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Objective: The My Baby's Movements (MBM) trial aimed to evaluate the impact on stillbirth rates of a multifaceted awareness package (the MBM intervention). Design: Stepped‐wedge cluster‐randomised controlled trial. Setting: Twenty‐seven maternity hospitals in Australia and New Zealand. Population: Women with a singleton pregnancy without major fetal anomaly at ≥28 weeks of gestation from August 2016 to May 2019. Methods: The MBM intervention was implemented at randomly assigned time points, with the sequential introduction of eight groups of between three and five hospitals at 4‐monthly intervals. Using generalised linear mixed models, the stillbirth rate was compared in the control and the intervention periods, adjusting for calendar time, study population characteristics and hospital effects. Main outcome measures: Stillbirth at ≥28 weeks of gestation. Results: There were 304 850 births with 290 105 births meeting the inclusion criteria: 150 053 in the control and 140 052 in the intervention periods. The stillbirth rate was lower (although not statistically significantly so) during the intervention compared with the control period (2.2/1000 versus 2.4/1000 births; aOR 1.18, 95% CI 0.93–1.50; P = 0.18). The decrease in stillbirth rate was greater across calendar time: 2.7/1000 in the first versus 2.0/1000 in the last 18 months. No increase in secondary outcomes, including obstetric intervention or adverse neonatal outcome, was evident. Conclusions: The MBM intervention did not reduce stillbirths beyond the downward trend over time. As a result of low uptake, the role of the intervention remains unclear, although the downward trend across time suggests some benefit in lowering the stillbirth rate. In this study setting, an awareness of the importance of fetal movements may have reached pregnant women and clinicians prior to the implementation of the intervention. The My Baby's Movements intervention to raise awareness of decreased fetal movement did not significantly reduce stillbirth rates. The My Baby's Movements intervention to raise awareness of decreased fetal movement did not significantly reduce stillbirth rates. Linked article This article is commented on by Alexander E. P. Heazell, p. 42 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16954. [ABSTRACT FROM AUTHOR]

Background: In 2015, the stillbirth rate after 28 weeks (late gestation) in Australia was 35% higher than countries with the lowest rates globally. Reductions in late gestation stillbirth rates have steadily improved in Australia. However, to amplify and sustain reductions, more needs to be done to reduce practice variation and address sub-optimal care. Implementing bundles for maternity care improvement in the UK have been associated with a 20% reduction in stillbirth rates. A similar approach is underway in Australia; the Safer Baby Bundle (SBB) with five elements: 1) supporting women to stop smoking in pregnancy, 2) improving detection and management of fetal growth restriction, 3) raising awareness and improving care for women with decreased fetal movements, 4) improving awareness of maternal safe going-to-sleep position in late pregnancy, 5) improving decision making about the timing of birth for women with risk factors for stillbirth.Methods: This is a mixed-methods study of maternity services across three Australian states; Queensland, Victoria and New South Wales. The study includes evaluation of 'targeted' implementer sites (combined total approximately 113,000 births annually, 50% of births in these states) and monitoring of key outcomes state-wide across all maternity services. Progressive implementation over 2.5 years, managed by state Departments of Health, commenced from mid-2019. This study will determine the impact of implementing the SBB on maternity services and perinatal outcomes, specifically for reducing late gestation stillbirth. Comprehensive process, impact, and outcome evaluations will be conducted using routinely collected perinatal data, pre- and post- implementation surveys, clinical audits, focus group discussions and interviews. Evaluations explore the views and experiences of clinicians embedding the SBB into routine practice as well as women's experience with care and the acceptability of the initiative.Discussion: This protocol describes the evaluation of the SBB initiative and will provide evidence for the value of a systematic, but pragmatic, approach to strategies to reduce the evidence-practice gaps across maternity services. We hypothesise successful implementation and uptake across three Australian states (amplified nationally) will be effective in reducing late gestation stillbirths to that of the best performing countries globally, equating to at least 150 lives saved annually.Trial Registration: The Safer Baby Bundle Study was retrospectively registered on the ACTRN12619001777189 database, date assigned 16/12/2019. [ABSTRACT FROM AUTHOR]

Objective: To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient.Design: Randomised controlled trial.Setting: Eight Australian maternity hospitals.Population: Women with uncomplicated term singleton pregnancies undergoing IOL for low-risk indications including post-term, advanced maternal age and 'social' reasons.Methods: Between September 2015 and October 2018, 347 women were randomised to a balloon outpatient group and 348 to a PG inpatient group. The PG group received Dinoprostone, either 2 mg gel or 10 mg controlled-release tape. The balloon group had a double-balloon catheter inserted and went home.Main Outcome Measures: The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidaemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported.Results: There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% versus 25.8%; relative risk = 0.77, 95% CI 0.51-1.02; P = 0.070), cord arterial pH <7.10 (3.5% versus 9.2%; P = 0.072), nursery admissions (12.6% versus 15.5%; P = 0.379), neonatal antibiotic use (12.1% versus 17.6%; P = 0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% versus 31.0%;P = 0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% versus 92.3%; P = 0.045).Conclusions: Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low.Tweetable Abstract: Multicentre trial shows outpatient induction using balloon catheter is safe and feasible for nulliparous women. [ABSTRACT FROM AUTHOR]

Background: Deficiencies in investigation and audit of perinatal deaths result in loss of information thereby limiting strategies for future prevention. The Perinatal Society of Australia and New Zealand (PSANZ) developed a clinical practice guideline for perinatal mortality in 2004. Aims: To determine the current use and views of the PSANZ guideline, focussing on the investigation and audit aspects of the guideline. Methods: A telephone survey was conducted of lead midwives and doctors working in birth suites of maternity hospitals with over 1000 births per annum in Australia and New Zealand. Results: Sixty-nine of the 78 eligible hospitals agreed to participate. A total of 133 clinicians were surveyed. Only 42% of clinicians surveyed were aware of the guideline; more midwives than doctors were aware (53 vs 28%). Of those, only 19% had received training in their use and 33% reported never having referred to them in practice. Implementation of even the key guideline recommendations varied. Seventy per cent of respondents reported regularly attending perinatal mortality audit meetings; midwives were less likely than doctors to attend (59 vs 81%). Almost half (45%) of those surveyed reported never receiving feedback from these meetings. The majority of clinicians surveyed agreed that all parents should be approached for consent to an autopsy examination of the baby; however, most (86%) reported the need for clinician training in counselling parents about autopsy. Conclusions: Effective implementation programmes are urgently required to address suboptimal uptake of best practice guidelines on perinatal mortality audit in Australia and New Zealand. [ABSTRACT FROM AUTHOR]

