Abstract
SummaryBackground2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth.MethodsThis stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022.Findings37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75–1·07; p=0·23).InterpretationThe RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven.FundingChief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.
Highlights
Stillbirth is a pervasive problem worldwide. 2·6 million babies were estimated to have died in utero in 2015.1 In high-income countries (HICs), one in 113–769 preg nancies end in stillbirth after 28 weeks.[2]
reduced fetal movement (RFM) is associated with fetal growth restriction[5] and placental abnormalities in pregnancies that do not end in stillbirth.[6,7]
RFM is only modestly associated with increased risk of stillbirth,[8,9] and whether RFM is a symptom of inevitable fetal death or whether it can be used as an alert to prompt action and improve outcome is unclear
Summary
Stillbirth is a pervasive problem worldwide. 2·6 million babies were estimated to have died in utero in 2015.1 In high-income countries (HICs), one in 113–769 preg nancies end in stillbirth after 28 weeks.[2]. 2·6 million babies were estimated to have died in utero in 2015.1 In high-income countries (HICs), one in 113–769 preg nancies end in stillbirth after 28 weeks.[2] Most stillbirths happen without fetal abnormality or pre-existing risk factors for stillbirth. Maternal perception of reduced fetal movement (RFM) has been identified as a potential strategy for stillbirth prevention. 30–55% of women whose pregnancies end in stillbirth experience RFM in the preceding week.[3,4] RFM is associated with fetal growth restriction[5] and placental abnormalities in pregnancies that do not end in stillbirth.[6,7] RFM is only modestly associated with increased risk of stillbirth (odds ratios [OR] 2·37–14·1),[8,9] and whether RFM is a symptom of inevitable fetal death or whether it can be used as an alert to prompt action and improve outcome is unclear. In a Cochrane review (dominated by one cluster-randomised trial of 68 000 women allocated to formal kick counting or usual treatment10), formal fetal movement counting was concluded to be of uncertain benefit as a test of fetal wellbeing.[11]
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