Lifestyle and sociodemographic risk factors for stillbirth by region of residence in South Australia: a retrospective cohort study.

BACKGROUND: Stillbirth rates remain a global priority and in Australia, progress has been slow. Risk factors of stillbirth are unique in Australia due to large areas of remoteness, and limited resource availability affecting the ability to identify areas of need and prevalence of factors associated with stillbirth. This retrospective cohort study describes lifestyle and sociodemographic factors associated with stillbirth in South Australia (SA), between 1998 and 2016. METHODS: All restigered births in SA between 1998 ad 2016 are included. The primary outcome was stillbirth (birth with no signs of life ≥ 20 weeks gestation or ≥ 400 g if gestational age was not reported). Associations between stillbirth and lifestyle and sociodemographic factors were evaluated using multivariable logistic regression and described using adjusted odds ratios (aORs). RESULTS: A total of 363,959 births (including 1767 stillbirths) were included. Inadequate antenatal care access (assessed against the Australian Pregnancy Care Guidelines) was associated with the highest odds of stillbirth (aOR 3.93, 95% confidence interval (CI) 3.41-4.52). Other factors with important associations with stillbirth were plant/machine operation (aOR, 1.99; 95% CI, 1.16-2.45), birthing person age ≥ 40 years (aOR, 1.92; 95% CI, 1.50-2.45), partner reported as a pensioner (aOR, 1.83; 95% CI, 1.12-2.99), Asian country of birth (aOR, 1.58; 95% CI, 1.19-2.10) and Aboriginal/Torres Strait Islander status (aOR, 1.50; 95% CI, 1.20-1.88). The odds of stillbirth were increased in regional/remote areas in association with inadequate antenatal care (aOR, 4.64; 95% CI, 2.98-7.23), birthing age 35-40 years (aOR, 1.92; 95% CI, 1.02-3.64), Aboriginal and/or Torres Strait Islander status (aOR, 1.90; 95% CI, 1.12-3.21), paternal occupations: tradesperson (aOR, 1.69; 95% CI, 1.17-6.16) and unemployment (aOR, 4.06; 95% CI, 1.41-11.73). CONCLUSION: Factors identified as independently associated with stillbirth odds include factors that could be addressed through timely access to adequate antenatal care and are likely relevant throughout Australia. The identified factors should be the target of stillbirth prevention strategies/efforts. SThe stillbirth rate in Australia is a national concern. Reducing preventable stillbirths remains a global priority.

Evaluation of an online education program for healthcare professionals on best practice management of perinatal deaths: IMPROVE eLearning.

BACKGROUND: The IMPROVE (IMproving Perinatal Mortality Review and Outcomes Via Education) eLearning, developed by the Stillbirth Centre of Research Excellence in partnership with the Perinatal Society of Australia and New Zealand was launched in December 2019. Based on the successful face-to-face program, the eLearning aims to increase availability and accessibility of high-quality online education to healthcare professionals providing care for families around the time of perinatal death, to improve the delivery of respectful and supportive clinical care and increase best practice investigation of perinatal deaths. AIMS: To evaluate participants' reported learning outcomes (change in knowledge and confidence) and overall acceptability of the program. METHODS: Pre- and post-eLearning in-built surveys were collected over two years (Dec. 2019-Nov. 2021), with a mix of Likert and polar questions. Pre- and post-eLearning differences in knowledge and confidence were assessed using McNemar's test. Subgroup analysis of overall acceptability by profession was assessed using Pearson's χ2 . RESULTS: One thousand, three hundred and thirty-nine participants were included. The majority were midwives (80.2%, n = 1074). A significant improvement in knowledge and confidence was shown across all chapters (P < 0.01). The chapter showing the greatest improvement was perinatal mortality audit and classification (21.5% pre- and 89.2% post-education). Over 90% of respondents agreed the online education was relevant, helpful, acceptable, engaging. Importantly, 80.7% of participants considered they were likely to change some aspect of their clinical practice after the eLearning. There was no difference in responses to relevance and acceptability of the eLearning program by profession. CONCLUSIONS: The IMPROVE eLearning is an acceptable and engaging method of delivery for clinical education, with the potential to improve care and management of perinatal deaths.

