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Background: There is now robust evidence that when women settle to sleep on their back in late pregnancy (>28 weeks) they are at increased risk of stillbirth. Therefore, there are several stillbirth prevention programs worldwide that have begun advising pregnant women to adopt a side position when settling to sleep in late pregnancy. However, some hold concerns that giving women information about sleep position and stillbirth risk may make them anxious. Aim: This study aimed to determine what influences how ‘safe sleep’ messages are perceived by pregnant women and if there is anxiety associated with receiving this message. Materials and Methods: An online survey of 537 Australian women (n = 97 were ‘currently pregnant’). The survey examined participant’s views regarding sleep position messages, type of information source as well as participant characteristics such as general anxiety and their fetal health locus of control (FHLC). Results: Our findings suggest that the FHLC may influence how health messaging regarding sleep in pregnancy is perceived and acted upon. We have also shown a subset of pregnant women may feel anxiety associated with the sleep position in pregnancy message. This may not be related to history of anxiety, but rather to their higher ‘internal’ FHLC, ie those who reflect a greater sense of personal agency over fetal health. Conclusions: Our findings suggest most women will perceive information about settling into sleep position as informative rather than anxiety provoking. Therefore, maternity care providers should not be overly concerned about provoking anxiety when providing this information. Refereed/Peer-reviewed

usc Objective: The objective of this review is to review and synthesize what is documented on the role and scope of practice of midwives and registered nurses working in acute early pregnancy care settings in Australia. Introduction: Women experiencing complications before 20 weeks of pregnancy may need to attend an acute care service, often a hospital emergency department. Both midwives and registered nurses provide care for women with early pregnancy complications, and it is important that their role and scope of practice is documented. This review will explore the literature relating to acute early pregnancy care in Australia to better understand how midwives’ and registered nurses’ roles and scope are currently described in this setting. Inclusion criteria: Any literature that explores the role and scope of practice of midwives and registered nurses who care for women who present to acute care services in Australia with early pregnancy complications will be considered for inclusion in the review. Methods: A 3-step review process will involve a preliminary search of MEDLINE and ProQuest, followed by a more detailed search of a larger selection of databases, using identified keywords and phrases from the initial search. Reference lists of retrieved literature will then be examined for relevant citations. Literature in English will be considered, including relevant gray literature. Search results will be imported into reference and review support software. Data that align with the inclusion criteria will be organized into tabulated and narrative formats for presentation. Refereed/Peer-reviewed

usc Background: Women receiving continuity of midwifery care have increased satisfaction and improved outcomes. Preparation of midwifery students to work in continuity models from the point of graduation may provide an ongoing midwifery workforce that meets rising demand from women for access to such care. Aim of the paper: The aim of this paper is to describe an innovative midwifery course based on a continuity model, where students acquire more than 50 % of clinical hours through continuity of care experiences. Additional educational strategies incorporated in the course to enhance the CCE experience within the philosophy of midwifery care, include a virtual maternity centre, case-based learning and the Resources Activities Support Evaluation (RASE) pedagogical model of learning. Discussion: Australian accredited midwifery courses vary in structure, format and philosophy; this new course provides students with an alternative option of study for those who have a particular interest in continuity of midwifery care. Conclusion: A midwifery course which provides the majority of clinical hours through continuity of care may prepare graduates for employment within midwifery group practice models by demonstrating the benefits of relationship building, improved outcomes and the reality of an on-call lifestyle. Refereed/Peer-reviewed

