Stillbirths: economic and psychosocial consequences

Cost-effectiveness and benefits of perinatal health interventions in high-income settings: A protocol for a systematic review of economic evaluations

BACKGROUND

Despite ongoing efforts, perinatal morbidity and mortality persist across all settings, imposing a dual burden of clinical and economic strain. Besides, the fragmented nature of economic evidence on perinatal health interventions hinders the formulation of effective health policies. Our review aims to comprehensively and critically assess the economic evidence for such interventions in high-income countries, where the balance of health outcomes and fiscal prudence is paramount.

METHODS AND ANALYSIS

We will conduct a comprehensive search for studies using databases including EconLit (EBSCO), Cost Effectiveness Analysis (CEA) Registry, Medline (Ovid), Embase (Ovid), CINAHL Ultimate (EBSCO), Global Health (Ovid), and PubMed. Furthermore, we will broaden our search to include Google Scholar and conduct snowballing from the final articles included. The search terms will encompass economic evaluation, perinatal health interventions, morbidity and mortality, and high-income countries. We will include full economic evaluations focusing on cost-effectiveness, cost-benefit, cost-utility, and cost-minimisation analyses. We will exclude partial economic evaluations, reports, qualitative studies, conference papers, editorials, and systematic reviews. Date restrictions will limit the review to studies published after 2010 and those in English during the study selection process. We will use the modified Drummond checklist to evaluate the quality of each included study. Our findings will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement. A summary will include estimated costs, effectiveness, benefits, and the incremental cost-effectiveness ratio (ICER). We also plan to conduct a subgroup analysis. To aid comparability, we will standardise all costs to the United States Dollar, adjusting them to their 2022 value using country-specific consumer price index and purchasing power parity.

ETHICS AND DISSEMINATION

This systematic review will not involve human participants and requires no ethical approval. We will publish the results in a peer-reviewed journal.

TRIAL REGISTRATION

We registered our record on PROSPERO (registration #: CRD42023432232).

Bereavement care guidelines used in health care facilities immediately following perinatal loss: a scoping review

OBJECTIVE

The objective of the scoping review was to explore the evidence and describe what is known about perinatal bereavement care guidelines provided within health care facilities prior to discharge. Additionally, the review sought to identify what is known about parents' mental health outcomes, and map these outcomes to the characteristics of the bereavement care guidelines.

INTRODUCTION

Perinatal loss poses a serious risk of emotional trauma and mental health sequelae. Conflicting evidence for international bereavement care guidelines and inconsistent implementation, a lack of experimental studies, and older syntheses with a limited focus or population made synthesis complex. Therefore, a scoping review was undertaken to determine the breadth and depth of the existing literature on this topic.

INCLUSION CRITERIA

Sources pertaining to bereavement care guidelines used in health care facilities immediately after perinatal loss (miscarriage, stillbirth, or neonatal death) and parents' mental health outcomes were included. Sources pertaining to family members other than parents, perinatal loss occurring outside of a health care facility, and physical care guidelines were excluded.

METHODS

The review was conducted using JBI methodology for scoping reviews. The team considered quantitative and qualitative studies, practice guidelines, case reports, expert opinions, systematic reviews, professional organization websites, and gray literature. CINAHL (EBSCOhost), PsycINFO (EBSCOhost), SocINDEX (EBSCOhost), Cochrane Library, JBI Evidence-based Practice Database (Ovid), Embase, PubMed (NLM), ProQuest Dissertations and Theses A&I (ProQuest), Web of Science Core Collection, and Epistemonikos were the major databases searched. OpenGrey, Google Scholar, and organizational websites were also searched. The earliest empirical study publication found (1976) served as the starting date limit. After pilot-testing the screening process, data were extracted, collated, and presented in narrative form as well as in tables and figures. The search was first conducted in September and October 2021, and an updated search was performed on February 9, 2023.

RESULTS

The results provide a broad view of bereavement care guidelines to support grieving parents' mental health. The included sources (n = 195) were comprised of 28 syntheses, 96 primary studies, and 71 literature review/text and opinion. From the studies that specified the number of participants, 33,834 participants were included. Key characteristics of bereavement care guidelines were categorized as i) making meaning/memories, ii) good communication, iii) shared decision-making, iv) effective emotional and social support, and v) organizational response. Parents' reported mental health outcomes included both negative outcomes, such as depression, anxiety, anger, and helplessness, and positive outcomes, including coping, healing, recovery, and well-being.

CONCLUSIONS

Conceptually the characteristics of published guidelines are fairly consistent across settings, with cultural variations in specific components of the guidelines. Despite the exponential increase in research pertaining to bereavement care after perinatal loss, there is a gap in research pertaining to certain characteristics of bereavement care guidelines accepted as best practice to support parents' mental health outcomes. This review provides support for future research given the trauma and mental health risks following perinatal loss. Policies ensuring consistent and appropriate implementation of bereavement care guidelines are essential to improve parents' mental health outcomes.

Women's Lived Experience of Fetal Death: A Descriptive Phenomenological

Pregnancy can be associated with risk factors that may lead to fetal loss, which is a profoundly distressing event impacting the psychological well-being, family dynamics, and overall quality of life of women. The present study aimed to explore women's lived experiences of fetal death. Conducted in 2023, this study employed a descriptive phenomenological approach, utilizing purposeful sampling to interview 12 pregnant women with a history of fetal loss. Data analysis was conducted using the seven-step method of Colaizzi. The study identified five main themes and fifteen sub-themes capturing women's experiences of fetal death. These themes include unfulfilled dreams, transitioning from happiness to grief, varied reactions among individuals, viewing a new healthy baby as a source of renewed hope, and the enduring long-term effects of fetal loss. Fetal death emerges as a deeply painful experience fraught with challenges for affected women. As such, these women require specialized attention from healthcare professionals, particularly midwives, gynecologists, and family specialists.

Communication, Training, and Debriefing After Stillbirth in U.S. Hospitals: A National Survey

Background: Stillbirth is a devastating event for families as well as hospital staff. Hospital practices around internal and external staff communication, debriefing, and training are unknown. Methods: We systematically sampled U.S. hospitals that provide obstetrical care. Staff knowledgeable of bereavement care on labor and delivery were invited to participate in an anonymous survey linked to hospital descriptors. We evaluated stillbirth communication, debriefing, and training for staff. Results: We received 289 usable surveys from 429 eligible staff (67% response). Most (94%) noted hospitals' marked rooms housing bereaved families, but only a third (37%) reported a marker on the paper or electronic medical record. Half of the hospitals had no standard debriefings post-loss, and 38% reported no perinatal loss training for labor and delivery nurses. Conclusions: Hospitals have significant variations and gaps in staff communication, support, and training, which are key aspects of respectful stillbirth care.

Short Term Coping-Behaviors and Postpartum Health in a Population-Based Study of Women with a Live Birth, Stillbirth, or Neonatal Death

OBJECTIVE

Responding to the National Institutes of Health Working Group's call for research on the psychological impact of stillbirth, we compared coping-related behaviors by outcome of an index birth (surviving live birth or perinatal loss - stillbirth or neonatal death) and, among individuals with loss, characterized coping strategies and their association with depressive symptoms 6-36 months postpartum.

METHODS

We used data from the Stillbirth Collaborative Research Network follow-up study (2006-2008) of 285 individuals who experienced a stillbirth, 691 a livebirth, and 49 a neonatal death. We conducted a thematic analysis of coping strategies individuals recommended following their loss. We fit logistic regression models, accounting for sampling and inverse probability of follow-up weights to estimate associations between pregnancy outcomes and coping-related behaviors and, separately, coping strategies and probable depression (Edinburgh Postnatal Depression Scale > 12) for those with loss.

RESULTS

Compared to those with a surviving live birth and adjusting for pre-pregnancy drinking and smoking, history of stillbirth, and age, individuals who experienced a loss were more likely to report increased drinking or smoking in the two months postpartum (adjusted OR: 2.7, 95% CI = 1.4-5.4). Those who smoked or drank more had greater odds of probable depression at 6 to 36 months postpartum (adjusted OR 6.4, 95% CI = 2.5-16.4). Among those with loss, recommended coping strategies commonly included communication, support groups, memorializing the loss, and spirituality.

DISCUSSION

Access to a variety of evidence-based and culturally-appropriate positive coping strategies may help individuals experiencing perinatal loss avoid adverse health consequences.

Professional approach to the care of women who have suffered a perinatal loss

To understand the experience, training, and needs of midwives in their approach to perinatal grief. A descriptive cross-sectional study was carried out using an online questionnaire with 26 questions related to institutional management and individual clinical practices in the care of a perinatal loss was developed by a team of midwives from the Hospital "La Mancha-Centro" of Alcazar de San Juan (Ciudad Real). Strobe checklist was followed. A total of 267 midwives participated. A total of 92.1% (246) of the centers had specific protocols for action, but each professional applied their own criteria. The presence of a perinatal psychology team was nonexistent according to 88% (235) of those surveyed. Regarding their training and professional experience, 16.5% (44) of the midwives had never received training. Only 4.1% (11) of the midwives felt very prepared to care for women with a perinatal loss. Among the factors associated with greater application of recommended practices in the face of perinatal death by midwives were being a woman, having prior training on care during perinatal death, and a greater perception of preparation (p < 0.05). The perception of lack of preparation on the part of midwives in the accompaniment of these families was high.

A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses

BACKGROUND

Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs.

OBJECTIVE

The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs.

METHODS

A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted.

RESULTS

Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children.

CONCLUSIONS

Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.

The impact of midwife/nurse-led psychosocial interventions on parents experiencing perinatal bereavement: An integrative review

BACKGROUND

Perinatal loss is a traumatic event associated with a high risk of parents experiencing negative psychological outcomes. Despite most parents being in regular contact with midwives and nurses during the perinatal period, there is a lack of evidence which hampers these professionals from using effective psychosocial interventions with parents.

