ANZSA Investigating Causes of Stillbirth: a prospective cohort study examining use and effectiveness of a comprehensive investigation protocol
Stillbirth is devastating to parents, their families and those who care for them. There has been no reduction in stillbirth rates for over two decades. Accurate cause of death data is the cornerstone of effective prevention and essential for parents facing this tragedy to understand what went wrong. However, the majority of stillbirths in Australia are not adequately investigated resulting in erroneous data on causation and a high proportion are ‘unexplained’.
This study addresses the call for better data on the causes of stillbirths from the NHMRC Maternity Services review and The Lancet Stillbirth Series and constitutes the major research agenda of the Australian and New Zealand Stillbirth Alliance (ANZSA). In this study we will identify causes of stillbirths in a large well-investigated cohort and improve the quality of data on stillbirths across Australia through identifying a cost-effective, evidence-based approach to stillbirth investigations.
Hospitals and Investigators Collaborating on the Stillbirth Investigations Study
Contact: Vicki Flenady
Classification Agreement Study
Accurate cause of stillbirth data along with consistent application of stillbirth classification systems is important for developing effective prevention strategies. The PSANZ Clinical Practice Guidelines on Perinatal Mortality Audit were developed to aid accuracy and consistency of data on classification of stillbirth. However, uptake of these guidelines is low. Lack of high level evidence for the recommended investigations is thought to be a major reason for low compliance. A NSW study showed the need for education of hospital committees with regards to stillbirth classification.
This study compared the level of agreement in classification of stillbirth according to PSANZ Perinatal Death Classification between hospital review committees and expert panel review. This quality control exercise identified a number of areas for improvement and the feedback of the expert panel review to the hospital committees will provide a learning opportunity. A manuscript of the study findings is in preparation.
Investigators: Ibinabo Ibiebele, Vicki Flenady, Michael Coory, Fran Boyle
Contact: Ibinabo Ibiebele
Detection and management of decreased fetal movements in Australia and New Zealand: A survey of obstetric practice
Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM. This study aims to identify current practices and views of obstetricians in Australia and New Zealand regarding DFM through postal survey of Fellows and Members, and obstetric trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
Of the 1700 surveys distributed, 1066 (63%) were returned, of these, 805 (76% of responders) were currently practising and included in the analysis. The majority considered that asking women about fetal movement should be a part of routine care. Sixty per cent reported maternal perception of DFM for 12 h was sufficient evidence of DFM and 77% DFM for 24 h. KICK charts were used routinely by 39%, increasing to 66% following an episode of DFM. Alarm limits varied, the most commonly reported was < 10 movements in 12 h (74%). Only 6% agreed with the internationally recommended definition of < 10 movements in two hours. Interventions for DFM varied, while 81% would routinely undertake a cardiotocograph, 20% would routinely perform ultrasound and 20% more frequent antenatal visits.
While monitoring fetal movement is an important part of antenatal care in Australia and New Zealand, variation in obstetric practice for DFM is evident. Large-scale randomised controlled trials are required to identify optimal screening and management options. In the interim, high quality clinical practice guidelines using the best available advice are needed to enhance consistency in practice including advice provided to women.
Contact: Vicki Flenady
Published paper: FLENADY, V., MacPHAIL, J., GARDENER, G., CHADHA, Y., MAHOMED, K., HEAZELL, A., FRETTS, R. and FRÃ˜EN, F. (2009), Detection and management of decreased fetal movements in Australia and New Zealand: A survey of obstetric practice. Australian and New Zealand Journal of Obstetrics and Gynaecology, 49: 358–363. doi: 10.1111/j.1479-828X.2009.01026.x
Epidemiology of stillbirth in Queensland
In Australia, around 1 in every 139 pregnancies reaching 20 weeks will end in stillbirth. There has been very little change in national stillbirth rates over the last two decades and some reports suggest the rates may be slowly increasing. In addition, there is marked disparity across the Australian population. Aboriginal and Torres Strait Islander women have stillbirth rates that are 1½ times higher than non-Indigenous women. The lack of high quality data on causes and contributing factors to stillbirth is a significant barrier to further reducing stillbirth rates. Using routinely collected population-based data, trends in stillbirth rates and causes were examined, the risk of stillbirth by gestational age was assessed and a prediction model was developed to identify pregnancies at risk of antepartum stillbirth around term. The findings from the trends analysis have been published.
Investigators: Ibinabo Ibiebele, Vicki Flenady, Michael Coory, Fran Boyle, Adrian Charles, Gordon Smith
Contact: Ibinabo Ibiebele
My Baby's Movements: a stepped wedge cluster randomised controlled trial to raise maternal awareness of fetal movements during pregnancy
The MBM Trial aims to develop, and assess the effects of, a personalised interactive mobile phone software program (MBM), using smart phones or SMS (Short Message Service), provided to pregnant women as part of their antenatal care, compared to women receiving routine antenatal care alone on:
Autopsy Consent Study
Autopsy is the gold standard for stillbirth investigation; however, rates of perinatal autopsy have been declining. Approaches to communication and consent for autopsy should be evidence based; however, these are currently based on supposition of parent’s wishes. The autopsy consent process is a difficult process for parents and clinicians alike. Parents are required to gain an understanding of detailed procedures while in a state of grief. Studies have shown that parents enduring powerful negative experiences may not recall information given to them. Clinicians may also be reluctant to place additional burden on parents or may feel ill equipped to approach parents for consent. Parents may regret decisions about autopsy, and this may be due to inadequate information or poor communication.
This mixed methods study using in-depth telephone interviews highlighted a number of themes related to parents’ experiences and expectations around stillbirth autopsy. A manuscript of the study findings is in preparation.
Investigators: Ibinabo Ibiebele, Fran Boyle, Vicki Flenady, Michael Coory
Contact: Fran Boyle