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Nyadanu SD, Foo D, Pereira G, Mickley LJ, Feng X, Bell ML. Short-term effects of wildfire-specific fine particulate matter and its carbonaceous components on perinatal outcomes: A multicentre cohort study in New South Wales, Australia. ENVIRONMENT INTERNATIONAL 2024; 191:109007. [PMID: 39278048 DOI: 10.1016/j.envint.2024.109007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 07/04/2024] [Accepted: 09/10/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND Epidemiological evidence on the association between wildfire-specific fine particulate matter (PM2.5) and its carbonaceous components with perinatal outcomes is limited. We aimed to examine the short-term effects of wildfire-specific PM2.5 and its carbonaceous components on perinatal outcomes. METHODS A multicentre cohort of 9743 singleton births during the wildfire seasons from 1 September 2009 to 31 December 2015 across six cities in New South Wales, Australia were linked with daily wildfire-specific PM2.5 and carbonaceous components (organic carbon and black carbon). Adjusted distributed lag Cox regression models with spatial clustering were performed to estimate daily and cumulative adjusted hazard ratios (aHRs) during the last four gestational weeks for preterm birth, stillbirth, nonvertex presentation, low 5-min Apgar score, special care nursery/neonatal intensive care unit (SCN/NICU) admission, and caesarean section. RESULTS Daily aHRs per 10 µg/m3 PM2.5 showed nearly inverted 'U'-shaped positive associations and daily cumulative aHRs that increased with increasing duration of the exposures. The aHRs for lag 0-6 days were 1.17 (95 % CI: 1.04, 1.32) for preterm birth, 1.40 (95 % CI: 1.11, 1.78) for stillbirth, 1.20 (95 % CI: 1.08, 1.33) for nonvertex presentation, 1.12 (95 % CI: 0.93, 1.35) for low 5-min Apgar score, 0.99 (95 % CI: 0.83, 1.19) for SNC/NICU admission, and 1.01 (95 % CI: 0.94, 1.08) for caesarean section. Organic carbon and black carbon components for lag 0-6 days showed positive associations. The highest component-specific aHRs were 1.09 (95 % CI: 1.03, 1.15) and 4.57 (95 % CI: 1.96, 10.68) for stillbirth per 1 µg/m3 organic carbon and black carbon, respectively. The subgroups identified as most vulnerable were female births, births to mothers with low socioeconomic status, and births to mothers with high biothermal exposure. CONCLUSIONS Positive associations of short-term wildfire-specific PM2.5 exposure and its carbonaceous components with adverse perinatal outcomes suggest that policies to reduce exposure would benefit public health.
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Affiliation(s)
- Sylvester Dodzi Nyadanu
- Curtin School of Population Health, Curtin University, Perth, Western Australia 6102, Australia; Healthy Environments and Lives (HEAL) National Research Network, Australia.
| | - Damien Foo
- Curtin School of Population Health, Curtin University, Perth, Western Australia 6102, Australia; Yale School of the Environment, Yale University, New Haven, CT, United States
| | - Gavin Pereira
- Curtin School of Population Health, Curtin University, Perth, Western Australia 6102, Australia; enAble Institute, Curtin University, Perth, Kent Street, Bentley, Western Australia 6102, Australia
| | - Loretta J Mickley
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, United States
| | - Xu Feng
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, United States
| | - Michelle L Bell
- Yale School of the Environment, Yale University, New Haven, CT, United States; School of Health Policy and Management, College of Health Sciences, Korea University, Seoul 02841, Republic of Korea
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Bowman A, Sullivan T, Makrides M, Flenady V, Shepherd E, Hawke K, Stuart-Butler D, Leane C, Middleton P. Lifestyle and sociodemographic risk factors for stillbirth by region of residence in South Australia: a retrospective cohort study. BMC Pregnancy Childbirth 2024; 24:368. [PMID: 38750442 PMCID: PMC11097586 DOI: 10.1186/s12884-024-06553-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
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.
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Affiliation(s)
- Anneka Bowman
- Aboriginal Communities and Families Health Research Alliance (ACRA), Adelaide, Australia.
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia.
- University of Adelaide, Adelaide, Australia.
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia.
| | - Thomas Sullivan
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - Maria Makrides
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - Vicki Flenady
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Emily Shepherd
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - Karen Hawke
- Aboriginal Communities and Families Health Research Alliance (ACRA), Adelaide, Australia
- Flinders University, Adelaide, Australia
| | - Deanna Stuart-Butler
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Cathy Leane
- Aboriginal Health Division of the Women's and Children's Health Network, Adelaide, Australia
| | - Philippa Middleton
- Aboriginal Communities and Families Health Research Alliance (ACRA), Adelaide, Australia
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
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Massi L, Lewis C, Stewart S, Jans D, Gautam R, Jalloub L, Bowman A, Middleton P, Vlack S, Boyle FM, Shepherd C, Flenady V, Stuart-Butler D, Rae KM. Looking after bubba for all our mob: Aboriginal and Torres Strait Islander community experiences and perceptions of stillbirth. Front Public Health 2024; 12:1385125. [PMID: 38689763 PMCID: PMC11059953 DOI: 10.3389/fpubh.2024.1385125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Abstract
The stillbirth rate among Aboriginal and Torres Strait Islander women and communities in Australia is around double that of non-Indigenous women. While the development of effective prevention strategies during pregnancy and improving care following stillbirth for women and families in communities has become a national priority, there has been limited progress in stillbirth disparities. With community permission, this study aimed to gain a better understanding of community experiences, perceptions, and priorities around stillbirth. We undertook an Indigenous researcher-led, qualitative study, with community consultations guided by a cultural protection protocol and within an unstructured research framework. A total of 18 communities were consulted face-to-face through yarning interviews, focus groups and workshops. This included 54 community member and 159 health professional participants across remote, regional, and urban areas of Queensland, Western Australia, Victoria, South Australia, and Northern Territory. Thematic analysis of consultation data identified common themes across five focus/priority areas to address stillbirth: Stillbirth or Sorry Business Baby care needs to be family-centered; using Indigenous "ways of knowing, being, and doing" to ensure cultural safety; application of Birthing on Country principles to maternal and perinatal care; and yarning approaches to improve communication and learning or education. The results underscore the critical need to co-design evidence-based, culturally appropriate, and community-acceptable resources to help reduce existing disparities in stillbirth rates.