AIM

This study aims to synthesise the existing evidence on the types of psychosocial interventions delivered by midwives/nurses for parents with perinatal bereavement, their impacts on bereaved parents' mental health and the experiences of midwives and nurses in delivering psychosocial interventions for parents experiencing perinatal loss.

DESIGN

An integrative review of the literature.

METHODS

Whittemore and Knafl's five-stage integrative review framework guided this review. A systematic literature search of the Medline, PsycINFO, Embase, CINAHL and ASSIA, Cochrane Library and ProQuest databases was conducted from inception to January 2023, with no language or geographical limiters set due to the paucity of research published in this subject area. Two researchers independently screened and reviewed each study's data extraction and methodological quality using the Joanna Briggs Institute and Mixed Method Appraisal Tool. Results were analysed and synthesised using narrative synthesis.

RESULTS

A total of 21 studies met the inclusion criteria. From these, we identified nine types of psychosocial interventions for perinatal bereavement that can be delivered by midwives and nurses. The positive impacts of midwife/nurse-led psychosocial interventions on grief, anxiety, depression posttraumatic stress disorder and other psychosocial outcomes amongst parents experiencing perinatal loss have been demonstrated. In addition, we identified the useful components of these interventions and the experiences of midwives and nurses in delivering psychosocial interventions, thereby highlighting barriers such as lack of knowledge and skills, stressful working environments and inadequate emotional support.

CONCLUSION

Our findings demonstrate that midwife/nurse-led psychosocial interventions have the potential to improve grief, anxiety, depression, posttraumatic stress disorder symptoms and other psychosocial outcomes for parents experiencing perinatal loss. Thus, future research should consider training, workload, time cost and emotional support for midwives/nurses when developing midwife/nurse-led psychosocial interventions for parents with perinatal loss.

REGISTRATION NUMBER

CRD42022369032.

TWEETABLE ABSTRACT

Midwife/nurse-led psychosocial interventions have the potential to improve mental health amongst parents experiencing perinatal loss.

Customization and acceptability of the WHO labor care guide to improve labor monitoring among health workers in Uganda. An iterative development, mixed method study

Cognisant of persistently high maternal and perinatal mortality rates, WHO called for adoption and evaluation of new adaptable and context-specific solutions to improve labor monitoring and health outcomes. We aimed at customizing/refining the new WHO labour care guide (LCG) to suite health care provider needs (HCP) in monitoring labour in Uganda. We used mixed methods to customize/refine and pilot test the new WHO LCG using stakeholder perspectives. Between 1st July 2023 and 30th December 2023, we conducted; 1)30 stakeholder interviews to identify user needs/challenges that informed initial modifications of the WHO LCG; 2)15 HCP in-depth interviews to identify any further needs to modify the LCG; 3) Two focus group discussions and 4) Two exit expert panels to identify any further user needs to further refine proposed modifications into the final prototype. Questionnaires were administered to assess acceptability. We interviewed 125 stakeholders with median age of 36 years (IQR;26-48) exposed to the LCG for at least 12 months with 11.8(SD = 4.6) years of clinical practice. Simple useful modifications/customizations based on format, HCP's perceived function and role in improving decision making during monitoring labour included; 1) Customizing LCG by adding key socio-demographic data; 2) Adjusting observation ordering; 3) Modification of medication dosages and 4) Provision for recording key clinical notes/labour outcome data on reverse side of the same A4 paper. All HCPs found the modified WHO LCG useful, easy to use, appropriate, comprehensive, appealing and would recommend it to others for labour monitoring. It was implementable and majority took less than 2 minutes to completely record/fill observations on the LCG after each labour assessment. Active involvement of end-users improved inclusiveness, ownership, acceptability and uptake. The modified LCG prototype was found to be simple, appropriate and easy-to-use. Further research to evaluate large-scale use, feasibility and effectiveness is warranted.

Care, connection, and social distancing: The challenges of baby loss during the COVID-19 pandemic in Aotearoa New Zealand

PROBLEM

The COVID-19 pandemic hindered access to routine healthcare globally, prompting concerns about possible increases in pregnancy loss and perinatal death.

BACKGROUND

PUDDLES is an international collaboration exploring the impact of the COVID-19 pandemic on parents who experience pregnancy loss and perinatal death in seven countries, including Aotearoa New Zealand.

AIM

To explore parents' experiences of access to healthcare services and support following baby loss during the COVID-19 pandemic in Aotearoa New Zealand.

METHODS

We conducted in-depth, semi-structured interviews with 26 bereaved parents, including 20 birthing mothers, and six non-birthing parents (one mother and five fathers). Types of loss included 15 stillbirths, four late miscarriages, and one neonatal death. Participant ethnicities were broadly representative of Aotearoa New Zealand's multi-ethnic society. Data were analysed using Template Analysis.

FINDINGS

Analysis revealed five themes relating to pandemic impact on bereaved parent's experiences. These were: 'Distanced and Impersonal care'; 'Navigating Hospital Rules'; Exclusion of Non-birthing Parents; 'Hindered Access to Social Support'; and 'Continuity of Relational Care'.

DISCUSSION

The COVID-19 pandemic exacerbated isolation of bereaved parents through perceived impersonal care by healthcare professionals and restrictions on movement hindered access to social and cultural support. Compassionate bending of the rules by healthcare professionals and community postnatal visits by continuity of care midwives following the bereavement appeared to be mitigating factors.

CONCLUSION

Social isolation is an added challenge for parents experiencing baby loss during a pandemic, which may be mitigated by flexible and compassionate care from healthcare professionals, especially continuity of care midwives.

Gaps in Stillbirth Bereavement Care: A Cross-Sectional Survey of U.S. Hospitals by Birth Volume

OBJECTIVES

The quality and scope of perinatal bereavement care in the United States has been evaluated by surveying bereaved parents, but little is known about how care varies across hospitals. We sought to survey clinicians about stillbirth bereavement care practices at U.S. hospitals and to evaluate care by hospital birth volume.

METHODS

Using American Hospital Association data, we employed stratified random sampling to select 300 hospitals from all centers with at least 100 annual deliveries. Within each state, we divided all hospitals into size quartiles and randomly selected from each until we reached the goal number per state. We then identified a staff member knowledgeable about typical bereavement care on labor and delivery at each hospital and sent an on-line survey about care. We linked survey data with hospital characteristics and used summary statistics, Chi squared, and Fisher's Exact test to compare care by hospital birth volume.

RESULTS

We reached an eligible respondent at 429/551 hospitals and 396 of the 429 (73%) agreed to participate. We received 289 usable surveys for an overall response rate of 67%. Only one third of hospitals (n = 96, 33%) reported staff protected time for perinatal bereavement care. Of 17 bereavement topics, just six were routinely offered by at least two-thirds of the hospitals. Financial limitations and staff shortages were the most commonly identified barriers to care and were most pronounced at small-volume hospitals.

CONCLUSIONS FOR PRACTICE

This study offers a snapshot in bereavement care and identified important gaps for both large and small hospitals.

Social Determinants of Health and Risk of Stillbirth in the United States

OBJECTIVE

 Our aim was to evaluate the impact of social determinants of health (SDoH) risk factors on stillbirth among pregnancy-related hospitalizations in the United States.

STUDY DESIGN

 We conducted a cross-sectional analysis of delivery-related hospital discharges using annualized data (2016-2017) from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. The International Classification of Diseases, 10th Revision ICD-10-CM codes were used to select women with singleton stillbirth. Z-codes were utilized to identify SDoH risk factors and their subtypes. The association between SDoH risk factors and stillbirth was assessed using survey logistic regression models.

RESULTS

 We analyzed 8,148,646 hospitalizations, out of which 91,140 were related to stillbirth hospitalizations, yielding a stillbirth incidence of 1.1%. An increased incidence was observed for non-Hispanic (NH) Blacks (1.7%) when compared with NH Whites (1.0%). The incidence of stillbirth was greater in hospitalizations associated with SDoH risk factors compared with those without risk factors [2.0% vs. 1.1% (p <0.001)]. Among patients with SDoH risk factors, the rate of stillbirth was highest in those designated as NH other (3.0%). Mothers that presented with SDoH risk factors had a 60% greater risk of stillbirth compared with those without (odds ratio [OR] = 1.61 [95% confidence interval (CI) = 1.33-1.95], p < 0.001). The SDoH issues that showed the most significant risk for stillbirth were: occupational risk (OR = 7.05 [95% CI: 3.54-9.58], p < 0.001), upbringing (OR = 1.87 [95% CI: 1.23-2.82], p < 0.001), and primary support group and family (OR = 5.45 [95% 3.84-7.76], p < 0.001).

CONCLUSION

 We found pregnancies bearing SDoH risk factors to be associated with a 60% elevated risk for stillbirth. Future studies should target a variety of risk reduction strategies aimed at modifiable SDoH risk factors that can be widely implemented at both the population health level as well as in the direct clinical setting.

KEY POINTS

· Health disparities exist in stillbirth rates, especially among NH Black women.. · Social determinants of health risk factors increase the risk of stillbirth.. · There is a need for further study on the impact of specific SDoH risk factors on stillbirth risk..

"The Dark Farewell to the Light of Life": A Qualitative Study About Prenatal Loss

AIM

This study was conducted to determine the experiences of women who encountered loss in the prenatal period.

METHOD

This study was a qualitative study conducted using the phenomenological method and was conducted according to the guidelines of the COREQ checklist. A total of 11 women who were experienced loss in the early prenatal period were interviewed. The data were analyzed using the content analysis.

RESULTS

Three main themes and eight sub-themes emerged. The themes were light of life (bubble of happiness, journey), dark farewell (silent scream inside, unfinished tale: motherhood, loneliness, family approach) and obscurity (uncertainty about the future, need for support). Women expressed that the loss process had negative effects on their mental health and that they needed help.

CONCLUSION

Pregnancy illuminates women's lives, while prenatal loss involves intense and various negative emotions, and women need support in many ways. These results show that women who experienced loss in the prenatal period should be allowed to express their feelings, thoughts and experiences, and the risks in terms of mental health should be reduced by supporting them during the loss and mourning process.

Adverse Pregnancy Outcomes and Subsequent First-Time Use of Psychiatric Treatment Among Fathers in Denmark

Importance

Becoming a first-time parent is a major life-changing event and can be challenging regardless of the pregnancy outcome. However, little is known how different adverse pregnancy outcomes affect the father's risk of psychiatric treatment post partum.

Objective

To examine the associations of adverse pregnancy outcomes with first-time psychiatric treatment in first-time fathers.

Design, Setting, and Participants

This nationwide cohort study covered January 1, 2008, to December 31, 2017, with a 1-year follow-up completed December 31, 2018. Data were gathered from Danish, nationwide registers. Participants included first-time fathers with no history of psychiatric treatment. Data were analyzed from August 1, 2022, to February 20, 2024.

Exposures

Adverse pregnancy outcomes including induced abortion, spontaneous abortion, stillbirth, small for gestational age (SGA) and not preterm, preterm with or without SGA, minor congenital malformation, major congenital malformation, and congenital malformation combined with SGA or preterm compared with a full-term healthy offspring.

Main Outcomes and Measures

Prescription of psychotropic drugs, nonpharmacological psychiatric treatment, or having a psychiatric hospital contact up to 1 year after the end of the pregnancy.

Results

Of the 192 455 fathers included (median age, 30.0 [IQR, 27.0-34.0] years), 31.1% experienced an adverse pregnancy outcome. Most of the fathers in the study had a vocational educational level (37.1%). Fathers experiencing a stillbirth had a significantly increased risk of initiating nonpharmacological psychiatric treatment (adjusted hazard ratio [AHR], 23.10 [95% CI, 18.30-29.20]) and treatment with hypnotics (AHR, 9.08 [95% CI, 5.52-14.90]). Moreover, fathers experiencing an early induced abortion (≤12 wk) had an increased risk of initiating treatment with hypnotics (AHR, 1.74 [95% CI, 1.33-2.29]) and anxiolytics (AHR, 1.79 [95% CI, 1.18-2.73]). Additionally, late induced abortion (>12 wk) (AHR, 4.46 [95% CI, 3.13-6.38]) and major congenital malformation (AHR, 1.36 [95% CI, 1.05-1.74]) were associated with increased risk of nonpharmacological treatment. In contrast, fathers having an offspring being born preterm, SGA, or with a minor congenital malformation did not have a significantly increased risk of any of the outcomes.

Conclusions and Relevance

The findings of this Danish cohort study suggest that first-time fathers who experience stillbirths or induced abortions or having an offspring with major congenital malformation had an increased risk of initiating pharmacological or nonpharmacological psychiatric treatment. These findings further suggest a need for increased awareness around the psychological state of fathers following the experience of adverse pregnancy outcomes.

Maternal and fetal factors associated with stillbirth in singleton pregnancies in 13 hospitals across six states in India: A prospective cohort study

OBJECTIVE

This study aimed to investigate the incidence of and risk factors for stillbirth in an Indian population.

METHODS

We conducted a secondary data analysis of a hospital-based cohort from the Maternal and Perinatal Health Research collaboration, India (MaatHRI), including pregnant women who gave birth between October 2018-September 2023. Data from 9823 singleton pregnancies recruited from 13 hospitals across six Indian states were included. Univariable and multivariable Poisson regression analysis were performed to examine the relationship between stillbirth and potential risk factors. Model prediction was assessed using the area under the receiver-operating characteristic (AUROC) curve.

RESULTS

There were 216 stillbirths (48 antepartum and 168 intrapartum) in the study population, representing an overall stillbirth rate of 22.0 per 1000 total births (95% confidence interval [CI]: 19.2-25.1). Modifiable risk factors for stillbirth were: receiving less than four antenatal check-ups (adjusted relative risk [aRR]: 1.75, 95% CI: 1.25-2.47), not taking any iron and folic acid supplementation during pregnancy (aRR: 7.23, 95% CI: 2.12-45.33) and having severe anemia in the third trimester (aRR: 3.37, 95% CI: 1.97-6.11). Having pregnancy/fetal complications such as hypertensive disorders of pregnancy (aRR: 1.59, 95% CI: 1.03-2.36), preterm birth (aRR: 4.41, 95% CI: 3.21-6.08) and birth weight below the 10th percentile for gestational age (aRR: 1.35, 95% CI: 1.02-1.79) were also associated with an increased risk of stillbirth. Identified risk factors explained 78.2% (95% CI: 75.0%-81.4%) of the risk of stillbirth in the population.

CONCLUSION

Addressing potentially modifiable antenatal factors could reduce the risk of stillbirths in India.

Labour Care Guide implementation as a decision-making tool for monitoring labour among healthcare providers in Uganda: protocol for a mixed-methods study

INTRODUCTION

The new WHO Labour Care Guide (LCG), also regarded as the 'next-generation partograph', is a core component of 2018 WHO consolidated guidelines on intrapartum care for positive childbirth experience. The Ugandan Ministry of Health is in the process of adopting the new WHO LCG with no local context-specific data to inform this transition. We will explore potential barriers and facilitators to healthcare providers' (HCPs) sustained engagement in labour monitoring in Mbarara city, Southwestern Uganda, and use the data to refine the new WHO LCG and develop a suitable implementation strategy to effectively integrate LCG into routine maternity care in Uganda. We shall then assess effectiveness, validity and other preliminary implementation outcomes of using the new LCG in detecting prolonged labour.

METHODS AND ANALYSIS

The study will use a mixed-methods approach to identify key LCG user perspectives to refine and customise the WHO LCG among 120 HCPs and stakeholders involved in maternity care and labour monitoring within facilities in Southwestern Uganda. The refined prototype will be deployed and used to monitor labour in all 14 basic and comprehensive emergency obstetric and newborn care facilities in the study area. We will review labour outcomes of 520 patients monitored using the new LCG and compare these outcomes with a historical cohort of 520 patients monitored using the partograph. The main effectiveness outcome will be the proportion of women diagnosed with prolonged labour and/or obstructed labour.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Mbarara University of Science and Technology Research Ethics Committee (MUST-2023-808) and Uganda National Council for Science and Technology (HS2864ES). We shall obtain written informed consent from each participant. The results of this study will be published in international peer-reviewed journals and presented to the Ugandan Ministry of Health as policy briefs and at selected national/international conferences.

TRIAL REGISTRATION NUMBER

NCT05979194.

Determinants of stillbirth among women who delivered in hospitals of North Wollo Zone, Northeast Ethiopia: A case-control study

BACKGROUND

Stillbirth is a silent tragedy that shatters the lives of women, families, and nations. Though affecting over 2 million infants globally in 2019, it remains overlooked, with no specific targets dedicated to its reduction in the sustainable development goals. Insufficient knowledge regarding the primary risk factors contributing to stillbirths hinders efforts to reduce its occurrence. Driven by this urgency, this study focused on identifying the determinants of stillbirth among women giving birth in hospitals across North Wollo Zone, Northeast Ethiopia.

METHODOLOGY

This study employed an institution-based unmatched case-control design, involving a randomly selected sample of 412 women (103 cases and 309 controls) who gave birth in hospitals of North Wollo Zone. Data were collected using a structured data extraction checklist. Data entry was conducted using Epi-data version 3.1, and analysis was performed using SPSS version 25.0. Employing a multivariable logistic regression model, we identified independent predictors of stillbirth. The level of statistical significance was declared at a p-value < 0.05.

RESULTS

Our analysis revealed several critical factors associated with an increased risk of stillbirth. Women who experienced premature rupture of membranes (AOR = 5.53, 95% CI: 2.33-9.94), induced labor (AOR = 2.24, 95% CI: 1.24-4.07), prolonged labor exceeding 24 hours (AOR = 3.80, 95% CI: 1.94-7.45), absence of partograph monitoring during labor (AOR = 2.45, 95% CI: 1.41-4.26) were all significantly associated with increased risk of stillbirth. Preterm birth (AOR = 3.46, 95% CI: 1.87-6.39), post-term birth (AOR = 3.47, 95% CI: 1.35-8.91), and carrying a female fetus (AOR = 1.81, 95% CI: 1.02-3.22) were at a higher risk of stillbirth.

CONCLUSION

These findings highlight the importance of early intervention and close monitoring for women experiencing premature rupture of membranes, prolonged labor, or induced labor. Additionally, consistent partograph use and enhanced prenatal care for pregnancies at risk of preterm or post-term birth could potentially contribute to reducing stillbirth rates and improving maternal and neonatal outcomes. Further research is needed to investigate the underlying mechanisms behind the observed association between fetal sex and stillbirth risk.

