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Objective: The PARENTS 1 study (Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death) found that parents would endorse the opportunity to give feedback into the perinatal mortality review (PNMR) process. In subsequent focus groups, healthcare professionals were positive about parental engagement, although they considered that there may be significant challenges. The objective of this study was to develop core principles and recommendations for parental engagement in PNMR in the UK.Methods: A two-round Delphi technique was followed to reach consensus on core principles for parental engagement in the PNMR process; Round 1 included a national consensus workshop and Round 2 an online questionnaire. The consensus meeting was attended by a national panel of stakeholders (clinical and academic experts, parent advocates, managers and commissioners) in stillbirth and neonatal and bereavement care. To develop recommendations for parental engagement, participants discussed four key areas comprising: communication with parents, including receiving feedback; the format of the PNMR meeting; the parental engagement pathway; and challenging aspects of engaging with parents in reviews. Content analysis was conducted to generate recommendations from the meeting for a subsequent anonymous web-based survey. Attendees of the consensus workshop and members of the PARENTS 2 Project Advisory Board were asked to rank recommendations using a 9-point Likert scale from 1 (not important) to 9 (critically important). It had been agreed a priori, in compliance with established Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria, that 'consensus' would be achieved if over 70% of participants scored the principle as 'critical' (score of 7-9) and fewer than 15% scored the principle as 'not important' (score of 1-3). Principles for which consensus was achieved were included in the core recommendations.Results: Of the 29 invited stakeholders, 22 participated in the consensus meeting and 25 (86% response rate) in the subsequent online questionnaire in June 2017. Consensus was agreed on 12 core principles. Of the 25 participants, 96% agreed that a face-to-face explanation of the PNMR process was of critical importance, 72% considered that parents should be offered the opportunity to nominate a suitable advocate, 92% believed that responses to parents' comments should be formally documented, 96% indicated that it was vital for action plans to be translated into lessons learnt and that this process should be monitored, and 100% of stakeholders voted that a plain-English summary should be produced for the parents following the meeting. There was good agreement on a further seven principles.Conclusions: Key national stakeholders were unanimously supportive of parental engagement in the PNMR process and agreed on core principles to make this process feasible, meaningful and robust. A 6-month pilot of parental engagement in the PNMR process (PARENTS 2 study) in two UK units took place after the consensus on core principles. In collaboration with the National Perinatal Epidemiology Unit, the findings will inform the national standardized PNMR tool. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Background: Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement.Objective: To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs.Search Strategy: Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL.Selection Criteria: Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs.Data Collection and Analysis: Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES).Main Results: In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth.Conclusions: Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately.Tweetable Abstract: Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs. [ABSTRACT FROM AUTHOR]

The spectacular kilometer‐thick Funzie Conglomerate is a deformed and metamorphosed high‐energy sedimentary deposit that occurs in Shetland (Scottish Caledonides). Its age and tectonic significance in relation to Early Ordovician (485–475 Ma) and Late Ordovician (450–445 Ma) accretionary orogenic events and the culminating Silurian (430–425 Ma) continental collision and closure of the Iapetus Ocean have hitherto been unknown. U‐Pb zircon dating indicates that the clast population of the conglomerate was derived from easterly sources comprising Neoproterozoic metasedimentary rocks and the northern extension of the Ordovician‐Silurian Midland Valley Arc that formed during Iapetus closure. A lower age limit of 440 Ma is indicated by the ages of the youngest matrix detrital zircon grains and the youngest granitic clast. Deformation and metamorphism of the conglomerate is attributed to sinistrally oblique extension at ca. 430 Ma that excised at least 10 km of crustal section. Sedimentation of the conglomerate is therefore constrained to a 10‐myr time span (440–430 Ma). The tectonic setting is interpreted as a synorogenic basin that received detritus from, and was buried by, advancing thrust nappes during the Early Silurian collision of Laurentia and Baltica. Tectonic burial was followed rapidly by ductile deformation during oblique extensional unroofing of the metamorphic pile and accounts for preservation of the Funzie Conglomerate as a rare example of a synorogenic basin within the metamorphic hinterland of the North Atlantic Caledonides. Key Points: U‐Pb zircon dating in combination with published mineral age data shows that the deformed and metamorphosed Funzie Conglomerate in Shetland, Scottish Caledonides, was deposited in the Early Silurian between ca. 440 and 430 MaThe clast population was derived from easterly (offshore) sources comprising Neoproterozoic metasedimentary rocks and the northern extension of the Ordovician Midland Valley Arc that formed during closure of the Iapetus OceanThe tectonic setting is interpreted as a synorogenic basin that received detritus from, and was buried by, advancing thrust nappes during the collision of Laurentia and Baltica [ABSTRACT FROM AUTHOR]

