Volume 50, Issue 6 - Special Issue: Understanding and Preventing Stillbirth: A Global Task; Issue Editors: Jason Gardosi and Alexander Heazell

Objectives To analyze the spatial-temporal patterns of fetal mortality according to its relationship with social vulnerability, identifying priority areas for intervention. Methods Ecological study conducted in the state of Pernambuco, Northeast region of Brazil, from 2011 to 2018. The mean fetal mortality rate per city was calculated for the studied period. A cluster analysis was performed to select cities with homogeneous characteristics regarding fetal mortality and social vulnerability, then the Attribute Weighting Algorithm and Pearson correlation techniques were employed. In the spatial analysis it was used the local empirical Bayesian modeling and global and local Moran statistics. Results Twelve thousand nine hundred and twelve thousand fetal deaths were registered. The fetal mortality rate for the period was 11.44 fetal deaths per 1,000 births. The number of groups formed was 7, in which correlation was identified between fetal mortality and dimensions, highlighting the correlations between fetal mortality rate and the Index of Social Vulnerability urban infrastructure for the municipalities in group 1 and 5, the values of the correlations found were 0.478 and 0.674 respectively. The spatial analysis identified areas of higher risk for fetal mortality distributed in regions of medium, high and very high social vulnerability. Conclusions The study allowed observing the existing correlations between fetal mortality and social vulnerability and identifying priority areas for intervention, with a view to reducing fetal mortality in the state.

Objectives Data collected worldwide on stillbirth (SB) rates during the Covid-19 pandemic are contradictory. Variations may be due to methodological differences or population characteristics. The aim of the study is to assess the changes in SB rate, risk factors, causes of death and quality of antenatal care during the pandemic compared to the control periods. Methods This prospective study is based on the information collected by the Emilia-Romagna Surveillance system database. We conducted a descriptive analysis of SB rate, risk factors, causes of death and quality of cares, comparing data of the pandemic (March 2020–June 2021) with the 16 months before. Results During the pandemic, the SB rate was 3.45/1,000 births, a value in line with the rates of previous control periods. Neonatal weight >90th centile was the only risk factor for SB that significantly changed during the pandemic (2.2% vs. 8.0%; p-value: 0.024). No significant differences were found in the distribution of the causes of death groups. Concerning quality of antenatal cares, cases evaluated with suboptimal care (5.2%) did not change significantly compared to the control period (12.0%), as well as the cases with less than recommended obstetric (12.6% vs. 14%) and ultrasound evaluations (0% vs. 2.7%). Conclusions During the COVID-19 pandemic, no significant differences in SB rates were found in an area that maintained an adequate level of antenatal care. Thus, eventual associations between SB rate and the COVID-19 infection are explained by an indirect impact of the virus, rather than its direct effect.

Objectives The Covid-19 pandemic affected antenatal care in many parts of the world. It brought about many changes as part of control and containment measures. We examined the effect of the first and second waves of the pandemic in India on stillbirth rates, as indicators of quality of maternity care. Methods Observational study at a tertiary referral perinatal centre with approximately 10,000 births annually. The Covid-19 first wave period was taken as January to December 2020 with lockdown March to June 2020, which included complete shut down of clinics and ultrasound services. The second wave was from January to September 2021. All women with singleton pregnancy who had hospital based antenatal care were included. We investigated monthly trends in obstetric load (new antenatal registrations, total obstetric clinic numbers and total births) with stillbirth numbers as the pandemic continued (daily Covid case trend). We compared first and second wave stillbirth rates, overall as well as those that were small for gestational age (<10th centile) at delivery. Results There were 9,251 births with 32 stillbirths in the first wave (rate 3.46/1,000) and 6,228 births with 14 stillbirths in the second wave (2.25/1,000). This represented a 54% higher rate in the first phase and extended lockdown period (p=0.08). The incidence of stillbirths that were SGA was significantly higher in the first wave: 14 vs. 2, (p=0.03). Conclusions Reduced access to planned antenatal care during Covid-19 pandemic lockdown was associated with a significant increase in SGA stillbirths.

