Last night the Select committee on Stillbirth research and education tabled its report in the Australian senate. It’s 187 pages and includes 16 recommendations that, if they are all implemented, WILL undoubtedly save Australian babies lives.
Anyone who knows me well will know I am an emotional at the best of times so as I was watching these senators deliver their accompanying speeches  about this very important report …well it would be fair to say that there wasn’t a dry eye in my house :)
The report addresses the senate terms of reference but also makes new recommendations addressing concerns raised by witnesses at the inquiry.
To quote Senator Keneally from her speech:
Broadly speaking, this report makes recommendations in three key areas. First, prevention: there are several recommendations that go to how we can help families and clinicians reduce the risk of stillbirth and know when we should intervene to save babies' lives. This includes national education, community campaigns, continuity-of-care models, and education and training for clinicians. Second, investigation: this includes investigating and understanding why stillbirth occurs, in order to better advise families in subsequent pregnancies and to recommend changes to clinical practice. These recommendations include investigating stillbirth properly, which we do not do, and that includes pathology and with autopsies. As a nation, we need to record information about stillbirths consistently and fully in the national dataset and make sure that data is made available to individual families, as well as in aggregate form to healthcare providers and researchers, as quickly as we can. Our recommendations also speak to the need for longer term funding certainty for research. Third, supporting families and clinicians after a stillbirth occurs: this includes care after a stillbirth to support families emotionally and, importantly, to ensure parents have access to paid parental leave and to help co-workers to support these parents when they return to work. Importantly, this report calls for a national stillbirth action plan that starts us on this effort by aiming to reduce the rate of stillbirth over the next three years by 20 per cent. This would be a remarkable achievement after 20 years of stagnation and inertia that has meant that so many lives have been lost and many more irreversibly changed.
[my emphasis]
There is much to be excited about in this report
Firstly “the committee recommends the Australian government”….is wording that starts most of the recommendations, this is wonderful because it takes the onus off those organisations that are currently struggling with running on a shoe string budget and most importantly means that the resulting action, implementations, advice, consultation, will be truly collaborative and supported by ALL stakeholders keenly interested in reducing the tragedy of stillbirth.
It is also exciting that the recommendations call for a “roundtable” of relevant stakeholders. Again this means that the committee realised that any one existing body would be better as a stakeholder presence at the round table rather than trying to led it. This also frees any one organisation from the responsibility of trying to pull this kind of thing together AND it also means all voices at the table will be likely to be heard
The government responded swiftly to the tabling of this report by putting out a media release (see below) announcing…amongst other things… a national roundtable to address the rate of stillbirth in Australia and a commitment of an “initial” amount of 7.2 million. This is amazing because when government support initiatives in other countries they have seen  reduction in stillbirth and one can only assume this is likely to also be the case in this country .

I’ve highlighted a key sentence and ask “since when is an increase in stillbirths at term from .75 per thousand to 1.0 per thousand considered non-significant?” Yes I get that this was not STATISTICALLY significant. But this is a huge number of babies and so it’s a number that is MASSIVELY clinically significant especially considering that while making a claim for non-significance the authors should have admitted that the main reason why it wasn’t ‘significant’ is that their study was not powered for stillbirth.  This is especially concerning because the authors then conclude
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​Of course I am all for minimizing mother-infant separation but certainly NOT at the expense of baby’s lives! The 39 week rule in the US has been associated time and time and time again with an increase in stillbirths and yet the narrative still seems to be that it’s a good idea because of reduced short stay nursery admissions. 
So once again I ask, do you think the .8% more mothers who were temporarily separated from their babies prior to the 39 week rule were harmed as much as the 33.33% more mothers who had a stillborn baby after it? Hmmm…stupid question.. right?

