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Third of stillbirths could be avoided if different care provided

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Six babies are stillborn and two die within 28 days of birth every day in Australia, according to the Australian Institute of Health and Welfare (AIHW).
 
Now new research, published in the Australian and New Zealand Journal of Obstetrics and Gynaecology, shows that a significant proportion of perinatal deaths could have been avoided if different care was provided.
 
For the study, researchers examined stillbirths in Queensland throughout 2018. During that year, 65 perinatal deaths eligible for the study were audited, including 56 stillbirths and nine neonatal deaths.
 
The researchers found that most deaths were classified as unexplained, but contributing factors were identified in 71% of deaths.

Lead researcher Professor Vicki Flenady is the Director of the Centre of Research Excellence in Stillbirth (Stillbirth CRE) at Mater Research at the University of Queensland. She told newsGP that in six of these deaths, the care ‘could have been improved, but it didn’t have any bearing on the outcome’.
 
‘We can still learn from these, as in another case this may have played a more important role,’ she said.
 
Professor Flenady says care ‘possibly’ played a role in the outcome in 17 of the stillbirths.
 
‘We can’t be totally sure that if care had been better in that area the baby would have survived, but we think there’s a possible link,’ she said.
 
Meanwhile care played a ‘significant’ role in the perinatal outcome in 16 stillbirths.
 
In those cases, Professor Flenady explains, ‘the panel agrees the death would not have occurred if a better course of action was taken’. She says similar findings have been replicated internationally.
 
‘But it really highlights the importance of undertaking these sorts of audits, this in-depth analysis of the situation of the circumstances around these deaths, to improve practice,’ she said.
 
Jackie Mead, the co-CEO of Red Nose Australia (including Sands Australia), told newsGP these findings are concerning.
 
‘It’s a statistic that’s worrying and certainly something that means we need to continue to educate to ensure that care is taken out as a factor that impacts upon rates of stillbirth,’ she said.
 
A key part of appropriate care involves identifying risk factors that place women at higher risk of having a stillbirth.
 
And yet, according to Professor Flenady, the ‘high proportion’ of perinatal deaths with contributing factors relating to care points to the fact that such patients do not receive appropriate management.
 
She says it is important to closely monitor pregnant women with risk factors, such as:

• pre-existing conditions, including diabetes, hypertension and maternal obesity
• previous adverse outcomes in pregnancy, including stillbirth and previous fetal growth restriction
• smoking
• advanced maternal age
• fetal growth restriction.

Professor Flenady says smoking remains one of the most important modifiable risk factors for stillbirth and GPs can help encourage pregnant women quit while explaining the need to quit early in pregnancy.
 
‘That’s a really important role of the GPs and I know that that’s being done well,’ she said.
 
She says pregnant women who smoke should be referred to the Quit helpline, but clinicians should also ensure women follow through with this.
 
‘We know that many women don’t actually take up that offer,’ she said.
 
‘So it’s the follow-up of those women to make sure they’re accessing the support that they need to stop smoking.’


Professor Vicki Flenady says the new research highlights the need to undertake audits to improve practice.

Advanced maternal age is also another ‘important’ risk factor for perinatal death.
 
‘Women over 35 are at increased risk, but the risk really jumps around 40,’ Professor Flenady said.
 
Another significant risk factor relates to undetected fetal growth restriction. Professor Flenady says performing serial scans on every woman is not feasible.
 
Instead, she stresses the importance of monitoring the growth of the baby through measuring fundal height and referring women for a growth scan, or serial scans, if there is suspicion of growth restriction.
 
While GPs can play a crucial role in monitoring growth in a pregnancy, Ms Mead says clinicians are also well-placed to deliver health information to patients in an easy-to-understand way.
 
She says doctors are still shying away from using the term ‘stillbirth’ and worries about the potentially detrimental effect of this reluctance.
Ms Mead says that when a doctor uses the term like ‘at an increased risk’ but omits the term ‘stillbirth’, women may not understand what is discussed.
 
For example, women may be told that ‘smoking puts them at increased risk’, but they may not understand this means that increased risk is referring to stillbirth.
 
‘So it’s really important that the language that we’re using allows people to fully assess the risks that they’re taking and understand what they are,’ Ms Mead said.
 
‘It is absolutely critical that GPs are using language that supports understanding of the risks.’
 
Ms Mead acknowledges it can be challenging to convey such risk without prompting fear.
 
‘It’s really important that [healthcare providers] understand how to communicate in a way that’s impactful but doesn’t scare women [and] provides [everything that they need,’ she said.
 
Another key finding of this research was the prevalence of Aboriginal and Torres Strait Islander women who experienced stillbirth.
 
The study found that six of the nine deaths to Aboriginal and Torres Strait Islander women mothers had contributing factors that were likely to have played a part in their perinatal loss.
 
‘The study did highlight that Aboriginal and Torres Strait Islander women were over-represented in this group of deaths and had very complex needs that weren’t met in many instances,’ Professor Flenady said.
 
‘So I’d just like to make another call for culturally appropriate care models for Indigenous women in particular.’
 
Ms Mead is also calling for greater understanding of the fact that pregnant women are best placed to inform health professionals of any relevant changes they are experiencing.
 
‘Mothers are experts in their own bodies,’ she said. ‘Very often we hear that the issues around care are around not taking action when women present with concerns.
 
‘And the views of the past – that women might be overly anxious, or hormonal, or simply worried about things they don’t need to be worried about  – are not appropriate anymore.
 
‘One of the important things that a GP can do is actually help women to be able to provide good information regarding the observations of their own pregnancy.’
 
Ms Mead believes women should be encouraged to identify their baby’s patterns of movement and seek care if they notice a change.  
 
Professor Flenady says it is also vital that clinicians are armed with the appropriate tools.
 
She says the Safer Baby Bundle eLearning program is designed to help reduce the perinatal mortality rate through further education of healthcare providers, and comprises five key components:
 

• Detection and management of impaired fetal growth
• Awareness and management of decreased fetal movement
• Advising women on safe sleeping positions
• Supporting women to stop smoking
• Better timing of birth for women with risk factors

 ‘We’ve had a number of GPs using the Safer Baby Bundle at the moment and they’ve found it really helpful,’ Professor Flenady said.
 
‘But we’d really like more GPs to get on board.’
 
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perinatal mortality stillbirths

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