​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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Last week I had an absolutely fantastic week with Prof Ingela Radestad from Sweden. I first met her in 2010 at the Sydney ISA/ISPID conference. Last week I discovered that she and I share many life experiences in common, we are both midwives, we have both lost a daughter to stillbirth, we have both come uncomfortably close to losing a grandchild to stillbirth, we began academic life committed to making a difference to bereavement care for families but in more recent years we have both come to the realisation that while bereavement care is, and always will be, vitally important that preventing stillbirth from happening in the first place is really what we should focus on.
How do we prevent stillbirth?
I think we need a three pronged attack. We need:

1. Public awareness that stillbirth happens
2. Pregnant woman awareness of warning signs to look out for and ways to protect herself and her baby during pregnancy
3. Care providers improved awareness of risk factors and what to look out for, taking care to listen to women and appropriately respond to their concerns

The organisation that is working hard to raise awareness and prevent stillbirth in Australia is Still Aware. This organisation was founded by a bereaved mother Claire Foord. I attended the Australian College of Midwives conference in Adelaide last week and was very privileged to hear Claire speak about stillbirth awareness to an audience of nearly 400 midwives. Her message was incredibly simple yet very powerful.

• 6 babies die in Australia every single day (Stillbirth happens)
• Many pregnant women do not know the warning signs to look for and are unaware of simple measures they can take to keep their unborn baby safe. (She is working to address that by distributing information about how women can keep their unborn baby safe to maternity hospitals across Australia free of charge)
• Care providers need to tell women about stillbirth and ways to keep their baby safe (she is regularly holding care provider education sessions to address knowledge gaps, not in stillbirth management but stillbirth prevention)

 One of the midwives attending the conference congratulated Claire on Still Aware's simple yet understandable messaging. I also would like to congratulate Still Aware for the good work they are doing raising awareness of stillbirth in this country. It is my hope that as a result we will soon see a downward trend in stillbirth rates in Australia. Meanwhile, I would urge other stakeholders to join Still Aware, fund Still Aware and work with Still Aware so we can achieve what we all want and that is an end to preventable stillbirth in this country.
 

​Today I joined the army against stillbirth. Why?…because I want change!...

​Why was this an important placard for me to hold? Because my baby Emma was stillborn 24 years ago and frankly I am APPALLED that we were losing 6 Australian babies a day to stillbirth then and we are STILL losing that same number to stillbirth today.

What is the army all about?
StillAware have produced a document calling for “change to stop preventable stillbirth” which was recently sent to each health Minister. We are going to meet in a silent rally on the 6th of each month until the 3 actions we are calling for have been addressed. The three actions are :


1. Mandated policy
2. Coronial Jurisdiction
3. Access to information for all...

• The mandated policy requested is that maternity health care providers are required to undertake mandated professional development in ways to prevent stillbirth and that they be required to have discussions throughout pregnancy to inform pregnant women in their care about how to reduce their risk.
• We are asking for coronial jurisdiction to be extended to include stillbirth so that maternity care-providers are held accountable and the public can be assured that when a preventable stillbirth occurs that it has been properly investigated and recommendations made to prevent such deaths from occurring in the future.
• Finally we are asking for funds to raise public awareness. Currently there is silence and taboo around the word stillbirth (the reason why we stood silently today) But we need to break that silence and really the only way to do that is to make the public aware that 6 babies die each and every day and that that is simply NOT OK.

So wherever you are in Australia I invite you to join the army when it next is due to ‘fight’…the 6th of October. Whoever you are and whatever your connection to stillbirth is (parent, grandparent, or extended family member of victim) friend, near miss parent, health care provider or just a concerned person. Because as this placard so beautifully says: