Can promoting awareness of fetal movements and focusing interventions reduce fetal mortality? A stepped-wedge cluster randomised trial (AFFIRM)

Generalizing the information content for stepped wedge designs: A marginal modeling approach

Stepped wedge trials are increasingly adopted because practical constraints necessitate staggered roll-out. While a complete design requires clusters to collect data in all periods, resource and patient-centered considerations may call for an incomplete stepped wedge design to minimize data collection burden. To study incomplete designs, we expand the metric of information content to discrete outcomes. We operate under a marginal model with general link and variance functions, and derive information content expressions when data elements (cells, sequences, periods) are omitted. We show that the centrosymmetric patterns of information content can hold for discrete outcomes with the variance-stabilizing link function. We perform numerical studies under the canonical link function, and find that while the patterns of information content for cells are approximately centrosymmetric for all examined underlying secular trends, the patterns of information content for sequences or periods are more sensitive to the secular trend, and may be far from centrosymmetric.

Facility-based stillbirth surveillance review and response: an initiative towards reducing stillbirths in a tertiary care hospital of India

OBJECTIVES

India has the highest number of stillbirths in the world in 2019, with an estimated stillbirth rate of 13.9 per 1,000 births. Towards better identification and documentation, a stillbirth surveillance pilot was initiated with the World Health Organization Southeast Asia collaboration in Northern India in 2014. This study aimed to assess whether stillbirth surveillance is feasible and whether this approach provides sufficient information to develop strategies for prevention.

METHODS

This study followed the framework provided in "WHO Making Every Baby Count" in which mortality audit is conducted in six steps; (1) identifying cases; (2) collecting information; (3) analysis; (4) recommending solutions; (5) implementing solutions; and (6) evaluation.

RESULTS

A total of 5,284 births were examined between December 2018 and November 2019; 266 stillbirths were identified, giving a stillbirth rate of 50.6 per 1,000 births in a tertiary care referral hospital of northern India. Out of 266 stillbirths, 223 cases were reviewed and recommendations were formulated to strengthen obstetric triage, implementing fetal growth charts, strengthen the existing referral system and improve the communication skills of health care providers for better compliance with clinical practice guidelines.

CONCLUSIONS

Conducting stillbirth surveillance review and the response of cases in low-middle income countries setting is feasible. As countries progress towards ending preventable mortality, this has the potential to serve as a key process in improving evidence-based and context-specific planning and preventive strategies towards improving the quality of care.

Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a trial-based and model-based cost-effectiveness analysis from a stepped wedge, cluster-randomised trial

Background

The AFFIRM intervention aimed to reduce stillbirth and neonatal deaths by increasing awareness of reduced fetal movements (RFM) and implementing a care pathway when women present with RFM. Although there is uncertainty regarding the clinical effectiveness of the intervention, the aim of this analysis was to evaluate the cost-effectiveness.

Methods

A stepped-wedge, cluster-randomised trial was conducted in thirty-three hospitals in the United Kingdom (UK) and Ireland. All women giving birth at the study sites during the analysis period were included in the study. The costs associated with implementing the intervention were estimated from audits of RFM attendances and electronic healthcare records. Trial data were used to estimate a cost per stillbirth prevented was for AFFIRM versus standard care. A decision analytic model was used to estimate the costs and number of perinatal deaths (stillbirths + early neonatal deaths) prevented if AFFIRM were rolled out across Great Britain for one year. Key assumptions were explored in sensitivity analyses.

Results

Direct costs to implement AFFIRM were an estimated £95,126 per 1,000 births. Compared to standard care, the cost per stillbirth prevented was estimated to be between £86,478 and being dominated (higher costs, no benefit). The estimated healthcare budget impact of implementing AFFIRM across Great Britain was a cost increase of £61,851,400/year.

Conclusions

Perinatal deaths are relatively rare events in the UK which can increase uncertainty in economic evaluations. This evaluation estimated a plausible range of costs to prevent baby deaths which can inform policy decisions in maternity services.

Trial registration

The trial was registered with www.ClinicalTrials.gov, number NCT01777022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04563-9.

