Making real progress with stillbirth prevention

The global burden of stillbirth has far-reaching psychosocial impacts on women, families, caregivers and communities, and wide-ranging economic impact on health systems and society.1 An estimated 2.64 million babies die after 28 weeks gestation but before birth each year.2 Many stillbirths are preventable, particularly beyond 28 weeks, where survival for those born alive in high-income country (HIC) settings such as Australia, approaches 100%.3 Currently, there are over 2000 stillbirths annually in Australia, equating to one in every 140 women (at 20 weeks gestation or more)4 and around one in every 416 women from 28 weeks.3 Although there have been some reductions in stillbirth rates,4, 5 this has been far less than the reduction in neonatal deaths4 and more needs to be done.5 The 2011 Lancet Stillbirth Series call to action brought attention to stillbirth as a neglected global public health issue.6, 7 The 2016 Lancet series showed little real progress against the 2011 call to action. The series showed Australia lagged other developed countries, with a stillbirth rate beyond 28 weeks more than 30% higher than the group of best performing countries,8 equating to more than 200 excess stillbirths annually. For Aboriginal and Torres Strait Islander women and other disadvantaged and minority groups, this risk is often doubled.8 Progress is now being made in Australia with a national program to reduce stillbirth. This is a complex landscape that requires a multi-faceted approach involving innovative interventions, clinician, parent and community education and consumer engagement. The Centre of Research Excellence in Stillbirth (Stillbirth CRE), funded by the National Health and Medical Research Council, began operations in 2017. The Stillbirth CRE has set out to build capacity to enable a sustainable network to address a priority-driven research program,9 leading to measurable change. The aim is to reduce stillbirth rates after 28 weeks gestation and improve quality of care for women and families after stillbirth through addressing the call to action of the Lancet 2016 series on Ending Preventable Stillbirths8 and the specific priorities pertinent to Australia. High-quality clinical audits show that around one-third of stillbirths could be avoided with better care.7 Therefore, an initial priority of the Stillbirth CRE was to target known evidence-practice gaps. Bundles of care in stillbirth prevention in the UK10 and Scotland11 have been associated with a 20% reduction in stillbirth. Over the last two years, much progress has been made toward the development and implementation of the Safer Baby Bundle (SBB) in Australia12 which targets key practice gaps in antenatal care. The COVID-19 pandemic has resulted in widescale changes in the way antenatal care is provided and has resulted in some delays in implementing the SBB and modifications to the elements.13 Despite these challenges, there are currently 82 maternity services involved in varying stages of implementation across Queensland, New South Wales and Victoria accounting for approximately half of all births in these states. All other jurisdictions are planning to implement the SBB over the coming year. The SBB combines five elements of practice improvements commonly identified through audits of stillbirth and are as follows: (i) screen all women for smoking in early pregnancy and offer tailored smoking cessation support; (ii) screen women for risk factors (RF) for fetal growth restriction and provide individualised ongoing management; (iii) increase awareness and improve management of women with decreased fetal movements (DFM); (iv) increase awareness of the importance of non-supine maternal sleep position in late pregnancy; and (v) screen all women for stillbirth RF in early pregnancy and provide individualised care including informed decision-making on timing of birth. Underpinning the SBB is high-quality perinatal mortality audit as a continuous quality improvement exercise. Without adequate investigation and audit, important information may be lost. The IMPROVE educational program,12 based on national guidelines,14 aims to support clinicians in best practice care for women and families after perinatal death, including investigation and audit. Another fundamental principle of the SBB is reducing fragmentation to enable thoughtful, individualised care which is critical in stillbirth prevention. Through development of the SBB clinical recommendations, areas of controversy and need for further research were identified such as the management of DFM. DFM is a well-accepted ‘warning sign’ of potential fetal compromise carrying around a four-fold increased risk of stillbirth15 and is a common pregnancy concern for women and their care providers. The recent AFFIRM trial showed that a package of care around DFM targeting women and clinicians did not reduce stillbirth rates (although a positive trend was shown), while increasing inductions and neonatal admissions to special care.16 While questions remain about the fidelity and applicability of the AFFIRM intervention,17 the results do highlight the need for caution about unintended consequences of interventions to reduce