An expert review of environmental heat exposure and stillbirth in the face of climate change: Clinical implications and priority issues

Exposure to extreme heat in pregnancy increases the risk of stillbirth. Progress in reducing stillbirth rates has stalled, and populations are increasingly exposed to high temperatures and climate events that may further undermine health strategies. This narrative review summarises the current clinical and epidemiological evidence of the impact of maternal heat exposure on stillbirth risk. Out of 20 studies, 19 found an association between heat and stillbirth risk. Recent studies based in low- to middle-income countries and tropical settings add to the existing literature to demonstrate that all populations are at risk. Additionally, both short-term heat exposure and whole-pregnancy heat exposure increase the risk of stillbirth. A definitive threshold of effect has not been identified, as most studies define exposure as above the 90th centile of the usual temperature for that population. Therefore, the association between heat and stillbirth has been found with exposures from as low as >12.64°C up to >46.4°C. The pathophysiological pathways by which maternal heat exposure may lead to stillbirth, based on human and animal studies, include both placental and embryonic or fetal impacts. Although evidence gaps remain and further research is needed to characterise these mechanistic pathways in more detail, preliminary evidence suggests epigenetic changes, alteration in imprinted genes, congenital abnormalities, reduction in placental blood flow, size and function all play a part. Finally, we explore this topic from a public health perspective; we discuss and evaluate the current public health guidance on minimising the risk of extreme heat in the community. There is limited pregnancy-specific guidance within heatwave planning, and no evidence-based interventions have been established to prevent poor pregnancy outcomes. We highlight priority research questions to move forward in the field and specifically note the urgent need for evidence-based interventions that are sustainable.

"Trying to Find North": Fathers Voice the Nature of Their Bereavement

Fathers' lived experience of bereavement is not well understood. This article presents findings from a Heidegerrian phenomenological study, which aimed to describe fathers' bereavement. Fathers' bereavement is a life-long journey along which a father navigates through devastating and traumatic loss with great strength; has profound grief that mirrors the profound love he has for his child; chooses to live life with intention and engages in meaningful activities that create purpose aimed at honoring his child, continuing his child's legacy, and using his own suffering for the good of others; is anchored by a continuing bond of love that fuels an ongoing relationship with his child; and needs a supportive community to sustain him as he travels down the healing road where it is possible to find faith, hope, and love while being forever transformed by loss. Findings amplify fathers' voice so nurses gain a deeper understanding of their experience.

Support interventions to reduce psychological distress in families experiencing stillbirth in high income countries: A systematic review

BACKGROUND

Previous research indicates disparities in the care of bereaved parents and siblings following a stillbirth in the family. The aim of this systematic review was to assess the effects of interventions aimed at reducing psychological distress among parents or siblings in high-income countries after experiencing a stillbirth.

METHODS

The databases CINAHL, Medline, PsycInfo, Cochrane Library, and EMBASE were searched in August 2022.

RESULTS

Four intervention studies from the United States (US), the United Kingdom (UK), Finland, and Australia, met the inclusion criteria. The interventions comprised a perinatal grief support team; a perinatal counselling service; a grief support program; and a support package including contacts with peer supporters and health care staff. No studies of interventions for siblings were found. The results could not be synthesised due to disparities in interventions and outcome measures. The risk of bias was assessed as high in all four studies and the certainty for all outcomes was rated as very low.

CONCLUSION

More controlled trials with rigorous methods are needed to evaluate the effect of bereavement support interventions in parents and siblings after stillbirth. Future studies should include a core outcome set to make them more comparable. Most of the studies in this review were assessed to have an overall high risk of bias, mainly due to problems with missing outcome data; thus, future studies could specifically target this problem.

Student midwives' lived experiences of caring for bereaved parents following perinatal loss using actor-based simulation: A phenomenological study

BACKGROUND

Student midwives frequently encounter bereaved parents in clinical practice; however, the experience of caring for bereaved parents can be a significant source of traumatic stress. Although the use of simulation to teach bereavement care is considered a powerful experiential form of learning, evidence for its effectiveness as a transformative learning strategy is limited.

AIM

To explore student midwives' lived experience of caring for bereaved parents experiencing perinatal loss using high-fidelity simulation.

DESIGN

Students midwives participated in an actor-based bereavement simulated scenario. Data was collected using semi-structured interviews. Interpretative Phenomenological Analysis was conducted to gain a deep understanding of the meaning of the experience. Mezirow's Transformative Learning Theory was applied as an analytical framework to illustrate how the student midwives made sense of and learned from the experience of caring for bereaved parents experiencing perinatal loss.

SETTING

One BSc (Hons), 156-week undergraduate midwifery programme within a university in the Northwest of England.

PARTICIPANTS

A purposeful sample of nine first-and second-year student midwives volunteered to participate in the study.

FINDINGS

One of the superordinate themes that emerged from the analysis (1) 'trying to console and making things easier' and the related subthemes (1a)'what words can I say', (1b)'my instinct was to console the mum', (1c)'left to sort of pick up the pieces' captured the deep sense of powerlessness and the professional dilemmas experienced as students struggled to emotionally console and communicate the right words to say to the grieving parents.

CONCLUSION

The study highlights the vital role of simulation as a defined model of bereavement education that equips students with the necessary knowledge, skills, and confidence to provide compassionate care to bereaved parents experiencing perinatal loss.

IMPLICATIONS FOR PRACTICE

The emotional toll of caring for bereaved parents is significant, and higher education institutions should adopt experiential forms of learning using actor-based simulation scenarios to emotionally prepare students to care holistically for parents affected by perinatal loss.

Measuring EQ-5D-5L utility values in parents who have experienced perinatal death

BACKGROUND

Policymakers use clinical and cost-effectiveness evidence to support decisions about health service commissioning. In England, the National Institute for Health and Care Excellence (NICE) recommend that in cost-effectiveness analyses "effectiveness" is measured as quality-adjusted life years (QALYs), derived from health utility values. The impact of perinatal death (stillbirth/neonatal death) on parents' health utility is currently unknown. This knowledge would improve the robustness of cost-effectiveness evidence for policymakers.

OBJECTIVE

This study aimed to estimate the impact of perinatal death on parents' health utility.

METHODS

An online survey conducted with mothers and fathers in England who experienced a perinatal death. Participants reported how long ago their baby died and whether they/their partner subsequently became pregnant again. They were asked to rate their health on the EQ-5D-5L instrument (generic health measure). EQ-5D-5L responses were used to calculate health utility values. These were compared with age-matched values for the general population to estimate a utility shortfall (i.e. health loss) associated with perinatal death.

RESULTS

There were 256 survey respondents with a median age of 40 years (IQR 26-40). Median time since death was 27 months (IQR 8-71). The mean utility value of the sample was 0.774 (95% CI 0.752-0.796). Utility values in the sample were 13% lower than general population values (p < 0.05). Over 10 years, this equated to a loss of 1.1 QALYs. This reduction in health utility was driven by anxiety and depression.

CONCLUSIONS

Perinatal death has important and long-lasting health impacts on parents. Mental health support following perinatal bereavement is especially important.

Partners in Pain, Two Sides of a Zipper - Midwives' Experiences With Stillbirth: A Qualitative Study

This study was conducted to explore and understand the experiences of midwives who care for women experiencing stillbirth and the challenges they face in this process. A qualitative study was conducted with 11 midwives using the phenomenological method. Descriptive analysis of the data revealed four main themes: 1) Silent screams in the face of despair (women's reactions to stillbirth), 2) Being a partner in pain, "two sides of a zipper" (midwives' experience of stillbirth), 3) Efforts to cope with the pain, and 4) Just two words: "if only." The impact of stillbirths on midwives should not be disregarded. Emotions such as shock, horror, fear, guilt, and anger experienced by midwives following a stillbirth can adversely affect their mental health. The guilt experienced by midwives can also negatively impact their health and quality of life, as well as cause burnout and distancing from the profession.

Proportion of stillbirth and associated factors among women who deliver at public hospitals in Bahir Dar city, north-West Ethiopia

INTRODUCTION

The annual global burden of stillbirths is estimated to be 3.2 million, of which 98% occur in low and middle-income countries (LMICs). In the Amhara region of Ethiopia, the prevalence of stillbirth outcomes was 85 per 1000. Ethiopia is experiencing an increase in the number of health professionals attending deliveries, however, stillbirth rates are not decreasing as anticipated. However, there are limited numbers of studies done related to the proportion of stillbirths and associated factors in the study area. This study aimed to assess the proportion of stillbirths and associated factors among women who attended deliveries at Tibebe Ghion Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital.

METHODS

An institutional-based cross-sectional study was conducted on 366 women who delivered at two referral hospitals in Bahir Dar from April 1, 2020, to August 30, 2020. Study participants were selected using systematic random sampling techniques. A checklist and structured questionnaire were used to retrieve information from the clients and their attendants. The collected data were cleaned, coded, and entered into Epi-data version 3.1 and then exported into SPSS 23 for analysis. Bivariate and multivariable logistic regression analysis was computed to identify statistically significant associated factors with a P value < 0.05. The results were presented in tables and charts.

RESULT

The proportion of stillbirths was 3.8% in this study area. This study showed that level of education, who completed primary school (AOR = 0.12; 95% CI (0.01, 0.98)), not using partograph (AOR = 3.77, 95%; CI (1.02; 13.93)), and obstetric complication (AOR = 6.7; 95% CI (1.54, 29.79) were the major factors affecting the stillbirth.

CONCLUSION

Our study found that stillbirth rate remains a major public health problem. Illiteracy, not using a partograph, and having obstetric complications were major associated factors for stillbirth. The risk factors identified in this study can be prevented and managed by providing appropriate care during preconception, antepartum, and intrapartum periods.

Postpartum readmission risk: a comparison between stillbirths and live births

BACKGROUND

Stillbirth occurs more commonly among pregnant people with comorbid conditions and obstetrical complications. Stillbirth also independently increases maternal morbidity and imparts a psychosocial hazard when compared with live birth. These distinct needs and burden may increase the risk for postpartum readmission after stillbirth.

OBJECTIVE

This study aimed to examine the risk for maternal postpartum readmission after stillbirth in comparison with live birth and to identify indications for readmission and the associated risk factors.