Objectives Maternal report of reduced fetal movements (RFM) is a means of identifying fetal compromise in pregnancy. In live births RFM is associated with altered placental structure and function. Here, we explored associations between RFM, pregnancy characteristics, and the presence of placental abnormalities and fetal growth restriction (FGR) in cases of stillbirth. Methods A retrospective cohort study was carried out in a single UK tertiary maternity unit. Cases were divided into three groups: 109 women reporting RFM, 33 women with absent fetal movements (AFM) and 159 who did not report RFM before the diagnosis of stillbirth. Univariate and multivariate logistic regression was used to determine associations between RFM/AFM, pregnancy characteristics, placental insufficiency and the classification of the stillbirth. Results AFM or RFM were reported prior to diagnosis of stillbirth in 142 (47.2%) of cases. Pregnancies with RFM prior to diagnosis of stillbirth were independently associated with placental insufficiency (Odds Ratio (OR) 2.79, 95% Confidence Interval (CI) 1.84, 5.04) and were less frequently associated with maternal proteinuria (OR 0.16, 95% CI 0.07, 0.62) and previous pregnancy loss <24 weeks (OR 0.20, 95% CI 0.07, 0.70). When combined, AFM and RFM were less frequently reported in twin pregnancies ending in stillbirth and in intrapartum stillbirths. Conclusions The association between RFM and placental insufficiency was confirmed in cases of stillbirth. This provides further evidence that RFM is a symptom of placental insufficiency. Therefore, investigation after RFM should aim to identify placental dysfunction.

Objectives Stillbirth remains a global public health issue; in low-resource settings stillbirth rates remain high (>12 per 1,000 births target of Every Newborn Action Plan). Preeclampsia is major risk factor for stillbirths. This study aimed to determine the prevalence and risk factors for stillbirth amongst women with severe preeclampsia at Mpilo Central Hospital. Methods A retrospective cross-sectional study was conducted of women with severe preeclampsia from 01/01/2016 to 31/12/2018 at Mpilo Central Hospital, Bulawayo, Zimbabwe. Multivariable logistic regression was used to determine risk factors that were independently associated with stillbirths. Results Of 469 women that met the inclusion criteria, 46 had a stillbirth giving a stillbirth prevalence of 9.8%. The risk factors for stillbirths in women with severe preeclampsia were: unbooked status (adjusted odds ratio (aOR) 3.01, 95% (confidence interval) CI 2.20–9.10), frontal headaches (aOR 2.33, 95% CI 0.14–5.78), vaginal bleeding with abdominal pain (aOR 4.71, 95% CI 1.12–19.94), diastolic blood pressure ≥150 mmHg (aOR 15.04, 95% CI 1.78–126.79), platelet count 0–49 × 10 9 /L (aOR 2.80, 95% CI 1.26–6.21), platelet count 50–99 × 10 9 /L (aOR 2.48, 95% CI 0.99–6.18), antepartum haemorrhage (aOR 12.71, 95% CI 4.15–38.96), haemolysis elevated liver enzymes syndrome (HELLP) (aOR 6.02, 95% CI 2.22–16.33) and fetal sex (aOR 2.75, 95% CI 1.37–5.53). Conclusions Women with severe preeclampsia are at significantly increased risk of stillbirth. This study has identified risk factors for stillbirth in this high-risk population; which we hope could be used by clinicians to reduce the burden of stillbirths in women with severe preeclampsia.

