Reduction In Stillbirths Research Articles

Pre-Term, Deferred and Referred Deliveries Contribute to Stillbirths in the Indian State of Bihar: Results from a Population-Based Survey of All Births

Background: The Indian government has adopted a target of <10 stillbirths per 1,000 births by 2030 through the India Newborn Action Plan (INAP). A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population. Methods: Detailed interviews were conducted in a representative sample of all births irrespective of the birth outcome between January to December 2016 from 182,486 households (96.2% participation) in 1,657 clusters in the India state of Bihar. A stillbirth was defined as fetal death with gestation period of >28 weeks wherein the fetus did not show any sign of life. We investigated the association of stillbirth with a variety of socio-demographic, maternal, pregnancy, labour and delivery related risk factors among all births using a hierarchical logistic regression model approach. Findings: A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1,000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1,000 births, respectively. In the final logistic regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities and home (OR 2.23, 95% CI 1.67-2.99). Varied risk factors were associated with antepartum and intrapartum stillbirths. Among the facility deliveries, the referred deliveries had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43). Interpretation: This study finds increased risk of stillbirths in deferred and referred deliveries in addition to identifying demographic and clinical risk factors for antepartum and intrapartum stillbirths from population-based data, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise the findings of this study to further strengthen its approach to meet the stillbirth reduction target by 2030. Funding Statement: This work was supported by the Bill & Melinda Gates Foundation. Declaration of Interests: PN and DB are employees of the Bill & Melinda Gates Foundation, India Country Office, New Delhi. The other authors have no conflict of interest. Ethics Approval Statement: This study was approved by the Institutional Ethics Committee of the Public Health Foundation of India. All participants provided written informed consent, and for those who could not read or write, the participant information sheet and consent form were explained by the trained interviewer and a thumb impression obtained.

Role of maternity waiting homes in the reduction of maternal death and stillbirth in developing countries and its contribution for maternal death reduction in Ethiopia: a systematic review and meta-analysis

BackgroundEvery family expect to have a healthy mother and new born baby after pregnancy. Especially for parents, pregnancy is a time of great anticipation. Access to maternal and child health care insures safer pregnancy and its outcome. MWHs is one the strategy. The objective was to synthesize the best available evidence on effectiveness of maternity waiting homes on the reduction of maternal mortality and stillbirth in developing countries.MethodsBefore conducting this review non-occurrences of the same review is verified. To avoid introduction of bias because of errors, two independent reviewers appraised each article. Maternal death and stillbirth were the primary outcomes. Review Manager 5 were used to produce a random-effect meta-analysis. Grade Pro software were used to produce risk of bias summary and summary of findings.ResultIn developing countries, maternity waiting homes users were 80% less likely to die than non-users (OR = 0. 20, 95% CI [0.08, 0.49]) and there was 73% less occurrence of stillbirth among users (OR = 0.27, 95% CI [0.09, 0.82]). In Ethiopia, there was a 91% reduction of maternal death among maternity waiting homes users unlike non-users (OR = 0.09, 95% CI [0.04, 0.19]) and it contributes to the reduction of 83% stillbirth unlike non-users (OR = 0.17, 95% CI [0.05, 0.58]).ConclusionMaternity waiting home contributes more than 80% to the reduction of maternal death among users in developing countries and Ethiopia. Its contribution for reduction of stillbirth is good. More than 70% of stillbirth is reduced among the users of maternity waiting homes. In Ethiopia maternity waiting homes contributes to the reduction of more than two third of stillbirths.

Risk factors of stillbirth in Yemen.

Yemen has the highest stillbirth rate among the Arab countries. However, the risk factors of this high rate are lacking. This study aimed to determine the maternal, newborn, and service related risk factors for stillbirths at the main maternity hospital in Sana'a city. A case-control study was conducted in the main maternity hospital in Sana'a city, Yemen. Case and controls were selected prospectively during the study period. Cases were women who delivered stillbirths after 24 weeks of gestation. Risk factors data for mothers and their neonates were collected using face-to-face interview and data abstraction from medical records. The study included 101 women with stillbirths and 202 women with singleton live births. Mothers older than 35 years (Odds ratio (OR) = 4.9) and those with low level of education were significantly more likely to give stillbirths. Prolonged labor (OR = 5.8), mothers' anemia (OR = 2.1), less than 4 antenatal visits (OR = 5.1) and meconium stained amniotic fluid (OR = 11.5) were significantly associated with increased odds of stillbirth. Prematurity (OR = 27), umbilical complications (OR = 6.4), low birth weight (OR = 17.7), and congenital complications (OR = 40.6) were significantly associated with higher odds of stillbirths. This study identified many risk factors of stillbirth that are amenable to intervention. Encouraging women to deliver at health facilities, providing better management of obstetrical complications, proper antenatal care, and prompt referral services are essential for reduction of stillbirths in Yemen.

