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First do no harm

2/23/2022

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One of the things we often have to weigh up, as health professionals, is the balance between risk and benefit.
For example, IF we make a decision towards planning an early birth, there are decisions that involve weighing risks and benefits of doing that. These include, the potential risk of stillbirth if the pregnancy continues, and if labour is induced, the risk of intervention such as forceps and epidural and informing parents that the baby born before 39 weeks is at slightly increased risk of developmental delays that could affect school performance. Because we are talking in terms of risks rather than certainties it is always challenging to have discussions such as these. They are made even more challenging because sometimes, with the benefit of hindsight, it can be seen that a less harmful decision could have been made at the time.
Maternity care providers have risk versus benefit conversations during pregnancy ALL the time. Information that is shared can be consciously or unconsciously affected by their own biases and fears. One such fear prevailing at present is the fear of Covid. I have to tell you that fear of Covid in Western Australia is palpable, AND in my view  the response is very much out of proportion to the level of risk. I have heard phrases like “DEFCON 1” and “Ebola like management ” so I know I am not the only person who thinks we are going to extreme and quite unnecessary lengths to “keep safe.”
“Safety “ is a euphemism for death so lets have a look at recent stats concerning the “risk of dying” from Covid in Australia according to age, sex and vaccination status. 
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​Its pretty obvious from this Australian research that even if you are not vaccinated at all that your risk of dying from Covid is incredibly low especially if you are under the age of 70. For example, if you are an unvaccinated male between the ages of 50 and 59  your risk of dying is only 11 per 10,000 cases and once triple vaxed this drops to 4 in 100,000.
You can also see from this chart that if you are an Australian  woman of childbearing age that the risk of dying from Covid is less than 1 per 100,000 especially if you have had any kind of vaccination.
Shouldn’t we be careful ? I hear you ask. I agree we should be careful and I ABSOLUTELY agree that we should be doing all we can to protect our elderly AND 1 in 100,000 young people dying is one too many BUT here is my point.
“how much harm are we prepared to cause to prevent that one death?”
Current approaches to managing  Covid in maternity settings is doing WAY more harm than good, in my view. To borrow from another campaign “Covid is a word not a sentence”.  
While there are physical harms being caused that I have talked about before on this blog I am also becoming more and more concerned about the long term emotional and psychological scarring we are undoubtably causing. I think that it won’t be too long at all before we look back in horror at our treatment of birthing families during Covid and ask “what were they thinking?”
Pregnancy and Birth is a special time and the experience can’t be regained or memories changed. Anxiety during pregnancy is common and Birth trauma is real, even when everything is apparently fine. Parent / Child bonding can be fragile and the negative, long term sequalae of disordered attachment is well known. What happens during pregnancy and birth is remembered and reflected upon for the rest of that persons’ life ask any 80-year-old mother!! There is much to be concerned about for pregnancy and birth during covid including:
  • Fathers not being allowed to enter a maternity hospital or if they are allowed in, there are MANY barriers including mask and vaccination mandates, and time limits
  • Fathers seeing ultrasound in a hospital car park via facetime
  • Requirement for support people to wear full PPE during those very first precious moments when greeting the new baby and establishing attunement which necessarily involves the parent and baby’s WHOLE face.
  • Siblings being denied entry
  • Extended family members being denied entry
  • No support person allowed in antenatal clinic. There are many situations that can arise in pregnancy when bad news might need to be broken and immediate comfort and support needed. NOT TO MENTION having another pair of ears in the room when explanations are given and another person to ask questions not thought of by the other person.
  • Time limits for support during birth   
I could go on but that’s more than enough to make my point!
 It may be, that even now, some people will look at this very limited list and say “surely that isn’t happening!” It seems draconian, heartless and cruel doesn’t it? While I think stopping people at the door of a nursing home and perhaps even a general hospital where there are sick children or adults is probably necessary, I take you back to my original point, care providers are sworn to “first do no harm” and as far as I can see we are doing tremendous harm to our birthing families for very little benefit.
So, can someone with a brain and a heart STOP this insane approach before we do any more immeasurable harm…. PLEASE! 
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Wouldn’t it be lovely?