Objective:The aim of the proposed scoping review is to explore and summarize the range of available evidence for bereavement care, specifically in relation to labor and birthing experiences of a stillborn baby.Introduction:Clinical practice guidelines for bereavement care following pregnancy loss have been developed. However, there remains a lack of evidence to guide recommendations for providing appropriate care to parents at the time of diagnosis, and during the labor and birth of a stillborn baby.Inclusion criteria:The proposed review will consider studies, reports, guidelines, evidence syntheses, and other relevant literature that explore the experiences, needs, and care provided to bereaved parents during labor and birth of a stillborn baby.Methods:The search strategy for the proposed scoping review will aim to locate both published and unpublished documents, using a three-step search strategy. An initial search will be conducted using the databases MEDLINE and CINAHL to identify relevant articles; a second search will be conducted across all included databases, incorporating identified keywords and index terms; and finally the reference lists of included studies will be screened for additional sources. Google Scholar and Web of Science will be searched for relevant gray literature. The search will restrict documents from 2000 to present to maintain clinical relevancy. Only studies published in English will be included. Results of the search will be exported into a template, where data will be categorized using five key domains (communication, recognition of parenthood, effective support, shared decision-making, and organizational response) summarized into positive, negative, or neutral outcomes, and further refined into common issues across these domains.Scoping review registration:Open Science Framework "birthing in grief: a scoping review" https://osf.io/xw9md.

Background A midwife’s ability to fully support women’s autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman’s agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision. Objectives A three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice. Methods Critical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results. Findings Findings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife’s ability to offer and the woman’s decision to use water immersion under the themes ‘the reality of the system’, ‘the authoritative ‘others’’ and ‘the pseudo decision-makers’. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care. Conclusions The insight gained from examining midwives’ views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.

usc Background: Presentations for decreased fetal movements comprise a significant proportion of acute antenatal assessments. Decreased fetal movements are associated with increased likelihood of adverse pregnancy outcomes including stillbirth. Consensus-based guidelines recommend pregnant women routinely receive information about fetal movements, but practice is inconsistent, and the information shared is frequently not evidence-based. There are also knowledge gaps about the assessment and management of fetal movement concerns. Women have indicated that they would like more accurate information about what to expect regarding fetal movements. Discussion: Historically, fetal movement information has focussed on movement counts. This is problematic, as the number of fetal movements perceived varies widely between pregnant women, and no set number of movements has been established as a reliable indicator of fetal wellbeing. Of late, maternity care providers have also advised women to observe their baby’s movement pattern, and promptly present if they notice a change. However, normal fetal movement patterns are rarely defined. Recently, a body of research has emerged relating to maternal perception of fetal movement features such as strength, presence of hiccups, and diurnal pattern as indicators of fetal wellbeing in addition to frequency. Conclusion: Sharing comprehensive and gestation-appropriate information about fetal movements may be more satisfying for women, empowering women to identify for themselves when their baby is doing well, and importantly when additional assessment is needed. We propose a conversational approach to fetal movement information sharing, focusing on fetal movement strength, frequency, circadian pattern, and changes with normal fetal development, tailored to the individual. Refereed/Peer-reviewed

Background The World Health Organization, and the 2011 and 2016 Lancet Stillbirth series as well as medical and scientific literature, have all called for stillbirth stigma to be reduced. However, few studies have explored or attempted to conceptualise the meaning of stigma in the context of stillbirth. Aim To explore the current knowledge surrounding stillbirth stigma, specifically the extent, type and experiences of bereaved parents. Methods A five-stage scoping review framework was utilised. A search of relevant databases (MedLine, EMBASE, PsychInfo, PsychArticles, and Ovid Emcare) was undertaken with several key words related to ‘stillbirth’ and ‘stigma.’ The reference lists of included studies were also searched. Findings A total of 23 resources met the inclusion criteria for this review. A thematic analysis regarding how stigma was conceptualised and/or experienced within results and/or discussion was employed on these studies. Five over-arching themes, with several sub-themes, were discovered: Type of stigma, identity, silence, bereaved mothers’ experiences of stigma in low-income countries and transformation. Discussion Stillbirth stigma remains an under-researched topic. Few articles conceptualised the experiences of the bereaved parent within a stigma framework. However, examples of bereaved parents enduring stigma were found within the literature. Common stigmatising experiences included, bereaved parents’ identities being challenged; and feelings of shame, guilt, and blame after their stillbirth. Stigmatising experiences could be different based on the bereaved parent’s cultural background. Conclusion Further research which attempts to conceptualise stillbirth stigma and explores those experiences from a bereaved parent perspective is needed to help inform stigma reduction strategies.