Classifications of perinatal deaths have been undertaken for surveillance of causes of death, but also for auditing individual deaths to identify suboptimal care at any level, so that preventive strategies may be implemented. This paper describes the history and development of the paired obstetric and neonatal Perinatal Society of Australia and New Zealand (PSANZ) classifications in the context of other classifications. The PSANZ Perinatal Death Classification is based on obstetric antecedent factors that initiated the sequence of events leading to the death, and was developed largely from the Aberdeen and Whitfield classifications. The PSANZ Neonatal Death Classification is based on fetal and neonatal factors associated with the death. The classifications, accessible on the PSANZ website ( ), have definitions and guidelines for use, a high level of agreement between classifiers, and are now being used in nearly all Australian states and New Zealand. [ABSTRACT FROM AUTHOR]

Introduction: We showed in a phase II randomised controlled trial (RCT) that oral sildenafil citrate in term labour halved operative birth for fetal distress. We outline the protocol for a phase III RCT (can i ntrapartum S ild E nafil safely A vert the R isks of C ontraction-induced H ypoxia? (iSEARCH)) of 3200 women in Australia to assess if sildenafil citrate reduces adverse perinatal outcomes related to intrapartum hypoxia., Methods and Analysis: iSEARCH will enrol 3200 Australian women in term labour to determine whether up to three 50 mg oral doses of sildenafil citrate versus placebo reduce the relative risk of a primary composite end point of 10 perinatal outcomes potentially related to intrapartum hypoxia by 35% (from 7% to 4.55%). Secondary aims are to evaluate reductions in the relative risk of emergency caesarean section or instrumental vaginal birth for fetal distress by 25% (from 20% to 15%) and in healthcare costs. To detect a 35% reduction in the primary outcome for an alpha of 0.05 and power of 80% with 10% dropout in each arm requires 3200 women (1600 in each arm). This sample size will also yield >90% power to detect a 25% reduction for the secondary outcome of any operative birth (caesarean section or instrumental vaginal birth) for fetal distress., Ethics and Dissemination: Ethical approval for the iSEARCH RCT was granted by the Hunter New England Human Research Ethics Committee (ref no: 2020/ETH02791). Results will be disseminated through websites, peer-reviewed publications, scientific meetings and social media, news outlets, television and radio., Trial Registration Number: ACTRN12621000231842., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Safer Baby Bundle (SBB) aimed to reduce stillbirth rates in Australia through improving pregnancy care across five elements; smoking cessation, fetal growth restriction (FGR), decreased fetal movements (DFM), side sleeping in late pregnancy and decision making around timing of birth. We assessed experiences of women and healthcare professionals (HCPs) with antenatal care practices around the five elements., Methods: A pre-post study design using online surveys was employed to assess change in HCPs awareness, knowledge, and frequency of performing recommended practices (22 in total) and women's experiences of care received related to reducing their chance of stillbirth. Women who had received antenatal care and HCPs (midwives and doctors) at services participating in the SBB implementation program in two Australian states were invited to participate. Surveys were distributed over January to July 2020 (pre) and August to December 2022 (post). Comparison of pre-post responses was undertaken using Fisher's exact, Pearson's chi-squared or Wilcoxon rank-sum tests., Results: 1,225 women (pre-1096/post-129) and 1,415 HCPs (pre-1148/post-267, ≥ 83% midwives) completed the surveys. The frequency of HCPs performing best practice 'all the time' significantly improved post-SBB implementation across all elements including providing advice to women on side sleeping (20.4-79.4%, p < 0.001) and benefits of smoking cessation (54.5-74.5%, p < 0.001), provision of DFM brochure (43.2-85.1%, p < 0.001), risk assessments for FGR (59.2-84.1%, p < 0.001) and stillbirth (44.5-73.2%, p < 0.001). Practices around smoking cessation in general showed less improvement e.g. using the 'Ask, Advise and Help' brief advice model at each visit (15.6-20.3%, p = 0.088). Post-implementation more women recalled conversations about stillbirth and risk reduction (32.2-50.4%, p < 0.001) and most HCPs reported including these conversations in their routine care (35.1-83.0%, p < 0.001). Most HCPs agreed that the SBB had become part of their routine practice (85.0%)., Conclusions: Implementation of the SBB was associated with improvements in practice across all targeted elements of care in stillbirth prevention including conversations with women around stillbirth risk reduction. Further consideration is needed around strategies to increase uptake of practices that were more resistant to change such as smoking cessation support., Trial Registration: The Safer Baby Bundle Study was retrospectively registered on the Australian New Zealand Clinical Trials Registry database, ACTRN12619001777189, date assigned 16/12/2019., (© 2024. The Author(s).)

The stillbirth rate among Aboriginal and Torres Strait Islander women and communities in Australia is around double that of non-Indigenous women. While the development of effective prevention strategies during pregnancy and improving care following stillbirth for women and families in communities has become a national priority, there has been limited progress in stillbirth disparities. With community permission, this study aimed to gain a better understanding of community experiences, perceptions, and priorities around stillbirth. We undertook an Indigenous researcher-led, qualitative study, with community consultations guided by a cultural protection protocol and within an unstructured research framework. A total of 18 communities were consulted face-to-face through yarning interviews, focus groups and workshops. This included 54 community member and 159 health professional participants across remote, regional, and urban areas of Queensland, Western Australia, Victoria, South Australia, and Northern Territory. Thematic analysis of consultation data identified common themes across five focus/priority areas to address stillbirth: Stillbirth or Sorry Business Baby care needs to be family-centered; using Indigenous "ways of knowing, being, and doing" to ensure cultural safety; application of Birthing on Country principles to maternal and perinatal care; and yarning approaches to improve communication and learning or education. The results underscore the critical need to co-design evidence-based, culturally appropriate, and community-acceptable resources to help reduce existing disparities in stillbirth rates., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Massi, Lewis, Stewart, Jans, Gautam, Jalloub, Bowman, Middleton, Vlack, Boyle, Shepherd, Flenady, Stuart-Butler and Rae.)