Investigating maternal risk factors for stillbirth in a population-based cohort in the South of England

Introduction In the UK there has been little improvement on the rates of stillbirth; the stillbirth rate was 2.9 per 1000 in 2015 (≥ 28 weeks gestation) and the annual rate reduction (ARR) of stillbirths was 1.4% from 2000–2015, which is roughly in the bottom one-third of high-income countries. Until now, most studies have only identified individual maternal risk factors associated with stillbirth and, to our knowledge, only one study has produced a stillbirth prediction model in the UK. Our study aimed to investigate risk factors for stillbirth (defined as a baby delivered with no signs of life after 24 weeks of pregnancy) using routinely-collected healthcare data at a regional level in the South of England. Methods Analysis of a population-based cohort using routine antenatal care and delivery data collected between 2003–2017 in Southampton, UK. Stillbirth was defined as born with no signs of life after 24 weeks gestation. Univariable comparisons between livebirth and stillbirth pregnancies were made using chi-squared test for categorical variables and independent t-test for continuous variables. Logistic regression modelling produced unadjusted and adjusted odd ratios (aOR) for stillbirth risk, adjusting for within-participant clustering of multiple pregnancies. A stillbirth prediction model was developed using backward stepwise regression. The model's derivation area under receiver operator curve (AUROC) was calculated. For the purpose of generating and testing a stillbirth risk score, the cohort was divided chronologically into derivation (n = 44,108) and internal validation cohorts (n = 24,684). An unweighted risk score variable consisting of the number of risk factors was generated for each pregnancy. A weighted risk score variable was generated taking into account the magnitude of the association of each risk factor with stillbirth (OR). Results The total sample size was 81,798 (81,366 livebirth pregnancies and 432 stillbirths), giving a stillbirth incidence rate (≥ 24 weeks gestation) of 5.28/1000 (95% CI 4.80–5.80). A total of15,813 births were excluded in the multivariable model due to missing data, hence giving a total number of 65,985 births (65,663 livebirths and 322 stillbirths). Significant risk factors for stillbirth in the multivariable model of the whole cohort (n = 65,985) included: maternal age ≥ 35 years (aOR 1.39, 95% CI 1.03–1.87), Asian ethnicity (aOR 1.80, 95% CI 1.22–2.66), mothers with unemployed partners (aOR 1.53 95% CI 1.07–2.18]), no previous livebirths (aOR 1.49, 95% CI 1.13–1.97), maternal educational qualification of secondary school or below (aOR 1.46, 95% CI 1.07–2.00) and college (aOR 1.49, 95% CI 1.05–2.12) (compared to university qualification or above), maternal obesity (aOR 1.58, 95% CI 1.18, 2.12), diastolic hypertension (aOR 4.3, 95% CI 2.04–9.06) and pre-existing diabetes (aOR 2.35, 95% CI 1.35, 4.11). Upon investigating the proportion of women in the study population (n = 65 985) with significant risk factors identified in the multivariable analysis; 5126 (7.42%) had none, 25,430 (36.80%) had one, 27,442 (39.71%) had two, 9518 (13.77%) had three and 1586 (2.30%) had ≥ 4 significant risk factors. When conducting the multivariable model in the derivation cohort (n = 44 108) and testing the risk score in the validation cohort (n = 24 684), for each additional significant risk factor, there was a 16% increased risk of stillbirth (95% CI 6–27%, P = 0.001). The stillbirth prediction model's AUROC was 0.64 (95% CI 0.61–0.67). Conclusion This study identifies the characteristics associated with stillbirth in this English cohort and that the risk of stillbirth is amplified in women with co-existing risk factors. Derived using routinely-collected healthcare data, this prediction model, if externally validated, can help early identification of pregnant mothers at risk of stillbirth from their first antenatal appointment. Interventions attempting to prevent stillbirth could then be targeted at the high-risk mothers.