Background: Fetal movements are a key indicator of fetal health. Research has established significant correlations between altered fetal activity and stillbirth. However, women are generally unaware of this relationship. Providing pregnant women with information about the importance of fetal movements could improve stillbirth rates. However, there are no consistent fetal movements awareness messages globally for pregnant women. Aims: This study aimed to explore the antenatal care experiences of Australian mothers who had recently had a live birth to determine their knowledge of fetal movements, the nature and source of that information. Methods: An online survey method was used for 428 women who had a live birth and received antenatal care in Australia. Women’s knowledge of fetal movements, stillbirth risk, and the sources of this knowledge was explored. Findings: A large proportion of participants (84.6%; n = 362) stated they had been informed by health care professionals of the importance of fetal movements during pregnancy. Open-ended responses indicate that fetal movements messages are often myth based. Awareness that stillbirth occurs was high (95.2%;n = 398), although, 65% (n = 272) were unable to identify the current incidence of stillbirth in Australia. Conclusion: Women who received antenatal care have high-awareness of fetal movements, but the information they received was inconsistent. Participants knew stillbirth occurred but did not generally did not indicate they had obtained that knowledge from health care professionals. We recommend a consistent approach to fetal movements messaging throughout pregnancy which focuses on stillbirth prevention. Refereed/Peer-reviewed

Background: The prevalence of stillbirth in many high income countries like Australia has remained unchanged for over 30 years. The 2018 Australian government Senate Select Committee on Stillbirth Research and Education highlighted the need for a public health campaign to encourage public conversations and increase awareness. However, there is little evidence about the community's knowledge and perceptions towards pregnancy and stillbirth, nor their aspirations for a public health campaign. Aims: To assess the general knowledge, perceptions, myths and attitudes towards stillbirth to inform future public health campaigns. Methods: Australian participants (n = 344; predominately women n = 294 (85.5%)) were recruited via Facebook.com. They completed a cross-sectional online survey designed to assess their knowledge of pregnancy and stillbirth, with additional questions on socio-demographic characteristics. Results: Stillbirth knowledge and awareness of incidence was low in this sample. Prominent myths, such as baby runs out of room in the uterus (n = 112, 33%) and baby slows down when preparing for labour (n = 24, 27%) were endorsed. Only 25% (n = 85) knew the prevalence of stillbirth in Australia (six per day). Almost two-thirds (n = 205; 62%) agreed that there needs to be a public health campaign, however one in five (n = 65; 20%) were concerned that talking about stillbirth with pregnant women may cause them to worry. Discussion and conclusion: Our findings reinforce the need for a targeted campaign, which educates the general population about the definition and prevalence of stillbirth, stillbirth risks and modifiable health behaviours. Appropriate messaging should target pregnant women during antenatal care as well as their support and care systems (family, friends, and care providers).53 Refereed/Peer-reviewed

usc Issue addressed: To raise expectant fathers' awareness of risk factors for stillbirth. Methods: A set of brief text messages was developed addressing recognised risk factors for stillbirth: avoidance of maternal cigarette smoking, maternal going to sleep on side messaging, awareness of the importance of noticing and reporting changes in foetal movement and fathers' involvement in shared decision making for timing of birth. Eight messages were inserted into the SMS4dads pilot program being conducted by NSW Health. Feedback on the messages was requested. Participants rated the quality of the messages on a three-point Likert scale and provided comments. Results: Overall, 2528 messages were sent to 626 fathers' mobile phones, 45% of fathers replied with 666 ratings and 115 comments evaluating the texts. The quantitative ratings indicated substantial overall approval of the messages. Within the coding category “Evaluation of Message Content,” three themes described fathers' reactions and feelings about the smoking, movement, side sleeping and birth timing messages: “important-good information,” “not appropriate/anxiety provoking” and “not relevant-obvious.” Three themes reflecting the attributes of the messages within the “Service Quality” category were “need more information,” “complements public health” and “child voice fit.” Conclusions: Results indicate that the messages are an acceptable way to provide information and suggested actions addressing stillbirth risk factors to fathers-to-be. So what?: Fathers' awareness of the risk factors for stillbirth can assist mothers to take appropriate actions for a healthy birth. Information on risk factors can be provided to fathers via a father-focused text messaging service. Refereed/Peer-reviewed