Recently I was in a room full of ‘intelligent’ people. Many clinicians, researchers, bereaved parents, or all of the above, ALL passionate about reducing preventable Stillbirth in Australia. It was curious to me therefore, how very little I heard anything about the woman during the day. Perhaps it’s because I am a midwife and the midwifery philosophy of care is woman-centered but it was concerning to me how much of what was said and agreed to, completely lacked consideration of what the pregnant woman might be able to contribute to protecting her baby from the calamity of stillbirth, and instead how much paternalism was in the room.
One particular comment that stood out as a shining example was this one, in relation to the group considering evidence that any change in fetal behaviour was important for the woman to report, rather than simply a decrease:
I think we need to be careful about not worrying too many women and getting the whole cascade of intervention… “decrease versus change”, sounds simple but its going to alter the number of women who come in, we need to stick to safe evidence and make sure we evaluate a potential increase in adversity for the potential benefits we might get. We need to carefully balance benefit with potential risk, solid evidence rather than stuff that’s “possibly true.”
I was tempted to respond BUT this comment was almost immediately followed by someone saying that perhaps they should change their flight and I thought, “if I get started on what was a load of !@## .well… we would all have needed to change our flights!”
So let me jump on my soap box here and say what I should have said …if we had all had many more hours there.
Firstly to ‘safe’ evidence. The evidence that we have that ANY change in fetal behaviour is a potential cause of concern is from case-control studies, one of our highest forms of strong evidence. In fact, the VERY SAME case-control studies that provide us with evidence that settling to sleep on your back increases the risk of stillbirth. So IF we are going to say we need to stick to “safe” evidence, then we need to also steer clear of giving the side-to-sleep message until we get ‘safe’ evidence that isn’t reliant on ‘recall bias’. We really can’t be so inconsistent as to accept some of the findings from these studies and “worry” women about sleeping position and be afraid to “worry” women with evidence FROM THOSE SAME STUDIES that shows ANY change in strength, frequency or pattern is something the woman should report.
There also seemed to be a misconception in the room that ‘change’ was only to do with a change in frequency (decrease or sudden increase) however the evidence from ALL the aforesaid studies VERY consistently points to change in strength and pattern (especially not moving at bed time) as also being concerning symptoms, that need to be properly assessed. So the “change” evidence we have is to do with strength, frequency and pattern.
So saying this again and louder, Decrease in frequency of fetal movement is undoubtably one of the most common SYMPTOMS that something may be amiss with the unborn baby. We now know from case-control studies that a decrease in strength, or a change in pattern, or a sudden burst of activity (described by the mother as “crazy”), are also ALL potential symptoms that the unborn baby MAY not be well.
For a 20 minute youtube summary about this evidence go to this youtube video https://youtu.be/vVW8E4psnDk

I often use heart attack as an analogy by way of making a point about how we currently treat the symptom of altered fetal activity so very differently from the symptom of chest pain, when perhaps we shouldn't. The prevailing symptom of heart attack is chest pain BUT we all know it is not the only symptom. Imagine for a minute that we regressed to the dark ages where doctors thought giving people life saving information about ALL symptoms to be aware of and report was not a good thing … (wait :) …anyway), image that we thought that we would have too many presentations to emergency room if we gave the general public all the symptoms of heart attack and so to keep things simple for ourselves and catch MOST of the heart attack victims we only said present to emergency if you have chest pain. Would we not miss those people who presented with atypical symptoms such as pain or discomfort in one or both arms, the back, neck, jaw or stomach, or shortness of breath without chest discomfort,  or other less typical , but still concerning signs, such as breaking out in a cold sweat, nausea or lightheadedness. YES …WE …WOULD.
So WHY do we feel we shouldn’t give ALL women, every bit of strong repetitively validated evidence we have to help them keep themselves and their baby safe? …………………..it comes down to that word “worry”. I put “worry” in quotes because we have ABSOLUTELY NO evidence that giving women information about how to keep herself and her baby safe during pregnancy is worrying. In fact, withholding vital health care information because we think it might be worrying is the stuff of dark ages that we have moved on from in EVERY other field of health care provision, apart from obstetrics. Even so we do routinely give pregnant women all sorts of other ‘worrying’ information without worrying that we are worrying her :). We tell her to avoid soft cheese, and alcohol yet the risks of her actually losing her baby to Listeriosis or FASD are astronomically low, FAR FAR lower than the number of babies who die following an episode of altered fetal activity.
Some smart people in that room were worried that giving more information, might increase unscheduled presentations to antenatal care and therefore the potential for harm such as induction of labour, but here’s the thing, IF more women present to be assessed because we have given them more information then OF COURSE that presentation MAY result in detecting the baby who is showing signs of being unwell, and that baby being induced and the thing about that is that if we induce and the baby is born alive and well then some clinicians seem to think that is an adverse outcome. This kind of thinking is totally illogical and akin to those who seem to staunchly believe in the concept of the “unnecessarean”, people who think that if a baby was born alive and well following an emergency caesarean that the caesarean was unnecessary!!
So let’s all get a grip and trust care providers that they are not going to intervene to end a pregnancy unless they see a good reason and also trust women that they are not vulnerable people to be protected, but mothers who can be trusted , have agency and thus need to be given ALL the evidence we have at hand to enable them to advocate for their unborn baby and help protect them from harm.