Objective: To understand challenges in care after stillbirth and provide tailored solutions.Design: Multi-centre case study.Setting: Three maternity hospitals.Population: Parents with a stillborn baby, maternity staff.Methods: Thematic analysis of parent interviews and staff focus groups and service provision investigation.Outcomes: 1 Themes; 2 Triangulation matrix; 3 Recommendations.Results: Twenty-one women, 14 partners, and 22 staff participated. Service Provision: Care for parents after stillbirth varies excessively; there are misconceptions; post-mortem does not delay follow-up.Presentation: Women 'do not feel right' before stillbirth; their management is haphazard and should be standardised.Diagnosis: Stillbirth is an emergency for parents but not always for staff; communication can seem cold; well-designed bereavement space is critical. Birth: Staff shift priorities to mother and future, but for parents their baby is still a baby; parents are not comfortable with staff recommending vaginal birth as the norm; there are several reasons why parents ask for a caesarean; better care involves clear communication, normal behaviour, and discussion of coping strategies. Post-mortem: Parents are influenced by discussions with staff. Staff should 'sow seeds', clarify its respectful nature, delineate its purpose, and explain the timescale.Follow-up: It is not standardised; parents wish to see their multi-professional team.Conclusions: There is unacceptable variation in care after stillbirth, and insensitive interactions between staff and bereaved parents. Understanding parents' needs, including why they ask for caesarean birth, will facilitate joint decision-making. Every bereaved parent is entitled to good, respectful care.Tweetable Abstract: Care too varied & interactions often insensitive after stillbirth; national pathway & training urgently needed PLAIN LANGUAGE SUMMARY: Why and how was the study carried out? Previous studies have shown that improving care after stillbirth is important for families. We investigated the opinions of bereaved parents and maternity staff to find ways to improve care. At three hospitals in 2013, all women who experienced a stillbirth were invited to an interview along with their partners. Thirty-five parents of 21 babies agreed to participate. Twenty-two obstetricians and midwives took part in focus group discussions. What were the main findings? Care was often not as good as it should and could be. Communication with parents was not always as sensitive as they would have liked because staff did not have appropriate training. Some women reported they did not 'feel right' before going to hospital. Once they arrived, there was no standard approach to how care was given. Sometimes there were long delays before the death of the baby was confirmed and action was taken. After it had been confirmed that the baby had died, staff focussed on the mothers' needs, but the parents' priorities were still with their baby. There were several reasons why parents asked for a caesarean birth that staff had not considered. Staff influenced parents' decisions about post-mortem examinations. Parents found it helpful when staff explained the respectful nature and purpose of the examination. After discharge from hospital, there was no consistent plan for how follow-up care would be given. Parents would have liked more information about their next hospital appointment. What are the limitations of the work? The parents interviewed depended on their memories of the details of the care, which happened some time ago. In staff group discussions, junior doctors may not have spoken openly because there were senior doctors present. Further research is necessary to understand and improve care globally. What is the implication for parents? Every bereaved parent is entitled to the best possible care after stillbirth, but some do not get good care. Parents and staff made suggestions that can help to develop processes for how care is given after stillbirth. These suggestions can also inform staff training, so that every single parent is treated respectfully and participates in decision making. [ABSTRACT FROM AUTHOR]