2/12/2022

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Today I was sad to see that my fears expressed on this blog in April 2020 were confirmed with this story in the Sydney Morning Herald. Reporting that we now know stillbirths in NSW rose to their highest rate in more than a decade during the first year of the pandemic.
Professor Jonathan Morris (Professor of obstetrics) said the rate was up from 8 per thousand in 2019 to 9.1 per thousand in 2020. Describing this rate rise as “slight”. Later in the article it was pointed out that this equates to 100 more families in NSW alone who suffered a stillbirth in 2020 than in 2019. I don’t know about you but I’d be willing to bet that none of those families , nor indeed anyone of us who has suffered a stillbirth, would describe a 100 more deaths in just one State as a “slight” rise
Why did this rate rise occur? The usual suspects are blamed including the move from face-to-face consultation to telehealth, strain on maternity services  and my favourite (NOT) the mothers fault delaying ‘presentation” to hospital because of being  “anxious” to attend.  The report adds that it was “too early to pinpoint a cause”
This is where I beg to differ. Far from it being too early it is WAY too late to try to pinpoint a cause. Why? Because the rate data is two years old. Even if a cause was pin pointed and mothers were        blamed for delaying presentation what can be done about it now? If that cause was “pin pointed” at the time then strategies and education could have been put into place. Now its WAY to late to act even if a cause could be pinpointed
I have heard time and time again a “wouldn’t that be lovely” in response to my and others requests to collect and quickly report stillbirth rate data. Jurisdictional boundaries and regulations  and MANY other issues are cited as “reason’ why we cant get data on stillbirth rate until it is WAY too late to know if telehealth, strain or anxiety have anything or everything to do with it.
But is it actually possible to get that information before 2 years has passed?  Certainly, I point you to what we know about Covid -19 by way of example. We know , rates from every jurisdiction within 24 hours, not only that we know ages of victims and even if they have “underlying conditions”. This information has enabled us to learn so much more about Covid than we would have known if all the data we had was 2 years old! The information includes what we need to look out for and how to protect ourselves. Has this information evolved over the course of the pandemic BECAUSE of our immediate access to information?  YOU BETCH YA.
 Information we have from our Covid experience tells us that we can, and indeed we MUST collect and report data about stillbirth rate FAR more frequently than we currently do and IF we do we will discover further risks and ways to protect women and families from stillbirth in time to take steps to actually address the likely problem AND to see  the effect of any changes we make !
I challenge those who are in a position to influence the collection and reporting of stillbirth data to make it available as quickly as they can in much the same way as Covid deaths are reported.  Daily if possible, weekly at the outside. This will have the combined effect of raising community awareness of stillbirth but also allow us to make any changes to the way antenatal care is delivered across Australia in response to real-time data rather than trying to shut the stable door 2 years after the horse has bolted.  
 
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Raising awareness about stillbirth or triggering anxiety and distress?

2/1/2021

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Ok its time for me to get picky and express my grumpiness.
Today a stillbirth awareness campaign was launched
https://preventstillbirth.org.au/
Its been a while in the coming so ordinarily a launch like this would give me cause to celebrate instead as a bereaved mother, stillbirth researcher and clinician I am shocked, horrified, disappointed and to be frank... downright angry. Here is why:
The main video can be seen here https://youtu.be/p6-A1k5gk2A .
WARNING its likely to be triggering for bereaved parents
•             The video shows a clinician struggling to find a fetal heart (FH). As a bereaved mum I fear this scene will be very triggering for those who have not had the happy ending that this couple had. I also wonder if it actually gives a stillbirth message to any naïve / uninformed pregnant couples who have not had a stillbirth, I would suggest not. To me I would think the main message is “don’t worry if your clinician can’t find the baby’s heart because after a moment they will”….heart stopping (no pun intended…) certainly but I am not sure how this translates to a message about stillbirth or stillbirth awareness? However, for the couple who has experienced stillbirth it recreates that awful moment we all share, of a clinician not being able to find our baby’s heartbeat, it instantly and traumatically sends us back to that moment when our lives changed forever, so when this airs it is likely to be repetitively traumatic for the family who have suffered a stillbirth while probably ineffective in giving the right /anticipated awareness message to families who have not.
•             As a clinician I am concerned that this actually isn’t depicting stillbirth because all it is showing is a moment of a clinician not being able to find the fetal heart (FH). Further, in my experience, what is depicted simply would not occur. While momentarily being unable to find the FH for a CTG is an everyday occurrence, especially for larger women or an inexperienced clinician, this video actually depicts clinician incompetence because if you can see the baby’s anatomy via ultrasound (with a fetal head the size it is) , you can easily locate the chest and therefore the heart. I realise that such a video doesn’t have to be clinically correct BUT in this case it probably should be because the campaign is supposed to be complementary to the Safer baby bundle campaign aimed at clinicians. If the producers are expecting clinicians to promote it in ,say, an antenatal clinic I would argue that most clinicians will not want to show something as inaccurate as that!
•             As a clinician I would also be concerned that the instruction to call providers immediately your baby’s movement change is very likely to inundate care providers with unnecessary presentations. This is because a message such as this is actually disempowering, it’s important to empower women with knowledge that they know themselves and their baby best. So informing her that getting to know her unborn baby is vitally important and what needs to be “immediately reported” is not any old change but a change that concerns HER. As a StillAware leaflet puts it “if something feels irregular”  if the mother notices her baby’s movements changing (getting stronger) towards the end of pregnancy then this isn’t a “change“ to immediately report and be seen about, in fact it is a reassuring sign that all is well. 
•             As a researcher I am concerned this isn’t giving correct evidence-based information “sleep on your side after 28weeks” is incorrect it needs to be “go to sleep on your side…”  this might seem pedantic but it is important because there are more and more reports in social media of women thinking they need to sleep all-night on their side which is anxiety provoking, likely deprives them of a restful sleep AND is impossible to do, everyone changes position while asleep!
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The accompanying videos are also inaccurate and actually just plain wrong. For example:
  • Smoking is actually NOT one of the biggest “CAUSEs” of stillbirth. I am unaware of any research which reports smoking causes stillbirth. It’s not mentioned as a cause in our AIHW data. https://www.aihw.gov.au/reports/mothers-babies/stillbirths-and-neonatal-deaths-in-australia/contents/overview-of-perinatal-deaths/timing-causes-and-investigation-of-perinatal-deaths
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  • While smoking is certainly a risk factor for stillbirth, even then the risk is modest. With previous stillbirth, change in fetal movements, fetal growth restriction, no antenatal care, settling to sleep supine, pre-existing diabetes, assisted reproduction, pre-existing hypertension, pre-eclampsia, maternal obesity and maternal age ALL having demonstrably higher adjusted odds ratios /relative risk than smoking.
 