Stillbirths in urban Guinea-Bissau: A hospital- and community-based study.

BackgroundStillbirth rates remain high in many low-income settings, with fresh (intrapartum) stillbirths accounting for a large part due to limited obstetrical care. We aimed to determine the stillbirth rate and identify potentially modifiable factors associated with stillbirth in urban Guinea-Bissau.MethodsThe study was carried out by the Bandim Health Project (BHP), a Health and Demographic Surveillance System site in the capital Bissau. We assessed stillbirth rates in a hospital cohort consisting of all deliveries at the maternity ward at the National Hospital Simão Mendes (HNSM), and in a community cohort, which only included women from the BHP area. Stillbirth was classified as fresh (FSB) if fetal movements were reported on the day of delivery.ResultsFrom October 1 2007 to April 15 2013, a total of 38164 deliveries were registered at HNSM, among them 3762 stillbirths (99/1000 births). Excluding deliveries referred to the hospital from outside the capital (9.6%), the HNSM stillbirth rate was 2786/34490 births (81/1000). During the same period, 15462 deliveries were recorded in the community cohort. Of these, 768 were stillbirths (50/1000).Of 11769 hospital deliveries among women from Bissau with data on fetal movement, 866 (74/1000) were stillbirths, and 609 (70.3%) of these were FSB, i.e. potentially preventable. The hospital FSB rate was highest in the evening from 4 pm to midnight (P = 0.04). In the community cohort, antenatal care (ANC) attendance correlated strongly with stillbirth reduction; the stillbirth rate was 71/1000 if the mother attended no ANC consultations vs. 36/1000 if she attended ≥7 consultations (P<0.001).ConclusionIn Bissau, the stillbirth rate is alarmingly high. The majority of stillbirths are preventable FSB. Improving obstetrical training, labour management (including sufficient intrapartum monitoring and timely intervention) and hospital infrastructure is urgently required. This should be combined with proper community strategies and additional focus on antenatal care.

Electronic fetal monitoring is more important than freedom of maternal position in labour: FOR: Position in labour is important but EFM can be vital.

There is universal acceptance (except perhaps by ‘free-birthers’) that there is a likely benefit from some form of fetal surveillance during labour. Currently, the choice is between intermittent auscultation and continuous electronic fetal monitoring (cEFM). Even intermittent ‘auscultation’ is commonly performed using a portable Doppler ultrasound fetal heart detector, the only sensible option if the mother is very obese. Although meta-analyses have shown a statistically significant 30% reduction in stillbirth attributed to asphyxia when cEFM is used rather than auscultation (Vintzileos et al. Obstet Gynecol 1995;85:149–55) and a statistically significant 50% reduction in neonatal convulsions (Thacker et al. Obstet Gynecol 1995;86:613–20), the 2014 UK National Institute of Health and Clinical Excellence guidelines still recommend intermittent auscultation for women ‘without risk factors’ (https://www.nice.org.uk/guidance/cg190). But how many women have/develop risk factors? I analysed 29 443 births from 1988 to 1998 at the West London/Chelsea and Westminster Hospitals and found that 74% had at least one risk factor where cEFM is recommended (maternal age ≥40, diabetes, cardiac or renal disease, antepartum haemorrhage, diastolic blood pressure ≥90 mmHg, non-cephalic presentation, induced or augmented labour, epidural anaesthesia, pyrexia, meconium staining of the amniotic fluid, or labour >12 hours). So in only 26% was cEFM not indicated at some time during labour. How important is posture in labour? I accept that the supine position should be avoided. Williams in 1952 illustrated the adverse effect on uterine activity of the supine position compared with sitting (frequency of contractions doubled and active pressure halved [J Obstet Gynaecol Br Emp 1952; 59:635–641]) and this was corroborated in 1960 by Caldeyro-Barcia (Am J Obstet Gynecol 1960;80:284–90), in 1978 by Turnbull (figure 4.11, Scientific Basis of Obstetrics and Gynaecology, 1978;79–108) and by my personal observations (unpublished). But does any particular position other than supine confer an advantage? Is gravity helpful? Mendez-Bauer suggested in 1975 that standing improved progress in labour, but his comparison was with the supine position (J Perinat Med 1975;3:89–100). When challenged to repeat the study comparing standing with lateral recumbency, he found no difference (Roberts et al. J Reprod Med 1984;29:477–81). In human childbirth, where the baby has to be pushed through a birth canal commonly smaller than the unmoulded fetal head, the driving force is uterine contractions, not gravity. This is elegantly demonstrated by the fact that labour in a birthing pool, where the effect of gravity is negated by the buoyancy of the water, has the same duration as labour on dry land (Cluett & Burns. Cochrane Database Syst Rev 2009;(2):CD000111). These data support the 2014 NICE recommendation that women should be discouraged from being supine but encouraged to adopt any other position they find comfortable. Some women value freedom to move, but in many cases, cEFM is vitally important, and with telemetry there is, in any case, no reason why maternal movement should be restricted. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Fetal growth surveillance - Current guidelines, practices and challenges.