Objective: To assess the frequency of additional care, and parents' perceptions of quality, respectful care, in pregnancies subsequent to stillbirth.Design: Multi-language web-based survey.Setting: International.Population: A total of 2716 parents, from 40 high- and middle-income countries.Methods: Data were obtained from a broader survey of parents' experiences following stillbirth. Data were analysed using descriptive statistics and stratified by geographic region. Subgroup analyses explored variation in additional care by gestational age at index stillbirth.Main Outcome Measures: Frequency of additional care, and perceptions of quality, respectful care.Results: The majority (66%) of parents conceived their subsequent pregnancy within 1 year of stillbirth. Additional antenatal care visits and ultrasound scans were provided for 67% and 70% of all parents, respectively, although there was wide variation across geographic regions. Care addressing psychosocial needs was less frequently provided, such as additional visits to a bereavement counsellor (10%) and access to named care provider's phone number (27%). Compared with parents whose stillbirth occurred at ≤ 29 weeks of gestation, parents whose stillbirth occurred at ≥ 30 weeks of gestation were more likely to receive various forms of additional care, particularly the option for early delivery after 37 weeks. Around half (47-63%) of all parents felt that elements of quality, respectful care were consistently applied, such as spending enough time with parents and involving parents in decision-making.Conclusions: Greater attention is required to providing thoughtful, empathic and collaborative care in all pregnancies following stillbirth. Specific education and training for health professionals is needed.Tweetable Abstract: More support for providing quality care in pregnancies after stillbirth is needed.Plain Language Summary: Study rationale and design More than two million babies are stillborn every year. Most parents will conceive again soon after having a stillborn baby. These parents are more likely to have another stillborn baby in the next pregnancy than parents who have not had a stillborn baby before. The next pregnancy after stillbirth is often an extremely anxious time for parents, as they worry about whether their baby will survive. In this study we asked 2716 parents from 40 countries about the care they received during their first pregnancy after stillbirth. Parents were recruited mainly through the International Stillbirth Alliance and completed on online survey that was available in six languages. Findings Parents often had extra antenatal visits and extra ultrasound scans in the next pregnancy, but they rarely had extra emotional support. Also, many parents felt their care providers did not always listen to them and spend enough time with them, involve them in decisions, and take their concerns seriously. Parents were more likely to receive various forms of extra care in the next pregnancy if their baby had died later in pregnancy compared to earlier in pregnancy. Limitations In this study we only have information from parents who were able and willing to complete an online survey. Most of the parents were involved in charity and support groups and most parents lived in developed countries. We do not know how well the findings relate to other parents. Finally, our study does not include parents who may have tried for another pregnancy but were not able to conceive. Potential impact This study can help to improve care through the development of best practice guidelines for pregnancies following stillbirth. The results suggest that parents need better emotional support in these pregnancies, and more opportunities to participate actively in decisions about care. Extra support should be available no matter how far along in pregnancy the previous stillborn baby died. [ABSTRACT FROM AUTHOR]

The authors discuss prevalence and prevention of stillbirths in response to the 2017 Every Woman Every Child (EWEC) progress report on the global strategy developed for women's and children's health. Topics explored include the occurrence of stillbirths in low- and middle-income nations, the integration of health interventions into maternal and newborn care practices, and the need to acknowledge psychological and psychosocial impact of stillbirths.