  • The “if baby feels still” https://preventstillbirth.org.au/if-baby-feels-still/ is catchy and nicely matches the campaign title but is actually dangerous advice. If the baby feels still then I would think it means the baby is already deceased so if the mum waits for the baby to "feel still" then she has waited too long. Further this advice overlooks characteristics of fetal movement that are other warning signs that all might not be well, such as a change in the strength of her baby’s movements (getting weaker over time) as well as a change in pattern (e.g. not moving at bedtime as usual)
Overall message
I reiterate that I am not an expert but to me it’s pretty logical when planning a public awareness campaign that the first step would be to tell people about of what it is you want them to be aware? IMHO this ‘campaign’ falls short of the mark because while stillbirth is mentioned and the figure 6-per-day is given, the audience are not told what stillbirth actually is. It really can’t be assumed the general public know what stillbirth is, in fact we have good evidence from other high income countries and also some from Australia that the general public actually don’t know what stillbirth is and that there are MANY widely held myths and misconceptions. Some of these are that it is similar to miscarriage, that it’s inevitable, nature’s way or that the woman did something wrong. I would have hoped that a campaign that claims to be addressing stigma and raising awareness would first focus attention on correcting these myths before launching into giving information about how to reduce risk.
It is also my opinion that to raise awareness you need to make your campaign relatable. What I mean by that is that the expectant family should see themselves in the scenario. When I showed this video to my husband who is a bereaved dad but has NO medical knowledge…..NONE. He made two pretty telling comments he asked “where is the male point of view portrayed?” and he also asked “Why are they showing a miscarriage ultrasound?” When we lost our daughter Emma he felt largely ignored, and still does actually. This ad does nothing to reassure male partners that we now fully understand that men are impacted by stillbirth too.
I’m no expert but it would seem to me that if you are aiming to portray stillbirth then showing an ultrasound and relying on those with no medical knowledge to understand what is going on is a bit of an ask! If you are going to raise awareness then you need to tell the audience that stillbirth is a baby dying not imply that its trouble finding a heartbeat. To address public awareness don’t you need to bite the bullet and actually portray the reality of stillbirth? Rather than showing an ultrasound just let he audience hear the words “I’m so sorry there is no heartbeat your baby has died.” To show it can happen to anyone why not depict this message being given to 6 different couples who together represent the full diversity of Australian multiculturalism.
So in sum, as an Australian tax payer I’m wondering if the dollars used to create this campaign have been efficiently and well spent, as a bereaved parent I know that I will be retraumatised each time it airs and hundreds of thousands of other Australians like me will be too, as a cis woman I am concerned that male partners have been ignored, as a clinician I am concerned this will provoke anxiety rather than empowerment and as a researcher I am sad that the attention to evidenced-based detail needed is absent or inaccurate.
Ordinarily I would hold my tongue but on this occasion, I feel compelled to speak out because of my concern that this campaign does very little to raise public awareness about what stillbirth actually is and that such information needs to come FIRST. Instead I have real concerns it will do much to provoke anxiety in pregnancy and distress for bereaved families. I for one can’t in good conscience stay silent about that!
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Human intelligence always trumps Artificial intelligence

12/16/2020

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Today I read that Monash university have been successful in gaining several NHMRC ideas grants. Congratualtions to them!!
One of these is $1M to fund
Soft wearable patches for stillbirth prevention
I quote from the press release: 

Professor Wenlong Cheng from the Faculty of Engineering will lead a project to develop next-generation soft wearable patches that use artificial intelligence (AI) to help prevent stillbirths.
This project aims to directly tackle this unmet clinical challenge by revolutionising the way fetal movements are evaluated through the development of a compact, soft, inexpensive, smart patch, which can automatically detect and report fetal movements anytime anywhere taking advantage of the world-leading advanced electronic skin sensing technologies and AI.
“If successful, this will be world-first wearable technology enabling out-of-hospital screening with the penultimate goal of stillbirth prevention,” said Professor Cheng.

Sounds exciting right?
But I have my concerns because as good as AI may be it can’t replace human intelligence, neither should it. Further AI can’t be programmed for maternal intuition or human response.
I have often heard mothers report a ‘decrease’ in their baby’s movements which machines like a CTG dont seem to detect. This is because it is often the case that the woman is reporting not so much a decrease in frequency but concern about a change. In my experience women will often say “I cant put my finger on it but my baby's movements just feel different”
The algorithm for this new device is going to have to include strength, frequency and pattern all of which have been shown to be important in fetal wellbeing. Pattern includes time of day the baby moves and their usual response to things like hearing a siblings voice, or startling when there is a loud noise. AI is good but can it possibly be that good ?
I am not suggesting for one minute that this patch wont be useful but I do fear that we as a society tend to put our trust in machines  and technology . In the case of maternity care this is often at the expense of trusting the woman, her baby, her understanding of her baby and her maternal instincts. PROVIDED this patch is used as a supplement to all then it can be useful however I suspect that it may be yet another device , in a long line of devices, that are overly relied upon and hence further disempowers the pregnant woman.
 I hope that we don’t EVER see this patch marketed as “better than a woman” but I suspect we may. I hope I am wrong…we shall see!
 
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Shocking but true

12/4/2020

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I think it would be fair to say that many social media-ites were shocked to hear that a grieving mother was asked to return her baby gifts following her baby’s stillbirth.
https://www.newshub.co.nz/home/lifestyle/2020/12/grieving-mother-of-stillborn-shares-shocking-exchange-with-friend-who-asked-for-baby-gifts-back.html
This story has received wide condemnation because of the shockingly insensitive actions of this poor mums ‘friend’
One has to ask, why on earth would a “friend” act in such a way?  And I would like to offer that it is for two reasons:
  1. Mother blaming and
  2. Societal lack of understanding that a stillborn baby is still a baby.
To explain what I mean, imagine that the gift was for a wedding that was cancelled at the last minute.  In this case a “friend” may feel that if the wedding didn’t go ahead that their gift wouldn’t be needed or perhaps even wanted. Certainly, there would be a sense that if the giftee was the one who called off the wedding that the “friend” may even think that having the gift as a reminder of the failed wedding might cause them pain and distress.  
Using this as an analogy helps us understand that while the actions of this person were deplorable, that they came from a place of complete ignorance of the true meaning and impact of stillbirth. Further while the actions of this “friend” were obviously completely insensitive, society and even mothers themselves do tend to overtly or covertly blame themselves for their baby’s death. Many think that reminders of the baby’s existence are harmful rather than healing, distressing rather than comforting. Further the “friend” clearly didn’t understand that a mother of a stillborn baby would still want to wrap their baby in something to keep them warm. This depth of maternal care defies logic but is certainly there for most of us who have lost a baby.
So, the actions of this “friend” really represent the extreme end of widely held societal views. Society needs to understand that having a stillborn baby is not at all like calling off a wedding. Having a stillborn baby is a lifechanging event with lifelong impact. As this couple have discovered, having a stillborn baby provides opportunities for friendships to be lost but also for friends to be made. Further, having a stillborn baby causes a quantum shift in one’s life where old paths are forever blocked but new paths forged. 

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Asking a Question without blaming the victim.

11/12/2020

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Today I read this interesting article:
https://www.chadwicklawrence.co.uk/legal-news/rise-stillbirths-pandemic-prompts-safety-review/
which starts by saying: 

The Healthcare Safety Investigation Branch (HSIB) has begun a national review in England following a rise in stillbirths between April and June, during the peak of the coronavirus pandemic, when there were 40 stillbirths recorded after the start of labour, compared with 24 in the same period last year.