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Affiliation(s)
- Luciana Massi
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Indigenous Health Research Group, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Carolyn Lewis
- Curtin Medical School, Curtin University, Perth, WA, Australia
| | | | - Diana Jans
- Apunipima Cape York Health Council, Cairns, QLD, Australia
| | - Rupesh Gautam
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Lina Jalloub
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Anneka Bowman
- Department Aboriginal Communities and Families Research Alliance, South Australia Health and Medical Research Institute, Adelaide, SA, Australia
| | - Philippa Middleton
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Pregnancy and Perinatal Care, South Australia Health and Medical Research Institute, Adelaide, SA, Australia
| | - Sue Vlack
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Frances M. Boyle
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Institute for Social Science Research (ISSR), The University of Queensland, Brisbane, QLD, Australia
| | - Carrington Shepherd
- Curtin Medical School, Curtin University, Perth, WA, Australia
- Ngangk Yira Research Institute, Murdoch University, Perth, WA, Australia
- Telethon Kids Institute, Perth, WA, Australia
| | - Vicki Flenady
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Deanna Stuart-Butler
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Kym M. Rae
- Stillbirth Centre of Research Excellence, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Indigenous Health Research Group, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Medeiros PDB, Flenady V, Andrews C, Forbes M, Boyle F, Loughnan SA, Meredith N, Gordon A. Evaluation of an online education program for healthcare professionals on best practice management of perinatal deaths: IMPROVE eLearning. Aust N Z J Obstet Gynaecol 2024; 64:63-71. [PMID: 37551966 DOI: 10.1111/ajo.13743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/23/2023] [Indexed: 08/09/2023]
Abstract
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.
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Affiliation(s)
- Poliana de Barros Medeiros
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Vicki Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Christine Andrews
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Madeline Forbes
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Fran Boyle
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Social Science Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Siobhan A Loughnan
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Natasha Meredith
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Adrienne Gordon
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
- The University of Sydney, Sydney, New South Wales, Australia
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Chan L, Owen KB, Andrews CJ, Bauman A, Brezler L, Ludski K, Mead J, Birkner K, Vatsayan A, Flenady VJ, Gordon A. Evaluating the reach and impact of Still Six Lives: A national stillbirth public awareness campaign in Australia. Women Birth 2023; 36:446-453. [PMID: 36858915 DOI: 10.1016/j.wombi.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The Still Six Lives campaign aimed to increase awareness of stillbirth among Australian women and educate people about three modifiable behaviours that pregnant women could take to reduce the risk of stillbirth. The campaign used earned media, digital advertising and social media. AIM The aim of this study is to evaluate the impact of the campaign on Australian women's awareness of stillbirth, and knowledge of the three modifiable behaviours. METHODS The study collected process evaluation data about campaign implementation from digital platforms. The impact evaluation comprised of two components: a three-wave community survey of Australian women aged 18-50 years old, and a pre-post cross-sectional maternity service survey of pregnant women. RESULTS The campaign gained significant reach, including 2,974,375 completed video views and 910,000 impressions via social media influencers. The community surveys had 1502 participants at baseline, 1517 mid-campaign and 1598 post-campaign. Participants were slightly more likely to have encountered messages about stillbirth after the campaign (aOR 1.30, 95% CI 1.09-1.55). There were increases in awareness of each behaviour after the campaign: be aware of baby's movements (aOR 1.26, 95% CI 1.08-1.47), quit smoking (aOR 1.27, 95% CI 1.10-1.47) and going-to-sleep on side (aOR 1.55, 95% CI 1.32-1.82). The antenatal clinic survey had 296 participants at baseline and 178 post-campaign. Post-campaign, there was an increased likelihood that women were aware of side-sleeping (aOR 3.11, 95% CI 1.74-5.56). CONCLUSIONS The national campaign demonstrated some evidence of change in awareness of three modifiable behaviours that can reduce the risk of stillbirth.
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Affiliation(s)
- Lilian Chan
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Camperdown, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia.