Introduction: Apatite is widely used to evaluate the origin, abundance, and evolution of volatile species in plantary bodies [1], provide thermochronological constraints on geological processes and meteorite impact events [2, 3] and track magmatic evolution through trace element and isotopic studies [4]. This is due to the incorporation of volatile species in apatite group minerals, hexagonal Ca5[PO4]3[F,Cl,OH], and the fact that it is a principal carrier of a widerange of trace elements such as rare earth elements, uranium, and thorium in many planetary crustal rocks. Despite this wide-ranging importance, the in-situ measurement of many of these chemical records in apatite remains challenging. Specific analytical issues include the migration of volatiles (including halogens), and related crystallographic orientation effects, during electron beam interaction, and the requirement to integrate data from several approaches with different analytical volumes (e.g. major elements by EPMA, halogens, and isotope ratios by SIMS, NanoSIMS, LA-ICP-MS, etc.). Here we report on the development of a new approach to the concurrent acquisition of halogens, major & trace elements, and U-Th-Pb isotope ratios in apatite group minerals at the 20 to 30 µm scale, using tandem femtosecond laser ablation (LA) and laser-induced breakdown spectroscopy (LIBS) coupled with ICP-MS. Analytical approach: Analyses are being performed at the University of Portsmouth, using an Applied Spectra J200 Tandem LA-LIBS system that is equipped with a 343 nm femtosecond laser source, novel two-volume ablation and LIBS cell design, and two intensified CCD spectrometers. Terrestrial apatite reference materials with a wide-range of chlorine and fluorine compositions are being used to optimize laser and spectrometer detection conditions for the measurement of the major elements Ca and P, along with F by LIBS, and concurrent analysis of Cl, a wide-range of trace elements, and U-Th-Pb isotope ratios using an Agilent 8900 ICP-MS/MS system (building on the LA-ICP-MS protocols of [5, 6]). Analyses are being performed with the laser-focused to either 20 or 30 µm on the sample, fluences between 5 and 10 Jcm-2, and laser repetition rate of 10 Hz (200 shots total). Progress and opportunities: Although previous LIBS studies have determined F contents in phosphates using the 685.6 nm atomic emission line [7], we find only weak emission of halogen atomic lines using our analytical setup. This is not particularly unexpected, as these emissions require high excitation energies (and hence laser conditions) that are not well suited to LA-ICP-MS analyses. Alternatively, alkali earth-halogen molecular emission can be used to quantify F contents by LIBS [8]. Here, we focus on CaF molecular emission at ~532 nm. The dual ICCD spectrometer setup of the LIBS system allows for optimization of P and Ca atomic emission lines at a relatively short gate delay (~0.1 µs; length of time between the laser pulse and the spectrometer detection), and separation of CaF molecular emission from potentially interfering atomic and ionic emission lines using longer gate delay (>0.3 µs). As a result, background-corrected count rates for CaF are in the Mcps range from terrestrial fluorapatite, and we report on the accuracy and detection limits of LIBS calibration of F, along with Ca and P for use as independently determined internal standard elements for LA-ICP-MS trace element measurements. Initial results from terrestrial reference materials show the tremendous potential of the technique to enable concurrent halogen, major, trace, and U-Th-Pb geochronology from terrestrial and planetary apatite. [ABSTRACT FROM AUTHOR]

Assessment for source of stroke is a common indication for transoesophageal echocardiography (TOE). Although an abnormality is frequently found, it remains uncertain how frequently the findings alter patient management. Also, the role of transthoracic echocardiography (TTE) prior to or instead of TOE is not well defined. We sought to determine the use of TTE prior to TOE, the outcome of the TOE and its impact on management. We retrospectively reviewed the records and echocardiography results of 100 consecutive patients who underwent TOE for any reason at a tertiary hospital. In 35 subjects (35%), the indication was evaluation for source of stroke. Among these, we determined clinical risk factors for stroke, if a TTE was performed prior to their TOE, the results of the TOE and its effect on management. The mean age of the stroke patients was 64.6 years (17-90) and 49% were women. Eighty per cent had at least one risk factor for stroke and 17% had atrial fibrillation. A TTE, performed in 40% prior to the TOE, found an abnormality in 14% (2/14). The TOE showed an abnormality in 71% of patients; 54% had aortic atheroma; 17% PFO; 14% spontaneous echo contrast; 6% left atrial appendage thrombus, 3% left ventricular thrombus and 3% vegetation. In only one patient (3%) the management was altered based on the abnormal TOE findings. An abnormality on TOE, although common (71%) and more sensitive than TTE, altered management in only 3% of subjects referred for stroke assessment. Its role requires further consideration. [ABSTRACT FROM AUTHOR]