There is a certain skill in the search for answers as to why an event might have occurred without pointing fingers and causing the victim to feel blame. For example asking open ended questions like:
  • How did it happen?
  • Can you tell me about it?
  • Help me to understand…I don’t know what this means?
  • Can you tell me more?
  • What can be done to help this situation?
  • Can we figure out how to solve this? Etc
 
There is also a way to inquire about something happening that immediately causes the victims of the event to feel somehow responsible and blamed. Proposing you already know why something occurred ahead of what the investigation might reveal is one of these.  
Unfortunately of the two ways its seems that the second is being employed in this instance.
While of course it is wonderful that they are investigating this spike at all it IS concerning that the victims of this spike in stillbirth are already being blamed through reported comments  like:  
Pregnancy and childbirth experts say this may have been due to a delay in women seeking care.
Dr Edward Morris, president of the RCOG, said antenatal care was “essential” and urged all women to attend appointments.
He went on to say
Dr Morris said “This may have been due to confusion around whether these appointments are essential, fear of attending a hospital or not wanting to burden the NHS.
“We have consistently advised women who have concerns or worries about their or their baby’s health – including the baby’s movements – should seek medical advice from their midwife or hospital immediately.”

As I have said before on this blog the spike in stillbirths that has occurred globally is multifactorial but IMHO is MUCH more to do with maternity services not being adequate, antenatal care taking place remotely or not at all and women not being informed by their care provider what to do if they are concerned in the context of the pandemic.
I refer back to comments made by Australian women to back this up :
Maternity care has been stripped back to if you’re alive and so is the baby, that'll do.
I haven't been allowed to have any face to face appts at the hospital, I can’t be thoroughly checked over the phone.
Worst care during this pregnancy

Hopefully this national UK review will identify ALL of the factors leading to an increase in the stillbirth to benefit not only UK but other high income countries and not simply lay the blame at the feet of the victims.  
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Can we agree to agree

8/23/2020

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Wait..what?
 
Yesterday there was a story in NewsGP (the newsletter of the Australian college of GPs) responding to concerns that Australia might be experiencing an spike in Stillbirths in Australia.  
The headline read “Significant increase in stillbirth at a UK hospital during pandemic” and the by-line was “But experts say there is little evidence to support the idea it may be happening in Australia.”
The experts were Dr Alex Polyakov, a senior lecturer in the Department of Obstetrics and Gynaecology at the University of Melbourne and a consultant obstetrician, gynaecologist and fertility specialist at the Reproductive Biology Unit at the Royal Women’s Hospital in Melbourne and Dr Wendy Burton, Chair of the RACGP Specific Interests Antenatal and Postnatal Care network. They both agree that they don’t believe Australian hospitals are seeing a similar rise in stillbirths. I hope they are right!
What has led them to this belief? Polyakov’s “anecdotal evidence from working at a tertiary hospital and a fairly busy private practice, we haven’t observed such [a] major increase in stillbirth over the past few months” and Dr Burton going so far as to ask Dr Michael Beckman from Mater Mothers Hospital (MMH) in Brisbane, Australia’s largest maternity hospital, to review their data Dr Beckman reported lower numbers of stillbirths in the period from February to June 2020 at MMH.’
If one concerned Doctor can ask another to have a look at their stillbirth rate in one hospital in Australia then I would call for every maternity hospital (both public and private) as well as every private provider conducting births at home to provide data for this six month time period AND not only that …if we can do that once then I would suggest it can be done regularly and systematically from now on.
Dr Burton agrees “the numbers [from MMH] are small and we need to look at larger population data, not individual hospital event rates’
One of the amazing things about the data that we have had access to during the Covid crisis is that it comes to us daily, we all know how many tests were done just yesterday, how many were positive, how many are in hospital , how many are in intensive care and what age group they are in. This has enabled us to know as much as we can about this virus and as the months have gone by we have learned a great deal about it and thus how to protect ourselves from it in a way that few countries in the world have managed. In contrast we are flying totally blind with respect to stillbirth while, of course, there is some reassurance in one hospital’s data and anecdotal report we really do owe it to our pregnant women to do better than that and find out what is actually happening to our smallest and most vulnerable Australians.
The other thing that is welcome about this story is the concerns Dr Polyakov shares about telehealth:
Dr Polyakov harbours further concerns about the shift away from face-to-face appointments during the pandemic, and its potential effects on pregnancy outcomes.
‘You can only do so much via telehealth,’ he said.
‘For example, you can’t measure blood pressure and you can’t assess fetal movements or fetal heart rate with telehealth, and so this is something that needs to be kept in mind when we change the patterns of antenatal care.’
Dr Polyakov believes the routine schedule of antenatal appointments should ideally be kept at their usual intervals despite the pandemic.
‘And those appointments should really be face-to-face because otherwise there will be some women who will slip through the net and will have adverse events happen to them because they haven’t seen a doctor face-to-face for months,’ he said.
‘So my advice for [clinicians] who participate in shared antenatal care is to make every attempt to stick to the recommended appointment times or schedule, rather than doing it via telehealth or doing it less frequently.
‘My personal feeling is that because antenatal care is designed to minimise stillbirth and various other complications, it really should be done unchanged irrespective of the COVID pandemic.’
 
Back to the headline of this article, we have “little evidence” that a spike in stillbirth is happening in Australia perhaps because we haven’t really looked. BUT, we do know that women are not seeing their care provider face to face and we know that face to face antenatal care IS designed to minimise stillbirth so it absolutely should be being done unchanged irrespective of the COVID pandemic. Because there is no doubt that antenatal care has changed we really do need to check that if we haven’t inadvertently caused an increase in stillbirth. 
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Should we ask the Pilot or the black box?

7/31/2020

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One of my favourite films at the moment is “Sully.” If you recall, Sully was the Pilot who performed a forced water landing on the Hudson river after a flock of birds flew into both his engines crippling his aircraft. The film depicts that when this ‘air crash’ was investigated the investigators referred to the black box and ran simulations that all showed that Sully could have made it back to dry land and they therefore came to the preliminary conclusion he had made a pilot error by landing on the Hudson. When Sully finally got the opportunity to speak to the air crash investigators, he was able to point out that the simulations needed to factor in a few seconds for decision making. After they did this, they realised that Sully actually couldn’t make it back to dry land and that not only did his actions result in the lives of everyone on board being saved but also that he had avoided crashing into New York city as well.
How does this relate to stillbirth and stillbirth research I hear you asking?
Recently this article came up in my “citation alerts.” It’s a report of a trial conducted in the UK of increased fetal movements which was designed to prospectively examine outcomes from women who report an increase in fetal movements (IFM). The authors reported there was not a significant relationship between woman who report IFM and poor pregnancy outcomes.
This study is a classic example of referring to the black box rather than the pilot. They actually thoroughly examined the black box (the CTG, the woman’s blood, the placenta and pregnancy outcomes). What they didn’t do was ask their participants for a qualitative description of the movements. They actually admit this is a limitation:  
Furthermore, this study did not include a qualitative description of IFM which is potentially important in determining their significance with regards to stillbirth [Warland et al 2015]
“Potentially important” is something of an understatement. “Vitally import” would have been more accurate!
What information did the authors miss out on? Well they actually allude to this in the reference they cite. That paper, one that I am pretty familiar with :) , gives crucial information about descriptors women use for IFM which probably indicate fetal health and when they, potentially, don’t. Women who experience stillbirth use descriptors for IFM like “crazy” wild” ballistic” nuts” “bananas” over a very short period of time. The authors of this new study suggest that women presented to the hospital with a period of IFM lasting 1 to 24 hours. This is therefore not likely to be the short “crazy” increase we reported as possibility associated with stillbirth in 2015. In fact, it seems pretty likely to me that this study picked a group of women who were reporting an increase in their baby’s movements that was actually demonstrating their baby was healthy and well BUT because these authors didn’t ask the woman for her qualitative description we wont know how many, if any, of them might have been using those key words versus the others who might have been using words known to be associated with fetal health like “strong and vigorous.” Certainly, you wouldn’t think that a baby in trouble would be able to sustain a increase in fetal movement for a period of 24 hours!
The authors of this study call for additional prospective studies which incorporate women’s description of fetal activity to differentiate between women’s experienced of IFM. All I can say is “hear hear” to that idea! 

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Danger Will Robinson

7/14/2020

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​One of my favourite television shows when I was growing up was Lost in space…the 60s version …yes I am that old!
Anyway the Robot must have had pretty easy lines to learn as usually all he repetitively said was “Danger Will Robinson” or “warning warning.” I am beginning to know how he must have felt as I have been repetitively warning now for a few months that the current Pandemic will inevitably cause an increase in stillbirths. I take no pleasure at all in saying there is more and more evidence emerging to support my view.
Last week the Scots , who seem to be able to report population based perinatal outcomes faster than anyone else in the world,  reported a concerning spike in stillbirth rates in the last quarter. 
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A spokesperson for Public Health Scotland said rates of extended perinatal deaths - stillbirths and neonatal deaths combined - “are being closely monitored” after they reached the warning limit in May, for first time in three years. …PHS said infant mortality during the pandemic could be an important indicator of "maternal health and well-being" and "how maternity services are provided".[my emphasis]
 