| | - Katherine B Owen
- Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Camperdown, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia
| | - Christine J Andrews
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Adrian Bauman
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Camperdown, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia
| | - Leigh Brezler
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Stillbirth Foundation Australia, North Sydney, Australia
| | | | | | | | | | - Vicki J Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Adrienne Gordon
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia
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Marsden T, Khong TY, Dahlstrom JE, Ellwood D, Moghimi A, Prystupa S, O'brien C, Cassam F, Martin S, Coory M, Boyle FM, Flenady V. Validation of a tool for determining the clinical utility of stillbirth investigations. Aust N Z J Obstet Gynaecol 2023; 63:535-540. [PMID: 37144747 PMCID: PMC10952271 DOI: 10.1111/ajo.13681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/25/2023] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
- Tania Marsden
- NHMRC Centre of Research Excellence in StillbirthMater Research Institute – University of QueenslandBrisbaneQueenslandAustralia
| | - T. Yee Khong
- SA PathologyWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Jane E. Dahlstrom
- ACT PathologyCanberra Health Services and Australian National University Medical SchoolCanberraAustralian Capital TerritoryAustralia
| | - David Ellwood
- NHMRC Centre of Research Excellence in StillbirthMater Research Institute – University of QueenslandBrisbaneQueenslandAustralia
- School of Medicine & DentistryGriffith UniversityGold CoastQueenslandAustralia
- Maternal‐Fetal MedicineGold Coast University HospitalGold CoastQueenslandAustralia
| | - Ali Moghimi
- The Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | | | | | | | - Skye Martin
- Townsville University HospitalTownsvilleQueenslandAustralia
| | - Michael Coory
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneMelbourneVictoriaAustralia
| | - Frances M. Boyle
- NHMRC Centre of Research Excellence in StillbirthMater Research Institute – University of QueenslandBrisbaneQueenslandAustralia
| | - Vicki Flenady
- NHMRC Centre of Research Excellence in StillbirthMater Research Institute – University of QueenslandBrisbaneQueenslandAustralia
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Holliday M, Uddipto K, Castillo G, Vera LE, Quinlivan JA, Mendz GL. Insights into the Genital Microbiota of Women Who Experienced Fetal Death in Utero. Microorganisms 2023; 11:1877. [PMID: 37630436 PMCID: PMC10456767 DOI: 10.3390/microorganisms11081877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/10/2023] [Accepted: 07/21/2023] [Indexed: 08/27/2023] Open
Abstract
The aim of this work was to achieve a better understanding of the bacterial pathogens associated with stillbirths that would serve to inform clinical interventions directed at reducing this adverse pregnancy outcome. A prospective observational study was conducted with the participation of 22 women from northern Peru, of whom 11 experienced fetal death in utero and 11 delivered preterm births. Swabs were taken from the vagina, placenta, amniotic fluid and axilla of the infant at birth by Caesarean section. The bacterial populations in the vagina and the amniotic space of each participant were determined by employing the amplicon sequencing of the V4 region of the 16S rRNA genes. The sequence data were analysed using bioinformatics tools. The work showed differences in the composition of the genital microbiomes of women who experienced preterm birth or fetal death in utero. There were no differences in the alpha diversity between the genital microbiotas of both groups of women, but there were more different taxa in the vagina and amniotic space of the preterm participants. Lactobacillus spp. was less abundant in the stillbirth cases. E. coli/Shigella, Staphylococcus, Gardnerella, Listeria and Bacteroides taxa were associated with the stillbirths. In each woman, there was a minimal concordance between the bacterial populations in the vagina and amniotic space.
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Affiliation(s)
- Mira Holliday
- College of Health and Medicine, Australian National University, Canberra, ACT 2601, Australia; (M.H.); (J.A.Q.)
| | - Kumar Uddipto
- School of Medicine, Sydney, University of Notre Dame Australia, Darlinghurst, NSW 2010, Australia;
| | - Gerardo Castillo
- Área de Ciencias Biomédicas y Policlínico, University of Piura, San Eduardo, Piura 20009, Peru; (G.C.); (L.E.V.)
| | - Luz Estela Vera
- Área de Ciencias Biomédicas y Policlínico, University of Piura, San Eduardo, Piura 20009, Peru; (G.C.); (L.E.V.)
| | - Julie A. Quinlivan
- College of Health and Medicine, Australian National University, Canberra, ACT 2601, Australia; (M.H.); (J.A.Q.)
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA 6160, Australia
| | - George L. Mendz
- School of Medicine, Sydney, University of Notre Dame Australia, Darlinghurst, NSW 2010, Australia;
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Thompson RA, Thompson JMD, Wilson J, Cronin RS, Mitchell EA, Raynes-Greenow CH, Li M, Stacey T, Heazell AEP, O'Brien LM, McCowan LME, Anderson NH. Risk factors for late preterm and term stillbirth: A secondary analysis of an individual participant data meta-analysis. BJOG 2023. [PMID: 36852504 DOI: 10.1111/1471-0528.17444] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/14/2022] [Accepted: 01/09/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Identify independent and novel risk factors for late-preterm (28-36 weeks) and term (≥37 weeks) stillbirth and explore development of a risk-prediction model. DESIGN Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors. SETTING An IPD database from five case-control studies in New Zealand, Australia, the UK and an international online study. POPULATION Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257). METHODS Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second-hand smoking, antenatal-care utilisation, and detailed fetal movement and sleep variables. MAIN OUTCOME MEASURES Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth. RESULTS After model building, 575 late-stillbirth cases and 1541 controls from three contributing case-control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hiccoughs, increasing strength, frequency or vigorous fetal movements) aOR of stillbirth. Poor antenatal-care utilisation increased risk while more-than-adequate care was protective. The area-under-the-curve was 0.84 (95% CI 0.82-0.86). CONCLUSIONS Similarities in risk factors for late-preterm and term stillbirth suggest the same approach for risk-assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal-care utilisation could be valuable in late-stillbirth risk assessment.