AIM: This paper is a report of a study conducted to explore strategies for retaining nurses and their implications for the primary and community care nursing workforce. BACKGROUND: An ageing nursing workforce has forced the need for recruitment and retention of nurses to be an important feature of workforce planning in many countries. However, whilst there is a growing awareness of the factors that influence the retention of nurses within secondary care services, little is known about those that influence retention of nurses in primary and community care. Little is known about the age profile of such nurses or the impact of the ageing nursing workforce on individual nursing specialities in the England. METHODS: Nursing databases were analysed to explore the impact of age on nursing specialities in primary and community care. The nurse retention literature was reviewed from 1995 to 2006. FINDINGS: Workforce statistics reveal that primary and community care nurses have a higher age profile than the National Health Service nursing workforce as a whole. However, there are important gaps in the literature in relation to the factors influencing retention of older primary and community care nurses. Specific factors exist for older nurses within primary care that are unique. Implications for their retention are suggested. CONCLUSION: Particular attention needs to be paid to factors influencing retention of older nurses in primary and community care. These factors need to be incorporated into local and national policy planning and development. [ABSTRACT FROM AUTHOR]

Title. Retaining older nurses in primary care and the community. Aim. This paper is a report of a study conducted to examine issues associated with the impact of age on the retention of female primary and community care nurses in the National Health Service in England. Background. Little is known about why older nurses in the primary and community care workforce leave and what might encourage them to stay. Methods. A cross-sectional survey using a semi-structured postal questionnaire was carried out during 2005. Responses were received from 485 (61%) district nurses, health visitors, school nurses and practice nurses in five primary care trusts in England. Data were analysed to test for associations. Results. Older nurses were more likely than younger ones to report that their role had lived up to expectations ( P = 0·001). Issues important for older nurses were feeling valued and being consulted when change was implemented. Important factors encouraging nurses to stay were pension considerations, reduced working hours near retirement, and reduced workload. For those with degree-level qualifications, enhanced pay was a factor encouraging retention ( P = 0·044). Nurses might leave in response to high administrative workloads, problems in combining work and family commitments ( P <= 0·001), and lack of workplace support ( P = 0·029). Retirement and pensions advice was not widely available. Conclusion. Since two-thirds of nurses were generally happy in their role, it is important that the conditions necessary to maintain this level of satisfaction are continued throughout a nurse's working life. Nurses may all too easily consider leaving prematurely unless policy makers and managers ensure that their working environment reflects the issues nurses consider to be conducive to retention. [ABSTRACT FROM AUTHOR]

Abstract Several thrombolytic agents for the treatment of acute ischaemic stroke have been examined; however, to date, only the i.v. administration of recombinant tissue plasminogen activator is licensed in Australia. Although no trials directly comparing intra-arterial and i.v. delivery of thrombolytics exist, intra-arterial thrombolysis has several potential advantages, including angiographic assessment of the thrombus and the site of occlusion and collateral circulation, improved recanalization, and delivery of higher local concentrations of thrombolytic agents and extending the therapeutic time window for treatment. We conducted a retrospective audit of our experience with the use of intra-arterial urokinase to treat acute ischaemic stroke at an Australian tertiary-care hospital between June 1993 and June 2003. We examined time from stroke onset to assessment, computerized tomography scan, cerebral angiography and thrombolysis, anatomical classification of intra-arterial thrombus, rates of symptomatic intracerebral haemorrhage, and clinical outcome at 3 months. We believe that in carefully selected individuals in appropriate centres of expertise, intra-arterial thrombolytic therapy holds great promise. (Intern Med J 2005; 35: 300–302) [ABSTRACT FROM AUTHOR]

The article discusses a study related to ways to improve postmortem testing for perinatal death, conducted by C. Lewis and others, published within the periodical's issue. Topics discussed include parent's decision of pursuing testing that could provide more information about their baby's death; and importance of postmortem testing to learn about cause of death and implications for future health and pregnancies.

Presents a letter to the editor on the results of an observational study of patients admitted with a diagnosis of stroke or transient ischaemic attack.

