拉开窗帘或开灯。房间里一片漆黑。这和我当时的心情一样。我给帖子配了标题'孔悦子'"。
(M8, no religion)  (M8，无宗教信仰）
“I couldn't sleep when I thought about it. I missed my baby so much, especially at night. Kong yuezi are really hard to get through.”
"我一想到这件事就睡不着觉。我非常想念我的孩子，尤其是在晚上。孔悦子真的很难熬过去"
(M21, no religion)  (M21，无宗教信仰）
3.2.2.3. Embarrassment at postpartum visits
3.2.2.3.产后就诊时的尴尬
According to Chinese etiquette and customs, it is customary for relatives and friends to visit patients or mothers who have been recently discharged from the hospital. This social etiquette is known as the Chinese “human relationship” (Fang, 2016), and it is an important concept in traditional Chinese society. Most of the participants indicated that during their postpartum confinement they were visited frequently, and they were required to accept these embarrassing postpartum visits. Mothers reported that they often found themselves in uncomfortable and challenging situations, especially when they had to share their stillbirth experiences, which they perceived as embarrassing. Some mothers preferred to maintain greater privacy during this difficult time, viewing external visits as an intrusion into their personal space. The cultural norms dictating postpartum visits clashed with their emotional needs. The participants commonly viewed visits during the confinement period as a psychological burden. The prospect of these visits triggering painful memories of loss and grief added another layer of complexity. Some mothers chose to decline or reject postpartum visits to avoid unwillingly sharing their experiences and prevent the resurgence of unpleasant memories. These feelings differed from those of mothers who desired expression but felt constrained by societal expectations.
根据中国的礼仪和习俗，亲戚朋友有探望刚出院的病人或母亲的习惯。这种社交礼仪被称为中国的 "人情往来"（Fang，2016），是中国传统社会的一个重要概念。大多数参与者表示，在产后住院期间，她们经常被探视，而且她们必须接受这些令人尴尬的产后探视。母亲们表示，她们经常发现自己处于不舒服和具有挑战性的境地，尤其是当她们不得不分享自己的死产经历时，她们认为这很尴尬。一些母亲更希望在这一困难时期保持更大的隐私，认为外部探访是对其个人空间的侵犯。产后探视的文化规范与她们的情感需求相冲突。参与者普遍认为产褥期探访是一种心理负担。产后探访可能会引发她们对失去亲人的痛苦回忆，这又增加了一层复杂性。一些母亲选择了拒绝或排斥产后探访，以避免不情愿地分享自己的经历，并防止不愉快的回忆再次出现。这些感受与那些渴望表达但又觉得受到社会期望限制的母亲的感受不同。
“Some of my relatives came to visit me as they would normally visit a mother in postpartum recovery. I didn't want them to come and visit me. I didn't know what to do, what to say, whether to cry or to hold it in… To be honest, I didn't want to listen to their reassurances. I didn't want to say anything. I didn't want to see them at all.”
"我的一些亲戚来探望我，因为他们通常会探望产后恢复中的母亲。我不想让他们来看我。我不知道该怎么办，该说什么，是哭还是忍着......说实话，我不想听他们的安慰。我什么也不想说。我根本不想见他们"
(M8, no religion)  (M8，无宗教信仰）
“It was actually awkward for them to visit me because the visit was supposed to be to welcome a newborn baby. We didn't know how to face it or what to say to each other.”
"他们来探望我其实很尴尬，因为这次探望本来是为了迎接新生儿的到来。我们不知道该如何面对，也不知道该说些什么"。
(M25, no religion)  (M25，无宗教信仰）
3.2.2.4. Cultural taboos on dealing with deceased babies' possessions
3.2.2.4.处理婴儿遗物的文化禁忌
The participants and some family members perceived the garments and other items procured for their stillborn infants as objects bearing ill fortune. The majority of mothers did not keep items belonging to their deceased children as mementos. Some mothers reported that having these items would serve as a constant reminder of the unfortunate event, making it challenging to move on and start anew. They expressed a strong desire to quickly let go of the past and initiate a new chapter in their lives. Some mothers mentioned that keeping the child's belongings might create a tether, potentially affecting the child's spiritual journey to the afterlife.
参与者和一些家庭成员认为，为死产婴儿购买的服装和其他物品是不吉利的物品。大多数母亲都没有保留夭折子女的物品作为纪念。一些母亲表示，保留这些物品会让人不断想起那件不幸的事，使她们难以继续生活并重新开始。她们表达了一种强烈的愿望，那就是尽快忘掉过去，开启生活的新篇章。一些母亲提到，保留孩子的物品可能会造成一种束缚，可能会影响孩子来世的精神之旅。
“I was afraid it would be unlucky. So my husband threw them away.”
"我怕会不吉利。所以我丈夫就把它们扔了
(M26, no religion)  (M26，无宗教信仰）
Some mothers expressed reluctance to give away their babies' possessions. In Chinese culture, it is customary for a mother who has successfully conceived and given birth to present something that she used during her pregnancy to another woman who is planning to become pregnant as a kind of good-luck charm. However, for some mothers in this study, the opposite situation occurred. After experiencing a stillbirth, they were afraid that giving the belongings prepared for the baby to other expectant mothers might bring their misfortune to others. Some participants reported that to avoid passing on bad luck, they chose to dispose of or burn the clothing and supplies purchased for their stillborn babies instead of giving them away to friends or family or donating them.
有些母亲表示不愿意把婴儿的物品送给别人。在中国文化中，按照习俗，成功怀孕并分娩的母亲会将自己在怀孕期间使用过的东西送给另一位准备怀孕的妇女，作为一种吉祥物。然而，本研究中的一些母亲却遇到了相反的情况。在经历了死胎之后，她们害怕把为婴儿准备的物品送给其他准妈妈，可能会把自己的不幸带给别人。一些参与者表示，为了避免将厄运传递给他人，她们选择将为死产婴儿购买的衣物和用品处理掉或烧掉，而不是送给亲朋好友或捐献出去。
“I gave some baby clothes to my friend, but later I found that she left them under the cabinet in front of my door and didn't take them away. I think that she might have been afraid of bad luck.”
"我把一些婴儿衣服送给了我的朋友，但后来我发现她把衣服放在了我家门口的柜子下面，并没有拿走。我想，她可能是怕倒霉吧。"
(M11, no religion)  (M11，无宗教信仰）