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Affiliation(s)
- R A Thompson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - J M D Thompson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - J Wilson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - R S Cronin
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Women's Health Division, Counties Manukau Health, Auckland, New Zealand
| | - E A Mitchell
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - C H Raynes-Greenow
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - M Li
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Women's Health Division, Counties Manukau Health, Auckland, New Zealand
| | - T Stacey
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - A E P Heazell
- University of Manchester, Manchester, UK
- University of Michigan, Ann Arbor, Michigan, USA
| | - L M O'Brien
- University of Michigan, Ann Arbor, Michigan, USA
| | - L M E McCowan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - N H Anderson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
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9
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Fletcher R, Symonds I, StGeorge J, Warland J, Stark M. Testing the acceptability of stillbirth awareness messages in an SMS program for fathers. Health Promot J Austr 2023; 34:149-155. [PMID: 36450663 PMCID: PMC10107767 DOI: 10.1002/hpja.686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 10/04/2022] [Accepted: 11/20/2022] [Indexed: 12/04/2022] Open
Abstract
ISSUE ADDRESSED To raise expectant fathers' awareness of risk factors for stillbirth. METHODS A set of brief text messages was developed addressing recognised risk factors for stillbirth: avoidance of maternal cigarette smoking, maternal going to sleep on side messaging, awareness of the importance of noticing and reporting changes in foetal movement and fathers' involvement in shared decision making for timing of birth. Eight messages were inserted into the SMS4dads pilot program being conducted by NSW Health. Feedback on the messages was requested. Participants rated the quality of the messages on a three-point Likert scale and provided comments. RESULTS Overall, 2528 messages were sent to 626 fathers' mobile phones, 45% of fathers replied with 666 ratings and 115 comments evaluating the texts. The quantitative ratings indicated substantial overall approval of the messages. Within the coding category "Evaluation of Message Content," three themes described fathers' reactions and feelings about the smoking, movement, side sleeping and birth timing messages: "important-good information," "not appropriate/anxiety provoking" and "not relevant-obvious." Three themes reflecting the attributes of the messages within the "Service Quality" category were "need more information," "complements public health" and "child voice fit." CONCLUSIONS Results indicate that the messages are an acceptable way to provide information and suggested actions addressing stillbirth risk factors to fathers-to-be. SO WHAT?: Fathers' awareness of the risk factors for stillbirth can assist mothers to take appropriate actions for a healthy birth. Information on risk factors can be provided to fathers via a father-focused text messaging service.
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Affiliation(s)
- Richard Fletcher
- School of Health Sciences, The University of Newcastle, Newcastle, NSW, Australia
| | - Ian Symonds
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Jennifer StGeorge
- School of Health Sciences, The University of Newcastle, Newcastle, NSW, Australia
| | - Jane Warland
- School of Nursing, Curtin University, Perth, WA, Australia
| | - Michael Stark
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
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10
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Pearson T, Due C, Obst K. Culturally and Linguistically Diverse Men's Grief Experiences Following Perinatal Death in Australia. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231153545. [PMID: 36689624 DOI: 10.1177/00302228231153545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
To explore the grief experiences of men from culturally and linguistically diverse (CALD) backgrounds following perinatal death in Australia. Qualitative analysis of interview data using thematic analysis. Participants were health service providers (n = 6), and CALD community members (n = 10) who were either community leaders with experience working with CALD men following perinatal death in Australia (n = 6), or were CALD men who had lived experience of perinatal death (n = 4). Thematic analysis identified four themes related to CALD men's grief. These included the role of religion and rituals, grief as stoic, the partner- and family-centred nature of men's grief, and finally grief as ensuring and changeable over time. This research points to the strong need for CALD men's specific needs to be included in the development of policy and practice surrounding perinatal death.
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Affiliation(s)
- Thomas Pearson
- School of Psychology, The University of Adelaide, Adelaide, SA, Australia
| | - Clemence Due
- School of Psychology, The University of Adelaide, Adelaide, SA, Australia
| | - Kate Obst
- School of Psychology, The University of Adelaide, Adelaide, SA, Australia
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11
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Black KI, Middleton P, LibSt G, Huda TM, Srinivasan S. Interconception Health: Improving Equitable Access to Pregnancy Planning. Semin Reprod Med 2022; 40:184-192. [PMID: 35901810 DOI: 10.1055/s-0042-1744517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Challenges remain with the implementation of preconception care, as many women do not plan their pregnancies and clinicians do not initiate preconception consultations. However, the interconception period may present a more opportune time to address health issues that impact on pregnancy outcomes and may influence future conceptions. It is also an important time to focus on pregnancy complications that may influence a person's health trajectory. This review discusses the evidence pointing to a need for greater attention on interconception health and focuses on five areas of care that may be particularly important in affecting equitable access to good care before a subsequent pregnancy: interpregnancy intervals, contraception, weight, nutrition, and gestational diabetes follow-up. Several programs internationally have developed models of care for interconception health and this review presents one such model developed in the United States that explicitly seeks to reach vulnerable populations of women who may otherwise not receive preconception care.
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Affiliation(s)
- Kirsten I Black
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | | | - GradDip LibSt
- Pregnancy and Perinatal Care, SAHMRI Women and Kids, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Tanvir M Huda
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sukanya Srinivasan
- UPMC McKeesport Family Medicine Residency, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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12
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Loughnan SA, Boyle FM, Ellwood D, Crocker S, Lancaster A, Astell C, Dean J, Horey D, Callander E, Jackson C, Shand A, Flenady V. Living with Loss: study protocol for a randomized controlled trial evaluating an internet-based perinatal bereavement program for parents following stillbirth and neonatal death. Trials 2022; 23:464. [PMID: 35668502 PMCID: PMC9167910 DOI: 10.1186/s13063-022-06363-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stillbirth and neonatal death are devastating pregnancy outcomes with long-lasting psychosocial consequences for parents and families, and wide-ranging economic impacts on health systems and society. It is essential that parents and families have access to appropriate support, yet services are often limited. Internet-based programs may provide another option of psychosocial support for parents following the death of a baby. We aim to evaluate the efficacy and acceptability of a self-guided internet-based perinatal bereavement support program "Living with Loss" (LWL) in reducing psychological distress and improving the wellbeing of parents following stillbirth or neonatal death. METHODS This trial is a two-arm parallel group randomized controlled trial comparing the intervention arm (LWL) with a care as usual control arm (CAU). We anticipate recruiting 150 women and men across Australia who have experienced a stillbirth or neonatal death in the past 2 years. Participants randomized to the LWL group will receive the six-module internet-based program over 8 weeks including automated email notifications and reminders. Baseline, post-intervention, and 3-month follow-up assessments will be conducted to assess primary and secondary outcomes for both arms. The primary outcome will be the change in Kessler Psychological Distress Scale (K10) scores from baseline to 3-month follow-up. Secondary outcomes include perinatal grief, anxiety, depression, quality of life, program satisfaction and acceptability, and cost-effectiveness. Analysis will use intention-to-treat linear mixed models to examine psychological distress symptom scores at 3-month follow-up. Subgroup analyses by severity of symptoms at baseline will be undertaken. DISCUSSION The LWL program aims to provide an evidence-based accessible and flexible support option for bereaved parents following stillbirth or neonatal death. This may be particularly useful for parents and healthcare professionals residing in rural regions where services and supports are limited. This RCT seeks to provide evidence of the efficacy, acceptability, and cost-effectiveness of the LWL program and contribute to our understanding of the role digital services may play in addressing the gap in the availability of specific bereavement support resources for parents following the death of a baby, particularly for men. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12621000631808 . Registered prospectively on 27 May 2021.
