In it are these words “The significant reduction of stillbirth at term persists” and they show this graph
which shows that since 2010 there has been a steady and significant drop in stillbirth rates in NZ:
My questions are:
- WHY is this happening?
- How is NZ different?
- What happened in 2010?
- and most importantly of all… Can we replicate what is happening in NZ in Australia …and indeed the world?
Even though NZ has seen a steady reduction in term stillbirth rate since 2010 their previous perinatal reports have been silent as to why this might be the case. This year the following “reasons” are offered:
The previously reported significant reduction in stillbirth at term persists. This is independent of a reduction in births at 40 and 41+ weeks. There are numerous reasons why this might have occurred, such as:
a. improved peripartum care (suggested by a reduction in hypoxic peripartum death rate)
b. a reduction in deaths from perinatal infection
c. a reduction in deaths from antepartum haemorrhage
d. increased iatrogenic early birth of at-risk babies
e. a reduction in smoking.
I have also heard all sorts of other hypotheses put forward as to why NZ’s stillbirth rate is dropping. None of them…apart from one (see below), makes any kind of sense to me. For example at a recent conference that I attended an eminent stillbirth researcher congratulated a NZ researcher on their stillbirth reduction putting it down to New Zealand’s perinatal audit practices (option f). That amazed me because, of course, if you start to count any kind of population based data better, then invariably the rate jumps up (for a year (or two) Before returning to the same kind of trend as previously seen. What is happening in NZ is therefore not at all consistent with this “explanation.”
How is NZ different?
If you think about the differences between Australia and NZ on pregnancy management of a-e and also (f) and IF they were the real reason for the reduction in stillbirths then there is no reason why Australia would not have seen a similar drop. This makes me think that the real reason for the drop is “none of the above.”
New Zealand is different from Australia in one pretty important way. The introduction of the 1990 Nurses Amendment Act meant that NZ has a midwifery led model of maternity care. In NZ, women can and do choose to have their pregnancy and birth solely under the care of a midwife, and since 1990 midwives are no longer required to train as a nurse first - they can enter directly into midwifery training. This means that midwives in NZ have a high degree of autonomy in practice which is not at all in case for midwives in the obstetrician led model of care which prevails in Australia. So since 1990 the vast majority of women are cared for during pregnancy by a known midwife who is willing and able to direct care.
What happened in 2010?
A NZ midwife called Tomasina Stacey finished her PhD. She found that women who went to sleep on their back the night before their baby was born were two and a half times more likely (2.54 (95% CI 1.04 to 6.18) to suffer a stillbirth than those who settled to sleep on their left side.
The message for pregnant women to avoid settling to sleep on their backs was disseminated widely in NZ by midwives such that a recent study showed that the supine sleep position is significantly less common now in NZ than it was in 2010. Tomasina herself made the prediction that “if sleep was found to be associated with stillbirth that there could be significant reduction in stillbirth by simply modifying this risk factor”.
So of all the possible reasons why the late term stillbirth rate in NZ is dropping I agree with a stillbirth researcher from that country who said “it is tempting to think that it is because midwives are telling women to avoiding supine sleep,” that woman are doing this in unprecedented numbers compared with anywhere else in the world and that it is this change in behaviour that is reducing the numbers of late term stillbirths in NZ.
Can we replicate what is happening in NZ here in Australia and elsewhere in the world?
I certainly hope so!
What needs to happen? I realise there are LOTS of barriers to doing this but I really think it could be as simple as maternity care providers following New Zealand midwives lead and alerting women that settling to sleep in the supine position should be avoided in late pregnancy!
I for one am working at removing some of the barriers as a matter of urgency, more about this to follow.