3.2.3. Finding significance in the spiritual healing process
3.2.3.在精神康复过程中寻找意义

The respondents reported engaging in diverse self-healing activities related to cultural and spiritual significance. These activities included contemplating philosophical perspectives on life through movies, reading spiritual literature, praying, making offerings, practising sutra calligraphy, chanting scriptures for babies, and lighting temple lamps. Additionally, this study found that although the majority of participants were atheists, their spiritual consciousness was aroused both by their own volition and by the influence of individuals with religious backgrounds in their social circle. This made it possible for participants to adopt spiritual healing practices irrespective of their religious orientation. Some participants noted that aspects of spiritual or religious practices were helpful in providing a sense of purpose after loss, facilitating enhanced acceptance of the loss, expediting recovery from grief, fostering personal growth, and reshaping their understanding of life and death.
受访者表示，他们参与了各种与文化和精神意义相关的自我疗愈活动。这些活动包括通过电影思考人生哲理、阅读精神文献、祈祷、供奉、练习经文书法、为婴儿诵经和点燃寺庙灯火。此外，本研究还发现，虽然大多数参与者都是无神论者，但他们的灵性意识是在自己的意愿和社交圈中具有宗教背景的人的影响下被唤醒的。这使得参与者无论其宗教取向如何，都有可能采用灵性疗法。一些参与者指出，精神或宗教实践的某些方面有助于在失去亲人后提供一种目标感，促进对失去亲人的进一步接受，加快从悲伤中恢复，促进个人成长，以及重塑他们对生命和死亡的理解。
3.2.3.1. Seeking the meaning in the event
3.2.3.1.在事件中寻求意义
The bereaved women expressed an inability to cease contemplating the event, and their minds persistently revisited the experienced loss. Striving to comprehend the situation, they embarked on a process of reflection, endeavouring to construct meaning and significance of the event. During this process, spiritual behaviours were recognised as a significant medium of attribution in their quest for answers. They thought that spirituality might offer the ultimate solution to questions about their loss, especially when answers were not found through other avenues.
失去亲人的妇女表示无法停止对这一事件的思考，她们的脑海中不断重现所经历的失 落。为了理解这种情况，她们开始了反思过程，努力构建事件的意义和重要性。在这一过程中，精神行为被认为是他们寻求答案的重要媒介。他们认为，尤其是在通过其他途径无法找到答案的情况下，灵性可能会为他们失去亲人的问题提供最终的解决方案。
“I've been trying to find out what the meaning and significance of this loss are. I thought maybe if I put it in the context of this [spiritual] path I would be able to explain it… Then, if I gave it meaning, I might reach some kind of closure from this loss. Actually, I wanted to give it a certain meaning.”
"我一直在试图找出这次损失的意义和重要性。我想，如果我把它放在这条[精神]道路的背景下，也许我就能解释它......那么，如果我赋予它意义，我也许就能从这次损失中得到某种了结。事实上，我想赋予它某种意义"。
(M2, no religion)  (M2，无宗教信仰）
“I think both [philosophy and religion] worked for me. …Whether through philosophy or science…Whatever kind of basic criteria or guidelines I use, I can extract what I think is reasonable from philosophy or religion, and it can explain everything I have experienced and define it [stillbirth] according to my own interpretation.”
"我认为[哲学和宗教]对我都有用。......无论是通过哲学还是科学......无论我使用什么样的基本标准或准则，我都可以从哲学或宗教中提取我认为合理的东西，它可以解释我所经历的一切，并根据我自己的解释来定义它[死产]。"
(M25, no religion)  (M25，无宗教信仰）
3.2.3.2. Accepting and reconciling the loss
3.2.3.2.接受和调节损失
The bereaved mothers in this study reported feeling unable to accept the sudden loss of their babies within such a short period. Spirituality played a crucial role in facilitating the acceptance of the loss. The participants mostly attributed the stillbirth to their own actions, leading to feelings of guilt and a sense of responsibility for the unfortunate event. For instance, some of them stated that their poor lifestyle habits or behaviours directly or indirectly caused the stillbirth or that they had neglected to heed certain warning signs and missed an opportunity to save the baby. To cope with these emotions of guilt and responsibility, they embraced spiritual behaviours as a means to absolve themselves of culpability and initiated positive actions leading towards a better outcome.