Background Perinatal deaths are a devastating experience for all families and healthcare professionals involved. Audit of perinatal mortality (PNM) is essential to better understand the factors associated with perinatal death, to identify key deficiencies in healthcare provision and should be utilised to improve the quality of perinatal care. However, barriers exist to successful audit implementation and few countries have implemented national perinatal audit programs. Content We searched the PubMed, EMBASE and EBSCO host, including Medline, Academic Search Complete and CINAHL Plus databases for articles that were published from 1st January 2000. Articles evaluating perinatal mortality audits or audit implementation, identifying risk or care factors of perinatal mortality through audits, in middle and/or high-income countries were considered for inclusion in this review. Twenty articles met inclusion criteria. Incomplete datasets, nonstandard audit methods and classifications, and inadequate staff training were highlighted as barriers to PNM reporting and audit implementation. Failure in timely detection and management of antenatal maternal and fetal conditions and late presentation or failure to escalate care were the most common substandard care factors identified through audit. Overall, recommendations for perinatal audit focused on standardised audit tools and training of staff. Overall, the implementation of audit recommendations remains unclear. Summary This review highlights barriers to audit practices and emphasises the need for adequately trained staff to participate in regular audit that is standardised and thorough. To achieve the goal of reducing PNM, it is crucial that the audit cycle is completed with continuous re-evaluation of recommended changes.

Objectives The identification of causes of stillbirth (SB) can be a challenge due to several different classification systems of SB causes. In the scientific literature there is a continuous emergence of SB classification systems, not allowing uniform data collection and comparisons between populations from different geographical areas. For these reasons, this study compared two of the most used SB classifications, aiming to identify which of them should be preferable. Methods A total of 191 SBs were retrospectively classified by a panel composed by three experienced-physicians throughout the ReCoDe and ICD-PM systems to evaluate which classification minimizes unclassified/unspecified cases. In addition, intra and inter-rater agreements were calculated. Results ReCoDe defined: the 23.6% of cases as unexplained, placental insufficiency in the 14.1%, lethal congenital anomalies in the 12%, infection in the 9.4%, abruptio in the 7.3%, and chorioamnionitis in the 7.3%. ICD-PM defined: the 20.9% of cases as unspecified, antepartum hypoxia in the 44%, congenital malformations, deformations, and chromosomal abnormalities in the 11.5%, and infection in the 11.5%. For ReCoDe, inter-rater was agreement of 0.58; intra-rater agreements were 0.78 and 0.79. For ICD-PM, inter-rater agreement was 0.54; intra-rater agreements were of 0.76 and 0.71. Conclusions There is no significant difference between ReCoDe and ICD-PM classifications in minimizing unexplained/unspecified cases. Inter and intra-rater agreements were largely suboptimal for both ReCoDe and ICD-PM due to their lack of specific guidelines which can facilitate the interpretation. Thus, the authors suggest correctives strategies: the implementation of specific guidelines and illustrative case reports to easily solve interpretation issues.

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.

Objectives India has a high rate of stillbirths, and many deaths are due to fetal growth restriction and potentially preventable. Screening and identification of the small for gestational age (SGA) fetus during the antenatal period has been shown to reduce stillbirths. We set out to evaluate the impact of implementing the Growth Assessment Protocol (GAP), a programme designed for screening for SGA. Methods Observational study comparing two-time epochs; before (years 2011–2014) and after (years 2015–2018) introduction of GAP. The programme includes identification of risk factors, risk categorization, serial fundal height measurement, customised fetal growth charts and appropriate referral protocols. Fetal growth charts and birth centiles were generated based on the hospital database of normal outcome pregnancies, customised to women’s ethnicity, parity, height, and weight. The protocol was introduced following training of obstetric and midwifery care providers. We evaluated SGA detection rates, stillbirth rates (from 28 weeks) and neonatal morbidity at term. Results There were 26,199 and 31,498 births, with 115 and 108 stillbirths in the pre and post-GAP implementation periods, respectively. SGA detection rates increased from 51.1 to 67.1%, representing a 31% improvement (p<0.001). Overall stillbirth rates declined from 4.4 to 3.4 per 1000 births (RR 0.78 CI 95% 0.60–1.02) and at term from 1.5 to 0.6 (RR 0.37 CI 95% 0.20–0.66). Neonatal intensive care admission and neonatal encephalopathy in term neonates also decreased significantly. Conclusions Introduction of the GAP programme in an Indian tertiary maternity service was associated with improved antenatal detection of SGA and reduced stillbirth rates and neonatal morbidity.