Background: Ninety-eight percent of neonatal deaths worldwide occur in low- and middle-income countries (LMICs), yet there is little bereavement care guidance available for these settings., Objectives: To explore parents', families' and healthcare professionals' experiences of care after neonatal death in healthcare facilities in LMICs., Search Strategy and Selection Criteria: Four databases were searched for peer-reviewed literature, meeting the inclusion criteria of qualitative studies exploring the experiences of people who provided or received bereavement care following neonatal death in a LMIC healthcare setting., Data Collection and Analysis: Data were collected by two independent reviewers, collated through line-by-line coding and then reciprocal and refutational translation, and analysed through Noblit and Hare's seven-step meta-ethnography approach to create first-, second- and third-order themes., Main Results: Seven first-order themes extracted from the literature included emotional responses, social relationships, staff and systems, religion, connecting with the baby, coping strategies and economic concerns. From these data, three third-order themes arose: The individual, the healthcare setting and the community/context., Conclusions: Overarching themes in bereavement care shape grief responses and are often similar across geographical locations. Analysing these similarities allows a deeper understanding of the important elements of bereavement care and may be helpful to inform the creation of high-quality, bereavement care guidelines suitable for use in LMIC settings., (© 2024 The Author(s). BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Aim: To assess the safety and efficacy of hybrid closed-loop (HCL) insulin delivery 24/7 versus only evening and night (E/N), and on extended 24/7 use, in free-living children with type 1 diabetes., Materials and Methods: Prepubertal children (n = 122; 49 females/73 males; age, 8.6 ± 1.6 years; diabetes duration, 5.2 ± 2.3 years; insulin pump use, 4.6 ± 2.5 years; HbA1c 7.7% ± 0.7%/61 ± 5 mmol/mol) from four centres were randomized for 24/7 versus E/N activation of the Tandem Control-IQ system for 18 weeks. Afterwards, all children used the activated system 24/7 for 18 more weeks. The primary outcome was the percentage of time spent in the 70-180 mg/dL glucose range (TIR)., Results: HCL was active 94.1% and 51.1% of the time in the 24/7 and E/N modes, respectively. TIR from baseline increased more in the 24/7 versus the E/N mode (52.9% ± 9.5% to 67.3% ± 5.6% [+14.4%, 95% CI 12.4%-16.7%] vs. 55.1% ± 10.8% to 64.7% ± 7.0% [+9.6%, 95% CI 7.4%-11.6%]; P = .001). Mean percentage time below range was similarly reduced, from 4.2% and 4.6% to 2.7%, and the mean percentage time above range decreased more in the 24/7 mode (41.9% to 30.0% [-11.9%, 95% CI 9.7%-14.6%] vs. 39.8% to 32.6% [-7.2%, 95% CI 5.0%-9.9%]; P = .007). TIR increased through the whole range of baseline levels and always more with 24/7 use. The results were maintained during the extension phase in those initially on 24/7 use and improved in those with initial E/N use up to those with 24/7 use. Neither ketoacidosis nor severe hypoglycaemia occurred., Conclusions: The current study shows the safety and efficacy of the Tandem Control-IQ system in free-living children with type 1 diabetes for both E/N and 24/7 use; 24/7 use shows better outcomes, sustained for up to 36 weeks with no safety issues., (© 2021 John Wiley & Sons Ltd.)

Background: Stillbirth, the death of a baby before birth, is associated with significant psychological and social consequences that can be mitigated by respectful and supportive bereavement care. The absence of high-level evidence to support the broad scope of perinatal bereavement practices means that offering a range of options identified as valued by parents has become an important indicator of care quality. This study aimed to describe bereavement care practices offered to parents across different high-income and middle-income countries., Methods: An online survey of parents of stillborn babies was conducted between December 2014 and February 2015. Frequencies of nine practices were compared between high-income and middle-income countries. Differences in proportions of reported practices and their associated odds ratios were calculated to compare high-income and middle-income countries., Results: Over three thousand parents (3041) with a self-reported stillbirth in the preceding five years from 40 countries responded. Fifteen countries had atleast 40 responses. Significant differences in the prevalence of offering nine bereavement care practices were reported by women in high-income countries (HICs) compared with women in middle-income countries (MICs). All nine practices were reported to occur significantly more frequently by women in HICs, including opportunity to see and hold their baby (OR = 4.8, 95% CI 4.0-5.9). The widespread occurrence of all nine practices was reported only for The Netherlands., Conclusions: Bereavement care after stillbirth varies between countries. Future research should look at why these differences occur, their impact on parents, and whether differences should be addressed, particularly how to support effective communication, decision-making, and follow-up care., (© 2021 Wiley Periodicals LLC.)