Placenta-Specific Transcripts Containing Androgen Response Elements Are Altered In Silico by Male Growth Outcomes.

A birthweight centile (BWC) below the 25th is associated with an elevated risk of adverse perinatal outcomes, particularly among males. This male vulnerability may stem from alterations in placenta-specific androgen signalling, a signalling axis that involves the androgen receptor (AR)-mediated regulation of target genes containing androgen response elements (AREs). In this study, we examined global and ARE-specific transcriptomic signatures in term male placentae (≥37 weeks of gestation) across BWC subcategories (<10th, 10th-30th, >30th) using RNA-seq and gene set enrichment analysis. ARE-containing transcripts in placentae with BWCs below the 10th percentile were upregulated compared to those in the 10th-30th and >30th percentiles, which coincided with the enrichment of gene sets related to hypoxia and the suppression of gene sets associated with mitochondrial function. In the absence of ARE-containing transcripts in silico, <10th and 10th-30th BWC subcategory placentae upregulated gene sets involved in vasculature development, immune function, and cell adhesion when compared to those in the >30th BWC subcategory. Collectively, our in silico findings suggest that changes in the expression of ARE-containing transcripts in male placentae may contribute to impaired placental vasculature and therefore result in reduced fetal growth outcomes.

Neonatal mortality risk for vulnerable newborn types in 15 countries using 125.5 million nationwide birth outcome records, 2000-2020.

OBJECTIVE: To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000-2020. DESIGN: Population-based, multi-country study. SETTING: National data systems in 15 middle- and high-income countries. METHODS: We used individual-level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm [PT] versus term [T]) and size-for-gestational age (small [SGA], <10th centile, appropriate [AGA], 10th-90th centile or large [LGA], >90th centile) according to INTERGROWTH-21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types. MAIN OUTCOME MEASURES: Mortality of six newborn types. RESULTS: Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range [IQR] 45.6-73.9), PT + AGA (median 34.3, IQR 23.9-37.5) and PT + LGA (median 28.3, IQR 18.4-32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5-54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2-388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7-342.8) compared with those between 2500 g and 4000 g as a reference group. CONCLUSION: Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co-existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.

Stillbirths: Contribution of preterm birth and size-for-gestational age for 125.4 million total births from nationwide records in 13 countries, 2000-2020.

OBJECTIVE: To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'. DESIGN: Population-based multi-country analyses. SETTING: Births collected through routine data systems in 13 countries. SAMPLE: 125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020. METHODS: We included 635 107 stillbirths from 22+0 weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0 weeks versus term, T, ≥37+0 weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards. MAIN OUTCOME MEASURES: Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types. RESULTS: 635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0 weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age. CONCLUSIONS: In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Ending preventable stillbirths and improving bereavement care: a scorecard for high- and upper-middle income countries.

BACKGROUND: Despite progress, stillbirth rates in many high- and upper-middle income countries remain high, and the majority of these deaths are preventable. We introduce the Ending Preventable Stillbirths (EPS) Scorecard for High- and Upper Middle-Income Countries, a tool to track progress against the Lancet's 2016 EPS Series Call to Action, fostering transparency, consistency and accountability. METHODS: The Scorecard for EPS in High- and Upper-Middle Income Countries was adapted from the Scorecard for EPS in Low-Income Countries, which includes 20 indicators to track progress against the eight Call to Action targets. The Scorecard for High- and Upper-Middle Income Countries includes 23 indicators tracking progress against these same Call to Action targets. For this inaugural version of the Scorecard, 13 high- and upper-middle income countries supplied data. Data were collated and compared between and within countries. RESULTS: Data were complete for 15 of 23 indicators (65%). Five key issues were identified: (1) there is wide variation in stillbirth rates and related perinatal outcomes, (2) definitions of stillbirth and related perinatal outcomes vary widely across countries, (3) data on key risk factors for stillbirth are often missing and equity is not consistently tracked, (4) most countries lack guidelines and targets for critical areas for stillbirth prevention and care after stillbirth and have not set a national stillbirth rate target, and (5) most countries do not have mechanisms in place for reduction of stigma or guidelines around bereavement care. CONCLUSIONS: This inaugural version of the Scorecard for High- and Upper-Middle Income Countries highlights important gaps in performance indicators for stillbirth both between and within countries. The Scorecard provides a basis for future assessment of progress and can be used to help hold individual countries accountable, especially for reducing stillbirth inequities in disadvantaged groups.