Many stillbirths are associated with fetal growth restriction, and are hence potentially avoidable. The Growth Assessment Protocol (GAP) is a multidisciplinary program with an evidence based care pathway, training in risk assessment, fetal growth surveillance with customised charts and rolling audit. Antenatal detection of small for gestational age (SGA) has become an indicator of quality of care. Evaluation is essential to understand the impact of such a prevention program. Randomised trials will not be effective if they cannot ensure proper implementation before assessment. Observational studies have allowed realistic evaluation in practice, with other factors excluded that may have influenced the outcome. An award winning 10 year study of stillbirth data in England has been able to assess the effect of GAP in isolation, and found a strong, causal association with improved antenatal detection of SGA babies, and the sustained decline in national stillbirth rates. The challenge now is to apply this program more widely in low and middle income settings where the main global burden of stillbirth is, and to adapt it to local needs and resources.

Objectives Fetal growth and size are associated with stillbirth risk. We wanted to investigate the week by week predictive value of fetal size at term on the prospective risk of stillbirth. Methods Anonymised database from the UK GAP program, with 2,094,702 term (≥37 weeks) deliveries including 4,670 stillbirths. Prospective stillbirth risk was defined as fetal death in the current week divided by total undelivered pregnancies. The data were analysed in five centile bands for stillbirth risk and risk ratios (RR) for 38, 39, 40 and 41+ weeks, using appropriate for gestational age (AGA) at 37 weeks as reference. Results Baseline stillbirth risk at 37 weeks was 0.29 per 1,000 and rose to 1.39 at 41+ weeks, with RR increasing to 4.8. In the 3<10 centile band risk rose from 0.72 to 2.43 over the same period, with RR increasing from 2.5 to 8.4. In the <3 centile group, the stillbirth risk rose from 1.62 to 6.16 (RR (5.6 to 21.2). In the 97>90 centile band, risk increased from 0.40 to 1.50 (RR 1.4 to 5.2) and for >97 centiles, it rose from 0.80 to 2.13 (RR 2.8–7.3). Conclusions Prospective risk of fetal death at term is related to fetal size. The information provided, together with other considerations and results of investigations where available, will help clinicians to determine the advice to give to mothers about the best timing for delivery, balancing the baby’s risk of compromise with iatrogenic sequelae of early delivery.

Objectives Placental examination in a case of stillbirth can provide insight into causative/associated factors with fetal demise. The aim of this study was to compare placental and umbilical cord pathologies in singleton stillbirth and livebirth placentas, and to find prevalence of various associated maternal and fetal clinical factors. Methods This case-control study was conducted at a tertiary-care center in India over a period of 20 months. About 250 women who delivered stillborn fetus ≥28 weeks’ gestation and 250 maternal-age-matched controls were recruited. Sociodemographic and clinical details were noted and placental gross and microscopic examination was done. Placental findings were compared between stillbirth and livebirth (overall), preterm stillbirth and preterm livebirth as well as term stillbirth and term livebirth in six categories – placenta gross, cord gross, membranes gross, maternal vascular malperfusion, fetal vascular malperfusion and inflammatory response. Prevalence of 11 maternal and fetal factors were studied in all categories of placental findings in both livebirth and stillbirth. Results Placental findings in all six categories were significantly associated with stillbirths (p<0.05). The placental findings associated with stillbirth with highest odds included placental hypoplasia (OR 9.77, 95% CI 5.46–17.46), necrotizing chorioamnionitis (OR 9.30, 95% CI 1.17–73.96) and avascular villi (OR 8.45, 95% CI 3.53–20.25). More than half of the women with stillbirths had medical disorders (n=130, 52.0%) and the most prevalent was hypertensive disorder (n=45, 18.0%). Conclusions Changes in placenta are associated with development of stillbirth. Therefore, antenatal investigations to identify placental dysfunction should be investigated to determine whether these reduce stillbirth. Also, placental examination in a case of stillbirth can detect/diagnose many maternal/fetal conditions and thereby can help in preventing future stillbirths.

Objectives In the UK one in 250 pregnancies end in stillbirth. Abnormal placental villous maturation, commonly associated with gestational diabetes, is a risk factor for stillbirth. Histopathology reports of placental distal villous immaturity (DVI) are reported disproportionately in placentas from otherwise unexplained stillbirths in women without formal diagnosis of diabetes but with either clinical characteristics or risk factors for diabetes. This study aims to establish maternal factors associated with DVI in relation to stillbirth. Methods Placental histopathology reports were reviewed for all pregnant women delivering at University College London Hospital between July 2018 to March 2020. Maternal characteristics and birth outcomes of those with DVI were compared to those with other placental lesions or abnormal villous maturation. Results Of the 752 placental histopathology reports reviewed, 11 (1.5%) were reported as diagnostic of DVI. Eighty cases were sampled for clinical record analysis. All women with DVI had normal PAPP-A (>0.4 MoM), normal uterine artery Doppler studies (UtA-PI) and were normotensive throughout pregnancy. Nearly one in five babies (2/11, 18.5%) with DVI were stillborn and 70% had at least one high glucose test result in pregnancy despite no formal diagnosis of diabetes. Conclusions These findings suggest that the mechanism underlying stillbirth in DVI likely relates to glucose dysmetabolism, not sufficient for diagnosis using current criteria for gestational diabetes, resulting in placental dysfunction that is not identifiable before the third trimester. Relying on conventional diabetes tests, foetal macrosomia or growth restriction, may not identify all pregnancies at risk of adverse outcomes from glucose dysmetabolism.

Objectives In this study, we aimed to compare prenatal ultrasound (USG) and postmortem examination findings of central nervous system (CNS) abnormalities in fetuses following termination of pregnancy (TOP). Methods A total of 190 fetuses with USG-confirmed fetal CNS abnormalities of terminated pregnancies between January 2001 and January 2017 were retrospectively analyzed and USG and postmortem examination findings were compared. Results The most frequent CNS abnormalities were acrania/anencephaly (n=45, 24%), spina bifida (n=43, 23%), and ventriculomegaly (n=35, 18%). In 144 of the 190 (76%) cases, there was total agreement between USG and postmortem examination diagnosis. Postmortem examination provided minor findings which did not change the major clinical diagnosis in two (1%) cases with spina bifida and ventriculomegaly. In six (3%) cases, the diagnosis changed after postmortem examination. In 25 of the 190 (13%) cases with multiple abnormalities as evidenced by USG, CNS abnormality was unable to be confirmed at postmortem examination. Conclusions Our study results show an overall high agreement (76%) between USG and postmortem examination findings for CNS malformations. Due to autolysis and fluid structure, USG-confirmed CNS diagnosis cannot be always confirmed by postmortem examination. This potential discrepancy should be explained to patients before considering TOP. Postmortem examination is the gold standard to confirm prenatal diagnosis.

Objectives Despite the use of post-mortem investigations, approximately 20% of stillbirths remain unexplained. Cardiac ion channelopathies have been identified as a cause of death in Sudden Infant Death Syndrome (SIDS) and could be associated with unexplained stillbirths. This study aimed to understand if the expression or localisation of cardiac ion channels associated with channelopathies were altered in cases of unexplained stillbirths. Methods A case control study was conducted using formalin-fixed cardiac tissue from 20 cases of unexplained stillbirth and a control group of 20 cases of stillbirths from intrapartum hypoxia. 4 µm tissue sections were stained using haematoxylin and eosin, Masson’s trichrome (MT) and Elastic van Gieson (EVG). Immunohistochemistry (IHC) was performed using antibodies against CACNA1G, KCNJ2, KCNQ1, KCNH2 and KCNE1. The cardiac conduction system in samples stained with MT and EVG could not be identified. Therefore, the levels of immunoperoxidase staining were quantified using QuPath software. Results The nuclear-cytoplasmic ratio of sections stained with haematoxylin and eosin was higher for the hypoxia group (hypoxia median 0.13 vs. 0.04 unexplained, p < 0.001). CACNA1G (unexplained median 0.26 vs. hypoxia 0.30, p=0.009) and KCNJ2 (unexplained median 0.35 vs. hypoxia 0.41, p=0.001) had lower staining intensity in the unexplained stillbirth group. There were no statistically significant differences in the staining intensity of KCNQ1, KCNH2 and KCNE1. Conclusions Two ion channels associated with channelopathies demonstrated lower levels of expression in cases of unexplained stillbirth. Further genetic studies using human tissue should be performed to understand the association between channelopathies and otherwise unexplained stillbirths.