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Affiliation(s)
- Siobhan A Loughnan
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.
| | - Frances M Boyle
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,Institute for Social Science Research, The University of Queensland, 80 Meiers Rd, Indooroopilly, QLD, Australia
| | - David Ellwood
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,School of Medicine, Griffith University, Parklands Drive, Gold Coast, QLD, Australia.,Gold Coast University Hospital, 1 Hospital Drive, Southport, QLD, Australia
| | - Sara Crocker
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
| | - Ann Lancaster
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
| | - Chrissie Astell
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
| | - Julie Dean
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,Institute for Social Science Research, The University of Queensland, 80 Meiers Rd, Indooroopilly, QLD, Australia
| | - Dell Horey
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia.,La Trobe University, Plenty Rd &, Kingsbury Dr, Bundoora, VIC, Australia
| | - Emily Callander
- Monash University, 553 St Kilda Road, Melbourne, VIC, Australia
| | | | - Antonia Shand
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Vicki Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute-University of Queensland, Raymond Terrace, Level 3 Aubigny Place, South Brisbane, QLD, Australia
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13
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Jardine J, Walker K, Gurol-Urganci I, Webster K, Muller P, Hawdon J, Khalil A, Harris T, van der Meulen J. Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study. Lancet 2021; 398:1905-1912. [PMID: 34735797 DOI: 10.1016/s0140-6736(21)01595-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/15/2021] [Accepted: 07/01/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Socioeconomic deprivation and minority ethnic background are risk factors for adverse pregnancy outcomes. We aimed to quantify the magnitude of these socioeconomic and ethnic inequalities at the population level in England. METHODS In this cohort study, we used data compiled by the National Maternity and Perinatal Audit, based on birth records from maternity information systems used by 132 National Health Service hospitals in England, linked to administrative hospital data. We included women who gave birth to a singleton baby with a recorded gestation between 24 and 42 completed weeks. Terminations of pregnancy were excluded. We analysed data on stillbirth, preterm birth (<37 weeks of gestation), and fetal growth restriction (FGR; liveborn with birthweight <3rd centile by the UK definition) in England, and compared these outcomes by socioeconomic deprivation quintile and ethnic group. We calculated attributable fractions for the entire population and specific groups compared with least deprived groups or White women, both unadjusted and with adjustment for smoking, body-mass index (BMI), and other maternal risk factors. FINDINGS We identified 1 233 184 women with a singleton birth between April 1, 2015, and March 31, 2017, of whom 1 155 981 women were eligible and included in the analysis. 4505 (0·4%) of 1 155 981 births were stillbirths. Of 1 151 476 livebirths, 69 175 (6·0%) were preterm births and 22 679 (2·0%) were births with FGR. Risk of stillbirth was 0·3% in the least socioeconomically deprived group and 0·5% in the most deprived group (p<0·0001), risk of a preterm birth was 4·9% in the least deprived group and 7·2% in the most deprived group (p<0·0001), and risk of FGR was 1·2% in the least deprived group and 2·2% in the most deprived group (p<0·0001). Population attributable fractions indicated that 23·6% (95% CI 16·7-29·8) of stillbirths, 18·5% (16·9-20·2) of preterm births, and 31·1% (28·3-33·8) of births with FGR could be attributed to socioeconomic inequality, and these fractions were substantially reduced when adjusted for ethnic group, smoking, and BMI (11·6% for stillbirths, 11·9% for preterm births, and 16·4% for births with FGR). Risk of stillbirth ranged from 0·3% in White women to 0·7% in Black women (p<0·0001); risk of preterm birth was 6·0% in White women, 6·5% in South Asian women, and 6·6% in Black women (p<0·0001); and risk of FGR ranged from 1·4% in White women to 3·5% in South Asian women (p<0·0001). 11·7% of stillbirths (95% CI 9·8-13·5), 1·2% of preterm births (0·8-1·6), and 16·9% of FGR (16·1-17·8) could be attributed to ethnic inequality. Adjustment for socioeconomic deprivation, smoking, and BMI only had a small effect on these ethnic group attributable fractions (13·0% for stillbirths, 2·6% for preterm births, and 19·2% for births with FGR). Group-specific attributable fractions were especially high in the most socioeconomically deprived South Asian women and Black women for stillbirth (53·5% in South Asian women and 63·7% in Black women) and FGR (71·7% in South Asian women and 55·0% in Black women). INTERPRETATION Our results indicate that socioeconomic and ethnic inequalities were responsible for a substantial proportion of stillbirths, preterm births, and births with FGR in England. The largest inequalities were seen in Black and South Asian women in the most socioeconomically deprived quintile. Prevention should target the entire population as well as specific minority ethnic groups at high risk of adverse pregnancy outcomes, to address risk factors and wider determinants of health. FUNDING Healthcare Quality Improvement Partnership.