A systematic review of interventions to increase the use of smoking cessation services for women who smoke during pregnancy.

BACKGROUND: Although many pregnant women accept referrals to stop-smoking support, the uptake of appointments often remains low. AIM: The aim was to review the success of interventions to increase the uptake of external stop-smoking appointments following health professional referrals in pregnancy. MATERIALS AND METHODS: Embase, PubMed, Cochrane Central Register of Controlled Trials, Scopus and CINAHL were searched in February 2023 for studies with interventions to increase the uptake rates of external stop-smoking appointments among pregnant women who smoke. Eligible studies included randomised, controlled, cluster-randomised, quasi-randomised, before-and-after, interrupted time series, case-control and cohort studies. Cochrane tools assessing for bias and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Two before-and-after studies were included, including a combined total of 1996 women who smoked during pregnancy. Both studies had a serious risk of bias, and meta-analysis was not possible due to heterogeneity. One study testing carbon monoxide monitors and opt-out referrals showed increased uptake of external stop-smoking appointments, health professional referrals and smoking cessation rates compared to self-identified smoking status and opt-in referrals. Results were limited in the second study, which used carbon monoxide monitors, urinary cotinine levels and self-disclosed methods to identify the smoking status with opt-out referrals. Only post-intervention data were available on the uptake of appointments to external stop-smoking services. The number of health professional referrals increased, but change in smoking cessation rates was less clear. CONCLUSIONS: There is insufficient evidence to inform practice regarding strategies to increase the uptake of external stop-smoking appointments by women during pregnancy.

Current approach and attitudes toward neonatal near-miss and perinatal audits: An exploratory international survey.

BACKGROUND: Combined with perinatal mortality review, neonatal near-miss (NNM) audit has the potential to inform strategies to better prevent adverse perinatal outcomes. Nonetheless, there is lack of standardised definitions of NNM and limited evidence of implementation of NNM audits. AIM: To describe definitions of NNM and assess current approaches and attitudes toward perinatal mortality and morbidity audit. MATERIALS AND METHODS: Online survey from December 2021 to February 2022, with a mix of Likert scales, polar, pool, multi-choice, and open-ended questions, disseminated through national and international organisations to perinatal healthcare workers from high-income countries. RESULTS: One hundred and twenty participants came from Australia (n = 86), New Zealand (n = 18), Canada (n = 7), USA (n = 4), Netherlands (n = 2), other countries (n = 3). Neonatologists (35%), midwives (21.7%), obstetricians (12.5%), neonatal nurse practitioners (11.7%) and others (23.3%) responded. Most respondents thought the main characteristics to define NNM were birth asphyxia needing therapeutic hypothermia (68.3%), unexpected resuscitation at birth (67.5%), need for intubation/chest compression/adrenaline (65.0%) and metabolic acidosis at birth (60.0%). There were 97.5% of participants who considered NNM important for identifying cases for perinatal morbidity audits. However, only 10.0% of their institutions used a NNM definition. Overall, 98.4% of participants considered perinatal mortality and morbidity audits important to prevent adverse outcomes. CONCLUSION: Neonatal near-miss audit is viewed as a valuable tool to reduce adverse neonatal outcomes. There was reasonable consensus that NNM encompassed evidence of birth asphyxia and/or advanced neonatal resuscitation. Data from this international survey identifies a starting point for a consensus definition of NNM, which can be used for perinatal audits to identify opportunities for improvement.

Validation of a tool for determining the clinical utility of stillbirth investigations.