Objectives To analyze the role of viral infections as etiology of stillbirths in Mexico and their epidemiological impact in the context of the global Every Newborn Initiative. Methods A comprehensive literature search was performed in electronic databases related to stillbirth and viral infections published prior to January 19th 2021. Stillbirths records and causes from National Mexican databases, during 2008–2019 period were also computed. Results Only two articles with a direct relationship between viral infection and stillbirth were found, and one article with an indirect serological association was identified. During the analyzed period there were 198,076 stillbirths, with a National stillbirth rate (SBR) ranging from 6.9 to 6.5 between 2008 and 2014, with a subsequent increase to reach 7.7 in 2019. Only 19 cases were attributed to viral causes and a specific virus was identified in 11. The main causes of early stillbirth were a fetus with premature rupture of membranes and light for gestational age, and for late stillbirth these were fetus affected by oligohydramnios and slow fetal growth. The percentage classified as unspecified deaths varied from 34.4-41.9%. Conclusions In Mexico, there has been an increase in SBR during last years, but the goals of the Every Newborn Initiative is met. More than 14,500 stillbirths with at least 5,100 unspecified cases have been reported per year, and only 11 cases were attributable to a specific virus, highlighting the serious underestimation of cases and the need of implementation of routine viral diagnosis methods to improve the care of this global health problem.

Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto–maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies’ testing, anti-Ro and anti-La antibodies’ measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.

Objectives We compared delivery characteristics and outcome of women with stillbirth to those with live birth. Methods This was a retrospective case-control study from Helsinki University Hospital, Finland. The study population comprised 214 antepartum singleton stillbirths during 2003–2015. Two age-adjusted controls giving live birth in the same year at the same institution were chosen for each case from the Finnish Medical Birth Register. Delivery characteristics and adverse pregnancy outcomes were compared between the cases and controls, adjusted for gestational age. Results Labor induction was more common (86.0 vs. 22.0%, p<0.001, gestational age adjusted odds ratio [aOR] 35.25, 95% confidence interval [CI] 12.37–100.45) and cesarean sections less frequent (9.3 vs. 28.7%, p<0.001, aOR 0.21, 95% CI 0.10–0.47) among women with stillbirth. Duration of labor was significantly shorter among the cases (first stage 240.0 min [115.0–365.0 min] vs. 412.5 min [251.0–574.0 min], p<0.001; second stage 8.0 min [0.0–16.0 min] vs. 15.0 min [4.0–26.0 min], p<0.001). Placental abruption was more common in pregnancies with stillbirth (15.0 vs. 0.9%, p<0.001, aOR 8.52, 95% CI 2.51–28.94) and blood transfusion was needed more often (10.7 vs. 4.4%, p=0.002, aOR 6.5, 95% CI 2.10–20.13). The rates of serious maternal complications were low. Conclusions Most women with stillbirth delivered vaginally without obstetric complications. The duration of labor was shorter in pregnancies with stillbirth but the risk for postpartum interventions and bleeding complications was higher compared to those with live birth.