Background: Stillbirth has a profound impact on women, families, and healthcare workers. The burden is highest in low- and middle-income countries (LMICs). There is need for respectful and supportive care for women, partners, and families after bereavement., Objective: To perform a qualitative meta-summary of parents' and healthcare professionals' experiences of care after stillbirth in LMICs., Search Strategy: Search terms were formulated by identifying all synonyms, thesaurus terms, and variations for stillbirth. Databases searched were AMED, EMBASE, MEDLINE, PsychINFO, BNI, CINAHL., Selection Criteria: Qualitative, quantitative, and mixed method studies that addressed parents' or healthcare professionals' experience of care after stillbirth in LMICs., Data Collection and Analysis: Studies were screened, and data extracted in duplicate. Data were analysed using the Sandelowski meta-summary technique that calculates frequency and intensity effect sizes (FES/IES)., Main Results: In all, 118 full texts were screened, and 34 studies from 17 countries were included. FES range was 15-68%. Most studies had IES 1.5-4.5. Women experience a broad range of manifestations of grief following stillbirth, which may not be recognised by healthcare workers or in their communities. Lack of recognition exacerbates negative experiences of stigmatisation, blame, devaluation, and loss of social status. Adequately developed health systems, with trained and supported staff, are best equipped to provide the support and information that women want after stillbirth., Conclusions: Basic interventions could have an immediate impact on the experiences of women and their families after stillbirth. Examples include public education to reduce stigma, promoting the respectful maternity care agenda, and investigating stillbirth appropriately., Tweetable Abstract: Reducing stigma, promoting respectful care and investigating stillbirth have a positive impact after stillbirth for women and families in LMICs., (© 2018 Royal College of Obstetricians and Gynaecologists.)

Objective: To understand challenges in care after stillbirth and provide tailored solutions., Design: Multi-centre case study., Setting: Three maternity hospitals., Population: Parents with a stillborn baby, maternity staff., Methods: Thematic analysis of parent interviews and staff focus groups and service provision investigation., Outcomes: 1 Themes; 2 Triangulation matrix; 3 Recommendations., Results: Twenty-one women, 14 partners, and 22 staff participated. Service Provision: Care for parents after stillbirth varies excessively; there are misconceptions; post-mortem does not delay follow-up., Presentation: Women 'do not feel right' before stillbirth; their management is haphazard and should be standardised., Diagnosis: Stillbirth is an emergency for parents but not always for staff; communication can seem cold; well-designed bereavement space is critical. Birth: Staff shift priorities to mother and future, but for parents their baby is still a baby; parents are not comfortable with staff recommending vaginal birth as the norm; there are several reasons why parents ask for a caesarean; better care involves clear communication, normal behaviour, and discussion of coping strategies. Post-mortem: Parents are influenced by discussions with staff. Staff should 'sow seeds', clarify its respectful nature, delineate its purpose, and explain the timescale., Follow-Up: It is not standardised; parents wish to see their multi-professional team., Conclusions: There is unacceptable variation in care after stillbirth, and insensitive interactions between staff and bereaved parents. Understanding parents' needs, including why they ask for caesarean birth, will facilitate joint decision-making. Every bereaved parent is entitled to good, respectful care., Tweetable Abstract: Care too varied & interactions often insensitive after stillbirth; national pathway & training urgently needed PLAIN LANGUAGE SUMMARY: Why and how was the study carried out? Previous studies have shown that improving care after stillbirth is important for families. We investigated the opinions of bereaved parents and maternity staff to find ways to improve care. At three hospitals in 2013, all women who experienced a stillbirth were invited to an interview along with their partners. Thirty-five parents of 21 babies agreed to participate. Twenty-two obstetricians and midwives took part in focus group discussions. What were the main findings? Care was often not as good as it should and could be. Communication with parents was not always as sensitive as they would have liked because staff did not have appropriate training. Some women reported they did not 'feel right' before going to hospital. Once they arrived, there was no standard approach to how care was given. Sometimes there were long delays before the death of the baby was confirmed and action was taken. After it had been confirmed that the baby had died, staff focussed on the mothers' needs, but the parents' priorities were still with their baby. There were several reasons why parents asked for a caesarean birth that staff had not considered. Staff influenced parents' decisions about post-mortem examinations. Parents found it helpful when staff explained the respectful nature and purpose of the examination. After discharge from hospital, there was no consistent plan for how follow-up care would be given. Parents would have liked more information about their next hospital appointment. What are the limitations of the work? The parents interviewed depended on their memories of the details of the care, which happened some time ago. In staff group discussions, junior doctors may not have spoken openly because there were senior doctors present. Further research is necessary to understand and improve care globally. What is the implication for parents? Every bereaved parent is entitled to the best possible care after stillbirth, but some do not get good care. Parents and staff made suggestions that can help to develop processes for how care is given after stillbirth. These suggestions can also inform staff training, so that every single parent is treated respectfully and participates in decision making., (© 2017 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Objective: To assess the frequency of additional care, and parents' perceptions of quality, respectful care, in pregnancies subsequent to stillbirth., Design: Multi-language web-based survey., Setting: International., Population: A total of 2716 parents, from 40 high- and middle-income countries., Methods: Data were obtained from a broader survey of parents' experiences following stillbirth. Data were analysed using descriptive statistics and stratified by geographic region. Subgroup analyses explored variation in additional care by gestational age at index stillbirth., Main Outcome Measures: Frequency of additional care, and perceptions of quality, respectful care., Results: The majority (66%) of parents conceived their subsequent pregnancy within 1 year of stillbirth. Additional antenatal care visits and ultrasound scans were provided for 67% and 70% of all parents, respectively, although there was wide variation across geographic regions. Care addressing psychosocial needs was less frequently provided, such as additional visits to a bereavement counsellor (10%) and access to named care provider's phone number (27%). Compared with parents whose stillbirth occurred at ≤ 29 weeks of gestation, parents whose stillbirth occurred at ≥ 30 weeks of gestation were more likely to receive various forms of additional care, particularly the option for early delivery after 37 weeks. Around half (47-63%) of all parents felt that elements of quality, respectful care were consistently applied, such as spending enough time with parents and involving parents in decision-making., Conclusions: Greater attention is required to providing thoughtful, empathic and collaborative care in all pregnancies following stillbirth. Specific education and training for health professionals is needed., Tweetable Abstract: More support for providing quality care in pregnancies after stillbirth is needed., Plain Language Summary: Study rationale and design More than two million babies are stillborn every year. Most parents will conceive again soon after having a stillborn baby. These parents are more likely to have another stillborn baby in the next pregnancy than parents who have not had a stillborn baby before. The next pregnancy after stillbirth is often an extremely anxious time for parents, as they worry about whether their baby will survive. In this study we asked 2716 parents from 40 countries about the care they received during their first pregnancy after stillbirth. Parents were recruited mainly through the International Stillbirth Alliance and completed on online survey that was available in six languages. Findings Parents often had extra antenatal visits and extra ultrasound scans in the next pregnancy, but they rarely had extra emotional support. Also, many parents felt their care providers did not always listen to them and spend enough time with them, involve them in decisions, and take their concerns seriously. Parents were more likely to receive various forms of extra care in the next pregnancy if their baby had died later in pregnancy compared to earlier in pregnancy. Limitations In this study we only have information from parents who were able and willing to complete an online survey. Most of the parents were involved in charity and support groups and most parents lived in developed countries. We do not know how well the findings relate to other parents. Finally, our study does not include parents who may have tried for another pregnancy but were not able to conceive. Potential impact This study can help to improve care through the development of best practice guidelines for pregnancies following stillbirth. The results suggest that parents need better emotional support in these pregnancies, and more opportunities to participate actively in decisions about care. Extra support should be available no matter how far along in pregnancy the previous stillborn baby died., (© 2016 Royal College of Obstetricians and Gynaecologists.)