在这项研究中，失去亲人的母亲表示无法接受在如此短的时间内突然失去婴儿的事实。灵性在促进接受丧子之痛方面发挥了至关重要的作用。参与者大多将死产归咎于自己的行为，从而产生了内疚感和对这一不幸事件的责任感。例如，其中一些人表示是自己不良的生活习惯或行为直接或间接导致了死产，或者是自己忽视了某些警示信号，错过了挽救婴儿的机会。为了应对这些内疚和责任情绪，她们采用精神行为作为免除罪责的手段，并开始采取积极行动，以实现更好的结果。
“I went to the temple to light a lamp for my baby…But my baby did not have a name. I thought of a name and wrote it [on the lamp]. It was like I had accepted that there was a real baby that existed. I felt more at peace…I prayed that day that she would be reincarnated and go to a good home. I felt relief immediately.”
"我去寺庙为我的孩子点灯......但我的孩子没有名字。我想了一个名字，并把它写在（灯上）。就好像我接受了一个真实存在的宝宝。我感到更加平静了......那天我祈祷她能转世投胎，去一个好的家庭。我立刻感到了解脱"。
(M11, no religion)  (M11，无宗教信仰）
“My friend told me that chanting would help it reincarnate, so I did then. I feel better.”
"我的朋友告诉我，诵经可以帮助它转世，所以我就诵经了。我感觉好多了。"
(M16, no religion)
Some of them attributed the cause to fate because, in the Chinese spiritual context, fate is preset by god; it is irreversible and cannot be prevented. In addition, the women used another approach that adopted spiritual narratives, such as reincarnation, which provided them with the hope that their babies would return to this world and be reborn into a better family. By doing so, they found that they could forgive themselves and find psychological comfort, acceptance, and reconciliation in the loss.
她们中的一些人将原因归结为命运，因为在中国人的精神世界中，命运是由神预设的，是不可逆的，也是无法阻止的。此外，妇女们还采用了另一种方法，即采用轮回等精神叙事，为她们提供了希望，即她们的孩子会回到这个世界，投胎到一个更好的家庭。通过这样做，她们发现自己可以原谅自己，并在失去孩子的痛苦中找到心理安慰、接受和和解。
“That [stillbirth] was her fate, right? And our fate, too. It was called no ‘Yuan Fen’ (destiny) between her and me. Sometimes I wonder why the baby was gone, just like that, gone. …We are particularly powerless in front of life and death. … What is serious, ah, nothing but only life and death is a big deal.”
"死产是她的命运，对吗？也是我们的命运。我和她之间没有'缘分'。有时候我在想，为什么孩子就这样没了，就这样没了。......在生死面前，我们特别无力。......什么是大事，啊，什么都不是，只有生死是大事"。
(M8, no religion)  (M8，无宗教信仰）
3.2.3.3. Reshaping beliefs and views about life and death
3.2.3.3.重塑关于生与死的信念和观点
The participants indicated that their experiences with stillbirth challenged their previous understanding and beliefs about death. The loss of a stillborn child was inconsistent with their original worldview. Experiencing a stillbirth prompted them to reflect on life and death and consider the possibility that their worldview might be incorrect. Some participants reported that the occurrence of loss unsettled their religious and spiritual beliefs, altered their attitudes and behaviours in daily life, and reshaped their perspectives on life and death. This phenomenon was particularly apparent amongst participants with no prior bereavement experience.
参与者表示，死产的经历挑战了他们以往对死亡的理解和信念。失去死产婴儿与他们原有的世界观不一致。死产的经历促使他们反思生与死，并考虑到他们的世界观可能是不正确的。一些参与者报告说，丧子事件扰乱了他们的宗教和精神信仰，改变了他们在日常生活中的态度和行为，重塑了他们的生死观。这种现象在没有丧亲经历的参与者中尤为明显。
“My answer is that [my views on life and death] must be very different. Before, I had never considered whether there is reincarnation. I thought it was ridiculous. I didn't believe in ghosts or gods. But to tell the truth, now, I hope there is. When I put the baby's photo there [on the desk], I hope reincarnation exists.”
"我的回答是，[我对生死的看法]肯定大不相同。以前，我从未考虑过是否存在轮回。我觉得这很荒谬。我不相信鬼神。但说实话，现在我希望真的有。当我把孩子的照片放在那里（桌子上）时，我希望轮回是存在的"。
(M23, no religion)  (M23，无宗教信仰）
The influence of loss events on prior beliefs either strengthened or weakened religious and spiritual beliefs. Some participants reported that they were atheists, but after experiencing a stillbirth, they embraced religiosity. They became religious and started to practice good deeds to accumulate merit and virtue for favourable outcomes in the future. By immersing themselves in philosophical and religious literature, exploring concepts of life and death, and finding solace through spiritual activities, they demonstrated that stillbirth could fortify spiritual and religious convictions. Conversely, some participants who were previously devout became sceptical after experiencing loss. They described feeling betrayed after engaging in faith-related activities, such as praying for a healthy child during pregnancy, which did not yield the expected results. This shook their confidence in their religious and spiritual beliefs.
丧亲事件对先前信仰的影响或加强或削弱了宗教和精神信仰。一些参与者报告说，他们原本是无神论者，但在经历了死胎事件后，他们开始信奉宗教。他们开始信教，并开始行善积德，为将来的好结果积累功德。他们沉浸在哲学和宗教文献中，探索生与死的概念，并通过精神活动寻求慰藉，这表明死产可以强化精神和宗教信念。相反，一些以前虔诚的参与者在经历丧子之痛后变得怀疑起来。他们描述说，在参与了与信仰有关的活动（如在怀孕期间为健康的孩子祈祷）后，他们感到自己被背叛了，而这些活动并没有产生预期的结果。这动摇了他们对宗教和精神信仰的信心。
“…no longer believe in karma. I never did anything bad, so why (this result)? I made a vow to the Buddha. …didn't have any help…might not believe again.”
"......不再相信因果报应。我从没做过坏事，为什么会有这种结果？我向佛祖发过誓。......没有任何帮助......可能不会再相信了"。
(M17, Buddhism)  (M17, 佛教)
“…My grandmother was a Buddhist, so even though I was not religious, I still used to go to the temple to worship Buddha. …But, you see, in the end, I still had this loss. It seems that God and Buddha did not bless me. So I probably won't believe that much anymore and won't use such methods anymore.”
"......我的祖母是佛教徒，所以尽管我不信教，我还是经常去寺庙拜佛。......但是，你看，到头来，我还是吃了亏。看来，上帝和佛祖并没有保佑我。所以，我可能不会再那么相信了，也不会再用这种方法了"。
(M5, no religion)  (M5，无宗教信仰）
3.2.3.4. Achieving personal growth
3.2.3.4.实现个人成长
The participants reported that their stillbirth experience was not entirely negative; it also had some positive aspects. They recounted receiving unexpected levels of help, understanding, and support from family, friends, and colleagues, which gave them a new sense of appreciation and gratitude for the people in their lives. Some mothers stated that the loss induced changes in their relationships, attitudes towards work and life, and family and social responsibilities, enabling them to discard limiting beliefs and achieve personal growth. They gained a renewed sense of purpose and direction and felt motivated to make positive changes in their lives. They believed that their spiritual practices offered them insights and wisdom that were applicable to their lives and aided in their personal growth as individuals.
参与者报告说，他们的死产经历并不完全是消极的，也有一些积极的方面。她们讲述了从家人、朋友和同事那里得到的意想不到的帮助、理解和支持，这让她们对生活中的人们产生了新的感激之情。一些母亲表示，失去孩子使她们的人际关系、工作和生活态度、家庭和社会责任发生了变化，使她们能够摒弃限制性信念，实现个人成长。她们重新获得了目标感和方向感，并感到有动力对生活做出积极的改变。他们认为，精神修炼为他们提供了适用于其生活的洞察力和智慧，有助于他们的个人成长。
“I feel I gained a lot—a lot of care, generosity, and kindness. This is probably the nicest thing I've ever gotten.”
"我觉得我收获了很多--很多关怀、慷慨和仁慈。这可能是我得到过的最美好的东西"。
(M22, no religion)  (M22，无宗教信仰）
“During this time, some friends and family members made me feel love, warmth, and kindness. At times, these gifts seemed to overshadow the sadness of losing a child. So I thought I was pretty lucky.”
"在这段时间里，一些朋友和家人让我感受到了爱、温暖和善意。有时，这些礼物似乎盖过了失去孩子的悲伤。所以我觉得我很幸运"。
(M25, no religion)  (M25，无宗教信仰）

4. Discussion  4.讨论

This study is one of the few to describe how Chinese culture and spirituality influence grief expression and healing processes amongst bereaved women following a stillbirth. The findings highlighted the significant roles of Chinese cultural and spiritual beliefs in the expression, experience and healing processes after a stillbirth (Chow, 2010) and showed that customs, social norms, policies, rules, and spiritual beliefs might contribute to adaptation to bereavement within Chinese society. As some studies (Ayebare et al., 2021; Roberts et al., 2012) note, in certain countries, these factors can lead to a culture of silent grieving and the imposition of taboos around stillbirth, potentially resulting in isolation, shame, stigma, and challenges in seeking support (Hsu et al., 2002; Kiguli et al., 2016). Additionally, some scholars (Neimeyer et al., 2014) have proposed that grief is a socially constructed model. They argue that grief is fundamentally social and involves not only personal and familial contexts but also the search for meaning in broader community and cultural spheres. The findings of this study support previous research whilst offering new insights.
本研究是为数不多的描述中国文化和精神信仰如何影响死产后丧亲妇女的悲伤表达和愈合过程的研究之一。研究结果强调了中国文化和精神信仰在死产后的表达、体验和愈合过程中的重要作用（Chow，2010），并表明习俗、社会规范、政策、规则和精神信仰可能有助于适应中国社会中的丧亲。正如一些研究（Ayebare 等人，2021 年；Roberts 等人，2012 年）所指出的，在某些国家，这些因素可能会导致一种无声哀悼的文化和对死产的禁忌，可能会造成孤立、羞耻、耻辱和寻求支持方面的挑战（Hsu 等人，2002 年；Kiguli 等人，2016 年）。此外，一些学者（Neimeyer 等人，2014 年）提出，悲伤是一种社会建构模式。他们认为，悲伤从根本上说是社会性的，不仅涉及个人和家庭背景，还涉及在更广泛的社区和文化领域寻找意义。本研究的结果支持了之前的研究，同时也提供了新的见解。
Spirituality in China, which is anchored in Confucianism, Buddhism, and Taoism, provides frameworks and guidance for shaping cultural beliefs about life and death (Neimeyer and Young-Eisendrath, 2015). Buddhism is a significant spiritual tradition that imparts teachings on suffering and the cycle of birth, death, and rebirth. The concept of reincarnation offers solace to grieving parents by suggesting that the child's soul will have another chance at life (Taniyama et al., 2021). Taoism underscores harmony with the natural order, assisting mothers in accepting life's impermanence, managing emotions, and achieving self-reconciliation (Burik, 2018). Although many Chinese people claim no religious beliefs, these deeply ingrained cultural convictions subtly influence Chinese society. This research demonstrated that even atheist mothers in the study participated in spiritual practices spontaneously or were guided by their families. The spiritual pathway played a crucial role and presented a multifaceted aspect of coping with grief, encompassing both positive and challenging effects for bereaved mothers.
中国的精神信仰以儒家、佛教和道教为基础，为塑造有关生与死的文化信仰提供了框架和指导（Neimeyer 和 Young-Eisendrath，2015 年）。佛教是一种重要的精神传统，传授有关痛苦和生死轮回的教义。轮回的概念暗示孩子的灵魂将有另一次生命的机会，这为悲伤的父母提供了慰藉（Taniyama et al.）道教强调与自然秩序的和谐，帮助母亲接受生命的无常，管理情绪，实现自我和解（Burik，2018）。尽管许多中国人声称自己没有宗教信仰，但这些根深蒂固的文化信念却潜移默化地影响着中国社会。本研究表明，即使是研究中的无神论母亲，也会自发或在家人的引导下参与灵性实践。灵修途径发挥了至关重要的作用，是应对悲伤的一个多面性方面，对失去亲人的母亲既有积极影响，也有挑战性影响。
This study found that spiritual practices facilitated the alleviation of feelings of guilt and responsibility, fostered better acceptance of the loss, provided psychological comfort and reconciliation (DeFrain, 1991), expedited recovery from grief, and promoted personal growth. Some mothers employed various spiritual narratives to navigate the emotional aftermath of stillbirth. They adopted stories that emphasised reincarnation, offering solace and a sense of continuity with the potential for reunion in the future. Initially, some mothers attributed the stillbirth to their actions, which led to feelings of guilt and responsibility. However, spirituality provided explanations beyond medical or personal responsibility to provide a means for them to relinquish this culpability. Some mothers interpreted the loss as a predestined event and believed that the circumstances were beyond their control and part of a larger divine plan. By attributing the cause to fate or divine intervention, they could find a way to release themselves from the burden of guilt and to facilitate forgiveness and self-compassion. This attribution served as a coping mechanism and provided a narrative for understanding the unexplainable. The loss experience prompted a re-evaluation of life's priorities, relationships, and personal responsibilities. Some individuals discover meaning in positive transformations, such as enhanced relationships or a renewed sense of purpose. The transformative nature of this process may foster a more nuanced and resilient worldview even amid profound grief. Religiosity may assist in coping with stressful situations (Becker et al., 2007). Participation in religious activities may also provide an important venue for interpersonal support and encouragement.
这项研究发现，灵性实践有助于减轻负罪感和责任感，促进更好地接受失去亲人的事实，提供心理安慰与和解（DeFrain，1991 年），加快从悲伤中恢复，并促进个人成长。一些母亲利用各种精神叙事来度过死产的情感后遗症。她们采用了强调轮回的故事，以提供慰藉和未来可能重聚的延续感。起初，一些母亲将死产归咎于自己的行为，从而产生了负罪感和责任感。然而，灵性提供了医学或个人责任之外的解释，为她们提供了放弃这种罪责的途径。有些母亲将失去孩子解释为命中注定的事件，认为当时的情况超出了她们的控制，是更大的神圣计划的一部分。通过将原因归咎于命运或上天的干预，她们可以找到一种方法，将自己从内疚的负担中解脱出来，并促进宽恕和自我同情。这种归因是一种应对机制，为理解无法解释的事情提供了一种叙事方式。失去亲人的经历促使人们重新评估生活的优先次序、人际关系和个人责任。有些人在积极的转变中发现了意义，比如人际关系的改善或目标感的更新。这一过程的转变性质可能会培养出一种更细致入微、更有韧性的世界观，即使是在深重的悲痛中。宗教信仰可能有助于应对压力环境（Becker 等人，2007 年）。参与宗教活动还可以提供重要的人际支持和鼓励。
Conversely, this study showed that barriers in the spiritual pathway arising from cultural or religious pressures may hinder the grieving process (Klass and Goss, 2003). Some mothers who believe in karma might associate loss with divine punishment or guilt. They might internalise the belief that their loss is a result of their own shortcomings or bad behaviour. This pressure could become a barrier to spiritual healing, impeding the acceptance and processing of grief. Some mothers may have doubts about the fairness of life and the efficacy of religious explanations as they grapple with the incongruity between their experiences and religious doctrines. This research demonstrated how collectivist tendencies in Chinese Confucian culture contribute to emotional concealment. Within the family-oriented Chinese culture, some bereaved mothers remained strong for the sake of the family, restraining their personal grief to maintain collective harmony. They prioritised their family members' feelings over their own (Brewer and Chen, 2007). This culture of prioritising family well-being over individual emotions may also become a barrier to expressing grief. Additionally, the cultural norms of postpartum visits were viewed as a psychological burden. Mothers intentionally concealed their grief to avoid embarrassing situations, maintain their privacy and engage in self-protective measures to avoid amplifying their sorrow. Both the passive restraint of grief and the active concealment of sorrow represent diverse approaches within Chinese cultural customs regarding how mothers navigate the grieving process following a stillbirth and the complexity of individual journeys in navigating the questions raised by such a profound loss. This study highlights the dynamic interplay between personal experiences, cultural influences, and spiritual frameworks.
相反，这项研究表明，文化或宗教压力造成的精神途径障碍可能会阻碍悲伤的过程（Klass and Goss, 2003）。一些相信因果报应的母亲可能会将失去亲人与神的惩罚或内疚联系起来。她们可能会将失去亲人是自己的缺点或不良行为造成的这一信念内化。这种压力可能会成为心灵治愈的障碍，阻碍对悲伤的接受和处理。有些母亲可能会对生命的公平性和宗教解释的有效性产生怀疑，因为她们要努力克服自己的经历与宗教教义之间的不一致。本研究证明了中国儒家文化中的集体主义倾向是如何导致情感隐匿的。在以家庭为中心的中国文化中，一些丧亲母亲为了家庭而保持坚强，克制个人悲伤以维护集体和谐。她们将家人的感受置于自己的感受之上（Brewer 和 Chen，2007 年）。这种将家庭幸福置于个人情感之上的文化也可能成为表达悲伤的障碍。此外，产后探访的文化规范也被视为一种心理负担。母亲们有意隐藏自己的悲伤，以避免尴尬的局面，维护自己的隐私，并采取自我保护措施，避免扩大悲伤。无论是被动克制悲伤还是主动隐藏悲伤，都代表了中国文化习俗中关于母亲如何在死产后经历悲伤过程的不同方法，以及个人在面对如此重大损失所引发的问题时所经历的复杂历程。 这项研究强调了个人经历、文化影响和精神框架之间的动态相互作用。
