Progress on stillbirth prevention and support in general practice

Morgan Liotta

24/03/2022 2:56:15 PM

The RACGP has welcomed development of a new stillbirth clinical standard, which is expected to provide ‘fit-for-purpose’ guidance for GPs.

Two women in serious discussion
GPs can provide support and ‘a safe space’ for people who have recently experienced stillbirth, according to Dr Wendy Burton.

According to the most recent data, there were 2183 stillbirths across Australia in 2019, equating to 7.2 stillbirths per 1000 births.
While rates of stillbirth have seen little change in the past three decades, a significant portion are preventable, with appropriate care a defining factor.
As a key part of a national approach to reduce rates of preventable stillbirth by 20% by 2025 and provide families experiencing stillbirth with supportive bereavement care, the Federal Government released the National stillbirth action and implementation plan in December 2020.
The plan includes development of a national clinical care standard for stillbirth prevention and bereavement care to support healthcare providers in delivering appropriate, evidence-based care while reducing unwarranted variation.
The Stillbirth Clinical Care Standard (the Standard) is expected to promote shared decision-making between patients, carers and healthcare providers, and in February this year the Australian Commission on Safety and Quality in Health Care sought feedback on the draft.
The RACGP’s submission to the draft Standard reinstates GPs’ central place in pregnancy care, including identifying risk factors and providing postnatal support following stillbirth.
Dr Wendy Burton, Chair of RACGP Specific Interests Antenatal and Postnatal Care told newsGP development of the Standard is an important step forward in the primary care setting.
‘Fit-for-purpose guidance that is consistent across the maternity sectors makes it easier for GPs, who see the vast majority of women of child-bearing age intermittently, to keep up to date and to provide advice consistent with our obstetric and midwifery colleagues,’ Dr Burton said.
In its submission, the college welcomes that advice in the draft Standard is consistent with the Red Book recommendations on preventive activities prior to pregnancy as part of a risk assessment, and supports the ongoing monitoring of risk factors to prevent stillbirth during pregnancy.
In addition to antenatal advice and care, Dr Burton said GPs can apply a number of approaches when helping families and individuals plan for pregnancies and assess for risk factors. 
‘[It’s about] being aware and initiating conversations, [such as] preconception discussions about smoking, being aware of the evidence around going to sleep on the side, along with long-recognised risk factors such as growth restriction, reduced foetal movements and the timing of birth,’ she said.
Maternal age, hypertension and diabetes, congenital anomaly, and preterm birth are other risk factors for stillbirth. Aboriginal and Torres Strait Islander women and women living in remote and disadvantaged areas are also at higher risk.
One of the defined goals of the Stillbirth Clinical Care Standard is to ‘reduce unwarranted clinical variation in the prevention and investigation of stillbirth’.
However, the college’s submission states this goal may not be met ‘for reasons beyond the control of the clinician or patient’, identifying that there are ‘broader systemic and societal issues’ relating to stillbirth risk factors, including:

  • access to services in rural and remote areas
  • affordability for people from lower socioeconomic areas
  • lifestyle factors, such as environment and family abuse and violence.
As a result, barriers may exist for screening, tests, treatments and support to monitor and manage risk factors for these populations, and the college states it is vital for healthcare providers to tailor responses to patients’ individual circumstances and needs.
The RACGP calls for this approach to be considered in the Standard due to concerns that a suggested ‘checklist’ approach can potentially serve more of a purpose of delivering key performance indicators than delivering quality care.
Dr Burton agrees this is an important issue that requires better investment.
‘We need to rethink how we deliver care, not just to those in rural and remote areas, but those who cannot access care in the inner-city due to the mounting cost barriers,’ she said.
‘Well-informed [patients] have the best chance of managing their modifiable risk factors, but we need state and federal governments to resource the recommendations, not just endorse guidelines that can’t actually be followed by a significant percentage of the population.’ 
Providing support and follow-up care after a stillbirth requires a comprehensive and tailored approach, and the RACGP recommends a broader definition of relevant local services to link families and individuals following bereavement, including social prescribing groups.
Patient-reported experiences of compassionate care as a measurable outcome are also important considerations, the college says.
According to Dr Burton, GPs’ role in bereavement care after stillbirth follows the individual or family’s needs, as well as the therapeutic relationship.
‘It’s about being open to having the conversation, being aware of supports available online, via telehealth or face-to-face, if what [patients] need is beyond our skillset,’ she said.
‘Including this important event in the past history, so that those we refer to can know, if appropriate, this important part of a family’s journey.
‘We can remember, and provide a safe space to say their name.’
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