Development of a core outcome set (COS) for studies relating to awareness and clinical management of reduced fetal movement: study protocol

BACKGROUND

Concerns regarding reduced fetal movements (RFM) are reported in 5-15% of pregnancies, and RFM are associated with adverse pregnancy outcomes including fetal growth restriction and stillbirth. Studies have aimed to improve pregnancy outcomes by evaluating interventions to raise awareness of RFM in pregnancy, such as kick counting, evaluating interventions for the clinical management of RFM, or both. However, there is not currently a core outcome set (COS) for studies of RFM. This study aims to create a COS for use in research studies that aim to raise awareness of RFM and/or evaluate interventions for the clinical management of RFM.

METHODS

A systematic review will be conducted, to identify outcomes used in randomised and non-randomised studies with control groups that aimed to raise awareness of RFM (for example by using mindfulness techniques, fetal movement counting, or other tools such as leaflets or mobile phone applications) and/or that evaluated the clinical management of RFM. An international Delphi consensus will then be used whereby stakeholders will rate the importance of the outcomes identified in the systematic review in (i) awareness and (ii) clinical management studies. The preliminary lists of outcomes will be discussed at a consensus meeting where one final COS for awareness and management, or two discrete COS (one for awareness and one for management), will be agreed upon.

DISCUSSION

A well-developed COS will provide researchers with the minimum set of outcomes that should be measured and reported in studies that aim to quantify the effects of interventions.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings

BACKGROUND

There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns.

OBJECTIVES

To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response.

DATA COLLECTION AND ANALYSIS

Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice.

MAIN RESULTS

We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies.

AUTHORS' CONCLUSIONS

Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

UK stillbirth trends in over 11 million births provide no evidence to support effectiveness of Growth Assessment Protocol program

OBJECTIVE

Use of the Growth Assessment Protocol (GAP) has increased internationally under the assumption that it reduces the stillbirth rate. The evidence for this is limited and based largely on an ecological time-trend study. Discordance in the uptake of the GAP program between Scotland and England/Wales enabled us to assess the assertion that implementation of GAP leads to a reduced stillbirth rate.

METHODS

We analyzed data from the National Records for Scotland and the Office for National Statistics on the number of singleton maternities and stillbirths in Scotland and in England and Wales, respectively, from 1 January 2000 to 31 December 2015. National uptake of the GAP program over time in each of the regions was recorded. Stillbirth rate per 1000 maternities was calculated, according to year of delivery, and compared between Scotland and England/Wales.

RESULTS

During the study period, there were 870 632 singleton maternities in Scotland, of which 4243 were stillbirths, and there were 10 469 120 singleton maternities in England and Wales, of which 51 562 were stillbirths. There was a marked difference in uptake of the GAP program between the two regions, with substantially fewer maternity units in Scotland implementing the program. Stillbirth rates were static up to 2010, with a decline thereafter in both regions, to 3.75 (95% CI, 3.25-4.30) per 1000 maternities in Scotland and 4.30 (95% CI, 4.15-4.46) per 1000 maternities in England and Wales in 2015. From 2010 onwards, the decline in Scotland was faster, equating to 48 (95% CI, 47.9-48.1) fewer stillbirths per 100 000 maternities in Scotland than in England and Wales from 2010 to 2015 compared with 2000 to 2009.

CONCLUSIONS

We observed a decline in stillbirth rate in England and Wales, which coincided with implementation of the GAP program. However, a concurrent decline in stillbirth rate was observed in Scotland in the absence of increased implementation of GAP. The secular rates of change in stillbirth rate in England and Wales cannot be used to infer efficacy of the GAP program. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Risk factors for poor neonatal outcome in pregnancies with decreased fetal movements

INTRODUCTION

The incidence of Swedish stillbirths has varied little in the past 40 years, with a reported frequency of 400-450 stillbirths/y (approximately 4‰), despite increased information about fetal movement in the media and awareness among healthcare providers. The objectives of this project were to describe the outcome of pregnancies with reduced fetal movement in a Swedish context and to investigate factors associated with poor neonatal outcome in this group.

MATERIAL AND METHODS

A retrospective cohort study was performed at Soder Hospital, Stockholm, Sweden. All single pregnancies at the hospital from January 2016 to December 2017 presenting with reduced fetal movement after 22 gestational weeks were included in the study. A composite neonatal outcome was constructed: 5-minute Apgar score ≤7, arterial pH in the umbilical cord ≤7.10, transfer to neonatal care unit for further care or intrauterine fetal death.