​There are a LOT of myths out there about fetal movements. Often it is thought that pregnant women are the only people that can hold to these myths and that maternity care providers know better but this is actually not always the case.
What is the definition of a myth?
a widely held but false belief or idea
Maternity care providers (and sometimes even researchers) often belief the myth that a well fetus will move an average of 10 times in 2 hours. This is dangerous because many care providers will tell a woman who is concerned about her baby’s movements to count to 10 over the next 2 hours and if the baby moves as little as that then all is well.
This advice is given because it is THOUGHT to be based on evidence. I hasten to say that believing this myth is not necessarily the care providers fault because this myth has even made its way into many clinical practice guidelines and once there has become part of circular citing. Circular citing is a pretty common occurrence where a paper has been incorrectly cited once (often by a person or body that appear authoritative) and then others also incorrectly cite it too. This results in a Chinese whisper of sorts that is often really hard to unpick
Most clinical practice guidelines that bother to give a reference for the “evidence”  that a well baby will move 10 times in 2 hours refer to an abstract reported by Moore and Piacquadio 1989. Seen in its entirety below
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OK its time for me to call Bul***it !!
A well conducted RCT has not shown the expected 30% drop in stillbirth and many commentators are suddenly ,and very dangerously ,saying that maternal awareness of fetal movements is not an important preventative factor for stillbirth.
This is nothing short of an astounding conclusion. It flies in the face of EVERYTHING we know from multiple well conducted observational and experimental studies done over many years. It doesn’t make sense and most importantly those who are using words like “harm” and “flop” in connection with this study and its findings should be ashamed of themselves as they are directly placing babies lives in danger.
As I already said the study actually does show a reduction in stillbirth, 9% …that’s NINE percent. About 77 women are holding their babies in their arms as a result of their hospital participating in this study instead of visiting their graves.  
So why is this study being called a flop, and a failure?
Well its because the investigators powered their study for at least a 25% drop. That means that when they calculated how many participants they needed to show a statistically significant difference in the stillbirth rate they looked at the aforesaid studies and made their calculations based on them, no doubt thinking that a RCT design would be able to show a similar effect size. With the benefit of hindsight I hope they are now thinking it would have been far better to have taken a more modest approach. Why? Because, of course, in the meantime the cat is well and truly out of the bag. What I mean is that the information that they gave the women in the study was already in general use as was the pathway for the care-providers response. In spite of this FACT the intervention STILL worked to reduce stillbirth by 9%! Why? Because mums were made aware of the importance of fetal movements and their care-provider acted appropriately when they reported those concerns.
I often compare protecting the vulnerable baby from stillbirth to how we have protected the vulnerable baby from SIDS and this is an appropriate analogy to make again here
I’d like the naysayers of this study to imagine that someone has recently completed and reported a very large well conducted RCT published in one of the best medical journals in the world. The study was an intervention in which parents were told to place their baby to sleep on their back to prevent SIDS. The study was powered on an 80% drop in the SIDS rate (as this is the drop that has been reported following the back to sleep campaigns). The study reports that they could not replicate this drop in their RCT and that therefore placing the baby in the supine position to prevent SIDS “remains unproven”. Would there, or would their not be an outcry from the SIDS community? Wouldn’t they say there is no way such an RCT would be able to show that kind of reduction now because the information about putting your baby back to sleep is already well known? YOU BET THEY WOULD and so actually the stillbirth research community AND those whose baby’s lives have been saved as a direct result of being made aware of the importance of fetal movements need to voice their concerns in the “controversy” that CI Norman seems to be expecting and do the same   
When it comes to investigating the effect of an intervention that is already well known RCTs can't possibly "prove" a concept thats already in no doubt, yet in spite of this the study showed a 9% reduction! If anything this shows that awareness IS important.
So now I am prepared to go on record and predict that when the other large randomised step wedge cluster RCT ‘my baby’s movements’ study in Australia is published it will also not show the expected drop in stillbirth and some might also call it a “flop” and a “failure”.  Hopefully most of us will be smart enough to shrug and say “of course not” and move on with continuing to save baby’s lives by telling the mum about the importance of fetal movements  and acting appropriately when she presents with concerns. 

​Anyone who knows me well would know that if there was a simple solution to the stillbirth epidemic in this country that I would be the first to advocate for it loudly and strongly.
Unfortunately there has been much misinformation spreading about the ARRIVE trial and what it means such that I think I now need to add my two pence worth.
This blog has been triggered by this story in today’s news titled “INDUCE TO CUT THE STILLBIRTH RISK” here are some quotes from it:
DOCTORS should induce labour in expectant mothers who reach 40 weeks to reduce the risk of stillbirths, according to one of WA’s most experienced obstetricians….
Dr Gannon said a 40-week delivery policy would require a “massive cultural change” for public hospitals. “But surely reducing the stillbirth rate is a worthy cause,” the immediate past president of the Australian Medical Association said.
Dr Gannon said research in Canada and the United States showed the benefits of inducing at 39 to 40 weeks included reduced stillbirths and caesareans.
So let me summarise what Dr Gannon seems to be saying. If we induce at 40 weeks instead of 40 weeks and 10 days, evidence shows that we will reduce both stillbirth and caesarean sections. That we should do this because it “worthy.”
So lets have a look at the “evidence” in the ARRIVE trial itself and what the authors themselves said about their findings
If you go to the journal there is this cute little video that sums the trial up quite nicely:

