ABSTRACT Recent research suggests that maternity care-providers often avoid discussing the possibility of stillbirth with women in their care. For example, a study by Pullen and Nalos (2009), showed miscarriage is presented as a possibility by the care-provider only 48% of the time and stillbirth only 11%. The reluctance to discuss this kind of poor outcome often is from a wish to avoid “scaring the woman” however, not to do so is missing an opportunity to educate and alert the woman to adopt behaviours to help keep her baby safe. Maternity Care providers should provide women with sufficient and accurate information to enable them to be have freedom to be self-determinant and autonomous when making choices in relation to their care. This type of care ensures women are informed and given every opportunity to be advocates of their own experience with the knowledge and understanding to make informed decisions. However, raising and discussing sensitive topics such as stillbirth during antenatal care can be seen as controversial. Walking the fine line between informing the woman and scaring her with too much information is often a challenge. Rather than having a conversation on what can go wrong during pregnancy, more beneficial would be for care givers to have an ongoing dialogue that encourages parent’s sense of empowerment, awareness, and intuitive knowing of their unborn baby. Antenatal visits would then shift concentration from providers imparting knowledge; to parents sharing what they are learning about their baby with their provider at each visit. This paper will suggest an evidenced based [1] method for sensitively raising and discussing the possibility of stillbirth with pregnant women. In particular the suggestion will be made that if maternity care providers raise the topic of stillbirth as important and also give information to women about what they can activity do to minimise their risk of stillbirth then this information will empower and enable women to keep her baby safe. Reference Warland J Keeping baby SAFE in pregnancy: piloting the brochure. Midwifery e-publication ahead of print 10-NOV-2012 DOI 10.1016/j.midw.2011.11.008

1. Discussing stillbirth
with pregnant women
Dr Jane Warland

2. Overview

Raising public awareness of stillbirth

Talking to pregnant women about stillbirth



Why should we?
Why don’t we?
Using the SAFE message to talk to women

3. Comparing stillbirth to SIDS

What can we learn from the success of the
reduction in SIDS ?

We still don’t know what causes SIDS

We have worked out how to protect the
vulnerable baby by sleeping all babies on
their back

4. Lessons from reduction in SIDS deaths

Key lessons:

Public Awareness

Simple do-able message

5. Public Awareness

The Public health promoter asks:


Why might the audience be motivated to do what you
are asking them to do?
In order to persuade people to do
something we must:

Keep it simple

Make it memorable

Evoke a response

6. Bugger Me! (Robyn Moore)

6 Australian babies die each and every day to Stillbirth

The annual rate of stillbirths in Australia exceeds the road toll by
more than 40%

7. Simple Doable
Message…SAFE

Sleep

Appointments

Feeling baby move

Early expert advice

The brochure is not meant as a recipe to
prevent stillbirth

8. Sleep

aims to encourage women to be
aware of their body and their
baby even as they settle to sleep
and if they wake during the
night.

This section includes the
suggestion to settle to sleep on
the left and avoid sleeping on
the back

9. Evidence base

Research:

increased risk of stillbirth if maternal sleep
position in late pregnancy (night before
stillbirth) was not the left position (OR=1.8
95% CI 1.1-2.8) (Stacey et al 2010)

Women who sleep on their backs in late
pregnancy are 6 times increased risk of
stillbirth (Gordon et al 2012)

Women who sleep supine are 8 times
more likely to experience a stillbirth
[O.R. 8.0, 95%CI 1.5-‐43.2] (Owusu, JT ,
et al (2013)

Practice (e.g. Thurlow & Kinsella 2002)

Physiology: (Kaupplia et al 1980)

Plausible (Warland 2013)

10. Always keep antenatal appointments

reminds them that it is
okay to discuss their
concerns and ask
questions during
antenatal visits

11. Evidence base

Regular attendance assists in detection of problems
(Gilbert 2011)

Reduced antenatal attendance increases risk of
perinatal mortality (Dowswell et al 2010)

Continuity of care provider facilitates women
centered care, increases satisfaction and results in
woman is more likely to discuss any concerns ( Fereday
et al 2009)

12. Feeling baby move

encourages the woman
to being aware of who
her baby is, how her
baby is and
immediately report if
there is a change

13. Evidence base

Fetal movements do not normally decrease close to
term. In fact decreased fetal movement at or near term
places the pregnancy at substantial increased risk (Tviet et
al 2006, O’Sullivan et al 2009 )

42.6% women who experienced a late term stillbirth
presented with DFMs at some time in their pregnancy
compared to 9% of live born controls. (Stacey et al 2011)

Clinical practice guideline for the management of
women who report decreased fetal movements.
(Preston et al 2010)

14. Can awareness of fetal movements be
protective against stillbirth?

Large multi-centred international RCT

68,000 participants

All risk groups i.e. entire clinics were recruited

‘Count to ten’ versus usual care

No Difference in stillbirth rate between groups BUT
Stillbirth rate fell , across the cohort , from an
expected 4:1000 to 2.8 :1000 ( Grant et al 1989)

15. Early expert advice

asks the woman to
monitor her own
pregnancy and
promptly report any
concerns

16. Evidence base

Identifying S&S for women to self
monitor and immediately report i.e
itchiness (cholestasis), headaches
and visual disturbances
(hypertension) should help . (Logic 101 )

17. Focus is maternal awareness 24/7

change the focus from what the maternity health care
provider can do for the pregnant woman, to what the woman
can do for herself in partnership with her provider.