Objectives Perinatal bereavement care is a complex area of practice. The COVID-19 pandemic led to reconfiguration of maternity and perinatal bereavement care services. This study explores Australian health care providers’ perspectives of the impact of COVID-19 on the provision of respectful and supportive care following stillbirth or neonatal death. Methods Members of a perinatal bereavement care network were consulted at the commencement of the pandemic in Australia using an online feedback form. Respondents provided ratings and free-text comments on the impact of COVID-19 on implementation of 49 recommendations contained in the Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Clinical Practice Guideline for Respectful and Supportive Perinatal Bereavement Care . Results Responses were received from 35 health care providers who provided perinatal bereavement care in clinical settings or through support organisations in Australia. Major impacts of COVID-19 were reported for 8 of 49 guideline recommendations. Impacts included reduced: support for mothers due to visitor restrictions; availability of cultural and spiritual support and interpreters; involvement of support people in decision-making; options for memory-making and commemorative rituals; and staff training and supervision. Adaptations to minimise impacts included virtual consultations, online staff training, use of cold cots, and increased staff support for memory-making. Conclusions Health care providers encounter substantial challenges as they strive to implement best practice perinatal bereavement care in pandemic conditions. Some practice adaptations developed during the COVID-19 pandemic could benefit parents; however, evaluation of their effectiveness and acceptability is needed.

Objectives To investigate which objective (actions/interventions) and subjective (perceptions of care quality) outcomes of care following stillbirth or termination of pregnancy predict perceived care quality. Methods A cross-sectional descriptive study using an anonymous online survey. The population was women who had experienced a stillbirth or termination of pregnancy from ≥16 weeks of gestation, in the Spanish health system. Multiple sequential regression analysis was used to identify predictors of perceived care quality (satisfaction, willingness to recommend, competence and ability to provide loss-focused care). Results Results from 610 women were analysed. A significant regression equation (p<0.001) was found in each of the objective only and objective-subjective models. In the case of overall care (satisfaction-recommend composite), 72.0% of variance (adj. R2) was explained. In general, subjective evaluations of care are more potent predictors of perceived care quality than objective care interventions (e.g. autopsy performed). Feeling free to ‘express emotions’, ‘teamwork between doctors and nurses/midwives’, and ‘being well-informed of all steps and procedures’ were the three strongest predictors, followed by perception of ‘medical negligence’. Information provision and loss-focused interventions had the weakest influence, except in the specific ‘loss-focused’ model. Conclusions The results indicate that the ‘atmosphere’ of care is a transversal dimension related to the context of loss and trauma and has the single greatest influence on perceptions of care quality. It is necessary to use a specific ‘loss-focused’ care variable to adequately capture perceptions of the quality of bereavement care and a custom scale to measure the influence of care interventions on perceived quality.

Objectives This study aimed to assess parents’ satisfaction with received care and support when experiencing stillbirth. Methods This was a questionnaire survey conducted at Helsinki University Hospital, Helsinki, Finland during 2016–2020. Separate questionnaires were sent to mothers and partners who had experienced an antepartum singleton stillbirth at or after 22 gestational weeks during 2016–2019. The questionnaire covered five major topics: stillbirth diagnosis, delivery, information on postmortem examinations, aftercare at the ward, and follow-up appointment. Results One hundred nineteen letters were sent and 57 (47.9%) of the mothers and 46 (38.7%) of their partners responded. Both mothers and their partners felt well supported during delivery. They were also satisfied with the time holding their newborn. Partners reported even higher satisfaction in this aspect with a significant within-dyad difference (p=0.049). Parents were generally pleased with the support at the ward. However, both groups were less satisfied with social worker counseling (mothers 53.7%, partners 61.0%). The majority felt that the follow-up visit was helpful. Nonetheless, a remarkable proportion felt that the follow-up visit increased their anxiousness (25.9%, 14.0%, p=0.018). Partners rated their mood higher than mothers (p=0.001). Open feedback revealed that the support received after discharge from hospital was often insufficient. Conclusions Our study showed that the parents who experience stillbirth in our institution receive mostly adequate care and support during their hospital stay. However, there is room for further training of healthcare professionals and other professionals contributing in stillbirth aftercare.