Refereed/Peer-reviewed Background: Some research attention has been paid to women's experiences of water immersion for labour and/or birth. Development of a psychometric scale specific to water immersion may provide further insight into women's experiences Aim: The objective of this paper is to share the development, and preliminary psychometric evaluation, of the Water immersion Agency plus Expectations and Relief (WA+ER) scale for assessing women's experiences of using water for labour and/or birth Methods: Items for the WA+ER scale were informed by a thorough literature review, and review by midwifery experts. An online survey was conducted, and 17 items were rated on a 7-point Likert scale (from entirely disagree to entirely agree) by 740 women who had used water immersion for labour and/or birth Results: An initial exploratory factor analysis was conducted to determine the initial structure of the scale. A confirmatory factor analysis showed that the initial 17-items were not a ‘good fit’ but with further statistical exploration, a good fit was achieved with 11-items. Results identified three factors with good reliability: Sense of Agency (4 items; α = 0.87;), Expectations (3 items; α = 0.83) and Relief (4 items α = 0.82). A confirmatory factor analysis confirmed good model fit (CFI=0.93; GFI=0.91; AGFI=0.85; TLI=0.90) Conclusions: The WA+ER scale is a statistically and theoretically sound tool for measuring women's experiences of labouring and/or birthing in water. Additional testing is required to further assess the validity and reliability of the scale and to determine the appropriateness of its use in other populations.

Refereed/Peer-reviewed Mothers who had experienced stillbirth (n = 436) were asked about their "faith base" and whether it was "helpful to their healing." Only 178 (24.5%) indicated their faith base was "helpful;" there was also a wide range of other responses including those who indicated their faith was "lost" following their baby's death. Findings are discussed in terms of what participants found helpful from their pastor and/or church community.

Refereed/Peer-reviewed Background: The 2011 and 2016 Stillbirth Lancet series made a call to action to identify mechanisms to reduce stillbirth stigma. This research answers that call, investigating the extent and dimensions of stillbirth stigma experienced by an international sample of mothers bereaved by stillbirth. Objective: To determine the prevalence and type as well as explore explanatory variables associated with higher levels of stillbirth stigma with bereaved mothers in high-income countries (Australia, United Kingdom, The United States of America and New Zealand). Method: An international survey of 889 bereaved mothers was conducted utilising the recently developed Still- birth Stigma Scale to explore the extent and types of stigma experienced, as well as the association between stigma and self-esteem (Rosenberg Self- Esteem Scales), perinatal grief (Perinatal Grief Scale), and perceived social sup- port (Perceived Social Support Scale). Demographic information (e.g. age, education, stillbirth history, sexual orientation and mental health) were collected to determine the association between individual demographic factors and stillbirth stigma. Results: Results of the Stillbirth Stigma Scale indicated that a majority (54%) of bereaved mothers experienced stigma. Self-stigma was the predominant type of stigma experienced (80%), followed by perceived devaluation (64.9%). Bereaved mothers also experienced discrimination (29.1%) and issues with disclosing their stillbirth to their community (36.7%). Stillbirth stigma scores were higher in bereaved mothers who had experienced the loss of their first child. High scores were associated with the mother’s mental health status (diagnoses prior to stillbirth, and/or after stillbirth (p < .05)).The other scales used indicated that higher stillbirth stigma scores were also associated with lower self-esteem (r (877) = -.304, p < .001), lower perceived social support (r (871) = -.448, p < .001) and higher levels of grief (r (829) = .609, p < .001) Conclusion: The current research was the first to identify that 54% of bereaved mothers experienced stigma, with self-stigma being the most prominent. Bereaved mothers endured discriminating experiences and had trouble disclosing their stillbirth to others within their community. The first-time mother with a self- reported history of mental illnesses appears to be the most at-risk of higher levels of stigma. Future longitudinal research needs to be conducted to determine the direction of the explanatory variables i.e. mental health, self-esteem and social support and develop interventions, which support the bereaved mother and reduce stillbirth stigma. Relevance: This study is the first to demonstrate the prevalence, extent, type and explanatory variables of stigma reported by bereaved mothers and the association between this and poorer outcomes including increased grief and decreased self-esteem. This study begins a dialogue about prevalence and explanatory variables of stillbirth stigma and its impact, to inform future prevention and support potential stigma reduction programs for community and bereaved mothers.