RESULTS

For women seeking care for reduced fetal movement, the occurrence of composite poor neonatal outcome ranged from 6.2% to 18.4% within different groups. The highest risk for poor neonatal outcome (18.4%) was found in the group of women with a small-for-gestational-age fetus. Another high-risk group (12.8%) was the one comprising women with normal birthweight/large-for-gestational-age fetuses with an in vitro fertilization pregnancy.

CONCLUSIONS

The highest incidence of poor neonatal outcome among women with reduced fetal movement was found in the groups with small-for-gestational-age fetuses in nulliparous and multiparous women. A routine ultrasound assessment for fetal growth in third trimester is supposedly most efficient to identify undiagnosed small for gestational age.

An evaluation of the potential to improve perinatal outcomes by improving antenatal detection of small for gestational age babies in Scotland: a retrospective population cohort study

Background: Small for gestational age (SGA) babies are at high risk of perinatal mortality. We aimed to determine the potential to reduce perinatal mortality by improving antenatal detection of SGA babies in Scotland. Methods: We conducted a retrospective population study of all singleton SGA babies born in the 15 Consultant-led maternity units in Scotland in a 3-month period (1st Dec 2014 to 28th Feb 2015 inclusive).  Demographic and pregnancy outcome data were extracted from Scottish birth records for all pregnancies; case note review was performed for all SGA cases [defined as birthweight less than the 10th centile for their gestational age at delivery as defined by the appropriate sex-specific UK-WHO Child Growth Standards]. Results: The SGA rate in Scotland was 5.5% (673/12218; 95% confidence interval [CI] 5.1, 5.9) and 27.6% (186/673; 95% CI 24.3, 31.2) of SGA cases were identified prior to delivery. SGA was associated with 18.2% (12/66; 95% CI [10.1%, 30.0%) of all perinatal deaths. The majority (10/12, 83.3%) of SGA babies who died had been identified as SGA in the antenatal period. There was no difference in perinatal mortality whether SGA was detected or not (5.4% [10/186; 95% CI 2.8, 10.0] in the SGA detected group vs 0.4% [2/487 [95% CI 0.3, 2.2] in the non-detected group after adjusting for risk factors for SGA, gestation at delivery and birthweight centile (Adjusted odds ratio [AOR] 0.85 [95% CI 0.5, 1.5], p=0.556). Conclusions: Despite only around a quarter of SGA babies being identified antenatally, the potential to reduce perinatal mortality in the Scottish population by improving SGA detection is limited. Only a minority of perinatal deaths occurred in SGA babies; and in the majority of these SGA was detected antenatally.

Normally Grown Non-dysmorphic Stillbirth Post 38 Weeks Gestation and Reduced Fetal Movements: A Matter of Reserve? A Retrospective Study

This study investigates the relationship between placental weight relative to birthweight and risk of stillbirth in non-dysmorphic fetuses ≥ 38 weeks gestation with no evidence of intrauterine growth restriction. This is a retrospective study of stillbirths who underwent post-mortem between 1st Jan 2011 and 31st Dec 2018 in South East Scotland (n = 55). The control group (n = 74) was matched for gestation, age of mother and maternal BMI. There was a significant difference (p = 0.0117) in the mean ratio of birth weight to placental weight (BW:PW) between the stillbirth group (8.17) and control group (7.33). Cases of stillbirths where the mother had reported reduced fetal movements (RFM) had a higher BW:PW compared to controls (p = 0.024). Within the RFM stillbirth group, 5/6 (83%) cases showed significant changes of maternal vascular malperfusion (MVM) and/or fetal vascular malperfusion (FVM); whilst within the RFM control group, 5/15 (33%) cases showed significant changes of MVM and/or FVM. There is a significantly higher BW:PW within the stillbirth group than within the control group, both groups show changes of MVM and/or FVM and our supposition is that these changes have a greater impact on placental reserve when the birthweight is high relative to placental weight. Reduced fetal movements may indicate diminished placental reserve. We propose that the ability to predict a high BW:PW within pregnancies where the mothers report RFM may help to prevent late stillbirth in non-IUGR infants.

Inequalities and stillbirth in the UK: a meta-narrative review

OBJECTIVE

To review what is known about the relationship between stillbirth and inequalities from different disciplinary perspectives to inform stillbirth prevention strategies.