Background: Working with bereaved parents in co-designed stillbirth research, policy and practice is essential to improving care and outcomes., Problem: Effective parent engagement is often lacking. This may be due to bereaved parents not feeling adequately and appropriately supported to be involved., Aim: To consult bereaved parents with the aim to understand their experiences, attitudes, and needs around involvement in stillbirth research and gain feedback about the usefulness and appropriateness of a proposed co-designed guide to support their involvement, including content and design aspects of this resource., Methods: An online co-designed survey was disseminated via Australian parent support organisations social media in August 2022., Findings: All 90 respondents were bereaved parents, 94% (n = 85) were female. Two-thirds (67%, n = 60) had never participated in stillbirth research, 80% (n = 72) agreed involvement of bereaved parents in research was important or extremely important and 81% (n = 73) were interested in future research involvement. Common motivations for involvement were wanting to leave a legacy for their baby and knowing research outcomes. Common barriers included not having been asked to participate or not knowing how. Most (89%, n = 80) agreed the proposed guide would be useful. Highly valued topics were the importance of bereaved parents' voices in stillbirth research and how they can make a difference., Conclusion: The majority of bereaved parents we surveyed want to be involved in stillbirth research and would value a resource to support this. The proposed concept and content for a co-designed guide to aid engagement was well supported., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Antenatal maternal magnesium sulfate (MgSO 4 ) administration is a proven efficacious neuroprotective treatment reducing the risk of cerebral palsy (CP) among infants born preterm. Identification of the neuroprotective component with target plasma concentrations could lead to neonatal treatment with greater efficacy and accessibility., Methods and Analysis: This is a prospective observational cohort study, in three tertiary Australian centres. Participants are preterm infants, irrespective of antenatal MgSO 4 exposure, born in 2013-2020 at 24 +0 to 31 +6 weeks gestation, and followed up to 2 years corrected age (CA) (to September 2023). 1595 participants are required (allowing for 17% deaths/loss to follow-up) to detect a clinically significant reduction (30% relative risk reduction) in CP when sulfate concentration at 7 days of age is 1 SD above the mean.A blood sample is collected on day 7 of age for plasma sulfate and magnesium measurement. In a subset of participants multiple blood and urine samples are collected for pharmacokinetic studies, between days 1-28, and in a further subset mother/infant blood is screened for genetic variants of sulfate transporter genes.The primary outcome is CP. Surviving infants are assessed for high risk of CP at 12-14 weeks CA according to Prechtl's Method to assess General Movements. Follow-up at 2 years CA includes assessments for CP, cognitive, language and motor development, and social/behavioural difficulties.Multivariate analyses will examine the association between day 7 plasma sulfate/magnesium concentrations with adverse neurodevelopmental outcomes. A population pharmacokinetic model for sulfate in the preterm infant will be created using non-linear mixed-effects modelling., Ethics and Dissemination: The study has been approved by Mater Misericordiae Ltd Human Research Ethics Committee (HREC/14/MHS/188). Results will be disseminated in peer-reviewed journal publications, and provided to the funding bodies. Using consumer input, a summary will be prepared for participants and consumer groups., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Involving patients and consumers in research design helps ensure relevance for those affected by the problem being investigated and can optimize recruitment to clinical trials. This is particularly important when conducting research involving pregnant women., Aims: We investigated women's motivations to participate in a hypothetical randomized control trial (RCT) of a third-trimester screening test for intrapartum fetal compromise (IFC) and adverse perinatal outcomes., Materials and Methods: Women attending for routine antenatal care at a tertiary center were invited to complete a short, anonymized patient acceptability survey. The survey was developed with the assistance of the Perinatal Society of Australia and New Zealand's Consumer Advisory Panel and consisted of Likert scales and open-ended questions. It was designed to ascertain women's responses to research issues, particularly the acceptability of being randomized to a non-revealed arm of a screening test RCT., Results: 100 pregnant women took part; 40% indicated that they would agree/strongly agree to participate in a hypothetical RCT regardless of whether they were given the result of a screening test and 31% were unsure. Randomization to either an intervention or control group was acceptable to 47%, 30% were unsure and 23% were not willing to be randomized. Reasons to participate included the desire to contribute to research and to improve pregnancy care., Conclusions: Participation in an RCT of a screening test for IFC involving non-disclosure of the test result was acceptable to a large minority of pregnant women. This finding supports the feasibility of conducting a large-scale study of this design.

Background: Stillbirth and neonatal death are devastating pregnancy outcomes with long-lasting psychosocial consequences for parents and families, and wide-ranging economic impacts on health systems and society. It is essential that parents and families have access to appropriate support, yet services are often limited. Internet-based programs may provide another option of psychosocial support for parents following the death of a baby. We aim to evaluate the efficacy and acceptability of a self-guided internet-based perinatal bereavement support program "Living with Loss" (LWL) in reducing psychological distress and improving the wellbeing of parents following stillbirth or neonatal death., Methods: This trial is a two-arm parallel group randomized controlled trial comparing the intervention arm (LWL) with a care as usual control arm (CAU). We anticipate recruiting 150 women and men across Australia who have experienced a stillbirth or neonatal death in the past 2 years. Participants randomized to the LWL group will receive the six-module internet-based program over 8 weeks including automated email notifications and reminders. Baseline, post-intervention, and 3-month follow-up assessments will be conducted to assess primary and secondary outcomes for both arms. The primary outcome will be the change in Kessler Psychological Distress Scale (K10) scores from baseline to 3-month follow-up. Secondary outcomes include perinatal grief, anxiety, depression, quality of life, program satisfaction and acceptability, and cost-effectiveness. Analysis will use intention-to-treat linear mixed models to examine psychological distress symptom scores at 3-month follow-up. Subgroup analyses by severity of symptoms at baseline will be undertaken., Discussion: The LWL program aims to provide an evidence-based accessible and flexible support option for bereaved parents following stillbirth or neonatal death. This may be particularly useful for parents and healthcare professionals residing in rural regions where services and supports are limited. This RCT seeks to provide evidence of the efficacy, acceptability, and cost-effectiveness of the LWL program and contribute to our understanding of the role digital services may play in addressing the gap in the availability of specific bereavement support resources for parents following the death of a baby, particularly for men., Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12621000631808 . Registered prospectively on 27 May 2021., (© 2022. The Author(s).)

Objectives: The purpose of this study was to identify differences in health service expenditure on Indigenous and non-Indigenous women who experience a stillbirth, women's out-of-pocket costs, and health service use., Methods: The project used a whole-of-population linked data set called "Maternity1000," which includes all women who gave birth in Queensland, Australia, between July 1, 2012, and June 30, 2018 (n = 396 158). Multivariable analysis was undertaken to assess differences in mean health service expenditure; and number of health care services accessed between Indigenous and non-Indigenous women who had a stillbirth from birth to twelve months postpartum. Costs are presented in 2019/20 Australian dollars., Results: There was a total of 1864 babies stillborn to women in Queensland between July 1, 2012, and June 30, 2018, with 135 being born to Indigenous women and 1729 born to non-Indigenous women. There was significantly lower total expenditure per woman for Indigenous women compared with non-Indigenous women ($16 083 and $18 811, respectively). This was consistent across public hospital inpatient ($12 564 compared with $14 075), outpatient ($1127 compared with $1470), community-based services ($198 compared with $313), pharmaceuticals ($8 compared with $22), private hospital ($434 compared with $1265), and for individual out-of-pocket fees ($21 compared with $86). Mean expenditure on emergency department services per woman was higher for Indigenous women compared with non-Indigenous women ($947 compared with $643). Indigenous women who experienced a stillbirth accessed fewer general practitioners, allied health, specialist, obstetrics, and outpatient services, and fewer pathology and diagnostic test than their non-Indigenous counterparts., Conclusions: Inequities in access to health services exist between Indigenous and non-Indigenous women who experience a stillbirth., (© 2021 Wiley Periodicals LLC.)