Antenatal surveillance of fetal growth is an essential part of good maternity care, as lack of detection of fetal growth restriction is directly associated with stillbirth and perinatal morbidity. New algorithms and guidelines provide care pathways which rely on regular third trimester ultrasound biometry and plotting of estimated fetal weight in pregnancies considered to be at increased risk, and their implementation has increased pressures on ultrasound resources. Customised growth charts have improved the distinction between constitutional and pathological smallness and reduced unnecessary referrals. Their introduction, together with clinicians' training, e-learning and audit as the key elements of the growth assessment protocol, has resulted in increased antenatal detection of small for gestational age babies and a reduction in avoidable stillbirths. However, missed case audits highlight that further improvements are needed, and point to the need to address quality assurance and resource issues in ultrasound services.

Causes and risk factors for singleton stillbirth in Japan: Analysis of a nationwide perinatal database, 2013\u20132014

Over 80% of perinatal mortality in Japan is due to stillbirths after 22 weeks of gestation, with one in 300 families experiencing fetal loss every year. This study aimed to assess causes and risk factors for singleton stillbirth in Japan. A retrospective cross-sectional study was conducted using the Japan Society of Obstetrics and Gynecology Perinatal Database from January 2013 to December 2014. A total of 379,211 births including 2,133 stillbirths were analyzed. Causes of death were classified into eight categories. A multi-level Poisson regression model was used to assess the relationship between stillbirth and key covariates. Causes of death were unknown in 25–40% of stillbirths across gestational age. Placental abnormality accounted for the largest proportion of known causes, followed by umbilical cord abnormality. Stillbirth risk was increased among small-for-gestational-age infants (adjusted relative risk [ARR]: 3.78, 95% confidence interval [CI]: 3.31–4.32) and nulliparous women (ARR: 1.19, 95% CI: 1.05–1.35). Maternal underweight, pregnancy-induced hypertension and oligohydramnios showed a protective effect. Our finding suggests that stillbirths occurring among women with known complications are likely already being prevented. Further reduction in stillbirths must target small-sized fetuses and nulliparous women. Improved recording of the causal pathways of stillbirths is also needed.

Potentially Preventable Stillbirth in a Diverse U.S. Cohort.

To estimate the proportion of potentially preventable stillbirths in the United States. We conducted a secondary analysis of 512 stillbirths with complete evaluation enrolled in the Stillbirth Collaborative Research Network from 2006 to 2008. The Stillbirth Collaborative Research Network was a multisite, geographically, racially, and ethnically diverse, population-based case-control study of stillbirth in the United States. Cases of stillbirth underwent standard evaluation that included maternal interview, medical record abstraction, biospecimen collection, postmortem examination, placental pathology, and clinically recommended evaluation. Each stillbirth was assigned probable and possible causes of death using the Initial Causes of Fetal Death algorithm system. For this analysis, we defined potentially preventable stillbirths as those occurring in nonanomalous fetuses, 24 weeks of gestation or greater, and weighing 500 g or greater that were 1) intrapartum, 2) the result of medical complications, 3) the result of placental insufficiency, 4) multiple gestation (excluding twin-twin transfusion), 5) the result of spontaneous preterm birth, or 6) the result of hypertensive disorders of pregnancy. Of the 512 stillbirths included in our cohort, causes of potentially preventable stillbirth included placental insufficiency (65 [12.7%]), medical complications of pregnancy (31 [6.1%]), hypertensive disorders of pregnancy (20 [3.9%]), preterm labor (16 [3.1%]), intrapartum (nine [1.8%]), and multiple gestations (four [0.8%]). Twenty-seven stillbirths fit two or more categories, leaving 114 (22.3%) potentially preventable stillbirths. Based on our definition, almost one fourth of stillbirths are potentially preventable. Given the predominance of placental insufficiency among stillbirths, identification and management of placental insufficiency may have the most immediate effect on stillbirth reduction.