stillbirth. The results of Australia’s My Baby’s Movements trial (testing a package of care targeting women and their care providers) are awaited and may shed light on optimal approaches to improve outcomes for women with DFM and future revisions to the SBB. The fifth element of the SBB, which addresses timing of birth for women with RF for stillbirth, has great potential for reducing stillbirth but also carries some significant risks. The prospective risk of stillbirth increases with gestational age at term, from 0.11 per 1000 births at 37 weeks gestation to 3.18 per 1000 births at 42 weeks gestation.18 However, the risk differs according to the woman’s individual risk profile. Important RF for stillbirth in HIC are now well defined.19 Major RF (with odds ratios of two or more) include maternal obesity, age over 40 years, smoking, previous stillbirth, pre-existing hypertension and diabetes, no antenatal care and small for gestational age (SGA). SGA is associated with around four-fold increased risk of stillbirth,19 highlighting the important contribution of placental dysfunction to stillbirth. Other RF which are not as strongly associated (odds ratios < 2) include maternal age 35–39 years, primiparity, and maternal overweight, but due to higher prevalence make an important contribution to stillbirth.19 South Asian, African, Indigenous and other disadvantaged groups often have constellations of RF (eg obesity, smoking, substance use, inadequate nutrition) and suboptimal antenatal care.8 These are deeply rooted in social deprivation and there can be no single approach to reducing risk, although culturally appropriate models of care will contribute across a range of important aspects. High-level evidence in support of induction of labour for women beyond 41 weeks gestation to reduce perinatal death20 has resulted in increasing uptake into practice. To date, there is little comparable evidence to support the non-targeted use of earlier induction to prevent stillbirth, but knowledge of RF should allow for planned birth to be targeted to those at greatest risk.21 Unless an accurate biomarker for stillbirth becomes available, the mainstay of late gestation stillbirth prevention remains identification of maternal RF to inform planned early birth. However, the benefits of early birth need to be carefully weighed against the risks of intervention at any given gestation. Avoiding stillbirth is one aim of ending pregnancy early, but there are significant associated morbidities for the baby born too soon. It is becoming increasingly apparent that both late preterm (36–37 weeks gestation) and early term birth (37–38 weeks gestation) are associated with increased short and longer-term mortality and morbidity and worse developmental outcomes.21 Some of these consequences of planned birth may not be apparent until later in childhood and are usually not reported in studies of perinatal outcomes. Maternal complications associated with planned early birth are also an important consideration.7, 22 There is likely to be additional costs related with health and educational services associated with increasing the rates of planned birth. Informed, shared decision-making is central to high-quality, woman-centred maternity care. Shared decision-making is ‘an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences’.22 All women should be given accurate information about their risks of stillbirth and a realistic understanding of the potential consequences of planned birth. Implementing the fifth element of the SBB includes training for providers in shared decision-making and we are confident that this approach will lead to better outcomes. There is now a real momentum behind a national program to address the once neglected tragedy of stillbirths. The engagement by politicians, and subsequently all levels of government, was initiated by Senator Kristina Keneally, and led to the Senate Enquiry into Stillbirth Research and Education which tabled its final report in late 2018. Two roundtables held at Parliament House in 2019 and 2020 toward the development of a Stillbirth National Action Plan for Australia, involving key stakeholders (including parent advocacy groups) have been followed by a significant injection from the Medical Research Future Fund to help with a national rollout of the SBB. More recently a national public education and awareness campaign has been funded. However, such national initiatives need the strong engagement of local maternity care providers. The SBB and IMPROVE e-learning resources12 are freely available and enable everyone to gain insight into the recommended approach to stillbirth prevention and good clinical practice after stillbirth. As the SBB rollout progresses across the country, there will be a greater opportunity for everyone to work together, to make a real difference. Every preventable stillbirth is a tragic outcome of pregnancy, and all those involved in maternity care must seize this opportunity to reduce these devastating events and improve the lives of women and their families. Supported by Clinical Excellence Queensland and the Stillbirth Centre of Research Excellence funded by the National Health and Medical Research Council (Grant Number: APP1116640).