STUDY DESIGN

This was a retrospective cohort of patients with singleton stillbirths or live births, delivered at ≥20 weeks' gestation, who were identified from the 2019 Nationwide Readmissions Database. The primary outcome was all-cause readmission within 6 weeks of discharge from the childbirth hospitalization. The association between stillbirth (vs live birth) and risk for readmission was assessed using multivariable regression models with adjustment for maternal age, sociodemographic characteristics, maternal and obstetrical conditions, and delivery characteristics. Within the stillbirth group, risk factors for readmission were further examined using multivariable regression. The secondary outcomes included principal indication for readmission (categorized based on principal diagnosis code of the readmission hospitalization) and timing of readmission (number of weeks after childbirth hospitalization). Differences in these secondary outcomes were compared between the stillbirth and live birth groups using chi-square tests. All analyses accounted for the complex sample design to generate nationally representative estimates.

RESULTS

Postpartum readmission occurred in 2.7% of 16,636 patients with stillbirths, whereas it occurred in 1.6% of 2,870,677 patients with live births (unadjusted risk ratio, 1.65; 95% confidence interval, 1.47-1.86). The higher risk for readmission after stillbirth (vs live birth) persisted after adjusting for maternal, obstetrical, and delivery characteristics (adjusted risk ratio, 1.27; 95% confidence interval, 1.11-1.46). The distribution of principal indication for readmission differed after stillbirth and after live birth and included hypertension (30.2% vs 39.5%; unadjusted risk ratio, 0.76; 95% confidence interval, 0.63-0.93), mental health or substance use disorders (6.8% vs 3.6%; unadjusted risk ratio, 1.90; 95% confidence interval, 1.15-3.16), and venous thromboembolism (5.8% vs 2.0%; unadjusted risk ratio, 2.87; 95% confidence interval, 1.60-5.17). Among patients with stillbirths, 56.0% of readmissions occurred within 1 week, 71.8% within 2 weeks, and 88.1% within 4 weeks; the timing of readmission did not differ significantly between the stillbirth and live birth cohorts. Pregestational diabetes (adjusted risk ratio, 1.87; 95% confidence interval, 1.20-2.93), gestational diabetes (adjusted risk ratio, 1.67; 95% confidence interval, 1.03-2.71), hypertensive disorders of pregnancy (adjusted risk ratio, 1.80; 95% confidence interval, 1.31-2.47), obesity (adjusted risk ratio, 1.46; 95% confidence interval, 1.01-2.12), and primary cesarean delivery (adjusted risk ratio, 1.74; 95% confidence interval, 1.17-2.58) were associated with a higher risk for readmission after stillbirth, whereas higher household income was associated with a lower risk for readmission (eg, adjusted risk ratio for income ≥$82,000 vs $1-$47,999, 0.48; 95% confidence interval, 0.30-0.77).

CONCLUSION

When compared with live births, the risk for postpartum readmission was higher after stillbirths, even after adjustment for differences in the patient demographic and clinical characteristics. Readmission for mental health or substance use disorders and venous thromboembolism is more common after stillbirths than after live births.

The impact of severe perinatal events on maternity care providers: a scoping review

BACKGROUND

Severe events during the perinatal period can be experienced as traumatic by pregnant women, their partners or others who are closely involved. This includes maternity care providers who can be affected by being involved in or observing these events. This may have an impact on their personal well-being and professional practice, influencing quality of care. The aim of this study is to map research investigating the impact of severe events during the perinatal period on maternity care providers, and how these experiences affect their well-being and professional practice.

METHOD

A scoping review following the manual of the Joanna Briggs Institute was undertaken. The electronic bibliographic databases included PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX, Cochrane, Scopus, Web of Science and databases for grey literature. Records passing the two-stage screening process were assessed, and their reference lists hand searched. We included primary research papers that presented data from maternity care professionals on the impact of severe perinatal traumatic events. A descriptive content analysis and synthesis was undertaken.

RESULTS

Following a detailed systematic search and screening of 1,611 records, 57 papers were included in the scoping review. Results of the analysis identified four categories, which highlighted the impact of traumatic perinatal events on maternity care providers, mainly midwives, obstetricians and nurses: Traumatic events, Impact of traumatic events on care providers, Changes in care providers' practice and Support for care providers; each including several subcategories.

CONCLUSION

The impact of traumatic perinatal events on maternity care providers ranged from severe negative responses where care providers moved position or resigned from their employment in maternity care, to responses where they felt they became a better clinician. However, a substantial number appeared to be negatively affected by traumatic events without getting adequate support. Given the shortage of maternity staff and the importance of a sustainable workforce for effective maternity care, the impact of traumatic perinatal events requires serious consideration in maintaining their wellbeing and positive engagement when conducting their profession. Future research should explore which maternity care providers are mostly at risk for the impact of traumatic events and which interventions can contribute to prevention.

Bridging the gap between pregnancy loss research and policy and practice: insights from a qualitative survey with knowledge users

BACKGROUND

The loss of a pregnancy or the death of baby around the time of their birth can have profound impacts on parents, families and staff involved. There is much opportunity to enhance the systematic uptake of evidence-based interventions to enhance service provision, lived experiences and outcomes. Challenges exist to translating pregnancy loss research evidence into policy and practice, however. Pregnancy loss remains a neglected area of research and resourcing and is steeped in stigma. While barriers and facilitators to the use of research evidence by decision-makers in public health and health services are well documented, we aimed to better understand the factors that influence the translation of pregnancy loss research into practice and policy.

METHODS

We conducted a qualitative online survey of pregnancy loss research knowledge users in Ireland, identified through our clinical and academic networks, between January and March 2022. The survey comprised ten questions, with three closed questions, informed by the Knowledge Translation Planning Template©. Questions included who could benefit from pregnancy loss research, perceived barriers and facilitators to the use of research evidence and preferred knowledge translation strategies. We analysed data using reflexive thematic analysis.

RESULTS

We included data from 46 participants in our analysis, from which we generated two central themes. The first-'End the silence; stigma and inequality around pregnancy loss to enhance awareness and understanding, public health and services and supports'-addresses issues related to the stigma, sensitivities and silence, lack of awareness and understanding, and lack of relevance or priority afforded to pregnancy loss. The second theme-'Use a range of tailored, accessible approaches to engage a large, diverse range of knowledge users'-highlights the need to use relevant, accessible, and engaging information, resources or materials in knowledge translation efforts, and a variety of tailored approaches to suit different audiences, including materials, workshops/webinars, media, knowledge brokers and champions or opinion leaders.

CONCLUSIONS

Our analysis provides rich insights into the barriers and facilitators to knowledge translation in the field of pregnancy loss research. We identified key strategies that can be used to inform knowledge translation planning in Ireland, and which have international applicability.

Understanding trimester-specific miscarriage risk in Indian women: insights from the calendar data of National Family Health Survey (NFHS-5) 2019-21

BACKGROUND

The primary public health issue, especially in low- and middle-income countries, is early pregnancy loss driven by miscarriage. Understanding early pregnancy losses and the characteristics of mothers who have miscarriages is essential to creating effective reproductive health strategies. Thus, this study's primary goal is to delve into the factors which impact miscarriages that take place prior to and following the first 12 weeks of gestation.

METHODS

The bivariate analysis was employed to determine the frequency of miscarriages. The factors associated with miscarriages in the first (≤12 weeks) and second & above (> 12 weeks) trimesters of pregnancy were then examined using a generalised linear regression model, with 95% confidence intervals. Finally, we use ArcGIS to illustrate the prevalence of miscarriage in the districts of India.

RESULTS

Our result shows that miscarriages occur often in India (4.9%), with 23% of cases occurring in the first trimester (≤12 weeks). In our bivariate analysis, we identified several factors associated with a higher prevalence of miscarriages in India. It was found that mothers aged thirty years or older, residing in urban areas, with less than ten years of education, belonging to the richest wealth quantile, expressing a desire for more children, having no demand for contraception, and possessing no parity experienced a higher prevalence of miscarriage in total pregnancies in India. On the other hand, the generalised linear model's findings show that mothers who are thirty years of age or older, practise other religions, live in urban areas, are members of other castes, want more children, marry before the age of eighteen, and meet their contraceptive needs are more likely to have miscarriages in total pregnancy. However, there is a larger likelihood of miscarriage in the first trimester (≤12 weeks) for mothers who follow other religions, live in urban areas, are from Other Backward Class (OBC), get married before the age of eighteen, and fall into the middle and upper wealth quantiles. A mother is more likely to miscarriage in the second & above (> 12 weeks) trimesters if she is older than thirty, from other castes, wants more children, has moderate media exposure, marries before turning eighteen, meets her contraceptive needs, and does not feel the need for contraception. After accounting for socioeconomic characteristics, all results were statistically significant.

CONCLUSIONS

Given the substantial number of miscarriages in India, police need to improve planning and guidance in order to lower pregnancy loss due to miscarriage. Miscarriage rates may be significantly decreased by enhancing the availability and quality of reproductive health care infrastructure, particularly in rural areas.

Clinical Experiences of Perinatal Palliative Care After a Stillbirth: A Narrative Therapy for Grief

Narrative care for families suffering from perinatal loss is rarely provided by medical institutions in China Mainland. However, with the advancement of the Chinese narrative medicine theory and practice, the clinical significance of narrative care has been increasingly recognized. Based on the principles of Chinese narrative medicine, this narrative case study described traumatic narrative foreclosures occuring in a family suffering from stillbirth, and highlighted the multidisciplinary collaboration for practising narrative care in the process of supporting the bereaved in our hospital. Meanwhile, we advocate the establishment of a narrative care ecology by training more obsteticians and nurses with good narrative competence in purpose of helping the family experiencing perinatal losses to overcome their tramatic narrative foreclosures, increasing the chances of another successful pregnancy and childbirth as well as enhancing their quality of life.