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Affiliation(s)
- Jennifer Jardine
- Royal College of Obstetricians and Gynaecologists, London, UK; Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK.
| | - Kate Walker
- Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Ipek Gurol-Urganci
- Royal College of Obstetricians and Gynaecologists, London, UK; Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Kirstin Webster
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Patrick Muller
- Royal College of Obstetricians and Gynaecologists, London, UK; Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Jane Hawdon
- Royal Free London NHS Foundation Trust, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Tina Harris
- Centre for Reproduction Research, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Jan van der Meulen
- Department of Health Services Research, London School of Hygiene & Tropical Medicine, London, UK
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14
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Flenady V, Gardener G, Ellwood D, Coory M, Weller M, Warrilow KA, Middleton PF, Wojcieszek AM, Groom KM, Boyle FM, East C, Lawford H, Callander E, Said JM, Walker SP, Mahomed K, Andrews C, Gordon A, Norman JE, Crowther C. My Baby's Movements: a stepped-wedge cluster-randomised controlled trial of a fetal movement awareness intervention to reduce stillbirths. BJOG 2021; 129:29-41. [PMID: 34555257 DOI: 10.1111/1471-0528.16944] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The My Baby's Movements (MBM) trial aimed to evaluate the impact on stillbirth rates of a multifaceted awareness package (the MBM intervention). DESIGN Stepped-wedge cluster-randomised controlled trial. SETTING Twenty-seven maternity hospitals in Australia and New Zealand. POPULATION Women with a singleton pregnancy without major fetal anomaly at ≥28 weeks of gestation from August 2016 to May 2019. METHODS The MBM intervention was implemented at randomly assigned time points, with the sequential introduction of eight groups of between three and five hospitals at 4-monthly intervals. Using generalised linear mixed models, the stillbirth rate was compared in the control and the intervention periods, adjusting for calendar time, study population characteristics and hospital effects. MAIN OUTCOME MEASURES Stillbirth at ≥28 weeks of gestation. RESULTS There were 304 850 births with 290 105 births meeting the inclusion criteria: 150 053 in the control and 140 052 in the intervention periods. The stillbirth rate was lower (although not statistically significantly so) during the intervention compared with the control period (2.2/1000 versus 2.4/1000 births; aOR 1.18, 95% CI 0.93-1.50; P = 0.18). The decrease in stillbirth rate was greater across calendar time: 2.7/1000 in the first versus 2.0/1000 in the last 18 months. No increase in secondary outcomes, including obstetric intervention or adverse neonatal outcome, was evident. CONCLUSIONS The MBM intervention did not reduce stillbirths beyond the downward trend over time. As a result of low uptake, the role of the intervention remains unclear, although the downward trend across time suggests some benefit in lowering the stillbirth rate. In this study setting, an awareness of the importance of fetal movements may have reached pregnant women and clinicians prior to the implementation of the intervention. TWEETABLE ABSTRACT The My Baby's Movements intervention to raise awareness of decreased fetal movement did not significantly reduce stillbirth rates.
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Affiliation(s)
- V Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - G Gardener
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Department of Maternal Fetal Medicine, Mater Misericordiae Limited, Brisbane, Queensland, Australia
| | - D Ellwood
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Gold Coast University Hospital, Southport, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - M Coory
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - M Weller
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - K A Warrilow
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - P F Middleton
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - A M Wojcieszek
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - K M Groom
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - F M Boyle
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Institute for Social Science Research, The University of Queensland, Brisbane, Queensland, Australia
| | - C East
- Judith Lumley Centre, School of Nursing & Midwifery, La Trobe University, Melbourne, Victoria, Australia
| | - Hls Lawford
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - E Callander
- Monash University, Melbourne, Victoria, Australia
| | - J M Said
- University of Melbourne, Melbourne, Victoria, Australia.,Sunshine Hospital, Western Health, St Albans, Victoria, Australia
| | - S P Walker
- University of Melbourne, Melbourne, Victoria, Australia
| | - K Mahomed
- Ipswich Hospital, Ipswich, Queensland, Australia
| | - C Andrews
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - A Gordon
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - J E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - C Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
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15
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Andrews C, Meredith N, Seeho S, Weller M, Griffin A, Ellwood D, Middleton P, Jennings B, Flenady V. Evaluation of an online education module designed to reduce stillbirth. Aust N Z J Obstet Gynaecol 2021; 61:675-683. [PMID: 34096613 DOI: 10.1111/ajo.13380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/08/2021] [Accepted: 04/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Safer Baby Bundle (SBB) eLearning is an online education module that addresses practice gaps in stillbirth prevention in Australia. It provides healthcare professionals with evidence-based resources for: smoking cessation; fetal growth restriction; decreased fetal movements; maternal safe going-to-sleep position; and timing of birth for women with risk factors for stillbirth. AIMS To determine whether participants' reported knowledge and confidence in providing care designed to reduce stillbirth changed following completion of the module. To assess the module's suitability and acceptability, and participants' reported likelihood to change practice. MATERIALS AND METHODS In-built surveys undertaken pre- and post-eLearning module assessed participant knowledge and confidence, module suitability and acceptability, and likelihood of practice change using Likert items. Responses were dichotomised. Differences pre- and post-module were tested using McNemar's test and differences by profession were examined using descriptive statistics and Pearson's χ2 test. RESULTS Between 15 October 2019 and 2 November 2020, 5223 participants across Australia were included. Most were midwives (82.0%), followed by student midwives (4.6%) and obstetricians (3.3%). Reported knowledge and confidence improved in all areas (P < 0.001). Post-module 96.7-98.9% 'agreed' they had a sound level of knowledge and confidence across all elements of the SBB. Over 95% of participants agreed that the module was helpful and relevant, well organised, and easy to access and use. Eighty-eight percent reported they were likely to change some aspect of their clinical practice. CONCLUSIONS The SBB eLearning module is a valuable education program that is well-received and likely to result in improvements in practice.