​In a nut shell it says:
The reason for the trial was that traditionally induction of labour (IOL) between 39 weeks and 41 weeks has been avoided due to concerns that this might increase risk of caesarean.
That in their randomised controlled trail of more than 6,000 women who have not had a baby before, that 3062 were randomly assigned to have their baby induced between 39 weeks and 39+4 and the other group were randomly assigned to expectant management until their pregnancy reached at least 40 +5.
They compared “perinatal mortality and severe neonatal morbidity” and found no apparent differences between their groups. They did report that the caesarean section rate was slightly less in their induction group than in their expectant management group”
Their conclusion “For low risk women having their first baby that if you induce at 39 weeks you get “similar” rates of adverse perinatal outcomes and less frequency of caesarean births”
So lets have a look at this...directly from the source.  

This is a table from the study showing the baby outcomes for the IOL versus the expectant management group. 
There are a few things to say about this table:

1. You can see that the perinatal deaths were 2 in the IOL group and 3 in the expectant management group and that this was not significantly different. So people who are saying that this study showed reduced risk of stillbirth as a result of induction of labour are incorrect
2. I think that it is disappointing that a study that set out to look at the “primary outcome” of perinatal mortality as well as perinatal morbidity was so underpowered to actually not be able to look at mortality.
3. Perinatal death covers both stillbirth and neonatal death. It would be important to know when the 5 deaths occurred.
4. I also think it is disappointing that they lumped all these outcomes in together and reported them as a composite…without comment. Don’t get me wrong of course it is completely fine to report the apparent lack of differences in the total score for rare outcomes but I have questions about the individual items making up this composite that are not answered anywhere in the paper and they are:
   1. When did the perinatal deaths occur?
   2. Is there any way the deaths could be linked to the intervention, for example did the 2 baby’s in the IOL group die as a result of a ruptured vasa praevia or cord prolapse? Did the 3 babies in the expectant management group die as a result of being in that group eg did their mothers present at 39 weeks and 2 days with altered fetal activity and there was a reluctance to induce because they were in the wrong arm of the trial?
   3. 11 babies in the IOL group had “seizures” versus only 4 in the expectant group. What were the seizures from ? and could these be linked in any way to the IOL?

So as you can see there was no difference in stillbirth rate in this trial, even if all 5 of the deaths occurred int he one group you could not infer anything from this. Neither do the authors suggest in any way shape or form that IOL is a way to stop stillbirth so lets stop ARRIVEing at the wrong conclusions about this trial. Essentially all the authors are saying is that IF IOL is needed at term and the reason why you don’t want to induce is that someone (either the mum or the obstetrician) is worried that this might increase the risk of caesearean, rest assured that …from this trial at least…that that doesn’t seem to be the case. That’s it 

“I’m sorry there is no heartbeat” These are words no midwife wants to utter yet most midwives do have to say them at some stage in their career. The time when I said them is burned in my mind in a similar… yet different… way as when I heard them before my own baby Emma was stillborn.
The woman, who was having her first baby, had arrived for admission to birth suite. I introduced myself and led her into the assessment room chatting as we went, neither of us had any clue about the tragedy which was about to unfold. I lay her down on the delivery bed to do an abdominal palpation and, still happily chatting, felt for the baby’s position. My hand touched the baby’s foot and a cold chill went down my spine as I realised that there was no reaction to my touch. My heart in my mouth I reached for the hand held Doppler and placed it directly over the anterior shoulder but there was no sound. Still a little disbelieving I checked the battery, which was full. I quietly said “I’m sorry there is no heartbeat, I’mgoing to arrange for you to have an urgent ultrasound but to be honest things don’t look good” it was time for the woman to be disbelieving, she later told me that she thought I was an “incompetent idiot” as she had felt her baby moving only a few hours earlier. Her beautiful baby girl was born still just a few hours later, not a mark on her perfect little body. 
Since that day I have cared for many other families as they have met their stillborn baby. Just as is the case with live birth, every single birth and every single circumstance was different. But unlike the many hundreds of live births that I have attended I still remember each and every one of the stillborn babies names, the bereaved parents names and the circumstances of the birth and very few of the baby’s and parents whose baby was born alive and well. Why? Well I think it is because when birth and death collide it is always memorable AND I think that it is the most enormous privilege to provide care to parents when they are at their most vulnerable and sad. I often say to my students that a key role for the midwife is one of advocacy and it is never more important to advocate for the woman and her family than when the baby is stillborn. 
So on this International day of the midwife as we celebrate the role of the midwife which is usually “being with” families at one of the most joyful times in their life, we should also remember the more than 7,000 babies across the world who will be stillborn today, their parents and their midwives who are “being with” them at one of the saddest times of their life. 
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