Mothers working to prevent early stillbirth study (MiNESS 20-28): a case-control study protocol

INTRODUCTION

In the UK, 1600 babies die every year before, during or immediately after birth at 20-28 weeks' gestation. This bereavement has a similar impact on parental physical and psychological well-being to late stillbirth (>28 weeks' gestation). Improved understanding of potentially modifiable risk factors for late stillbirth (including supine going-to-sleep position) has influenced international clinical practice. Information is now urgently required to similarly inform clinical practice and aid decision-making by expectant mothers/parents, addressing inequalities in pregnancy loss between 20 and 28 weeks.

METHODS AND ANALYSIS

This study focuses on what portion of risk of pregnancy loss 20-28 weeks' gestation is associated with exposures amenable to public health campaigns/antenatal care adaptation. A case-control study of non-anomalous singleton baby loss (via miscarriage, stillbirth or early neonatal death) 20+0 to 27+6 (n=316) and randomly selected control pregnancies (2:1 ratio; n=632) at group-matched gestations will be conducted. Data is collected via participant recall (researcher-administered questionnaire) and extraction from contemporaneous medical records. Unadjusted/confounder-adjusted ORs will be calculated. Exposures associated with early stillbirth at OR≥1.5 will be detectable (p<0.05, β>0.80) assuming exposure prevalence of 30%-60%.

ETHICS AND DISSEMINATION

NHS research ethical approval has been obtained from the London-Seasonal research ethics committee (23/LO/0622). The results will be presented at international conferences and published in peer-reviewed open-access journals. Information from this study will enable development of antenatal care and education for healthcare professionals and pregnant people to reduce risk of early stillbirth.

TRIAL REGISTRATION NUMBER

NCT06005272.

Short-Term Increases in NO2 and O3 Concentrations during Pregnancy and Stillbirth Risk in the U.S.: A Time-Stratified Case-Crossover Study

Associations between gaseous pollutant exposure and stillbirth have focused on exposures averaged over trimesters or gestation. We investigated the association between short-term increases in nitrogen dioxide (NO2) and ozone (O3) concentrations and stillbirth risk among a national sample of 116 788 Medicaid enrollees from 2000 to 2014. A time-stratified case-crossover design was used to estimate distributed (lag 0-lag 6) and cumulative lag effects, which were adjusted for PM2.5 concentration and temperature. Effect modification by race/ethnicity and proximity to hydraulic fracturing (fracking) wells was assessed. Short-term increases in the NO2 and O3 concentrations were not associated with stillbirth in the overall sample. Among American Indian individuals (n = 1694), a 10 ppb increase in NO2 concentrations was associated with increased stillbirth odds at lag 0 (5.66%, 95%CI: [0.57%, 11.01%], p = 0.03) and lag 1 (4.08%, 95%CI: [0.22%, 8.09%], p = 0.04) but not lag 0-6 (7.12%, 95%CI: [-9.83%, 27.27%], p = 0.43). Among participants living in zip codes within 15 km of active fracking wells (n = 9486), a 10 ppb increase in NO2 concentration was associated with increased stillbirth odds in single-day lags (2.42%, 95%CI: [0.37%, 4.52%], p = 0.02 for lag 0 and 1.83%, 95%CI: [0.25%, 3.43%], p = 0.03 for lag 1) but not the cumulative lag (lag 0-6) (4.62%, 95%CI: [-2.75%, 12.55%], p = 0.22). Odds ratios were close to the null in zip codes distant from fracking wells. Future studies should investigate the role of air pollutants emitted from fracking and potential racial disparities in the relationship between short-term increases in NO2 concentrations and stillbirth.

Incidence and determinants of perinatal mortality in five urban hospitals in Dar es Salaam, Tanzania: a cohort study with an embedded case-control analysis

INTRODUCTION

Tanzania has one of the highest burdens of perinatal mortality, with a higher risk among urban versus rural women. To understand the characteristics of perinatal mortality in urban health facilities, study objectives were: I. To assess the incidence of perinatal deaths in public health facilities in Dar es Salaam and classify these into a) pre-facility stillbirths (absence of fetal heart tones on admission to the study health facilities) and b) intra-facility perinatal deaths before discharge; and II. To identify determinants of perinatal deaths by comparing each of the two groups of perinatal deaths with healthy newborns.

METHODS

This was a retrospective cohort study among women who gave birth in five urban, public health facilities in Dar es Salaam. I. Incidence of perinatal death in the year 2020 was calculated based on routinely collected health facility records and the Perinatal Problem Identification Database. II. An embedded case-control study was conducted within a sub-population of singletons with birthweight ≥ 2000 g (excluding newborns with congenital malformations); pre-facility stillbirths and intra-facility perinatal deaths were compared with 'healthy newborns' (Apgar score ≥ 8 at one and ≥ 9 at five minutes and discharged home alive). Descriptive and logistic regression analyses were performed to explore the determinants of deaths.

RESULTS

A total of 37,787 births were recorded in 2020. The pre-discharge perinatal death rate was 38.3 per 1,000 total births: a stillbirth rate of 27.7 per 1,000 total births and an intra-facility neonatal death rate of 10.9 per 1,000 live births. Pre-facility stillbirths accounted for 88.4% of the stillbirths. The case-control study included 2,224 women (452 pre-facility stillbirths; 287 intra-facility perinatal deaths and 1,485 controls), 99% of whom attended antenatal clinic (75% with more than three visits). Pre-facility stillbirths were associated with low birth weight (cOR 4.40; (95% CI: 3.13-6.18) and with maternal hypertension (cOR 4.72; 95% CI: 3.30-6.76). Intra-facility perinatal deaths were associated with breech presentation (aOR 40.3; 95% CI: 8.75-185.61), complications in the second stage (aOR 20.04; 95% CI: 12.02-33.41), low birth weight (aOR 5.57; 95% CI: 2.62-11.84), cervical dilation crossing the partograph's action line (aOR 4.16; 95% CI:2.29-7.56), and hypertension during intrapartum care (aOR 2.9; 95% CI 1.03-8.14), among other factors.  CONCLUSION: The perinatal death rate in the five urban hospitals was linked to gaps in the quality of antenatal and intrapartum care, in the study health facilities and in lower-level referral clinics. Urgent action is required to implement context-specific interventions and conduct implementation research to strengthen the urban referral system across the entire continuum of care from pregnancy onset to postpartum. The role of hypertensive disorders in pregnancy as a crucial determinant of perinatal deaths emphasizes the complexities of maternal-perinatal health within urban settings.

Economic burden of adverse perinatal outcomes from births to age 5 years in high-income settings: a protocol for a systematic review

BACKGROUND

Adverse perinatal outcomes such as preterm, small for gestational age, low birth weight, congenital anomalies, stillbirth and neonatal death have devastating impacts on individuals, families and societies, with significant lifelong health implications. Despite extensive knowledge of the significant and lifelong health implications of adverse perinatal outcomes, information on the economic burden is limited. Estimating this burden will be crucial for designing cost-effective interventions to reduce perinatal morbidity and mortality. Thus, we will quantify the economic burden of adverse perinatal outcomes from births to age 5 years in high-income countries.

METHODS AND ANALYSIS

A systematic review of all primary studies published in English in peer-reviewed journals on the economic burden for at least one of the adverse perinatal outcomes in high-income countries from 2010 will be searched in databases-MEDLINE (Ovid), EconLit, CINAHL (EBSCO), Embase (Ovid) and Global Health (Ovid). We will also search using Google Scholar and snowballing of the references list of included articles. The search terms will include three main concepts-costs, adverse perinatal outcome(s) and settings. We will use the Consolidated Health Economics Evaluation Reporting Standards 2022 and 17 criteria from the critical appraisal of cost-of-illness studies to assess the quality of each study. We will report the findings based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 statement. Costs will be converted into a common currency (US dollar), and we will estimate the pooled cost and subgroup analysis will be done. The reference lists of included papers will be reviewed.

ETHICS AND DISSEMINATION

This systematic review will not involve human participants and requires no ethical approval. The results of this review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023400215.

Evaluating patient experience to improve care in a specialist antenatal clinic for pregnancy after loss

In the United Kingdom, roughly 1 in 250 babies are stillborn each year. Most women who experience stillbirth become pregnant again - 80% within a year of loss. Presently, obstetric-led care is recommended; though there is a growing body of evidence to support provision of specialist services. The Rainbow Clinic is a specialist antenatal service providing care for pregnancies after loss incorporating clinical and psychological care. This study aimed to assess patient experience at the Rainbow Clinic and identify areas for clinical improvement. A 13-item questionnaire was distributed to pregnant women who attended the Rainbow Clinics at the Oxford Road and Wythenshawe sites of Saint Mary's Hospital, Manchester, UK between July 2016 and June 2021. Descriptive statistics and unpaired t-test were used for quantitative data and summative content analysis for qualitative data. Four-hundred and fifty-six women completed the questionnaire. The mean patient experience score per quarter was stable with an average of 21.1 (± 3.0) for the five years, with a maximum attainable score of 25. The COVID-19 pandemic had no effect on patient experience at the Rainbow Clinic (pre-pandemic vs. during-pandemic: mean 21.2 v 21.3; p = 0.75). Free-text responses demonstrated women felt positively about the antenatal care received. Identified areas for improvement included "more awareness of the [Rainbow] sticker" to ensure women with previous loss are identified; increased publicity of the Rainbow Clinic services; developing more clinics at different locations to improve accessibility; and continuing specialist input into intrapartum care. Specialist antenatal care provided by the Rainbow Clinic was rated as of a high standard. Potential future improvements include sticker alterations (or other mechanisms to identify women who have experienced a previous loss) and develop increased awareness of the clinic in other institutions.