896: Quality improvement projects to reduce decision to incision time: A cost-effective approach to improve neonatal outcomes

Obstetric emergencies such as fetal bradycardia, uterine rupture, abruption, and cord prolapse require prompt recognition and expeditious delivery to avoid fetal hypoxia, acidemia, and the related short and long-term sequelae. Several studies have shown quality improvement projects to be successful in decreasing decision to incision intervals with a recent study demonstrating subsequent improvement in neonatal outcomes. We aimed to determine if a quality improvement project was a cost effective approach for improving neonatal outcomes in labor and delivery units of varying sizes. A decision-analytic model was built using TreeAge software and inputs derived from the literature. The model compared the outcomes with or without an educational program to reduce the decision-to-incision time at small, medium, and large volume institutions. Long-term outcomes included stillbirth, neonatal death, and cerebral palsy. The cost-effectiveness threshold was set to $100,000 per quality adjusted life year (QALY). Univariate sensitivity analyses were used to vary model inputs to investigate the robustness of the model results. In our model, an educational quality improvement project was the dominant strategy (greater effectiveness, lower costs) when compared to the current state. Program implementation and improved decision to incision intervals resulted in a reduction of stillbirths, neonatal deaths, and cases of cerebral palsy regardless of institutional volume. Furthermore it would save $65,516 and result in 2.87 additional QALYs per emergent cesarean delivery. In a medium volume hospital, performing approximately 50 emergent deliveries/year, this equates to a savings of $6.8 million dollars and more than two surviving neonates annually. Sensitivity analyses demonstrated that the model was robust even with variation in program cost and probability of adverse neonatal outcomes in the post-education group. Multidisciplinary quality improvement programs to improve decision to incision intervals are both effective and cost saving in improving neonatal outcomes regardless of obstetric volume. Translation of such programs broadly into obstetric units requires further implementation and research.

An autopsy based descriptive study of the spectrum of pulmonary lesions encountered in fetal deaths at a tertiary care center.

: Fetal autopsy has been an indispensable tool in evaluating the cause of death. The most common cause for fetal deaths is associated with respiratory disorders accounting for around 60%. This study was undertaken to evaluate the gross and microscopic features of lungs in fetal autopsies and estimate the incidence of deaths attributable to pulmonary causes. : All fetuses received for autopsy at our institute were included in the study with prior consent. Gross and microscopic findings along with relevant clinical data were recorded. A total of 426 autopsies were conducted from January 2011 to August 2016. Of those, 184 had abnormal pulmonary findings constituting 43.19%. Aspiration pneumonia was the most common finding with 67 cases (36.4%), followed by atelectasis 54 cases (29.3%), congenital cystic adenomatoid malformation in 13 cases (7.1%), lung hypoplasia 12 cases (6.5%), pulmonary hemorrhage 21 (11.4%), 15 cases (8.15%) of hyaline membrane disease, one case (0.5%) of heterotaxy, and one case of extralobar pulmonary sequestration (0.5%). Congenital malformations of lungs were seen in 27 (14.67%) cases and 38 cases (20.65%) had other associated anomalies. Pulmonary pathology is the most common finding in fetal deaths with aspiration pneumonitis being the most common avoidable cause. Accurate fetal autopsy along with clinical data are important in evaluating fetal deaths and can help in reduction of unexplained stillbirths.

Stillbirth prevention 1921 and 2016: the call for 'adequate antenatal supervision'.