An intriguing finding in our research was that certain Chinese cultural practices did not nurture a connection between mothers and their unborn babies but rather facilitated disconnection or detachment from their stillborn babies and the associated event. The same phenomenon has been observed in other cultures (Andajani-Sutjahjo and Manderson, 2004). Influenced by Chinese philosophical beliefs about life and death (Chen and Qiang, 2003), some mothers reported that detaching from the negative past could lead to a positive future. Some traditional beliefs dictate that a deceased baby can only reincarnate if unbounded by its previous family. For these mothers, an obsession with the lost baby might hinder their chance of starting a new life. Most mothers in this study did not keep their stillborn babies' belongings as mementos. After experiencing a stillbirth, they chose to discard their child's belongings as a means of severing the negative memories associated with the event. This situation differs from the Western approach to grieving stillbirth, which emphasises the use of tangible or intangible ways to build bonds with the stillborn child (Osman Mohamoud et al., 2017; Tseng et al., 2014). Further research is needed to determine what constitutes an appropriate approach for mothers who have experienced stillbirth within the Chinese cultural context.
我们研究中的一个有趣发现是，某些中国文化习俗并没有培养母亲与胎儿之间的联系，反而促进了母亲与胎死腹中的胎儿及相关事件的分离或疏离。在其他文化中也观察到了同样的现象（Andajani-Sutjahjo 和 Manderson，2004 年）。受中国人关于生与死的哲学信仰的影响（陈和强，2003 年），一些母亲表示，从消极的过去中脱离出来可以带来积极的未来。一些传统信仰认为，夭折的婴儿只有在不受先前家庭束缚的情况下才能转世投胎。对于这些母亲来说，对逝去婴儿的执念可能会阻碍她们开始新生活的机会。本研究中的大多数母亲都没有把死婴的遗物作为纪念品保存起来。在经历了死产之后，她们选择丢弃孩子的遗物，以此来消除与死产有关的负面记忆。这种情况不同于西方的死产哀悼方式，后者强调用有形或无形的方式与死产婴儿建立联系（Osman Mohamoud 等人，2017；Tseng 等人，2014）。要确定在中国文化背景下什么才是适合经历死产的母亲的方法，还需要进一步的研究。
Research has highlighted the influences of medical culture, medical policies, and the paternalistic nature of medical interactions between bereaved mothers and healthcare providers on post-stillbirth grief experiences in the Chinese context (Wang, 2022). These factors contribute to challenges within the medical environment for mothers who have experienced stillbirth, resulting in a mismatch between medical culture and the needs and preferences of mothers after stillbirth. This makes it difficult for mothers to receive adequate support and understanding in the medical setting because their needs are ignored. This might partially explain the scarcity of literature on the care needs of mothers following stillbirth in China. Therefore, it is necessary to implement cultural sensitivity training amongst healthcare professionals to enhance the understanding of diverse cultural needs and preferences with a specific focus on addressing the concerns and requirements of mothers who have undergone the traumatic experience of stillbirth (Roberts, 2003). It is necessary to promote effective communication between healthcare providers and mothers who have lost a child to encourage their active participation in the healthcare decision-making process and foster open dialogue to bridge the gap between healthcare culture and the individual needs of these mothers. Medical policies tailored to the unique requirements of these mothers should be developed and implemented to guarantee a more supportive environment throughout the grieving process.
研究强调了医疗文化、医疗政策以及失去亲人的母亲与医疗服务提供者之间的医疗互动的家长式性质对中国人死胎后悲痛经历的影响（Wang，2022）。这些因素给经历过死胎的母亲带来了医疗环境方面的挑战，导致医疗文化与死胎母亲的需求和偏好不匹配。这使得母亲在医疗环境中很难得到足够的支持和理解，因为她们的需求被忽视了。这或许可以部分解释为什么中国有关死产后母亲护理需求的文献很少。因此，有必要在医护人员中开展文化敏感性培训，以加强对不同文化需求和偏好的理解，并特别注重解决经历过死胎创伤的母亲的担忧和要求（Roberts，2003 年）。有必要促进医疗服务提供者与丧子母亲之间的有效沟通，鼓励她们积极参与医疗决策过程，并促进公开对话，以弥合医疗文化与这些母亲的个人需求之间的差距。应针对这些母亲的独特需求制定和实施医疗政策，以确保在整个悲伤过程中营造一个更具支持性的环境。

