Don’t shy away from stillbirth discussion

5 minute read

A new national standard advocates stillbirth education becoming part of routine pregnancy care.

Preconception and pregnancy care should include conversations about stillbirth as well as assessment and management of risk factors, Australia’s first stillbirth clinical care standard recommends.

Awareness of fetal movement is also a priority, and clinicians are advised to give patients verbal and written information between 20 and 27 weeks of pregnancy. Concerns about changes in fetal movement should be addressed “promptly” in line with an action plan developed with the patient.

“Note that a woman’s concern about fetal movements is an important indicator, and should always be taken seriously,” the standard recommends.

The Stillbirth Clinical Care Standard, developed by the Australian Commission on Safety and Quality in Health Care, was launched at the 2022 Annual National Stillbirth Forum in Brisbane this month.

Sydney GP and the commission’s clinical director, Associate Professor Liz Marles, said Australia was on a “positive trajectory” to address stillbirth issues, with 26 peak bodies and healthcare organisations endorsing the standard.

“Stillbirth is the most common form of perinatal death in Australia, accounting for seven in every 1000 births,” she said.

“Yet for many families, the experience of stillbirth remains hidden because of stigma and a culture of silence. The commission’s national standard will be the catalyst for real change to reduce the risk of stillbirth and help ease the grief for bereaved women and families.

“For the first time, this standard embeds stillbirth guidance into our maternity care that extends across the pregnancy journey. This begins when a family is planning for a baby, continues through pregnancy and sadly, in instances where a baby dies before birth, can involve a search for reasons for the death.”

Speaking at a panel discussion on the new standard at the conference, Professor Marles said GPs were well-placed to talk to women before they became pregnant about minimising the risks of a range of things, including stillbirth.

“Whether it is miscarriage, preterm birth, trying to get pregnant in the first place, I think stillbirth falls into that, and part of it is actually raising it as an issue that we don’t actually shy away from,” she said.

“It is a risk, it’s a small risk but it is a risk. And I think that it’s a risk that women would like to be able to address.”

More than 2000 Australian babies are stillborn every year, a statistic that has remained steady during the past 20 years.

Professor David Ellwood, co-director of the Centre of Research Excellence in Stillbirth (Stillbirth CRE) and Professor of Obstetrics and Gynaecology at Griffith University, said the standard clearly defined expectations of care for women in pregnancy and after stillbirth.

“We can do more in Australia to reduce our stillbirth rate, particularly for late-gestation stillbirths, which is almost 50% higher than in countries with the lowest rates worldwide, including the Netherlands, Finland and Denmark,” he said.

“In recent years, several countries have had success in reducing stillbirth rates, and Australia can learn from these initiatives to inform our approach to stillbirth prevention.”

The document aligns with the Safer Baby Bundle program and both aim to reduce rates of late-gestation stillbirth (after 28 weeks).

The standard highlights the importance of clinicians speaking openly with families about their experience and discussing options for tests to understand why a stillbirth may have occurred.

Professor Ellwood said expanding understanding of the causes of stillbirth through appropriate clinical conversations, relevant assessments during pregnancy, and clinical investigations after stillbirth, such as autopsy, was vital.

“While not all stillbirths can be prevented, research shows that in 20 to 30% of cases, the death may have been avoided had high-quality care been provided,” he said.

“This highlights the value of investigating why stillbirths are happening, then examining the evidence to improve our health response.

Factors that increase the risk for pregnant women include a history of a stillbirth, or complications during a previous pregnancy; medical conditions such as diabetes or hypertension, being pregnant with more than one baby; being aged under 20 years or over 35 years of age; smoking or living with household members who smoke; consuming alcohol or using other drugs; and being overweight or obese.

Other factors that may increase stillbirth risk include experiencing family violence and having limited access to health care, such as women living in rural or remote areas.

The standard also seeks to ensure cultural safety and improve equity in care, particularly for Aboriginal and Torres Strait Islander women and those living in very remote areas, where the stillbirth rates are much higher – 11 and 12 deaths, respectively, in every 1000 births.

“We need to recognise that women from diverse backgrounds, including Aboriginal and Torres Strait Islander women, may be less inclined to seek care from healthcare services that do not provide culturally safe care, which can prevent them from accessing maternity care. The way we provide care must take individual needs into account,” said Professor Marles.

The new standard has guidance on better care for women before and during pregnancy, encourages open discussions about investigations after a stillbirth and urges wide-ranging support after perinatal loss.

It includes 10 quality statements that relate to:

  1. Stillbirth risk assessment before pregnancy
  2. Stillbirth risk assessment during pregnancy
  3. Stillbirth awareness and strategies to reduce risk
  4. Ultrasound during pregnancy
  5. Change in fetal movements
  6. Informed decision-making about timing of birth
  7. Discussing investigations for stillbirth
  8. Reporting, documenting and communicating stillbirth investigation results
  9. Bereavement care and support after perinatal loss
  10. Subsequent pregnancy care after perinatal loss

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