BACKGROUND: Up to 20% of all stillbirths and 45% of term stillbirths are currently classified as unexplained. Many of these stillbirths do not undergo currently recommended investigations. This may leave questions unanswered and not identify stillbirths with a recurrence risk in subsequent pregnancies. AIMS: To validate a new tool (Stillbirth Investigation Utility Tool) to identify the clinical utility of investigations in stillbirth and the inter-rater agreement on cause of stillbirth using the Perinatal Society of Australia and New Zealand-Perinatal Death Classification (PSANZ-PDC). MATERIALS AND METHODS: Thirty-four stillbirths were randomly selected for inclusion, each assessed independently by five blinded assessors. The investigations were grouped into three categories: clinical and laboratory; placental pathology; and autopsy examination. The cause of death was assigned at the end of each group. Outcome measures were clinical utility of investigations measured by assessor rated usefulness and inter-rater agreement on the assigned cause of death. RESULTS: Comprehensive maternal history, maternal full blood count, maternal blood group and screen and placenta histopathology were useful in all cases. Clinical photographs were not performed and should have been performed in 50% of cases. The inter-rater agreement on cause of death assigned after all investigation results was 0.93 (95% CI 0.87-1.0). CONCLUSIONS: The new Stillbirth Investigation Utility Tool showed very good agreement in assigning the cause of death using PSANZ-PDC. Four investigations were useful in all cases. Minor refinements will be made based on feedback to enhance usability for wider implementation in research studies to assess the yield of investigations in stillbirths.

My Baby's Movements: An assessment of the effectiveness of the My Baby's Movements phone program in reducing late-gestation stillbirth rates.

BACKGROUND: Delayed reporting of decreased fetal movements (DFM) could represent a missed opportunity to prevent stillbirth. Mobile phone applications (apps) have the potential to improve maternal awareness and reporting of DFM and contribute to stillbirth prevention. AIMS: To evaluate the effectiveness of the My Baby's Movements (MBM) app on late-gestation stillbirth rates. MATERIALS AND METHODS: The MBM trial evaluated a multifaceted fetal movements awareness package across 26 maternity services in Australia and New Zealand between 2016 and 2019. In this secondary analysis, generalised linear mixed models were used to compare rates of late-gestation stillbirth, obstetric interventions, and neonatal outcomes between app users and non-app users including calendar time, cluster, primiparity and other potential confounders as fixed effects, and hospital as a random effect. RESULTS: Of 140 052 women included, app users comprised 9.8% (n = 13 780). The stillbirth rate was not significantly lower among app users (1.67/1000 vs 2.29/1000) (adjusted odds ratio (aOR) 0.79; 95% CI 0.51-1.23). App users were less likely to have a preterm birth (aOR 0.81; 0.75-0.88) or a composite adverse neonatal outcome (aOR 0.87; 0.81-0.93); however, they had higher rates of induction of labour (IOL) (aOR 1.27; 1.22-1.32) and early term birth (aOR 1.08; 1.04-1.12). CONCLUSIONS: The MBM app had low uptake and its use was not associated with stillbirth rates but was associated with some neonatal benefit, and higher rates of IOL and early term birth. Use and acceptability of tools designed to promote fetal movement awareness is an important knowledge gap. The implications of increased IOL and early term births warrant consideration in future studies.

Is care of stillborn babies and their parents respectful? Results from an international online survey.

OBJECTIVE: To quantify parents' experiences of respectful care around stillbirth globally. DESIGN: Multi-country, online, cross-sectional survey. SETTING AND POPULATION: Self-identified bereaved parents (n = 3769) of stillborn babies from 44 high- and middle-income countries. METHODS: Parents' perspectives of seven aspects of care quality, factors associated with respectful care and seven bereavement care practices were compared across geographical regions using descriptive statistics. Respectful care was compared between country-income groups using multivariable logistic regression. MAIN OUTCOME MEASURES: Self-reported experience of care around the time of stillbirth. RESULTS: A quarter (25.4%) of 3769 respondents reported disrespectful care after stillbirth and 23.5% reported disrespectful care of their baby. Gestation less than 30 weeks and primiparity were associated with disrespect. Reported respectful care was lower in middle-income countries than in high-income countries (adjusted odds ratio 0.35, 95% CI 0.29-0.42, p < 0.01). In many countries, aspects of care quality need improvement, such as ensuring families have enough time with providers. Participating respondents from Latin America and southern Europe reported lower satisfaction across all aspects of care quality compared with northern Europe. Unmet need for memory-making activities in middle-income countries was high. CONCLUSIONS: Many parents experience disrespectful care around stillbirth. Provider training and system-level support to address practical barriers are urgently needed. However, some practices (which are important to parents) can be readily implemented such as memory-making activities and referring to the baby by name. TWEETABLE ABSTRACT: One in four experience disrespectful care after stillbirth. Parents want more time with providers and their babies, to talk and memory-make.