To add to this yesterday a research letter titled Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic  was published in JAMA. This was reporting a pre v during  pandemic study in St George’s University Hospital, London . They compared pregnancy outcomes from 1681 births occurring at the hospital between October 1, 2019, to January 31, 2020 (preceding the first reported UK cases of COVID-19), with 1718 births from February 1, 2020, to June 14, 2020. Outcomes included stillbirth, preterm birth, cesarean delivery, and neonatal unit admission.Interestingly they did not find an increase in preterm birth, cesarean or neonatal admission between the two time frames. They did report fewer women with hypertension in the pandemic group (3.7% vs 5.7%; P = .005) but, of concern, here are their stillbirth findings:

The incidence of stillbirth was significantly higher during the pandemic period (n = 16 [9.31 per 1000 births]; none associated with COVID-19) than during the prepandemic period (n = 4 [2.38 per 1000 births]) (difference, 6.93 per 1000 births [95% CI, 1.83-12.0]; P = .01) and the incidence of stillbirth was significantly higher when late terminations for fetal abnormality were excluded during the pandemic period (6.98 per 1000 births vs 1.19 in the prepandemic period; difference, 5.79 [95% CI, 1.54-10.1]; P = .01).
During the pandemic period, 19 patients with COVID-19 were hospitalized in the study site maternity department. None of the pregnant women who experienced stillbirth had symptoms suggestive of COVID-19, nor did the postmortem or placental examinations suggest SARS-CoV-2 infection.

The authors suggest some plausible sounding reasons for the increase in numbers of stillbirths:
1.      A direct consequence of SARS-CoV-2 infection.
2.    indirect effects such as reluctance to attend hospital when needed (eg, with reduced fetal movements), fear of contracting infection, or not wanting to add to the National Health Service burden.
3.      Changes in obstetric services secondary to staff shortages or reduced antenatal visits, ultrasound scans, and/or screening.

Number 1 seems pretty unlikely especially as none of the mothers had any symptoms. Of course asymptomatic cases of COVID-19 are pretty common but I wouldn’t think it likely that a woman with mild enough symptoms to evade detection would suffer a stillbirth caused by this infection, especially if there was no sign of the infection at autopsy.
Number 2 is certainly possible but I am always pretty concerned when mothers are bashed in this way. While it is certainly common to hear the lament “ if only she had presented to care sooner” I would also suggest that it takes two to tango, meaning that in this context the care provider may also have been reluctant to ask her to attend hospital in an attempt to ‘protect’ her, and they could have been equally, if not more, concerned about not wanting to add to the NHS burden!
Which brings me to number 3, changes in obstetric services. These have occurred , not only in this hospital but, across the globe. The fact that the authors of this letter also point to fewer women being reported with hypertension isn’t at all likely to mean that there were actually fewer women, just that fewer women with hypertension were detected. Good antenatal care targets detection and management of many pregnancy problems and the fact that this really common problem was missed is an important indicator that maternity services are not as good as they should be. Further if this kind of problem is being missed then other problems that also increase risk of stillbirth are likely to be missed too.
​As the Australian college of midwives recent report indicates women are not impressed with changes in maternity care in Australia and are saying things like : I am concerned non-evidence based knee jerk reactions are becoming policy.  I wouldn’t think Australian women are unique in the world in this regard.
So what can be done? We need to abandon the changes to obstetric services that were made in haste and are obviously causing harm and return to thorough evidence based maternity care as quickly as possible. We need to rethink what is actually needed to protect woman from COVID-19 and that this is probably NOT telehealth, and full PPE. We need to understand that if we don’t know that a woman is developing hypertension during pregnancy that that most certainly puts her and her baby in harms way FAR more than the possible threat of harm to her and her baby from COVID-19. So those who have made these initial practice changes in haste need to be equally hastily and have a rethink. There are things like single patient use sphygmomanometers and midwives providing antenatal care in the woman’s own home that are far better safer choices!!
​Hopefully someone other than Will Robinson is listening to these concerns and will act before many more babies die! 
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Commentary on "Women’s experiences of maternity care during the height of the Covid-19 pandemic in Australia: ACM report"

7/6/2020

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Today the ACM released a report about Women’s experiences of maternity care during the height of the Covid-19 pandemic in Australia. It makes for compelling reading! The ACM was pretty quick off the mark to seek insight into the challenges and concerns of women by capturing their experiences through an anonymous survey. Nearly 3,000 women responded to their survey.  
The report states “that changes [to standard maternity care] are proving to be inconsistent, confusing and stressful”. While, of course, that is very worrying I think this report provides overwhelming support for the concerns I expressed in this blog on the 16th of April namely that what is happening in maternity care provision during the Covid-19 pandemic will inevitably result in an uptick in stillbirths and other poor pregnancy outcomes. This  increase in stillbirths. Has already been noticed in some countries, like Scotland. Reading quotes like this [some with my emphasis] are enough to make us all lose sleep about the unintended consequences of changing maternity care on Australia’s stillbirth rate:
 
Lack of access to information:
I have been having a hard time getting access to information as I have been told to stay away from the hospital and to go to private places for my scans and test which is costing me a fortune. I have felt so alone because my GP has become overwhelmed with appointment and I feel like I have to rely on google for answers.
 