Background: Going-to-sleep in the supine position in later pregnancy (≥28 weeks) has been identified as a risk factor for stillbirth. Internationally, public awareness campaigns have been undertaken encouraging women to sleep on their side during late pregnancy., Aim: This study aimed to identify sleep practices, attitudes and knowledge in pregnant women, to inform an Australian safe sleeping campaign., Methods: A web-based survey of pregnant women ≥28 weeks' gestation conducted from November 2017 to January 2018. The survey was adapted from international sleep surveys and disseminated via pregnancy websites and social media platforms., Findings: Three hundred and fifty-two women participated. Five (1.6%) reported going to sleep in the supine position. Most (87.8%) had received information on the importance of side-sleeping in pregnancy. Information was received from a variety of sources including maternity care providers (186; 66.2%) and the internet (177; 63.0%). Women were more likely to report going to sleep on their side if they had received advice to do so (OR 2.3; 95% CI 1.0-5.1). Thirteen (10.8%) reported receiving unsafe advice, including changing their going-to-sleep position to the supine position., Discussion: This indicates high level awareness and practice of safe late-pregnancy going-to-sleep position in participants. Opportunities remain for improvement in the information provided, and understanding needs of specific groups including Aboriginal and Torres Strait Islander women., Conclusion: Findings suggest Australian women understand the importance of sleeping position in late pregnancy. Inconsistencies in information provided remain and may be addressed through public awareness campaigns targeting women and their care providers., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objectives: Perinatal bereavement care is a complex area of practice. The COVID-19 pandemic led to reconfiguration of maternity and perinatal bereavement care services. This study explores Australian health care providers' perspectives of the impact of COVID-19 on the provision of respectful and supportive care following stillbirth or neonatal death., Methods: Members of a perinatal bereavement care network were consulted at the commencement of the pandemic in Australia using an online feedback form. Respondents provided ratings and free-text comments on the impact of COVID-19 on implementation of 49 recommendations contained in the Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Clinical Practice Guideline for Respectful and Supportive Perinatal Bereavement Care ., Results: Responses were received from 35 health care providers who provided perinatal bereavement care in clinical settings or through support organisations in Australia. Major impacts of COVID-19 were reported for 8 of 49 guideline recommendations. Impacts included reduced: support for mothers due to visitor restrictions; availability of cultural and spiritual support and interpreters; involvement of support people in decision-making; options for memory-making and commemorative rituals; and staff training and supervision. Adaptations to minimise impacts included virtual consultations, online staff training, use of cold cots, and increased staff support for memory-making., Conclusions: Health care providers encounter substantial challenges as they strive to implement best practice perinatal bereavement care in pandemic conditions. Some practice adaptations developed during the COVID-19 pandemic could benefit parents; however, evaluation of their effectiveness and acceptability is needed., (© 2022 Frances M. Boyle et al., published by De Gruyter, Berlin/Boston.)

Asthma is the most common respiratory illness in Aboriginal and Torres Strait Islander Australians. From the Mater Mothers routinely collected perinatal data in Brisbane we have identified that 24% of Indigenous and 17% of non-Indigenous women have pregnancies complicated by asthma. Indigenous women with asthma are more likely to have poorer birth outcomes when compared to non-Indigenous women with asthma, with neonatal death being doubled in asthmatic Indigenous women. These data indicate that asthma management during pregnancy is an unmet need for Indigenous women and essential if we are to avoid these devastating outcomes for Indigenous families., (© 2021 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective Stillbirth investigations incur healthcare costs, but these investigations are necessary to provide information that will help reduce the risk of a recurrent stillbirth, as well as advice regarding family planning and future pregnancies. The aims of this study were to determine the healthcare costs of investigations for stillbirths, identify drivers and assess cost differences between explained and unexplained stillbirths. Methods Data from 697 stillbirths were extracted from the Stillbirth Causes Study covering the period 2013-18. The dataset comprised all investigations related to stillbirth on the mother, baby and placenta. Unit costs applied were sourced from the Australian Medicare Benefits Schedule, local hospital estimates and published literature. Multivariable regression analyses were used to assess key factors in cost estimates. Results In all, 200 (28.7%) stillbirths were unexplained and 76.8% of these had between five and eight core investigations. Unexplained stillbirths were twice as likely to have eight core investigations as explained stillbirths (16.5% vs 7.7%). The estimated aggregated cost of stillbirth investigations for 697 stillbirths was A$2.13 million (mean A$3060, median A$4246). The main cost drivers were autopsies or cytogenetic screening. Mean costs were similar when stillbirths had known or unknown causes and by reason for stillbirth among cases with definable causes. Conclusion Investigations for stillbirth in Australia cost approximately A$4200 per stillbirth on average and are critical for managing future pregnancies and preventing more stillbirths. These findings improve our understanding of the costs that may be averted if stillbirths can be prevented through primary prevention initiatives. What is known about the topic? Approximately 2000 stillbirths occur each year in Australia, and this trend has not changed for several decades. Stillbirth investigations incur healthcare costs, but these investigations are necessary to provide information to help reduce the risk of a recurrent stillbirth and advice regarding family planning and future pregnancies. Recommendations for the core set of stillbirth investigations have recently been agreed upon by consensus. What does this paper add? The costs of stillbirth investigations are unknown in Australia. The assessment of these costs is challenging because not all investigations involved in stillbirths are recorded within formal administrative systems because a stillborn baby is not formally recognised as a patient. The present population-based analysis of 697 stillbirths in Australia estimated that, on average, A$4200 was spent on investigations for each stillbirth, with key drivers being autopsies and cytogenetic screening. These costs are typical, with most cases having between five and eight of the core eight recommended investigations. What are the implications for practitioners? There are cost implications for stillbirth investigations, and this analysis gives a true account of current practice in Australia. Together with the high downstream economic costs of stillbirths, the cost burden of stillbirth investigations is high but ultimately avoidable when practitioners adhere to the core investigations, build knowledge around preventable risk factors and use this information to reduce the number of stillbirths.