Prevention of stillbirth has been a goal of obstetrics for over a century. As Goldenberg et al. demonstrate in their model for prevention of stillbirths in sub-Saharan Africa, increased hospital care with fetal monitoring and access to caesarean section result in the greatest reduction in stillbirths (Goldenberg et al. BJOG 2018;125:119–129). Similarly, practitioners in the early twentieth century also sought to prevent stillbirth through increased use of hospitals, improved fetal monitoring and antenatal care. A 1921 case series of stillbirths by Francis J. Browne, a research pathologist at the Royal Maternity Hospital in Edinburgh, included causes such as craniotomy (delivery of obstructed labour by decompression of the fetal cranium), asphyxia neonatorum (antepartum or intrapartum), cerebral haemorrhage, syphilis and scopolamine–morphine narcosis (from the infamous ‘twilight sleep’; Browne. Br Med J 1921;2;140–5). Twenty-five years later, Evans et al. recorded causes of stillbirth after completion of autopsy at two hospitals in England. Asphyxia remained the leading cause of stillbirth, followed by infections and intracranial haemorrhage (Figure 1; Evans et al. J Obstet Gynaecol Br Emp 1946;53;440–52). Strategies for stillbirth prevention between 1921 and 1946 are strikingly similar to those used today. Evans called for ‘careful auscultation of the foetal heart in the second stage,’ just as Browne advised ‘keeping a careful watch’ on the fetal heart. Practitioners performed intermittent auscultation with a fetoscope, which, as Browne stated, could be very difficult with the ‘pains coming frequently, and the mother crying loudly’. Second, both argued for ‘adequate antenatal supervision’—something that was not performed, either routinely or as standard, until the second half of the century. Lastly, obstetricians argued for increased use and provision of maternity hospitals to achieve lower stillbirth and infant mortality rates (The Health Committee of the League of Nations. Br Med J 1930;13;441–2). Regular use of hospitals by labouring women was not commonplace until the mid-century. It is tempting to compare stillbirth in England a century ago to sub-Saharan Africa today. Of course, this is a gross simplification and an unfair representation of modern low-income countries. Granted, there are similarities regarding lack of access to prenatal care, fetal monitoring, hospitals and safe and timely operative delivery. However, the circumstances under which stillbirth prevention was attempted a century ago and that attempted in sub-Saharan Africa today are radically different. History teaches us that improving stillbirth rates is a long process that requires widespread change in medical practice, improvement in infrastructure, and close attention to cultural meanings and understandings of stillbirth. Even in high-income countries there is considerable room to further reduce stillbirth while decreasing the morbidity of interventions. Little did early twentieth century clinicians know that improved obstetric care would lead to its own set of difficulties (e.g. increased rates of caesarean delivery, placenta accreta and preterm birth). Just as in the early 1900s, identification of the causes of many stillbirths and the best methods of prevention remain elusive today. The author is grateful to Robert Silver, MD for editorial support. None declared. Completed disclosure of interests form available to view online as supporting information. ■ Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Modelling stillbirth mortality reduction with the Lives Saved Tool

BackgroundThe worldwide burden of stillbirths is large, with an estimated 2.6 million babies stillborn in 2015 including 1.3 million dying during labour. The Every Newborn Action Plan set a stillbirth target of ≤12 per 1000 in all countries by 2030. Planning tools will be essential as countries set policy and plan investment to scale up interventions to meet this target. This paper summarises the approach taken for modelling the impact of scaling-up health interventions on stillbirths in the Lives Saved tool (LiST), and potential future refinements.MethodsThe specific application to stillbirths of the general method for modelling the impact of interventions in LiST is described. The evidence for the effectiveness of potential interventions to reduce stillbirths are reviewed and the assumptions of the affected fraction of stillbirths who could potentially benefit from these interventions are presented. The current assumptions and their effects on stillbirth reduction are described and potential future improvements discussed.ResultsHigh quality evidence are not available for all parameters in the LiST stillbirth model. Cause-specific mortality data is not available for stillbirths, therefore stillbirths are modelled in LiST using an attributable fraction approach by timing of stillbirths (antepartum/ intrapartum). Of 35 potential interventions to reduce stillbirths identified, eight interventions are currently modelled in LiST. These include childbirth care, induction for prolonged pregnancy, multiple micronutrient and balanced energy supplementation, malaria prevention and detection and management of hypertensive disorders of pregnancy, diabetes and syphilis. For three of the interventions, childbirth care, detection and management of hypertensive disorders of pregnancy, and diabetes the estimate of effectiveness is based on expert opinion through a Delphi process. Only for malaria is coverage information available, with coverage estimated using expert opinion for all other interventions. Going forward, potential improvements identified include improving of effectiveness and coverage estimates for included interventions and addition of further interventions.ConclusionsKnown effective interventions have the potential to reduce stillbirths and can be modelled using the LiST tool. Data for stillbirths are improving. Going forward the LiST tool should seek, where possible, to incorporate these improving data, and to continually be refined to provide an increasingly reliable tool for policy and programming purposes.

Effect of locally tailored labour management guidelines on intrahospital stillbirths and birth asphyxia at the referral hospital of Zanzibar: a quasi-experimental pre-post study (The PartoMa study).