Changing focus from providers assigning risk and
maintaining control of information to recognising the woman
knows her body and her baby best.

This is the very heart of woman centred care (Johnson et al
2003).

18. Raising awareness by discussing
stillbirth with women

Why don’t we?

“Most doctors don’t talk about stillbirth, pregnancy is
a joyous thing, but there are many things that can go
wrong. If you sat down with a patient and told them
everything that could go wrong you’d scare the hell
out of them and no one would get pregnant. “
http://www.2theadvocate.com/features/53088387.h
tml?showAll=y&c=y

19. Why didn’t you tell me this could
happen to me?

The risks of meconium aspiration, postmaturity, uterine
rupture, maternal mortality and stillbirth are real, and need to
be discussed as openly as the benefits and risks of episiotomy,
amniotomy and epidurals are. The feeling that pregnant
mamas shouldn’t worry themselves that their babies could die,
because it stresses them out unnecessarily, is misplaced.
Mothers need to know that it can happen to them, because it
does happen to mothers just like them every day, so that they
can make informed decisions regarding their health care
providers, their birthing facilities and their births.

http://www.thedestinymanifest.com/2-12/08/she-was-still-born/

20. Suggested use for the SAFE brochure

Give out and discuss at the beginning of the third
trimester

Add to the discussion that you are ALREADY having
from then on e.g.


A :When you come next time we will …

F :Baby moving? Who, How, change?


S :How are you sleeping?
E : Don’t forget to call me if you have any concerns
Talk to women about keeping SAFE rather than use the
word “Stillbirth”

21. More information

Email: Jane.warland@unisa.edu.au

Follow links from my website
http://www.unisanet.unisa.edu.au/staff/homepage.asp?name=jane.warland

SAFE on facebook
http://www.facebook.com/safepregnancyAU

22. References
Dowswell T, Carroli G, Duley L, et al 2010. Alternative versus standard packages of antenatal care for low-risk pregnancy.
Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD000934. DOI:10.1002/14651858.CD000934.pub2.
Fereday J, Collins C, Turnball D, et al (2009) An evaluation of midwifery group practice : Part 11: Womens’s satisfaction Women
and Birth 22(1) 11-16
Gilbert E (2011) Manual of high risk pregnancy and delivery 5th Edition Mosby St Lois
Gordon A et al Risk factors for late pregnancy stillbirth: The Sydney Stillbirth Study paper to ISA conference Baltimore 2012
abstract available at http://www.firstcandle.org/cms/wp-content/uploads/2012/10/IC-Program-2012-PROOF-1.pdf
Grant A, et al 91989) Routine formal fetal movement counting and risk of antepartum late death in normally formed
singletons. Lancet. Aug 12;2(8659):345-9.
Johnson M, Stewart H, Langdon R, et al (2003) Woman-centred care and caseload models of midwifery. Collegian 10 (1) 30-34
Kauppila A et al (1980) Decreased intervillous and unchanged myometrial blood flow in supine recumbency Obstetrics and
gynecology 55 (2) 203-205
O’Sullivan O, Stephen G, Martindale E, et al 2009 Predicting poor perinatal outcome in women who present with decreased
fetal movements 29: (8) 705-710 journal of obstetrics and Gynaecology
Owusu, JT , et al (2013) Association Between Maternal Sleep Practices, Pre-eclampsia, Low Birth Weight, and Stillbirth in
Ghanaian Women International the International Journal of Gynecology & Obstetrics Jun;121(3):261-5
Preston S, Mahomed K, Chandha Y, et al. 2010 Clinical practice guideline for the management of women who report decreased
fetal movements. Brisbane, available online at
http://www.stillbirthalliance.org.au/doc/FINAL%20DFM%20guideline%20Ed1V1%201_16Sept2010.pdf
Stacey T, Thompson JM, Mitchell EA, et al. (2011) Association between maternal sleep practices and risk of late stillbirth: a
case-control study. BMJ ;342:d3403.
Thurlow J., Kinsella S 2002 Intrauterine resuscitation: active management of fetal distress International Journal of Obstetric
Anesthesia (11) 2 105-116
Tviet JV, Saastad E, Bordahl P et al 2006 The epidemiology of decreased fetal movements. Annual conference of the
Norwegian Perinatal Society. Oslo , Norway
Warland J, (2011) Pregnant women who experienced late stillbirth appear less likely to have slept on their left Commentary
on: Stacey T, Thompson JM, Mitchell EA, et al. Association between maternal sleep practices and risk of late stillbirth: a
case-control study. BMJ 2011;342:d3403. IN Evid Based Nurs 2011;Published Online First: 25 September 2011
doi:10.1136/ebn.2011.100175
Warland J (2013) Keeping baby SAFE in pregnancy: piloting the brochure. Midwifery 29 174-179