Background: Stillbirth is a major public health problem that is slow to improve in Australia. Understanding the causes of stillbirth through appropriate investigation is the cornerstone of prevention and important for parents to understand why their baby died., Aim: The aim of this study is to assess compliance with the Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Clinical Practice Guidelines (2009) for stillbirths., Methods: This is a prospective multi-centred cohort study of stillbirths at participating hospitals (2013-2018). Data were recorded into a purpose-built database. The frequency of the recommended core investigations was calculated, and χ 2 test was performed for subgroup analyses by gestational age groups and timing of fetal death. A 70% compliance threshold was defined for investigations. The cause of death categories was provided according to PSANZ Perinatal Death Classification., Results: Among 697 reported total stillbirths, 562 (81%) were antepartum, and 101 (15%) were intrapartum. The most common cause of death categories were 'congenital abnormality' (12.5%), 'specific perinatal conditions' (12.2%) and 'unexplained antepartum death' (29%). According to 2009 guidelines, there were no stillbirths where all recommended investigations were performed (including or excluding autopsy). A compliance of 70% was observed for comprehensive history (82%), full blood count (94%), cytomegalovirus (71%), toxoplasmosis (70%), renal function (75%), liver function (79%), external examination (86%), post-mortem examination (84%) and placental histopathology (92%). The overall autopsy rate was 52%., Conclusions: Compliance with recommended investigations for stillbirth was suboptimal, and many stillbirths remain unexplained. Education on the value of investigations for stillbirth is needed. Future studies should focus on understanding the yield and value of investigations and service delivery gaps that impact compliance., (© 2021 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: The Safer Baby Bundle (SBB) eLearning is an online education module that addresses practice gaps in stillbirth prevention in Australia. It provides healthcare professionals with evidence-based resources for: smoking cessation; fetal growth restriction; decreased fetal movements; maternal safe going-to-sleep position; and timing of birth for women with risk factors for stillbirth., Aims: To determine whether participants' reported knowledge and confidence in providing care designed to reduce stillbirth changed following completion of the module. To assess the module's suitability and acceptability, and participants' reported likelihood to change practice., Materials and Methods: In-built surveys undertaken pre- and post-eLearning module assessed participant knowledge and confidence, module suitability and acceptability, and likelihood of practice change using Likert items. Responses were dichotomised. Differences pre- and post-module were tested using McNemar's test and differences by profession were examined using descriptive statistics and Pearson's χ 2 test., Results: Between 15 October 2019 and 2 November 2020, 5223 participants across Australia were included. Most were midwives (82.0%), followed by student midwives (4.6%) and obstetricians (3.3%). Reported knowledge and confidence improved in all areas (P < 0.001). Post-module 96.7-98.9% 'agreed' they had a sound level of knowledge and confidence across all elements of the SBB. Over 95% of participants agreed that the module was helpful and relevant, well organised, and easy to access and use. Eighty-eight percent reported they were likely to change some aspect of their clinical practice., Conclusions: The SBB eLearning module is a valuable education program that is well-received and likely to result in improvements in practice., (© 2021 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objectives: To describe the frequency of neonatal resuscitation interventions implemented for newborn babies in the state of Queensland over a 10-year period and determine if these changes suggest adherence to changes in Australian guidelines., Study Design: A population-based retrospective cohort study utilising the Queensland Perinatal Data Collection dataset. All liveborn babies ≥23 + 0 weeks + days gestation born between 1 July 2007 and 30 June 2017 were included except those for whom resuscitation was not attempted and those babies <25 + 0 weeks for whom it was unsuccessful. Trends in resuscitation were demonstrated using Loess regression., Results: Of 618,589 eligible newborns,182,260 received any resuscitation manoeuvre (29.5%). The proportion receiving oxygen without assisted ventilation declined from 19.3% in 2007-08 to 5.6% in 2016-17. Upper airway suctioning also decreased. Assisted ventilation increased from 7.9% to 10.0% of all babies with the largest contribution from late preterm and term babies. The rate of endotracheal suctioning for meconium and the rate of narcotic antagonist use also declined. A greater proportion of babies received chest compressions (1.9-3.2 per 1000 babies) and adrenaline (epinephrine). Mortality decreased from 1.9 to 1.5 per 1000 babies in the cohort., Conclusion: Ten-year trends showed reduced use of oxygen or upper airway suctioning without assisted ventilation, reduced intubation to suction meconium, reduced use of narcotic antagonists and greater use of assisted ventilation suggesting appropriate practice change in response to Australian neonatal resuscitation guidelines. The increase in the use of chest compressions and adrenaline was unexpected and the reasons for it are unclear., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Reducing stillbirth rates is an international priority; however, little is known about the cost of stillbirth. This analysis sought to quantify the costs of stillbirth in Australia., Methods: Mothers and costs were identified by linking a state-based registry of all births between 2012 and 2015 to other administrative data sets. Costs from time of birth to 2 years postbirth were included. Propensity score matching was used to account for differences between women who had a stillbirth and those that did not. Macroeconomic costs were estimated using value of lost output analysis and value of lost welfare analysis., Results: Cost to government was on average $3774 more per mother who had a stillbirth compared with mothers who had a live birth. After accounting for gestation at birth, the cost of a stillbirth was 42% more than a live birth (P < .001). Costs for inpatient services, emergency department services, services covered under Medicare (such as primary and specialist care, diagnostic tests and imaging), and prescription pharmaceuticals were all significantly higher for mothers who had a stillbirth. Mothers who had a stillbirth paid on average $1479 out of pocket, which was 52% more than mothers who had a live birth after accounting for gestation at birth (P < .001). The value of lost output was estimated to be $73.8 million (95% CI: 44.0 million-103.9 million). The estimated value of lost social welfare was estimated to be $18 billion., Discussion: Stillbirth has a sustained economic impact on society and families, which demonstrates the potential resource savings that could be generated from stillbirth prevention., (© 2019 Wiley Periodicals, Inc.)