Maternal asthma during pregnancy and extremes of body mass index increase the risk of perinatal mortality: a retrospective cohort study.

OBJECTIVE: Asthma during pregnancy and extremes of body mass index (BMI) are independently associated with adverse pregnancy outcomes but the impact of the two conditions combined are currently unknown. The aim of this study was to determine the contribution of maternal BMI to adverse birth outcomes in pregnancies complicated by asthma. METHODS: The study utilized the routinely collected perinatal data on births at the Mater Mother's Hospital Brisbane, Australia, from January 2008 to December 2019. BMI was grouped as underweight (<18.5), normal weight (18.5-<24.99), overweight (25-29.99), and obese (≥30) and the population split by the presence and absence of maternal asthma. The comparison group was normal BMI, non-asthmatic pregnant women. A modified Poisson regression with robust variance was used to estimate the relative risk. RESULTS: In a retrospective cohort study of 110,057 pregnant women, 17.08% of women had asthma. Asthma and BMI were associated with an increased risk of poor fetal and neonatal outcomes. Asthma significantly increased the risk of stillbirth in underweight [adjusted RR: 2.22 (95% CI: 1.25-3.94] and obese [1.74 (1.11-2.71)]; neonatal death in underweight [3.41 (1.89-6.16)] and obese [2.22 (1.37-3.59)] and perinatal death in underweight [2.34 (1.50-3.66)] and obese [1.92 (1.38-2.67)] women. Admission to the neonatal intensive care unit was increased in neonates of underweight [1.65 (1.44-1.89)] and obese [1.26 (1.14-1.40)] asthmatic women. CONCLUSIONS: Extremes of BMI, specifically underweight and obesity, increased the risk of adverse perinatal outcomes among asthmatic women highlighting the importance of accounting for BMI during pre-conception and pregnancy related management of asthmatic women.

Inequitable use of health services for Indigenous mothers who experience stillbirth in Australia.

OBJECTIVES: The purpose of this study was to identify differences in health service expenditure on Indigenous and non-Indigenous women who experience a stillbirth, women's out-of-pocket costs, and health service use. METHODS: The project used a whole-of-population linked data set called "Maternity1000," which includes all women who gave birth in Queensland, Australia, between July 1, 2012, and June 30, 2018 (n = 396 158). Multivariable analysis was undertaken to assess differences in mean health service expenditure; and number of health care services accessed between Indigenous and non-Indigenous women who had a stillbirth from birth to twelve months postpartum. Costs are presented in 2019/20 Australian dollars. RESULTS: There was a total of 1864 babies stillborn to women in Queensland between July 1, 2012, and June 30, 2018, with 135 being born to Indigenous women and 1729 born to non-Indigenous women. There was significantly lower total expenditure per woman for Indigenous women compared with non-Indigenous women ($16 083 and $18 811, respectively). This was consistent across public hospital inpatient ($12 564 compared with $14 075), outpatient ($1127 compared with $1470), community-based services ($198 compared with $313), pharmaceuticals ($8 compared with $22), private hospital ($434 compared with $1265), and for individual out-of-pocket fees ($21 compared with $86). Mean expenditure on emergency department services per woman was higher for Indigenous women compared with non-Indigenous women ($947 compared with $643). Indigenous women who experienced a stillbirth accessed fewer general practitioners, allied health, specialist, obstetrics, and outpatient services, and fewer pathology and diagnostic test than their non-Indigenous counterparts. CONCLUSIONS: Inequities in access to health services exist between Indigenous and non-Indigenous women who experience a stillbirth.

Perinatal bereavement care during COVID-19 in Australian maternity settings.