Flood exposure and pregnancy loss in 33 developing countries

Floods have affected billions worldwide. Yet, the indirect health impacts of floods on vulnerable groups, particularly women in the developing world, remain underexplored. Here, we evaluated the risk of pregnancy loss for women exposed to floods. We analyzed 90,465 individual pregnancy loss records from 33 developing countries, cross-referencing each with spatial-temporal flood databases. We found that gestational flood exposure is associated with increased pregnancy loss with an odds ratio of 1.08 (95% confidence interval: 1.04 - 1.11). This risk is pronounced for women outside the peak reproductive age range (<21 or >35) or during the mid and late-stage of pregnancy. The risk escalated for women dependent on surface water, with lower income or education levels. We estimated that, over the 2010s, gestational flood events might be responsible for approximately 107,888 (CIs: 53,944 - 148,345) excess pregnancy losses annually across 33 developing countries. Notably, there is a consistent upward trend in annual excess pregnancy losses from 2010 to 2020, and was more prominent over Central America, the Caribbean, South America, and South Asia. Our findings underscore the disparities in maternal and child health aggravated by flood events in an evolving climate.

Prevalence of depression and depressive symptoms in women with previous miscarriages or stillbirths - A systematic review

Women who have had miscarriages or stillbirths are known to have an elevated risk for depression. However, the prevalence of depressive disorders and/or symptoms in this group is unclear. Therefore, our aim was to estimate the corresponding prevalence of depression and depressive symptoms. A systematic literature search of the databases MEDLINE, psycINFO and PSYNDEX was conducted to consider all studies published between 2000 and 2022 in English or German on the prevalence of depression or depressive symptoms in women following miscarriages or stillbirths. Studies using valid psychiatric diagnoses or validated assessment methods regarding depression were included in the systematic review. The PRISMA guidelines were followed. Data concerning depressive symptoms were extracted from 14 studies. The range regarding prevalence of depressive symptoms in women with previous miscarriages or stillbirths was very wide (5%-91.2%). All longitudinal studies demonstrate a reduction of depressive symptoms over time. The prevalence of depressive disorders had a range of 5.4 (only for minor depression according to DSM-IV) - 18.6% (for depressive disorders according to ICD-10). The included studies are very heterogeneous considering the investigated groups, the length of pregnancies and time passed since the occurrence of miscarriages or stillbirths. Women with miscarriages or stillbirths have an elevated risk for depressive symptoms and disorders. In most affected women, depressive symptoms are most pronounced in the first months after the pregnancy loss and diminish over time.

Determinants of stillbirths in sub-Saharan Africa: A systematic review

BACKGROUND

Sub-Saharan African (SSA) countries have high stillbirth rates compared with high-income countries, yet research on risk factors for stillbirth in SSA remain scant.

OBJECTIVES

To identify the modifiable risk factors of stillbirths in SSA and investigate their strength of association using a systematic review.

SEARCH STRATEGY

CINAHL Plus, EMBASE, Global Health and MEDLINE databases were searched for literature.

SELECTION CRITERIA

Observational population- and facility-level studies exploring stillbirth risk factors, published in 2013-2019 were included.

DATA COLLECTION AND ANALYSIS

A narrative synthesis of data was undertaken and the potential risk factors were classified into subgroups.

MAIN RESULTS

Thirty-seven studies were included, encompassing 20 264 stillbirths. The risk factors were categorised as: maternal antepartum factors (0-4 antenatal care visits, multiple gestations, hypertension, birth interval of >3 years, history of perinatal death); socio-economic factors (maternal lower wealth index and basic education, advanced maternal age, grand multiparity of ≥5); intrapartum factors (direct obstetric complication); fetal factors (low birthweight and gestational age of <37 weeks) and health systems factors (poor quality of antenatal care, emergency referrals, ill-equipped facility). The proportion of unexplained stillbirths remained very high. No association was found between stillbirths and body mass index, diabetes, distance from the facility or HIV.

CONCLUSIONS

The overall quality of evidence was low, as many studies were facility based and did not adjust for confounding factors. This review identified preventable risk factors for stillbirth. Focused programmatic strategies to improve antenatal care, emergency obstetric care, maternal perinatal education, referral and outreach systems, and birth attendant training should be developed. More population-based, high-quality research is needed.

Desired Care for Perinatal Bereavement: Meeting the Needs of Mothers After Discharge From the Hospital-a Qualitative Study

This study aimed to investigate the understanding and experiences of mothers who have suffered perinatal loss regarding their needs after being discharged from the hospital. Data were collected through semi-structured face-to-face and telephone interviews using purposive sampling with maximum diversity. The sample included 15 mothers and 6 midwives who had experienced fetal loss and perinatal bereavement. The interviews were audio-recorded and transcribed verbatim. Conventional content analysis was used to analyze the data. Sampling was conducted from July 2022 to March 2023, continuing until data saturation was reached. The study identified 2 main categories of needs for mothers who have experienced perinatal loss: continuous healthcare (including the Comprehensive Mother Tracking System, provision of psychological welfare, and educational needs) and provision of a support network, including "spouse and family support" and "peer and colleague support." The primary theme of this study was "Deliberating Care for Grieving Mothers." The study results indicate that mothers who experience perinatal loss require continuity of care after being discharged. Psychological screening and counseling support are essential for both parents. Considering the significant impact of spousal, familial, and community support on an individual's life, it is crucial to prepare the community to comprehend and embrace grieving parents.

Child bereavement-what matters to the families. Part 2: The long term

The death of a child is a devastating event. Families experience profound grief and loss immediately following the death, and this remains and evolves as time progresses. In this, the second in a series, we discuss the importance of longer term bereavement care and how continuing contact with healthcare can be navigated. As bereaved parents who are also doctors, we again share our experiences. The complex nature of parenting, supporting siblings or managing a pregnancy after loss are explored, and we look at the involvement of bereaved parents in developing bereavement services.

Child bereavement-what matters to the families. Part 1: Immediate and short-term communication and care

The death of a child is a complex and hugely significant time for a family and community. Sophisticated but sensitive management by clinicians can have both short-term and long-term impacts on how families process the death. There is a paucity of guidance for optimal child bereavement care. A description of the child death review process including key legalities is provided here, and other essential aspects such as memory making, cultural aspects and sibling involvement are explored. Useful agencies and resources are also detailed. We, as both clinicians and bereaved parents, can uniquely provide an overview of the logistics of managing such a challenging event and highlight important subtleties in communication. We attempt, using our own experiences, to provide a framework and best inform future practice.

Seasonal and District Level Geo-Spatial Variations in Stillbirth Rates in India: An Analysis of Secondary Data

Stillbirth is a major public health problem across the world as well as in India. The programmatic interventions to tackle stillbirth require granular data upto local levels. The Health Management Information System (HMIS) in India is one of the best sources of granular data on stillbirth. This analysis was conducted using HMIS stillbirth data of three pre-pandemic years 2017-2020 to study the geo-spatial patterns of stillbirth at district level in nine states of India, forming a high burden cluster of four central Indian states and a low burden cluster of five southern states. Geo-spatial variation at sub-district level was studied for Maharashtra given the ready availability of sub-district shapefiles required for such analysis. The analysis also explores the seasonal variations in stillbirths at all-India level. A granular intra-cluster spatial pattern of stillbirth was observed in all states analyzed, with a clear hotspot across a few districts in Odisha and Chhattisgarh (>20 stillbirths/1,000 total births in 2019-20). Even in the southern cluster, the hotspots (8-20 stillbirths/1,000 total births) were found. Availability of sub-district level data in Maharashtra helped to identify intra-state regional variations in stillbirth with high prevalence in certain district clusters. In temporal terms, stillbirths exhibit a regular peak during August-October and a dip during February-April which is inclined with the birth seasonality patterns. This review and analysis underscore the need for more granular data availability, regular analysis of such data by expert and program managers, more decentralized and context specific programme intervention both in locational and seasonal terms.

Women's experiences of care after stillbirth and obstetric fistula: A phenomenological study in Kenya

BACKGROUND

Stillbirth and (obstetric) fistula are traumatic life events, commonly experienced together following an obstructed labour in low- and middle-income countries with limited access to maternity care. Few studies have explored women's experiences of the combined trauma of stillbirth and fistula.

AIM

To explore the lived experiences of women following stillbirth and fistula.

METHODS

Qualitative, guided by Heideggerian phenomenology. Twenty women who had experienced a stillbirth were interviewed while attending a specialist Hospital fistula service in urban Kenya. Data were analysed following Van Manen's reflexive approach.

RESULTS

Three main themes summarised participants' experiences: 'Treated like an alien' reflected the isolation and stigma felt by women. The additive and multiplying impacts of stillbirth and fistula and the ways in which women coped with their situations were summarised in 'Shattered dreams'. The impact of beliefs and practices of women and those around them were encapsulated in 'It was not written on my forehead'.

CONCLUSION

The distress women experienced following the death of a baby was intensified by the development of a fistula. Health professionals lacked an understanding of the pathophysiology and identification of fistula and its association with stillbirth. Women were isolated as they were stigmatised and blamed for both conditions. Difficulty accessing follow-up care meant that women suffered for long periods while living with a constant reminder of their baby's death. Cultural beliefs, faith and family support affected women's resilience, mental health and recovery. Specialist services, staff training and inclusive policies are needed to improve knowledge and awareness and enhance women's experiences.

PATIENT OR PUBLIC CONTRIBUTION

A Community Engagement and Involvement group of bereaved mothers with lived experience of stillbirth and neonatal death assisted with the review of the study protocol, participant-facing materials and confirmation of findings.

Impact of contact with the baby following stillbirth on parental mental health and well-being: A systematic review and meta-analysis

AIM

This study aims to identify and synthesize available research reporting parental mental health outcomes related to contact with a stillborn baby.

BACKGROUND

Stillbirth is devastating events for parents. The effects of contact with the stillborn baby on parental mental health are uncertain.

METHODS

This was a systematic review and meta-analysis carried out by searching six international electronic databases including PubMed, EMBASE, Cochrane, Web of Science, PsycINFO and CNKI databases from inception to 15 January 2023. Review Manager software was used for data analysis.