Background: 'Bundles of care' are being implemented to improve key practice gaps in perinatal care. As part of our development of a stillbirth prevention bundle, we consulted with Australian maternity care providers., Objective: To gain the insights of Australian maternity care providers to inform the development and implementation of a bundle of care for stillbirth prevention., Methods: A 2018 on-line survey of hospitals providing maternity services included 55 questions incorporating multiple choice, Likert items and open text. A senior clinician at each site completed the survey. The survey asked questions about practices related to fetal growth restriction, decreased fetal movements, smoking cessation, intrapartum fetal monitoring, maternal sleep position and perinatal mortality audit. The objectives were to assess which elements of care were most valued; best practice frequency; and, barriers and enablers to implementation., Results: 227 hospitals were invited with 83 (37%) responding. All proposed elements were perceived as important. Hospitals were least likely to follow best practice recommendations "all the time" for smoking cessation support (<50%), risk assessment for fetal growth restriction (<40%) and advice on sleep position (<20%). Time constraints, absence of clear guidelines and lack of continuity of carer were recognised as barriers to implementation across care practices., Conclusions: Areas for practice improvement were evident. All elements of care were valued, with increasing awareness of safe sleeping position perceived as less important. There is strong support from maternity care providers across Australia for a bundle of care to reduce stillbirth., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background and Objective: Sildenafil citrate is a vasodilator used in erectile dysfunction and pulmonary hypertension. We tested whether it reduces emergency operative births for fetal compromise and improves fetal or uteroplacental perfusion in labor in a phase 2 double-blind randomized controlled trial., Study Design: Women at term in early labor or undergoing scheduled induction of labor at Mater Mother's Hospital, Brisbane, Australia, were randomly allocated 50 mg of sildenafil citrate orally 8 hourly up to 150 mg or placebo. Intrapartum fetal monitoring followed Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines. Primary outcomes were (1) emergency operative birth (by cesarean delivery or instrumental vaginal birth) for intrapartum fetal compromise and (2) mean indices of fetal and uteroplacental perfusion using Doppler ultrasound. Analysis was by intention-to-treat., Trial Registration Number: ANZCTRN12615000319572 RESULTS: Between September 2015 and January 2019, 300 women were randomized equally to sildenafil citrate or placebo. Sildenafil citrate reduced the risk of emergency operative birth by 51% (18% vs 36.7%; relative risk, 0.49, 95% confidence interval, 0.33-0.73, P=.0004, number needed to treat = 5 [3-11]). There was no difference in indices of fetal and uteroplacental perfusion, but these were ascertained in only 71 women. Sildenafil citrate reduced the risk of meconium-stained liquor or pathologic fetal heart rate patterns by 43% (25.3% vs 44.7%; relative risk, 0.57, 95% confidence interval, 0.41-0.79, P=.0005), but its effects on fetal scalp sampling rates (2.0% vs 6.7%; relative risk, 0.30, 95% confidence interval, 0.08-1.07, P=.06) and adverse neonatal outcome (20.7% vs 21.3%; relative risk, 0.97, 95% confidence interval, 0.62-1.50, P=.89) were inconclusive. Only 3.6% of maternal levels of sildenafil citrate or its metabolite were detected in cord blood. No differences in maternal adverse events were seen., Conclusion: Sildenafil citrate reduced operative birth for intrapartum fetal compromise, but much larger phase 3 trials of its effects on mother and child are needed before it can be routinely recommended., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient., Design: Randomised controlled trial., Setting: Eight Australian maternity hospitals., Population: Women with uncomplicated term singleton pregnancies undergoing IOL for low-risk indications including post-term, advanced maternal age and 'social' reasons., Methods: Between September 2015 and October 2018, 347 women were randomised to a balloon outpatient group and 348 to a PG inpatient group. The PG group received Dinoprostone, either 2 mg gel or 10 mg controlled-release tape. The balloon group had a double-balloon catheter inserted and went home., Main Outcome Measures: The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidaemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported., Results: There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% versus 25.8%; relative risk = 0.77, 95% CI 0.51-1.02; P = 0.070), cord arterial pH <7.10 (3.5% versus 9.2%; P = 0.072), nursery admissions (12.6% versus 15.5%; P = 0.379), neonatal antibiotic use (12.1% versus 17.6%; P = 0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% versus 31.0%;P = 0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% versus 92.3%; P = 0.045)., Conclusions: Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low., Tweetable Abstract: Multicentre trial shows outpatient induction using balloon catheter is safe and feasible for nulliparous women., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Background: High quality perinatal bereavement care is critical for women and families following stillbirth or newborn death. It is a challenging area of practice and a difficult area for guideline development due to a sparse and disparate evidence base., Aim: We present an overview of the newly updated Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Excellence guideline for perinatal bereavement care. The guideline aims to provide clear guidance for maternity health care providers and their services to support the provision of care that meets the needs of bereaved parents., Discussion: The Guideline for Respectful and Supportive Perinatal Bereavement Care is underpinned by a review of current research combined with extensive stakeholder consultation that included parents and their organisations and clinicians from a variety of disciplines. The Guideline contains 49 recommendations that reflect five fundamental goals of care: good communication; shared decision-making; recognition of parenthood; effective support; and organisational response., Conclusion: Best available research, parents' lived experiences and maternity care providers' insights have contributed to a set of implementable recommendations that address the needs of bereaved parents., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Stillbirth is a devastating pregnancy outcome that has a profound and lasting impact on women and families. Globally, there are over 2.6 million stillbirths annually and progress in reducing these deaths has been slow. Maternal perception of decreased fetal movements (DFM) is strongly associated with stillbirth. However, maternal awareness of DFM and clinical management of women reporting DFM is often suboptimal. The My Baby's Movements trial aims to evaluate an intervention package for maternity services including a mobile phone application for women and clinician education (MBM intervention) in reducing late gestation stillbirth rates., Methods/design: This is a stepped wedge cluster randomised controlled trial with sequential introduction of the MBM intervention to 8 groups of 3-5 hospitals at four-monthly intervals over 3 years. The target population is women with a singleton pregnancy, without lethal fetal abnormality, attending for antenatal care and clinicians providing maternity care at 26 maternity services in Australia and New Zealand. The primary outcome is stillbirth from 28 weeks' gestation. Secondary outcomes address: a) neonatal morbidity and mortality; b) maternal psychosocial outcomes and health-seeking behaviour; c) health services utilisation; d) women's and clinicians' knowledge of fetal movements; and e) cost. 256,700 births (average of 3170 per hospital) will detect a 30% reduction in stillbirth rates from 3/1000 births to 2/1000 births, assuming a significance level of 5%. Analysis will utilise generalised linear mixed models., Discussion: Maternal perception of DFM is a marker of an at-risk pregnancy and commonly precedes a stillbirth. MBM offers a simple, inexpensive resource to reduce the number of stillborn babies, and families suffering the distressing consequences of such a loss. This large pragmatic trial will provide evidence on benefits and potential harms of raising awareness of DFM using a mobile phone app., Trial Registration: ACTRN12614000291684. Registered 19 March 2014., Version: Protocol Version 6.1, February 2018.

Background: Stillbirth remains a public health concern in high-income countries. Over the past 20 years, stillbirth rates globally have shown little improvement and large disparities. The overall stillbirth rate, which measures risk among births at all gestations, masks diverging trends at different gestations. This study investigates trends over time in gestation-specific risk of stillbirth in Australia., Methods: Analytical epidemiological study using nationally reported gestational age data for births in Australia, 1994-2015. Average annual change in gestation-specific prospective risk of stillbirth (per 1000 fetuses at risk [FAR]) was calculated among births in 1994-2009 and 2010-2015 at term (37-41 weeks) and for preterm gestational age subgroups: 28-36, 24-27, and 20-23 weeks., Results: The decline in risk of stillbirth at term from 2010 to 2015 from 1.43 to 1.16 per 1000 FAR was more rapid than from 1994 to 2009; for preterm gestations from 24 to 27 weeks, there were no discernible trends; from 28 to 36 weeks, the decline between 1994 and 2009 was not sustained; among births from 20 to 23 weeks, the risk of stillbirth plateaued in 2010-2015, fluctuating around 3.3 per 1000 FAR., Conclusions: Improvement in the stillbirth rate from 28 weeks' gestation aligns with changes in other high-income countries, but more work is needed in Australia to achieve the levels of reduction seen elsewhere. Gestation-specific risk of stillbirth is more informative than the overall stillbirth rate. The message that the overall risk of stillbirth is not changing disregards gains at different stages of pregnancy., (© 2018 John Wiley & Sons Ltd.)