DESIGN

Systematic review using the meta-narrative method.

SETTING

Studies undertaken in the UK.

DATA SOURCES

Scoping phase: experts in field, exploratory electronic searches and handsearching. Systematic searches phase: Nine databases with no geographical or date restrictions. Non-English language studies were excluded.

STUDY SELECTION

Any investigation of stillbirth and inequalities with a UK component.

DATA EXTRACTION AND SYNTHESIS

Three authors extracted data and assessed study quality. Data were summarised, tabulated and presented graphically before synthesis of the unfolding storyline by research tradition; and then of the commonalities, differences and interplays between narratives into resultant summary meta-themes.

RESULTS

Fifty-four sources from nine distinctive research traditions were included. The evidence of associations between social inequalities and stillbirth spanned 70 years. Across research traditions, there was recurrent evidence of the social gradient remaining constant or increasing, fuelling repeated calls for action (meta-theme 1: something must be done). There was less evidence of an effective response to these calls. Data pertaining to socioeconomic, area and ethnic disparities were routinely collected, but not consistently recorded, monitored or reported in relation to stillbirth (meta-theme 2: problems of precision). Many studies stressed the interplay of socioeconomic status, deprivation or ethnicity with aggregated factors including heritable, structural, environmental and lifestyle factors (meta-theme 3: moving from associations towards intersectionality and intervention(s)). No intervention studies were identified.

CONCLUSION

Research investigating inequalities and stillbirth in the UK is underdeveloped. This is despite repeated evidence of an association between stillbirth risk and poverty, and stillbirth risk, poverty and ethnicity. A specific research forum is required to lead the development of research and policy in this area, which can harness the multiple relevant research perspectives and address the intersections between different policy areas.

PROSPERO REGISTRATION NUMBER

CRD42017079228.

Stillbirth: Perceptions among hospital staff in the Middle East and the UK

Objectives Stillbirth is an important and yet relatively unacknowledged public health concern in many parts of the world. Public awareness of stillbirth and its potentially modifiable risk factors is a prerequisite to planning prevention measures. Cultural and regional differences may play an important role in awareness and attitudes to stillbirth prevention. The objective of this study was to evaluate and compare the awareness of stillbirth among hospital staff in Qatar and the UK, representing two culturally different regions.

Study design An online population survey for anonymous completion was sent to the hospital email accounts of all grades of staff (clinical and non-clinical) at two hospitals in Qatar and one tertiary hospital Trust in the UK. The survey was used to gather information on the participants’ demographic background, the experience of stillbirth, knowledge of stillbirth, awareness of information and support sources, as well as attitude towards investigation and litigation. Data were analysed using descriptive and comparative statistics (Chi-Square test and Fisher’s exact test).

Results 1002 respondents completed the survey, including 349 in the Qatar group and 653 in the UK group. There were significant differences in group demographics in terms of language, religion, gender, nationality and experience of stillbirth. The groups also differed significantly in the knowledge of stillbirth, its incidence and risk factors. The two groups took different views on apportioning blame on healthcare services in cases of stillbirth. The Qatar group showed significantly less awareness of available support organisations and relied significantly more on online sources of information for stillbirths (p < 0.001).

Conclusions This comparative study demonstrated significant differences between the two culturally distinct regions in the awareness, knowledge and attitudes towards stillbirths. The complex cultural and other factors that may be contributory should be further studied. The results highlight the need for increasing public awareness around stillbirth as part of effective prevention strategies.

Are increased fetal movements always reassuring?

Many studies have reported on the association of reduced fetal movements and stillbirth, but little is known about excessive fetal movements and adverse pregnancy outcome. First described in 1977, sudden excessive fetal movement was noted to reflect acute fetal distress and subsequent fetal demise. Subsequently, little was reported regarding this phenomenon until 2012. However, emerging data suggest that 10-30% of the women that subsequently suffer a stillbirth describe a single episode of excessive fetal movement prior to fetal demise. These episodes are poorly understood but may reflect fetal seizure activity secondary to fetal asphyxia, cord entanglement or an adverse intrauterine environment. At present, the challenge in managing women with excessive fetal movements is a timely assessment of the fetus to identify those women at risk of adverse fetal outcomes who may benefit from intervention.

Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial

BACKGROUND

2·6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement (RFM), care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardised management, including timely delivery, would alter the incidence of stillbirth.

METHODS

This stepped wedge, cluster-randomised trial was done in the UK and Ireland. Participating maternity hospitals were grouped and randomised, using a computer-generated allocation scheme, to one of nine intervention implementation dates (at 3 month intervals). This date was concealed from clusters and the trial team until 3 months before the implementation date. Each participating hospital had three observation periods: a control period from Jan 1, 2014, until randomised date of intervention initiation; a washout period from the implementation date and for 2 months; and the intervention period from the end of the washout period until Dec 31, 2016. Treatment allocation was not concealed from participating women and caregivers. Data were derived from observational maternity data. The primary outcome was incidence of stillbirth. The primary analysis was done according to the intention-to-treat principle, with births analysed according to whether they took place during the control or intervention periods, irrespective of whether the intervention had been implemented as planned. This study is registered with www.ClinicalTrials.gov, number NCT01777022.

FINDINGS

37 hospitals were enrolled in the study. Four hospitals declined participation, and 33 hospitals were randomly assigned to an intervention implementation date. Between Jan 1, 2014, and Dec, 31, 2016, data were collected from 409 175 pregnancies (157 692 deliveries during the control period, 23 623 deliveries in the washout period, and 227 860 deliveries in the intervention period). The incidence of stillbirth was 4·40 per 1000 births during the control period and 4·06 per 1000 births in the intervention period (adjusted odds ratio [aOR] 0·90, 95% CI 0·75-1·07; p=0·23).

INTERPRETATION

The RFM care package did not reduce the risk of stillbirths. The benefits of a policy that promotes awareness of RFM remains unproven.

FUNDING

Chief Scientist Office, Scottish Government (CZH/4/882), Tommy's Centre for Maternal and Fetal Health, Sands.

Optimal Obstetric Management for Women with Diabetes: the Benefits and Costs of Fetal Surveillance

PURPOSE OF REVIEW

To elaborate on the risks and benefits associated with antenatal fetal surveillance for stillbirth prevention in women with diabetes.

RECENT FINDINGS

Women with pregestational diabetes have a 3- to 5-fold increased odds of stillbirth compared to women without diabetes. The stillbirth risk in women with gestational diabetes (GDM) is more controversial; while recent data suggest the odds for stillbirth are approximately 50% higher in women with GDM at term (37 weeks and beyond) than in those without GDM, it is unclear if this risk is seen in women with optimal glycemic control. Current professional society guidelines are broad with respect to fetal testing strategies and delivery timing in women with diabetes. The data supporting strategies to reduce the risk of stillbirth in women with diabetes are limited. Antepartum fetal surveillance should be performed to reduce stillbirth rates; however, the optimal test, frequency of testing, and delivery timing are not yet clear. Future studies of obstetric management for women with diabetes should consider not just individual but also system level costs and benefits associated with antenatal surveillance.

Alterations in maternally perceived fetal movement and their association with late stillbirth: findings from the Midland and North of England stillbirth case-control study

OBJECTIVE

To report perception of fetal movements in women who experienced a stillbirth compared with controls at a similar gestation with a live birth.

DESIGN

Case-control study.

SETTING

41 maternity units in the UK.

PARTICIPANTS

Cases were women who had a late stillbirth ≥28 weeks gestation (n=291) and controls were women with an ongoing pregnancy at the time of the interview (n=733). Controls were frequency matched to cases by obstetric unit and gestational age.

METHODS

Data were collected using an interviewer-administered questionnaire which included questions on maternal perception of fetal movement (frequency, strength, increased and decreased movements and hiccups) in the 2 weeks before the interview/stillbirth. Five fetal movement patterns were identified incorporating the changes in strength and frequency in the last 2 weeks by combining groups of similar pattern and risk. Multivariable analysis adjusted for known confounders.

PRIMARY OUTCOME MEASURE

Association of maternally perceived fetal movements in relation to late stillbirth.

RESULTS

In multivariable analyses, women who reported increased strength of movements in the last 2 weeks had decreased risk of late stillbirth compared with those whose movements were unchanged (adjusted OR (aOR) 0.18, 95% CI 0.13 to 0.26). Women with decreased frequency (without increase in strength) of fetal movements were at increased risk (aOR 4.51, 95% CI 2.38 to 8.55). Daily perception of fetal hiccups was protective (aOR 0.31, 95% CI 0.17 to 0.56).