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Affiliation(s)
- Christine Andrews
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Natasha Meredith
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Sean Seeho
- Women and Babies Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Megan Weller
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Alison Griffin
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - David Ellwood
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,Gold Coast University Hospital, and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Philippa Middleton
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Belinda Jennings
- Department of Health, Northern Territory Government, Darwin, Northern Territory, Australia
| | - Vicki Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
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16
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Warrilow KA, Gordon A, Andrews CJ, Boyle FM, Wojcieszek AM, Stuart Butler D, Ellwood D, Middleton PF, Cronin R, Flenady VJ. Australian women's perceptions and practice of sleep position in late pregnancy: An online survey. Women Birth 2021; 35:e111-e117. [PMID: 33867299 DOI: 10.1016/j.wombi.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Going-to-sleep in the supine position in later pregnancy (≥28 weeks) has been identified as a risk factor for stillbirth. Internationally, public awareness campaigns have been undertaken encouraging women to sleep on their side during late pregnancy. AIM This study aimed to identify sleep practices, attitudes and knowledge in pregnant women, to inform an Australian safe sleeping campaign. METHODS A web-based survey of pregnant women ≥28 weeks' gestation conducted from November 2017 to January 2018. The survey was adapted from international sleep surveys and disseminated via pregnancy websites and social media platforms. FINDINGS Three hundred and fifty-two women participated. Five (1.6%) reported going to sleep in the supine position. Most (87.8%) had received information on the importance of side-sleeping in pregnancy. Information was received from a variety of sources including maternity care providers (186; 66.2%) and the internet (177; 63.0%). Women were more likely to report going to sleep on their side if they had received advice to do so (OR 2.3; 95% CI 1.0-5.1). Thirteen (10.8%) reported receiving unsafe advice, including changing their going-to-sleep position to the supine position. DISCUSSION This indicates high level awareness and practice of safe late-pregnancy going-to-sleep position in participants. Opportunities remain for improvement in the information provided, and understanding needs of specific groups including Aboriginal and Torres Strait Islander women. CONCLUSION Findings suggest Australian women understand the importance of sleeping position in late pregnancy. Inconsistencies in information provided remain and may be addressed through public awareness campaigns targeting women and their care providers.
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Affiliation(s)
- K A Warrilow
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia.
| | - A Gordon
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - C J Andrews
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia
| | - F M Boyle
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia; Institute for Social Science Research, The University of Queensland, Brisbane, Australia
| | - A M Wojcieszek
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia
| | - D Stuart Butler
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia
| | - D Ellwood
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia; Griffith University, School of Medicine and Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - P F Middleton
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - R Cronin
- University of Auckland and Counties Manukau Health, Auckland, New Zealand
| | - V J Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), South Brisbane, Australia
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17
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Flenady V, Kettle I, Laporte J, Birthisel D, Hardiman L, Matsika A, Whelan N, Lehner C, Payton D, Utz M, Wojcieszek AM, Lawford H, Walsh T, Ellwood D. Making every birth count: Outcomes of a perinatal mortality audit program. Aust N Z J Obstet Gynaecol 2021; 61:540-547. [PMID: 33792893 DOI: 10.1111/ajo.13325] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Stillbirth rates have shown little improvement for two decades in Australia. Perinatal mortality audit is key to prevention, but the literature suggests that implementation is suboptimal. AIM To determine the proportion of perinatal deaths which are associated with contributing factors relating to care in Queensland, Australia. MATERIALS AND METHODS Retrospective audit of perinatal deaths ≥ 34 weeks gestation by the Health Department in Queensland was undertaken. Cases and demographic information were obtained from the Queensland Perinatal Data Collection. A multidisciplinary panel used the Perinatal Society of Australia and New Zealand (PSANZ) perinatal mortality audit guidelines to classify the cause of death and to identify contributing factors. Contributing factors were classified as 'insignificant', 'possible', or 'significant'. RESULTS From 1 January to 31 December 2018, 65 deaths (56 stillbirths and nine neonatal deaths) were eligible and audited. Most deaths were classified as unexplained (51.8% of stillbirths). Contributing factors were identified in 46 (71%) deaths: six insignificant (all stillbirths), 20 possibly related to outcome (17 stillbirths), and 20 significantly (16 stillbirths). Areas for practice improvements mainly related to the care for women with risk factors for stillbirth, especially antenatal care. The PSANZ guidelines were applied and enabled a systematic approach. CONCLUSIONS A high proportion of late gestation perinatal deaths are associated with contributing factors relating to care. Improving antenatal care for women with risk factors for stillbirth is a priority. Perinatal mortality audit is a valuable step in stillbirth prevention and the PSANZ guidelines allow a systematic approach to aid implementation and reporting.
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Affiliation(s)
- Vicki Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia
| | - Imogen Kettle
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Johanna Laporte
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Deborah Birthisel
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Leah Hardiman
- Maternity Choices Australia, Brisbane, Queensland, Australia
| | | | - Nikki Whelan
- Wesley Medical Research Ltd, Brisbane, Queensland, Australia
| | - Christoph Lehner
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Diane Payton
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Miles Utz
- Statistical Services Branch, Queensland Health, Brisbane, Queensland, Australia
| | - Aleena M Wojcieszek
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia
| | - Harriet Lawford
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia
| | - Teresa Walsh
- New Life Midwifery, Ipswich, Queensland, Australia
| | - David Ellwood
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia.,Griffith University and Gold Coast University Hospital, Gold Coast, Queensland, Australia
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18
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Stillbirth in Australia 5: Making respectful care after stillbirth a reality: The quest for parent-centred care. Women Birth 2020; 33:531-536. [PMID: 33092703 DOI: 10.1016/j.wombi.2020.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/12/2020] [Accepted: 08/19/2020] [Indexed: 02/03/2023]
Abstract
Stillbirth is a tragedy that can leave parents feeling powerless and vulnerable. Respectful and supportive bereavement care is essential to reducing adverse psychosocial impact. Initiatives of the Australian Centre of Research Excellence in Stillbirth are designed to improve care after stillbirth. At their heart are the voices of perinatally bereaved parents and support organisations and shared decision making between parents and health care providers. Priorities in future perinatal bereavement care research include ensuring appropriate care for population groups who experience higher rates of stillbirth and addressing implementation challenges to best practice in respectful and supportive bereavement care within our health systems.