The National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Stillbirth and the Perinatal Society of Australia and New Zealand (PSANZ) have recently partnered in updating an important clinical practice guideline, Care of pregnant women with decreased fetal movements. This guideline offers 12 recommendations and a suggested care pathway, with the aim to improve the quality of care for women reporting decreased fetal movements through an evidence-based approach. Adoption of the guideline by clinicians and maternity hospitals could result in earlier identification of higher-risk pregnancies, improved perinatal health outcomes for women and their babies, and reduced stillbirth rates., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Stillbirths and neonatal deaths are devastating events for both parents and clinicians and are global public health concerns. Careful clinical management after these deaths is required, including appropriate investigation and assessment to determine cause (s) to prevent future losses, and to improve bereavement care for families. An educational programme for health care professionals working in maternal and child health has been designed to address these needs according to the Perinatal Society of Australia and New Zealand Guideline for Perinatal Mortality: IMproving Perinatal mortality Review and Outcomes Via Education (IMPROVE). The programme has a major focus on stillbirth and is delivered as six interactive skills-based stations. We aimed to determine participants' pre- and post-programme knowledge of and confidence in the management of perinatal deaths, along with satisfaction with the programme. We also aimed to determine suitability for international use., Methods: The IMPROVE programme was delivered to health professionals in maternity hospitals in all seven Australian states and territories and modified for use internationally with piloting in Vietnam, Fiji, and the Netherlands (with the assistance of the International Stillbirth Alliance, ISA). Modifications were made to programme materials in consultation with local teams and included translation for the Vietnam programme. Participants completed pre- and post-programme evaluation questionnaires on knowledge and confidence on six key components of perinatal death management as well as a satisfaction questionnaire., Results: Over the period May 2012 to May 2015, 30 IMPROVE workshops were conducted, including 26 with 758 participants in Australia and four with 136 participants internationally. Evaluations showed a significant improvement between pre- and post-programme knowledge and confidence in all six stations and overall, and a high degree of satisfaction in all settings., Conclusions: The IMPROVE programme has been well received in Australia and in three different international settings and is now being made available through ISA. Future research is required to determine whether the immediate improvements in knowledge are sustained with less causes of death being classified as unknown, changes in clinical practice and improvement in parents' experiences with care. The suitability for this programme in low-income countries also needs to be established.

Background: With evidence of offspring harms and concern for younger women's drinking behaviours, this study uses a hospital cohort to trend the use and changes in women's reported alcohol consumption., Aims: To examine (i) the trend of women's reported alcohol consumption over time, (ii) whether any increases in the frequency of alcohol consumption prior to a pregnancy are accompanied by increases in the frequency of alcohol consumption in pregnancy and (iii) the characteristics of women consuming alcohol at these times., Methods: Midwives collected routine data on 19,699 women between 2001 and 2006. Data on women's alcohol use prior to pregnancy and at their pregnancy-booking visit were analysed using a non-parametric test for trend and with bivariate and multivariate tests adjusting for possible confounders., Findings: The proportion of women reporting at-least weekly alcohol use prior to pregnancy was 25.4% and 5.9% at their pregnancy-booking visit. A significant linear increase over time (p<0.001) was found in the rate of women aged 20 years and older reporting at-least weekly alcohol use prior to pregnancy. Tertiary-educated women were more likely to consume alcohol at-least weekly prior to pregnancy. Women aged less than 20 years were less likely to report at-least weekly alcohol use at both time points. Having more children and Asian ethnicity were associated with a lower risk of at-least weekly alcohol use at these times., Conclusion: The majority of women reduce their alcohol consumption once they learn they are pregnant, with some evidence this trend may have increased in recent years., (Copyright © 2014 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Stillbirth, among the most distressing experiences an adult may face, is also a time when parents must decide whether an autopsy or other post-mortem examinations will be performed on their infant. Autopsies can reveal information that might help explain stillbirth, yet little is known about how people make this difficult decision., Objectives: This study examines the influences on decisions about autopsy after stillbirth among Australian parents., Design: The study involved secondary analysis of transcripts of three focus groups using qualitative content analysis., Participants and Setting: Seventeen parents of 14 stillborn babies participated in consultations around the revision of a perinatal mortality audit guideline., Results: Parents shared the decision making. Four decision drivers were identified: parents' preparedness or readiness to make decisions; parental responsibility; concern for possible consequences of an autopsy and the role of health professionals. Each decision driver involved reasons both for and against autopsy. Two decision aftermath were also present: some parents who agreed to an autopsy were dissatisfied with the way the autopsy results were given to them and some parents who did not have an autopsy for their infant expressed some form of regret or uncertainty about the choice they made., Conclusions: To make decisions about autopsy after stillbirth, parents need factual information about autopsy procedures, recognition that there might be fear of blame, an environment of trust, and health services and professionals prepared and skilled for difficult conversations., (© 2012 John Wiley & Sons Ltd.)

Background: Babies born very preterm (before 30 weeks gestation) are at high risk of dying in their first weeks of life, and those who survive are at risk of developing cerebral palsy in childhood. Recent high-quality evidence has shown that giving women magnesium sulphate immediately prior to very early birth can significantly increase the chances of their babies surviving free of cerebral palsy. In 2010 Australian and New Zealand clinical practice guidelines recommended this therapy. The WISH (Working to Improve Survival and Health for babies born very preterm) Project aims to bi-nationally improve and monitor the use of this therapy to reduce the risk of very preterm babies dying or having cerebral palsy., Methods/design: The WISH Project is a prospective cohort study. The 25 Australian and New Zealand tertiary level maternity hospitals will be provided with a package of active implementation strategies to guide the introduction and local adaptation of guideline recommendations. Surveys will be conducted at individual hospitals to evaluate outcomes related to local implementation progress and the use and value of the WISH implementation strategies. For the hospitals participating in the 'WISH audit of uptake and health outcomes data collection', the primary health outcomes (assessed through case note review, and 24 month corrected age questionnaires) will be: the proportion of eligible women receiving antenatal magnesium sulphate; and rates of death prior to primary hospital discharge and cerebral palsy at two years corrected age in infants born to eligible mothers. For hospitals wishing to assess factors influencing translation locally, barriers and facilitators will be measured through interviews with health care professionals, to further guide implementation strategies. Study outcomes for the early phase of the project (Year 1) will be compared with the later intervention phase (Years 2 and 3)., Discussion: The WISH Project will offer insight into the effectiveness of a multifaceted implementation strategy to improve the uptake of a novel neuroprotective therapy in obstetric clinical practice. The successful implementation of antenatal magnesium sulphate for fetal neuroprotection in Australia and New Zealand could lead to over 90 fewer very preterm babies dying or suffering the long-term consequences of cerebral palsy each year.