My antenatal classes were cancelled and I have received no resources or information instead even after asking multiple times. Very disappointed with the level of care I am currently receiving.
 
Concerns re telehealth
How can a telehealth appointment check vital signs such as blood pressure, heart rates, feeling where baby is, thyroid checks etc. Just feel there is a lack of care for pregnant women right now.
 
I am 20+4 with high blood pressure high risk pregnancy. I was told I have a high chance of losing the baby any day from 20 weeks onwards. But due to covid 19 I’m only allowed phone appointments. I don’t see how that eases my anxiety and helps me stress less over this baby, when I can’t be thoroughly checked over the phone.
 
The lack of face to face and ‘rapid assessments’ is very impersonal. I feel pretty unsupported during these especially vulnerable times for pregnant women.
 
I haven't been allowed to have any face to face appts at the hospital, I haven't had any physical assessments/routine antenatal care performed, I haven't been able to meet any of the midwives to build trust, hospital tours have been cancelled and it sounds like caseload midwifery isn't really happening. The phone appts are less than 10mins and feel like a quick box ticking exercise to make sure their paperwork is in order. It's not contracting Covid-19 that worries me. It's giving birth in an unfamiliar environment with restricted care provided by total strangers that scares me.
 
Knee jerk policy and practice
I am concerned non-evidence based knee jerk reactions are becoming policy without
consideration to more favourable alternatives and without any consultation or regards to birthing mothers. And no care for the consequences... Excess stress is being imposed on pregnant mothers due to hospital policies for "everyone’s" health but no regard for the known health impacts of that stress on mother and baby.
 
A lot of the policies are irrational and cruel and have irrational rigidity with regards to enforcement (eg. Children cannot come, and you don't have childcare options? Too bad no care for you!). I'm also concerned many aspects may become normal practice after the pandemic is done. Scientific evidence is not being used to make policies. Unintended consequences are not being considered or even heard. Mothers are being treated like leapers and like their needs are luxuries and they are idiots.
 
Poor care
Worst care during this pregnancy. They stuffed up my initial appointment then gave me one 2 weeks later. Now there’s no plans to have any appointments until after 28 weeks and they are over the phone so I had to arrange all my blood tests including glucose tests otherwise they would have been missed. No one has checked fundal height etc.
 
Removing choices from pregnant/ birthing women is a gross negligence of care which will result in many negative consequences and adverse outcomes for women and babies. There is nothing remotely acceptable about what is currently happening in antenatal, birth, and postnatal ‘care’.
 
No support
No partners in scans, what if there was no heartbeat? No one should be alone for that.
 
I understand and support the restrictions however they are causing me a lot of grief and sadness. I am still breastfeeding my first. He will not be allowed in the hospital and I will not be allowed out to feed him (eg in car or something). Not being able to see my firstborn while in the hospital is awful. We also have no family support here so I am terrified I will deliver and be in the hospital all alone.
 
So if women are not getting the usual access to information, are not being physically assessed nor emotionally supported and they know their care is not of a high standard it doesn’t take much to figure out that the impact on pregnancy outcome is likely to be very poor. I for one am holding my breath to see just how poor!
I’ll finish with this quote that seems to sum the report up pretty well!
The standards and quality of care has gone to complete crap since coronavirus. The required support no longer exists in preference for 'the basics' in order to preserve health and fight the virus, forgetting entirely that midwifery care and the support needed around pregnancy birth and postnatal is so much more than ensuring a basic minimal level of physical wellbeing.
What about holistic health and wellbeing? Maternity care has been stripped back to if you’re alive and so is the baby, that'll do. Communication in particular is suffering, phone calls are insufficient to be 90% of care, we communicate with so much more than words.
Understanding, openness and a two way conversation that facilitates empowerment and informed choice is not something we are used to doing completely over the phone and so it's
not done well at all. I'll stop now because I could go on forever, but know this, women and babies are suffering as a result of the lowered standards of care. And the question really needs to be asked, is it worth it? You hold in your care not only my current health and wellbeing, but that of all my future pregnancies and births as well as setting up the lifelong
health of my child. I've entrusted that to you, don't let me down.
 
Surely, given the seriousness of this report the changes made to maternity care have NOT been worth it AT ALL!!!!! 

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