5. Limitations  5.局限性

This study has several limitations that should be considered when interpreting its findings in other contexts. First, although the participants in this study came from 16 ancestral cities, they represented multiple cultures and ethnicities. Since China is a multiethnic and multifaith country, the influence of subcultures on mothers' bereavement experiences should be further investigated. Second, the study focused primarily on the population of bereaved mothers. Future research could explore cultural and spiritual influences and spiritual coping paths for other family members, such as fathers. Third, participants with higher educational levels were overrepresented in this study. Education may influence the adoption of spiritual healing modalities. More participants with low education levels should be recruited for future studies.
本研究有几个局限性，在其他情况下解释研究结果时应加以考虑。首先，尽管本研究的参与者来自 16 个祖籍城市，但她们代表了多种文化和民族。由于中国是一个多民族、多信仰的国家，亚文化对母亲丧亲经历的影响有待进一步研究。其次，本研究主要关注丧亲母亲群体。未来的研究可以探讨文化和精神方面的影响，以及其他家庭成员（如父亲）的精神应对途径。第三，本研究中受教育程度较高的参与者比例较高。教育程度可能会影响精神治疗方式的采用。在未来的研究中，应招募更多教育水平较低的参与者。

6. Conclusion  6.结论

Chinese culture and spirituality play important roles in grieving and healing processes amongst bereaved mothers following a stillbirth. Given the multifaceted nature of spiritual pathways and their effects on grieving mothers, it is crucial that future research continues to explore this relationship. This research can lead to a better understanding of the specific aspects of spirituality that contribute to or hinder Chinese mothers' grieving process as well as how these aspects may vary between individuals. A better understanding of this process could allow health care providers to develop more effective and culturally sensitive interventions and support systems for bereaved mothers in the Chinese context who have experienced stillbirth, helping them navigate their grief and move towards healing. Future longitudinal studies could explore in greater depth the roles of Chinese culture and spirituality over time in the different stages of grief healing following stillbirth.
中国文化和灵性在死胎母亲的悲伤和康复过程中发挥着重要作用。鉴于灵性途径的多面性及其对悲伤母亲的影响，未来的研究必须继续探索这种关系。这项研究可以让我们更好地了解精神因素的哪些具体方面会促进或阻碍中国母亲的悲伤过程，以及这些方面如何因人而异。对这一过程有了更好的了解，医疗服务提供者就可以为经历过死胎的中国母亲制定更有效、更具有文化敏感性的干预措施和支持系统，帮助她们渡过悲伤并走向康复。未来的纵向研究可以更深入地探讨中国文化和灵性在死胎后不同阶段的悲伤愈合过程中的作用。

Funding  资金筹措

Zhejiang Provincial Education Department [2020KY173] funded the project. The funder had no influence on the research process at any stage.
浙江省教育厅[2020KY173]资助了该项目。资助方对研究过程的任何阶段均无影响。

CRediT authorship contribution statement
CRediT 作者贡献声明

Qiong Zheng: Writing – review & editing, Writing – original draft, Visualization, Validation, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Xiuxiu Yin: Writing – review & editing, Writing – original draft, Visualization, Resources, Investigation, Formal analysis, Data curation. Lu Liu: Software, Resources, Methodology, Investigation, Formal analysis. Cecilia Jevitt: Writing – review & editing, Writing – original draft, Methodology, Conceptualization. Dongmei Fu: Writing – review & editing, Resources, Investigation. Yaping Sun: Writing – review & editing, Data curation. Xiaoyan Yu: Writing – review & editing, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization.
郑琼写作 - 审阅和编辑、写作 - 原稿、可视化、验证、软件、资源、项目管理、方法学、调查、资金获取、形式分析、数据整理、概念化。尹秀秀写作--审阅和编辑、写作--原稿、可视化、资源、调查、正式分析、数据整理。Lu Liu：软件、资源、方法论、调查、形式分析。Cecilia Jevitt：写作--审阅和编辑、写作--原稿、方法论、概念化。傅冬梅写作--审阅和编辑、资源、调查。孙亚平写作--审阅和编辑、数据整理。于晓燕写作--审阅和编辑、验证、监督、资源、项目管理、方法学、调查、资金获取、形式分析、概念化。

Declaration of Competing Interest
竞争利益声明

The authors declare that they have no conflicts of interest.
作者声明他们没有利益冲突。

Acknowledgments  致谢

The researchers gratefully acknowledge all participants in the study and the support from Zhejiang Provincial Education Department. We would like to thank all midwives and nurses at the included hospitals for their assistance. We also thank Carrie Davies and Monica Chan for their help with the bilingual contextual translation of the interview content in the study.
研究人员对所有参与研究的人员以及浙江省教育厅的支持表示感谢。我们还要感谢所有助产士和所在医院护士的协助。我们还要感谢 Carrie Davies 和 Monica Chan 在本研究中对访谈内容的双语语境翻译所提供的帮助。

Data availability  数据可用性

Due to ethical reasons, the raw data would remain confidential and would not be shared. The processed data that support the findings of this study are available from the corresponding author [Xiaoyan Yu], upon reasonable request.
出于道德原因，原始数据将予以保密，不会与他人共享。支持本研究结果的处理数据可向通讯作者[Xiaoyan Yu]索取。

References

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