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19
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Andrews CJ, Ellwood DA, Gordon A, Middleton P, Homer CSE, Wallace EM, Nicholl MC, Marr C, Sketcher-Baker K, Weller M, Seeho SKM, Flenady VJ. Stillbirth in Australia 2: Working together to reduce stillbirth in Australia: The Safer Baby Bundle initiative. Women Birth 2020; 33:514-519. [PMID: 33092700 DOI: 10.1016/j.wombi.2020.09.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
The rate of late gestation stillbirth in Australia is unacceptably high. Up to one third of stillbirths are preventable, particularly beyond 28 weeks' gestation. The aim of this second paper in the Stillbirth in Australia series is to highlight one key national initiative, the Safer Baby Bundle (SBB), which has been led by the Centre of Research Excellence in Stillbirth in partnership with state health departments. Addressing commonly identified evidence practice gaps, the SBB contains five elements that, when implemented together, should result in better outcomes than if performed individually. This paper describes the development of the SBB, what the initiative aims to achieve, and progress to date. By collaborating with Departments of Health and other partners to amplify uptake of the SBB, we anticipate a reduction of at least 20% in Australia's stillbirth rate after 28 weeks' gestation is achievable.
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Affiliation(s)
- Christine J Andrews
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - David A Ellwood
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Griffith University, School of Medicine and Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Adrienne Gordon
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Philippa Middleton
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Euan M Wallace
- Safer Care Victoria, Department of Health and Human Services, Melbourne, Victoria, Australia; The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Michael C Nicholl
- Women and Babies Research, University of Sydney, Sydney, NSW, Australia
| | - Carrie Marr
- Clinical Excellence Commission, Department of Health, Sydney, NSW, Australia
| | | | - Megan Weller
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Sean K M Seeho
- Women and Babies Research, University of Sydney, Sydney, NSW, Australia
| | - Vicki J Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia.
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20
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Andrews CJ, Ellwood D, Middleton PF, Gordon A, Nicholl M, Homer CSE, Morris J, Gardener G, Coory M, Davies-Tuck M, Boyle FM, Callander E, Bauman A, Flenady VJ. Implementation and evaluation of a quality improvement initiative to reduce late gestation stillbirths in Australia: Safer Baby Bundle study protocol. BMC Pregnancy Childbirth 2020; 20:694. [PMID: 33187483 PMCID: PMC7664588 DOI: 10.1186/s12884-020-03401-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In 2015, the stillbirth rate after 28 weeks (late gestation) in Australia was 35% higher than countries with the lowest rates globally. Reductions in late gestation stillbirth rates have steadily improved in Australia. However, to amplify and sustain reductions, more needs to be done to reduce practice variation and address sub-optimal care. Implementing bundles for maternity care improvement in the UK have been associated with a 20% reduction in stillbirth rates. A similar approach is underway in Australia; the Safer Baby Bundle (SBB) with five elements: 1) supporting women to stop smoking in pregnancy, 2) improving detection and management of fetal growth restriction, 3) raising awareness and improving care for women with decreased fetal movements, 4) improving awareness of maternal safe going-to-sleep position in late pregnancy, 5) improving decision making about the timing of birth for women with risk factors for stillbirth. METHODS This is a mixed-methods study of maternity services across three Australian states; Queensland, Victoria and New South Wales. The study includes evaluation of 'targeted' implementer sites (combined total approximately 113,000 births annually, 50% of births in these states) and monitoring of key outcomes state-wide across all maternity services. Progressive implementation over 2.5 years, managed by state Departments of Health, commenced from mid-2019. This study will determine the impact of implementing the SBB on maternity services and perinatal outcomes, specifically for reducing late gestation stillbirth. Comprehensive process, impact, and outcome evaluations will be conducted using routinely collected perinatal data, pre- and post- implementation surveys, clinical audits, focus group discussions and interviews. Evaluations explore the views and experiences of clinicians embedding the SBB into routine practice as well as women's experience with care and the acceptability of the initiative. DISCUSSION This protocol describes the evaluation of the SBB initiative and will provide evidence for the value of a systematic, but pragmatic, approach to strategies to reduce the evidence-practice gaps across maternity services. We hypothesise successful implementation and uptake across three Australian states (amplified nationally) will be effective in reducing late gestation stillbirths to that of the best performing countries globally, equating to at least 150 lives saved annually. TRIAL REGISTRATION The Safer Baby Bundle Study was retrospectively registered on the ACTRN12619001777189 database, date assigned 16/12/2019.
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Affiliation(s)
- C J Andrews
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
| | - D Ellwood
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
- Gold Coast University Hospital, and School of Medicine, Griffith University, Gold Coast, Australia
| | - P F Middleton
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - A Gordon
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - M Nicholl
- University of Sydney, Sydney, NSW, Australia
| | - C S E Homer
- Burnet Institute, Melbourne, Victoria, Australia
| | - J Morris
- University of Sydney, Sydney, NSW, Australia
| | - G Gardener
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
| | - M Coory
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
| | - M Davies-Tuck
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - F M Boyle
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia
- Institute for Social Science Research, The University of Queensland, Brisbane, Australia
| | - E Callander
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - A Bauman
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - V J Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Mater Health Services, Level 3 Aubigny Place, South Brisbane, QLD, 4101, Australia.
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