CONCLUSIONS

Increased strength of fetal movements and fetal hiccups is associated with decreased risk of stillbirth. Alterations in frequency of fetal movements are important in identifying pregnancies at increased risk of stillbirth, with the greatest risk in women noting a reduction in fetal activity. Clinical guidance should be updated to reflect that increase in strength and frequency of fetal movements is associated with the lowest risk of stillbirth, and that decreased fetal movements are associated with stillbirth.

TRIAL REGISTRATION NUMBER

NCT02025530.

Understanding the associations and significance of fetal movements in overweight or obese pregnant women: a systematic review

INTRODUCTION

Presentation with decreased fetal movement (DFM) is associated with fetal growth restriction and stillbirth. Some studies report that DFM is frequent among overweight or obese mothers. We aimed to determine the significance and associations of fetal movements in women of increased body size.

MATERIAL AND METHODS

This systematic review was conducted in accordance with the PRISMA statement and the protocol was registered with PROSPERO (CRD42016046352). Major databases were explored from inception to September 2017, using a predefined search strategy. We restricted inclusion to studies published in English and considered studies of any design that compared fetal movements in women of increased and normal body size. Two authors independently extracted data and assessed quality.

RESULTS

We included 23 publications from 19 observational studies; data were extracted from 10 studies. Increased maternal body size was not associated with altered perception of fetal movement (four studies, 95 women, very low-quality evidence), but was associated with increased presentation for DFM (two cohort studies, 20 588 women, OR 1.56, 95% CI 1.27-1.92: three case-control studies, 3445 women, OR 1.32, 95% CI 1.12-1.54; low-quality evidence). Among women with DFM, increased maternal body size was associated with increased risk of stillbirth and fetal growth restriction (one study, 2168 women, very low-quality evidence).

CONCLUSIONS

This systematic review identified limited evidence that women with increased body size are more likely to present with DFM but do not have impaired perception of fetal movements. In women with DFM, increased body size is associated with worse pregnancy outcome, including stillbirth.

A randomised controlled trial comparing standard or intensive management of reduced fetal movements after 36 weeks gestation--a feasibility study

Background

Women presenting with reduced fetal movements (RFM) in the third trimester are at increased risk of stillbirth or fetal growth restriction. These outcomes after RFM are related to smaller fetal size on ultrasound scan, oligohydramnios and lower human placental lactogen (hPL) in maternal serum. We performed this study to address whether a randomised controlled trial (RCT) of the management of RFM was feasible with regard to: i) maternal recruitment and retention ii) patient acceptability, iii) adherence to protocol. Additionally, we aimed to confirm the prevalence of poor perinatal outcomes defined as: stillbirth, birthweight <10^th centile, umbilical arterial pH <7.1 or unexpected admission to the neonatal intensive care unit.

Methods

Women with RFM ≥36 weeks gestation were invited to participate in a RCT comparing standard management (ultrasound scan if indicated, induction of labour (IOL) based on consultant decision) with intensive management (ultrasound scan, maternal serum hPL, IOL if either result was abnormal). Anxiety was assessed by state-trait anxiety index (STAI) before and after investigations for RFM. Rates of protocol compliance and IOL for RFM were calculated. Participant views were assessed by questionnaires.

Results

137 women were approached, 120 (88%) participated, 60 in each group, 2 women in the standard group did not complete the study. 20% of participants had a poor perinatal outcome. All women in the intensive group had ultrasound assessment of fetal size and liquor volume vs. 97% in the standard group. 50% of the intensive group had IOL for abnormal scan or low hPL after RFM vs. 26% of controls (p < 0.01). STAI reduced for all women after investigations, but this reduction was greater in the standard group (p = 0.02). Participants had positive views about their involvement in the study.

Conclusion

An RCT of management of RFM is feasible with a low rate of attrition. Investigations decrease maternal anxiety. Participants in the intensive group were more likely to have IOL for RFM. Further work is required to determine the likely level of intervention in the standard care arm in multiple centres, to develop additional placental biomarkers and to confirm that the composite outcome is valid.

Trial registration

ISRCTN07944306