RESULTS

Ten studies were included (n = 3974). Contact with a stillborn baby increased the risks of anxiety, depression and post-traumatic stress disorder in the short term and increased the risks of anxiety and post-traumatic stress disorder in the long term. Parents who had contact with a stillborn baby were more satisfied with their decision. Subgroup analysis showed that seeing a stillborn baby had no significant effect on anxiety or depression, but holding a stillborn baby increased the risks of anxiety.

CONCLUSIONS

Caregivers should respect the parents' decision on whether to have contact with the stillborn baby and provide parents with continuous information, emotional and behavioural support after they have contact with stillborn babies.

Chance of healthy versus adverse outcome in subsequent pregnancy after previous loss beyond 16 weeks: data from a specialized follow-up clinic

PURPOSE

Women with a previous fetal demise have a 2-20 fold increased risk of another stillbirth in a subsequent pregnancy when compared to those who have had a live birth. Despite this, there is limited research regarding the management and outcomes of subsequent pregnancies. This study was conducted to accurately quantify the chances of a woman having a healthy subsequent pregnancy after a pregnancy loss.

METHODS

A retrospective study was conducted at a tertiary-level unit between March 2019 and April 2021. We collected data on all women with a history of previous fetal demise attending a specialized perinatal history clinic and compared the risk of subsequent stillbirth to those with a normal pregnancy outcome. Outcome data included birth outcome, obstetric and medical complications, gestational age and birth weight and mode of delivery. Those who had healthy subsequent pregnancies were compared with those who experienced adverse outcomes.

RESULTS

A total of 101 cases were reviewed. Ninety-six women with subsequent pregnancies after a history of fetal demise from 16 weeks were included. Seventy-nine percent of women (n = 76) delivered a baby at term, without complications. Overall, 2.1% had repeat pregnancy losses (n = 2) and 2.1% delivered babies with fetal growth restriction (n = 2). There were no cases of abruption in a subsequent pregnancy. Eighteen neonates were delivered prematurely (18.4%), 15 of these (83.3%) were due to iatrogenic causes and three (16.7%) were spontaneous. In univariable logistic regression analyses, those with adverse outcomes in subsequent pregnancies had greater odds of pre-eclampsia (Odds ratio *(OR) = 3.89, 95% CI = 1.05-14.43, p = .042) and fetal growth restriction (OR = 4.58, 95% CI = 1.41-14.82, p = 0.011) in previous pregnancies compared to those with healthy outcomes. However, in multivariable logistic regression analyses, neither variable had a significant odds ratio (OR = 2.03, 95% CI = 0.44-9.39, p = .366 and OR = 3.42, 95% CI = 0.90 - 13.09, p = .072 for pre-eclampsia and FGR, respectively).

CONCLUSION

Four in five women had a healthy subsequent pregnancy. This is a reassuring figure for women when contemplating another pregnancy, particularly if cared for in a specialist clinic.

The short-term effect of ozone on pregnancy loss modified by temperature: Findings from a nationwide epidemiological study in the contiguous United States

BACKGROUND

Pregnancy loss, a major health issue that affects human sustainability, has been linked to short-term exposure to ground-surface ozone (O3). However, the association is inconsistent, possibly because of the co-occurrence of O3 and heat episodes, as increased temperature is a risk factor for pregnancy loss. To explain this inconsistency, the effect of O3 on pregnancy loss needs to be examined jointly with that of high temperature.

METHODS

A total of 247,305 pregnancy losses during the warm season were extracted from fetal death certificates from the 386 counties in contiguous United States from 1989 to 2005. We assessed environmental exposure based on the daily maximum 8 h average of O3 from Air Quality System monitors and the 24 h average temperature from the North American Regional Reanalysis product. We conducted a bidirectional, time-stratified case-crossover study of the association between pregnancy loss and exposures to O3 and temperature and their multiplicative interaction. The main time window for the exposure assessment was the day of case occurrence and the preceding 3 days. To estimate the association, we used conditional logistic regression with adjustment for relative humidity, height of the planetary boundary layer, and holidays. Sensitivity analyses were performed on the lagged structure, nonlinearity, and between-subpopulation heterogeneity of the estimated joint effect.

RESULTS

The joint effect was first estimated by the regression against categorical exposure by tertile. Compared to the low-low exposure group (O3 ≤ 78 μg/m3 and temperature ≤ 18 °C), the odds of pregnancy loss was significantly higher by 6.0 % (95 % confidence interval [CI] 2.4-9.7 %), 9.8 % (6.1-13.8 %), and 7.5 % (4.7-10.3 %) in the high-low (>104 μg/m3 and ≤18 °C), low-high (≤78 μg/m3 and >23 °C), and high-high (>104 μg/m3 and >23 °C) groups. The model of linear exposure and the multiplicative interaction yielded similar results. Each increment of 10 μg/m3 in O3 and 1 °C in temperature was associated with a 3.0 % (2.0 %-4.0 %) and 3.9 % (3.5 %-4.3 %), respectively, increase in the odds of pregnancy loss. A decrease in odds of 0.2 % (0.1 %-0.2 %) was associated with the temperature × O3 interaction. The finding of an antagonistic interaction between temperature and O3 was confirmed by models parametrizing the joint exposure as alternative nonlinear terms (i.e., a two-dimensional spline term or a varying-coefficient term) and was robust to a variety of exposure lags and stratifications. Therefore, the marginal effect of O3 was estimated to vary by climate zone. A significant association between O3 and pregnancy loss was observed in the northern, but not southern, United States.

CONCLUSION

Joint exposure to O3 and high temperature can increase the risk for pregnancy loss. The adverse effect of O3 is potentially modified by ambient temperature. In high-latitude cities, controlling for O3 pollution could protect maternal health.

Successful Management and Birth After Perimortem Cesarean Delivery and Stillbirth Due to Anaphylaxis

Perimortem cesarean delivery is an effective procedure for cardiopulmonary resuscitation during pregnancy. However, there are no reports documenting long-term outcomes in perimortem cesarean delivery survivors. This may be the first report of a successful live birth, occurring two years after perimortem cesarean delivery. A 29-year-old primipara was transferred to the emergency center on account of cardiopulmonary arrest, at 33 weeks of gestation. She was resuscitated 47 min after cardiopulmonary arrest by perimortem cesarean delivery amongst other treatment modalities, although the fetus died. Two months later, she was discharged with a preserved uterus, and no neurological damage. The couple suffered from posttraumatic stress disorder, which they overcame with the support of the multidisciplinary team, then gave birth to a healthy baby 2 years later. To overcome cardiopulmonary arrest during pregnancy, a seamless approach by a multidisciplinary team is essential for a good patient outcome.

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

OBJECTIVE

To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'.

DESIGN

Population-based multi-country analyses.

SETTING

Births collected through routine data systems in 13 countries.

SAMPLE

125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020.

METHODS

We included 635 107 stillbirths from 22+0  weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0  weeks versus term, T, ≥37+0  weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards.

MAIN OUTCOME MEASURES

Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types.

RESULTS

635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0  weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age.

CONCLUSIONS

In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Pathway analysis of the impact of health literacy, social support and self-efficacy on self-management behaviors in pregnant women with gestational diabetes mellitus

Objective

The purpose of this study was to investigate the pathways by which health literacy (HL), social support, and self-efficacy influence self-management behaviors of pregnant women with Gestational diabetes mellitus (GDM) and the interrelationships between the variables.

Methods

A total of 565 pregnant women with GDM was recruited. The Demographic Characteristics Form, Health Literacy Scale, Perceived Social Support Scale, General Self-efficacy Scale and GDM Self-management Behavior Scale were used for data collection. Descriptive statistics, zero-ordered correlation analysis, and multiple linear regression analysis were performed on the variables; Structural Equation Model (SEM) were constructed for pathway analysis.

Results

A positive correlation was found between health literacy, social support, self-efficacy, and self-management behaviors among pregnant women with GDM after adjusting for age, education level, income level, work status, parity, and family history of diabetes (r ranging from 0.203 to 0.533). A further multiple linear regression analysis showed that functional HL, communicative HL, critical HL, social support, and self-efficacy were all independent influences on self-management behaviors and accounted for 36.3% of the variance. Communicative HL and critical HL explained the strongest self-management behaviors (β = 0.316 and 0.255, respectively, p < 0.001). The SEM model was suitable for χ2/DF = 2.860, RMSEA = 0.060, IFI = 0.953, TLI = 0.943, and CFI = 0.952. The results showed direct positive effects of health literacy on self-management behaviors and self-efficacy, direct positive effects of social support on health literacy and self-efficacy. Social support and self-efficacy have had no significant direct impact on self-management behaviors, but social support may indirectly influence self-management behaviors through the health literacy mediation role.

Conclusion

Healthcare providers should pay attention to the positive impacts of health literacy and social support on self-management behaviors of pregnant women with GDM. Improving the health literacy level of pregnant women with GDM should be the key point of intervention in practice, and the social support system should be fully mobilized to enhance emotional support and life support to promote the improvement of self-management behaviors.

No Baby to Bring Home: Perinatal Loss, Infertility, and Mental Illness-Overview and Recommendations for Care

PURPOSE OF REVIEW

Update readers on the state of the research on mental health, perinatal loss, and infertility with a focus on providing a comprehensive overview to empower clinicians in treating this population.

RECENT FINDINGS

Rates of psychiatric illness are increased in people that experience perinatal loss and infertility. The research remains largely below the clear need for focused screening, prevention, and treatment. Clinicians and researchers need to remain attuned to the impact of perinatal loss and infertility on the mental health of patients and families. Screening, referral, and expanded therapeutic and psychiatric resources are imperative to improving the well-being of these patients and families.