OBJECTIVES: Perinatal bereavement care is a complex area of practice. The COVID-19 pandemic led to reconfiguration of maternity and perinatal bereavement care services. This study explores Australian health care providers' perspectives of the impact of COVID-19 on the provision of respectful and supportive care following stillbirth or neonatal death. METHODS: Members of a perinatal bereavement care network were consulted at the commencement of the pandemic in Australia using an online feedback form. Respondents provided ratings and free-text comments on the impact of COVID-19 on implementation of 49 recommendations contained in the Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Clinical Practice Guideline for Respectful and Supportive Perinatal Bereavement Care. RESULTS: Responses were received from 35 health care providers who provided perinatal bereavement care in clinical settings or through support organisations in Australia. Major impacts of COVID-19 were reported for 8 of 49 guideline recommendations. Impacts included reduced: support for mothers due to visitor restrictions; availability of cultural and spiritual support and interpreters; involvement of support people in decision-making; options for memory-making and commemorative rituals; and staff training and supervision. Adaptations to minimise impacts included virtual consultations, online staff training, use of cold cots, and increased staff support for memory-making. CONCLUSIONS: Health care providers encounter substantial challenges as they strive to implement best practice perinatal bereavement care in pandemic conditions. Some practice adaptations developed during the COVID-19 pandemic could benefit parents; however, evaluation of their effectiveness and acceptability is needed.

Causes of perinatal deaths in Australia: Slow progress in the preterm period.

AIM: The majority of perinatal deaths occur in the preterm period; however, current approaches predominantly focus on prevention in the term period. Reducing perinatal deaths in the preterm period is, therefore, key to reducing the rates of perinatal death overall in Australia. The aim was to understand the classifications of causes of preterm stillbirth and neonatal death in Victoria over time and by gestation. MATERIALS AND METHODS: Retrospective study using state-wide, publicly available data. All births in Victoria between 2010 and 2018 included in the Victorian Perinatal Data Collection, excluding terminations of pregnancy for maternal psychosocial indications, were studied. Differences in causes of preterm perinatal mortality gestation group and over time were determined. RESULTS: Out of 7977 perinatal deaths reported, 85.9% (n = 6849) were in the preterm period. The most common cause of preterm stillbirths was congenital anomalies (n = 1574, 29.8%), followed by unexplained antepartum deaths (n = 557, 14.2%). The most common cause of preterm neonatal death was spontaneous preterm birth (sPTB; n = 599, 38.2%), followed by congenital anomalies (n = 493, 31.4%). The rate of preterm stillbirths due to hypertension (-14.9% (95% CI -27.1% to -2.7%; P = 0.02)), maternal conditions (-24.1% (95% CI -44.2% to -4.0%; P = 0.03)) and those that were unexplained (-5.4% (95% CI -9.8% to -1.2%; P = 0.02)) decreased per annum between 2010 and 2018. All other classifications did not change significantly over time. CONCLUSION: Prevention of congenital anomalies and sPTB is critical to reducing preterm perinatal mortality. Greater emphasis on understanding causes of preterm deaths through mortality investigations may reduce the proportion of those considered 'unexplained'.

Neonatal death is a major concern for Indigenous women with asthma during pregnancy and could be prevented with better models of care.

Asthma is the most common respiratory illness in Aboriginal and Torres Strait Islander Australians. From the Mater Mothers routinely collected perinatal data in Brisbane we have identified that 24% of Indigenous and 17% of non-Indigenous women have pregnancies complicated by asthma. Indigenous women with asthma are more likely to have poorer birth outcomes when compared to non-Indigenous women with asthma, with neonatal death being doubled in asthmatic Indigenous women. These data indicate that asthma management during pregnancy is an unmet need for Indigenous women and essential if we are to avoid these devastating outcomes for Indigenous families.

Neonatal near miss: A review of current definitions and the need for standardisation.

Neonatal near miss (NNM) refers to a newborn who almost died in the neonatal period and is often perceived as part of a spectrum that includes stillbirth and neonatal death. NNM audits might improve recognition of risk factors and substandard care, facilitate benchmarking and inform prevention strategies to improve perinatal outcomes. This review shows that available NNM definitions are inconsistent and vary widely. This is likely to undermine the development of effective prevention strategies and global comparisons. Expert opinion may help reaching a consensus, thus enabling targeting of the appropriate population which would lead to more meaningful data for perinatal audits.

Systematic review: fetal death reporting and risk in Zika-affected pregnancies.