To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2015 until 31 January 2016) [corrected]. Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). Stillbirths and neonates with 5-minute Apgar score ≤5. Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved. Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.

Global variation in pregnancy complications in women with epilepsy: A meta-analysis

ObjectiveWomen with epilepsy are at risk of pregnancy complications. Whether these vary globally is unknown. We undertook a systematic review to assess the overall rates of obstetric outcomes in women with epilepsy, and variations in estimates across geographical region, economic status of country, and over time. Study designWe searched Medline, Embase, Cochrane, AMED and CINAHL, (January 1, 1990 and November 29, 2016), without any language restrictions for studies reporting core maternal and fetal outcomes in women with epilepsy. We pooled the results using Freeman-Tukey Transformation random effectsanalysis, and reported our findings as rates of complications per 100 pregnancies with 95% confidence intervals (CI). We assessed for differences in risk across World Health Organisation (WHO) regions, income status, and year of publication. ResultsFrom the 7420 articles screened, we included 60 studies (62 articles). In women with epilepsy (116,105 pregnancies), the commonest complications were caesarean section (29.2 per 100 pregnancies; 95% CI 25.4–33.1, I2=98.44%), and admission to the neonatal intensive care unit (12.5 per 100 pregnancies; 95% CI 9.6–15.8, I2=60.63%). There were significant differences across the WHO regions, with the highest rates of caesarean section (37%, 95% CI 32%–42%); spontaneous miscarriage (39%, 95% CI 35%–44%) and preterm birth (10%, 95% CI 8%–12%) in the Americas; postpartum haemorrhage (9%, 95% CI 7%–12%), hypertensive disorders (14%, 95% CI 8%–21%) and perinatal death (2%, 95% CI 1%–7%) in the Western Pacific; induction of labour (30%, 95% CI 19%–41%) in South East Asia and antepartum haemorrhage (10%, 95% CI 5%–17%) in the Eastern Mediterranean. The reported rates of antepartum haemorrhage, caesarean section, gestational diabetes and spontaneous miscarriage were highest in high income and high-middle income countries. Over time, there was a significant increase in caesarean section, and reduction in stillbirths, perinatal deaths and admission to the neonatal intensive care unit in women with epilepsy. ConclusionThere is significant variation in reported maternal and offspring outcomes in pregnant women with epilepsy across geographical regions, economic status of country and over time, which needs to be considered in setting priorities for clinical management and research.

Using record linkage to demonstrate the benefits of maternal influenza immunisation in Western Australia

ABSTRACTObjectivesPregnant women are the highest priority for seasonal influenza vaccination. Previous research has found maternal immunisation may not only reduce respiratory infections in mothers and infants, but also prevents adverse birth outcomes. Although the vaccine has been offered to pregnant women under the National Immunisation Program since 2009, no population-based study has yet evaluated its impact on neonatal health in Australia.&#x0D; ApproachWe established a large retrospective cohort of 58,615 births between 2012 and 2013 in Western Australia using data linkage of state-held maternal vaccination records, birth registrations, hospital inpatient records, and midwives notifications. Cox regression models were used to compare the adjusted relative hazard (HR) of adverse birth outcomes and hospital admission for an acute respiratory illness (ARI) by vaccination status.&#x0D; ResultsIn total, 5,241 (8.9%) of infants were born to vaccinated mothers. Between 2012 and 2013, there were 23.6 ARI admissions per 1,000 infants &lt;6 months and 2.8 ARI admissions per 1,000 pregnant women. Influenza vaccination was associated with a 51% reduction in stillbirth (aHR: 0.49; 95% CI: 0.29-0.84) and a 25% reduction in infant admissions in the first six months of life (aHR: 0.75; 95% CI: 0.56-0.99). Most of the reduction in ARI admission in infants was observed when vaccination occurred in the third trimester (aHR: 0.68; 95% CI: 0.47-0.95).&#x0D; ConclusionsOur findings support the neonatal health benefits afforded by maternal influenza immunisation and underscore the importance of offering and promoting influenza vaccination to pregnant women. Considering more than 90% of women who choose to be immunised do so to protect their infant, these results could be used to powerfully promote maternal immunisation.

Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions.

Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions. We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered. Pregnancies in SSA in 2012. For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates. Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions. Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth. Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries. Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.