Increasing numbers of women are choosing to delay pregnancy. Pregnancy in older women is associated with increased risks, of which stillbirth is one of the most devastating. This retrospective cohort study reviewed the obstetric outcomes in women aged 40 and above over an 11-year period to determine whether maternal age is an independent risk factor for term stillbirth. The study shows that advanced maternal age is an independent risk factor for term stillbirth (odds ratio 2.42, 95% confidence interval 1.04-5.62)., (© 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Smoking in pregnancy is associated with a range of adverse pregnancy outcomes., Aim: To compare adverse pregnancy outcomes for women according to smoking status at the first antenatal visit in an Australian setting., Methods: A retrospective study using routinely collected data of all births between 1997 and 2006 at the Mater Mothers' Hospital Brisbane (MMH). Analysis was undertaken using multivariate logistic regression. The following comparisons were undertaken: (i) smokers versus non-smokers; (ii) recent quitters (quit within the last 12 months) versus smokers; and (iii) recent quitters versus non-smokers. Primary outcome measures were small for gestational age (SGA) <10th customised centile and preterm birth (PTB) <37 weeks., Results: Between 1997 and 2006, 40,193 women birthed at the MMH. Of these 30,524 (75.9%), for which adequate data were available, were included in the study. The smoking rate at booking was 15.4%. Compared to non-smokers (n = 25,814), women who were smoking at the first visit (n = 4710) were at increased risk of SGA (aOR = 2.26, 95%CI = 2.08-2.47) and PTB (aOR = 1.42, 95%CI = 1.27-1.59). In the subset (7801 births) used for comparisons two and three, compared to smokers (n = 1434), recent quitters (n = 945) were at a decreased risk of SGA (aOR = 0.43, 95%CI = 0.33-0.57) but not PTB (aOR = 0.92. 95%CI = 0.69-1.23). Outcomes for recent quitters and non-smokers (n = 5422) appeared similar., Conclusion: This study confirms the increased risk of continued smoking in pregnancy. Women who quit prior to or during early pregnancy appear to have similar risk to that of non-smokers., (© 2011 The Authors. ANZJOG © 2011 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Published customised birthweight models designed to account for individual constitutional variation have not been validated in an independent population to verify the results., Aims: To validate our previously reported customised birthweight model with additional data from the same hospital and to revise this model using a larger, more refined dataset., Methods: With the accumulation of further data, a set of coefficients was derived based on the 12-year dataset. Using shrinkage statistics, records between July 2005 and December 2008 were used to validate the model. Stepwise multiple regression using a more refined dataset of births between January 1997 and December 2008 was used to derive updated coefficients. Performance of the model was assessed using individualised birthweight ratios and the absolute difference between customised and actual birthweight., Results: Previous coefficients were validated, with shrinkage of less than 1%, indicating that the model is stable over time. An updated set of coefficients based on a dataset of 61,630 births, including refined ethnicity categories and the addition of a smoking term, is presented, which resulted in improved model statistics (primarily an improved multiple correlation coefficient of 0.51)., Conclusion: The customised birthweight model appears to be stable over time in the same hospital. Initial comparisons to literature indicate that models from different geographic locations may lead to similar coefficients; but, there remains a need to formally assess this aspect of birthweight models. The updated coefficients differ slightly from those previously published and are considered superior because of refinement in the dataset., (© 2010 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology © 2010 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM., Aims: To identify current practices and views of obstetricians in Australia and New Zealand regarding DFM., Methods: A postal survey of Fellows and Members, and obstetric trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists., Results: Of the 1700 surveys distributed, 1066 (63%) were returned, of these, 805 (76% of responders) were currently practising and included in the analysis. The majority considered that asking women about fetal movement should be a part of routine care. Sixty per cent reported maternal perception of DFM for 12 h was sufficient evidence of DFM and 77% DFM for 24 h. KICK charts were used routinely by 39%, increasing to 66% following an episode of DFM. Alarm limits varied, the most commonly reported was < 10 movements in 12 h (74%). Only 6% agreed with the internationally recommended definition of < 10 movements in two hours. Interventions for DFM varied, while 81% would routinely undertake a cardiotocograph, 20% would routinely perform ultrasound and 20% more frequent antenatal visits., Conclusions: While monitoring fetal movement is an important part of antenatal care in Australia and New Zealand, variation in obstetric practice for DFM is evident. Large-scale randomised controlled trials are required to identify optimal screening and management options. In the interim, high quality clinical practice guidelines using the best available advice are needed to enhance consistency in practice including advice provided to women.

Background and Aims: To assess the current use of vaginal progesterone in women at increased risk of preterm birth among practitioners within Australia and New Zealand, and the willingness of both clinicians and women to participate in a randomised controlled trial to further evaluate the role of progesterone in preterm birth., Methods: A survey of fellows and members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and women who had a spontaneous preterm birth at less than 34 weeks gestation, at the Women's and Children's Hospital was conducted., Results: A total of 1430 surveys were distributed to members and fellows, of which 738 (52%) were returned. Of these, 490 were from currently practising obstetricians (34% of total college membership). Twelve of the 490 (2%) respondents indicated that they currently use progesterone in women with a previous spontaneous preterm birth at less than 34 weeks gestation. Of the respondents, 317 (65%) indicated a willingness to participate in a multicentred randomised controlled trial assessing the use of progesterone in women with a previous spontaneous preterm birth at less than 34 weeks gestation. A total of 207 eligible women identified from the hospital database were sent a questionnaire, with responses obtained from 119 women (57%). Overall, women were satisfied with their preterm birth experience. Fifty-two women (44%) indicated a willingness to consider participation in a randomised trial of vaginal progesterone., Conclusions: Progesterone is not widely used in Australia and New Zealand for women considered at increased risk of preterm birth. Conducting a randomised trial of vaginal progesterone is feasible.

A mail-out questionnaire on management of women considered at high risk of preterm birth was sent to all members and fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. While the survey suggested that there is general consensus among practitioners as to what constitutes an increased risk of preterm birth, there is some variation in investigations and treatment currently undertaken.

Background: Published birthweight references in Australia do not fully take into account constitutional factors that influence birthweight and therefore may not provide an accurate reference to identify the infant with abnormal growth. Furthermore, studies in other regions that have derived adjusted (customised) birthweight references have applied untested assumptions in the statistical modelling., Aims: To validate the customised birthweight model and to produce a reference set of coefficients for estimating a customised birthweight that may be useful for maternity care in Australia and for future research., Methods: De-identified data were extracted from the clinical database for all births at the Mater Mother's Hospital, Brisbane, Australia, between January 1997 and June 2005. Births with missing data for the variables under study were excluded. In addition the following were excluded: multiple pregnancies, births less than 37 completed week's gestation, stillbirths, and major congenital abnormalities. Multivariate analysis was undertaken. A double cross-validation procedure was used to validate the model., Results: The study of 42,206 births demonstrated that, for statistical purposes, birthweight is normally distributed. Coefficients for the derivation of customised birthweight in an Australian population were developed and the statistical model is demonstrably robust., Conclusions: This study provides empirical data as to the robustness of the model to determine customised birthweight. Further research is required to define where normal physiology ends and pathology begins, and which segments of the population should be included in the construction of a customised birthweight standard.