OBJECTIVES: Zika virus is linked to several adverse pregnancy outcomes. We assessed whether Zika infection during pregnancy is associated with increased risk of foetal death (miscarriage, stillbirth, abortion) and whether there is incomplete reporting of such deaths. METHODS: We searched PubMed, Embase, CINAHL, Web of Science and LILACS for studies reporting Zika-affected completed pregnancies (ending in foetal death or live birth), excluding studies whose aim required live birth. Studies 'allowed' foetal death if their populations were defined to encompass both live births and foetal deaths, regardless of whether deaths were actually found. Two authors independently extracted data and assessed study quality. Foetal death absolute and relative risks in Zika-affected vs. unaffected pregnancies were calculated. RESULTS: We found 108 reports including 24 699 completed, Zika-affected pregnancies. The median absolute risk in 37 studies of completed, Zika-affected pregnancies was 6.3% (IQR 3.2%, 10.6%) for foetal death and 5.9% (IQR 0%, 29.1%) for non-fatal adverse outcomes (e.g. microcephaly). More studies allowed non-fatal adverse outcomes (95%) than foetal death (58%). Of studies which allowed them, 94% found at least one foetal death. In 37% of reports, it was unknown whether foetal deaths were allowed. Only one study had sufficient data to estimate a foetal death relative risk (11.05, 95% CI 3.43, 35.55). CONCLUSIONS: Evidence was insufficient to determine whether foetal death risk is higher in Zika-affected pregnancies, but suggests quality of foetal death reporting should be improved, including stating whether foetal deaths were found, how many, and at what gestational ages, or justifying their exclusion.

OBJECTIFS: Le virus Zika est lié à plusieurs issues défavorables de la grossesse. Nous avons évalué si l'infection à Zika pendant la grossesse était associée à un risque accru de mort fœtale (fausse couche, mortinaissance, avortement) et s'il y avait une déclaration incomplète de ces décès. MÉTHODES: Nous avons recherché dans PubMed, EMBASE, Cinahl, Web of Science et LILACS des études rapportant des grossesses terminées touchées par le virus Zika (se terminant par une mort fœtale ou une naissance vivante), à l'exclusion des études dont l'objectif nécessitait une naissance vivante. Les études «autorisaient¼ la mort fœtale si leur population était définie comme englobant à la fois les naissances vivantes et les décès fœtaux, indépendamment du fait que des décès aient été effectivement constatés. Deux auteurs ont indépendamment extrait les données et évalué la qualité des études. Les risques absolus et relatifs de mortalité fœtale dans les grossesses affectées par Zika par rapport aux grossesses non affectées ont été calculés. RÉSULTATS: Nous avons trouvé 108 reports dont 24.699 grossesses terminées et affectées par le virus Zika. Le risque médian absolu dans 37 études portant sur des grossesses terminées affectées par Zika était de 6,3% (IQR 3,2%, 10,6%) pour la mort fœtale et de 5,9% (IQR 0%, 29,1%) pour les issues indésirables non mortelles (par exemple microcéphalie). Plus d'études ont «autorisé¼ des résultats indésirables non mortels (95%) que la mort fœtale (58%). Parmi les études qui les ont «autorisé¼, 94% ont trouvé au moins un décès fœtal. Dans 37% des rapports, il n'est pas indiqué si la mort fœtale avait été «autorisée¼. Une seule étude contenait des données suffisantes pour estimer un risque relatif de mort fœtale (11,05 ; IC95%: 3,43, 35,55). CONCLUSIONS: Les données étaient insuffisantes pour déterminer si le risque de mort fœtale est plus élevé dans les grossesses touchées par le virus Zika, mais suggèrent que la qualité des reports sur les décès fœtaux devrait être améliorée, notamment en indiquant si des décès fœtaux ont été constatés, combien et à quel âge gestationnel, ou justifiant leur exclusion.

Systematic review of ambient temperature exposure during pregnancy and stillbirth: Methods and evidence.