Designing and Implementing the Helping Babies Breathe Program in Tanzania.

The first day and especially the first hour are critical to newborn survival with the highest risk of intrapartum-related neonatal deaths, from 60 to 70%, occurring within 24 hours of birth. Birth asphyxia (BA) or failure to initiate or sustain spontaneous breathing at birth contributes to approximately 27 to 30% of neonatal deaths. In 2009, Helping Babies Breathe (HBB), an evidence-based educational program developed to teach neonatal resuscitation techniques in limited-resource setting, was introduced and piloted in Tanzania. HBB resulted in a significant 47% reduction in early neonatal mortality from 13.4 to 7.1 per 1,000 live-born deliveries ( p < 0.0001) and a significant reduction (24%) in fresh stillbirths from 19.0 per 1,000 preimplementation to 14.4 per 1,000 births postimplementation ( p = 0.001). The use of stimulation and suctioning increased, whereas the need for bag mask ventilation decreased significantly post-HBB. This success was attributed to several key strategies including elevating BA as a national priority in health care, identification of a primary person (a pediatrician) at the ministerial level who assumed ownership of the program, local site ownership by a midwife, a commitment to train all birth attendants in the current health workforce in HBB, a commitment to provide required resuscitation equipment at all levels, and periodic review of the data (biannually) at a centralized meeting, under the direction of the Ministry of Health, involving all stakeholders to instill a sense of accountability. A national rollout of provider training is almost complete with almost 15,000 already trained.

Prevention and treatment of mother-to-child transmission of syphilis.

Athough more than 90% of syphilis cases are diagnosed in developing countries, syphilis rates in industrialized countries have been increasing since the 1980s. Untreated syphilis in pregnancy is associated with high rates of adverse pregnancy outcomes, including fetal loss, premature birth, congenital syphilis, and neonatal death. We reviewed the recent literature on adverse pregnancy outcomes associated with untreated syphilis and the benefits of early and effective treatment. Up to two-thirds of pregnant women with untreated syphilis may develop unwanted complications compared with a background rate of 14% in pregnant women without syphilis. A review of interventions to screen and manage infections during pregnancy found that those focusing on syphilis demonstrated an 80% reduction in stillbirths as compared with strategies to treat, detect, or prevent other infections in pregnancy, such as malaria (22% reduction), HIV (7% reduction) or bacterial vaginosis (12% reduction). Detection and treatment of syphilis before the third trimester (28 weeks) can revert the risk of adverse outcomes to background rates. Transplacental transmission of syphilis, especially in the third trimester, is associated with high rates of adverse outcomes, but the risk can be significantly reduced with early detection and treatment in the first and second trimesters, along with careful management of the infant after birth.

Seasonal Trivalent Influenza Vaccination During Pregnancy and the Incidence of Stillbirth: Population-Based Retrospective Cohort Study

Although antenatal influenza vaccination is an important public health intervention for preventing serious infection in pregnant women and newborns, reported vaccine coverage is often <50%. Concern for the safety to the fetus is a commonly cited reason for vaccine hesitancy and refusal. The incidence of stillbirth following pandemic vaccination has been previously studied; however, no population-based study has evaluated the incidence of stillbirth following seasonal trivalent influenza vaccination. We used probabilistic linking of perinatal and maternal vaccination records to establish a cohort of 58 008 births occurring between April 2012 and December 2013. Stillbirth was defined as birth ≥20 weeks' gestation with an Apgar score of zero at 1 and 5 minutes following delivery. Cox regression models adjusted for maternal smoking, Indigenous status, and propensity for vaccination were used to calculate adjusted hazard ratios (aHRs) in vaccinated and unvaccinated mothers. A total of 5076 (8.8%) pregnant women received trivalent influenza vaccine and 377 stillbirths occurred. There were 5.0 and 3.0 stillbirths per 100 000 pregnancy-days among unvaccinated and vaccinated women, respectively. After adjustment, stillbirth was 51% less likely among vaccinated vs unvaccinated mothers (aHR, 0.49; 95% confidence interval [CI], .29-.84). The largest relative reduction in stillbirths was observed for births occurring just after influenza season (aHR, 0.33; 95% CI, .12-.88). Mothers who received seasonal TIV during pregnancy were significantly less likely to experience stillbirth compared with unvaccinated mothers. These results support the safety of seasonal influenza immunization during pregnancy and suggest a protective effect.