BACKGROUND: Associations between ambient temperature exposure during pregnancy and stillbirth have been reviewed and described in the literature. However, there is no existing review of environmental and epidemiologic methods applied to measure stillbirths resulting from exposure to ambient temperatures during pregnancy. The objective of this study is to systematically review published methods, data sources, and data linkage practices to characterize associations between ambient temperature and stillbirth to inform stillbirth prevention and risk management strategies. METHODS: A systematic review of published studies that assess the association between ambient temperature exposure during pregnancy using any measures or approach and stillbirth was undertaken in Cochrane Library, PubMed, Medline, Scopus, Embase, and Web of Science of studies (2000-2020, inclusive). Selection of studies were assessed by pre-specified eligibility criteria and documented using PRISMA. Citations were managed using EndNote X8 whilst selection, reviewing, and data extraction were performed using Covidence. The screening, selection, and data extraction process consisted of two blind, independent reviews followed by a tertiary independent review. An adapted Critical Appraisal Skills Program (CASP) checklist was used to assess quality and bias. The main findings and characteristics of all studies was extracted and summarized. Where appropriate, a meta-analysis will be performed for measures of association. RESULTS: Among 538 original records, 12 eligible articles were identified that analysed associations between ambient temperature exposure and stillbirth for 42,848 stillbirths among 3.4 million births across seven countries. Varied definitions of stillbirth were reported based on gestational age, birthweight, both, or neither. The overall rate of stillbirth ranged from 1.9 to 38.4 per 1000 among six high-income countries and one low-middle-income country. All study designs were retrospective and included ten cohort studies, three case-crossover studies, and two additional case-control subgroup analysis. Exposure data for ambient temperature was mostly derived from standard municipal or country-level monitors based on weather stations (66.6%) or a forecasting model (16.7%); otherwise, not reported (16.7%). Results were not statistically pooled for a meta-analysis due to heterogeneity of methods and models among included studies. All studies reported associations of increased risk of stillbirth with ambient temperature exposures throughout pregnancy, particularly in late pregnancy. One study estimates 17-19% (PAR) of stillbirths are potentially attributable to chronic exposure to hot and cold ambient temperatures during pregnancy. Overall, risk of stillbirth was observed to increase below 15 °C and above 23.4 °C, where highest risk is above 29.4 °C. CONCLUSION: Exposure to hot and cold temperatures during pregnancy may increase the risk of stillbirth, although a clear causative mechanism remains unknown. Despite lack of causal evidence, existing evidence across diverse settings observed similar effects of increased risk of stillbirth using a variety of statistical and methodological approaches for exposure assessments, exposure windows, and data linkage. Managing exposure to ambient temperatures during pregnancy could potentially decrease risk of stillbirth, particularly among women in low-resource settings where access to safe antenatal and obstetric care is challenging. To fully understand the effects or dose-response relationship of maternal exposure to ambient temperatures and stillbirth, future studies should focus on biological mechanisms and contributing factors in addition to improving measurement of ambient temperature exposure.

Parents' experiences of care offered after stillbirth: An international online survey of high and middle-income countries.

BACKGROUND: Stillbirth, the death of a baby before birth, is associated with significant psychological and social consequences that can be mitigated by respectful and supportive bereavement care. The absence of high-level evidence to support the broad scope of perinatal bereavement practices means that offering a range of options identified as valued by parents has become an important indicator of care quality. This study aimed to describe bereavement care practices offered to parents across different high-income and middle-income countries. METHODS: An online survey of parents of stillborn babies was conducted between December 2014 and February 2015. Frequencies of nine practices were compared between high-income and middle-income countries. Differences in proportions of reported practices and their associated odds ratios were calculated to compare high-income and middle-income countries. RESULTS: Over three thousand parents (3041) with a self-reported stillbirth in the preceding five years from 40 countries responded. Fifteen countries had atleast 40 responses. Significant differences in the prevalence of offering nine bereavement care practices were reported by women in high-income countries (HICs) compared with women in middle-income countries (MICs). All nine practices were reported to occur significantly more frequently by women in HICs, including opportunity to see and hold their baby (OR = 4.8, 95% CI 4.0-5.9). The widespread occurrence of all nine practices was reported only for The Netherlands. CONCLUSIONS: Bereavement care after stillbirth varies between countries. Future research should look at why these differences occur, their impact on parents, and whether differences should be addressed, particularly how to support effective communication, decision-making, and follow-up care.