Background Rapid changes to how maternity health care is delivered has occurred in many countries across the globe in response to the COVID-19 pandemic. Maternity care provisions have been challenged attempting to balance the needs and safety of pregnant women and their care providers. Women experiencing a pregnancy after loss (PAL) during these times face particularly difficult circumstances. Aim In this paper we highlight the situation in three high income countries (Australia, Ireland and USA) and point to the need to remember the unique and challenging circumstances of these PAL families. We suggest new practices may be deviating from established evidence-based guidelines and outline the potential ramifications of these changes. Findings Recommendations for health care providers are suggested to bridge the gap between the necessary safety requirements due to the pandemic, the role of the health care provider, and the needs of families experiencing a pregnancy after loss. Discussion Changes to practices i.e. limiting the number of antenatal appointments and access to a support person may have detrimental effects on both mother, baby, and their family. However, new guidelines in maternity care practices developed to account for the pandemic have not necessarily considered women experiencing pregnancy after loss. Conclusion Bereaved mothers and their families experiencing a pregnancy after loss should continue to be supported during the COVID-19 pandemic to limit unintended consequences.

ObjectiveCurrent data on the role of the umbilical cord in pregnancy complications are conflicting; estimates of the proportion of stillbirths due to cord problems range from 3.4 to 26.7%. A systematic review and meta-analysis were undertaken to determine which umbilical cord abnormalities are associated with stillbirth and related adverse pregnancy outcomes.MethodsMEDLINE, EMBASE, CINAHL and Google Scholar were searched from 1960 to present day. Reference lists of included studies and grey literature were also searched. Cohort, cross-sectional, or case-control studies of singleton pregnancies after 20 weeks' gestation that reported the frequency of umbilical cord characteristics or cord abnormalities and their relationship to stillbirth or other adverse outcomes were included. Quality of included studies was assessed using NIH quality assessment tools. Analyses were performed in STATA.ResultsThis review included 145 studies. Nuchal cords were present in 22% of births (95% CI 19, 25); multiple loops of cord were present in 4% (95% CI 3, 5) and true knots of the cord in 1% (95% CI 0, 1) of births. There was no evidence for an association between stillbirth and any nuchal cord (OR 1.11, 95% CI 0.62, 1.98). Comparing multiple loops of nuchal cord to single loops or no loop gave an OR of 2.36 (95% CI 0.99, 5.62). We were not able to look at the effect of tight or loose nuchal loops. The likelihood of stillbirth was significantly higher with a true cord knot (OR 4.65, 95% CI 2.09, 10.37).ConclusionsTrue umbilical cord knots are associated with increased risk of stillbirth; the incidence of stillbirth is higher with multiple nuchal loops compared to single nuchal cords. No studies reported the combined effects of multiple umbilical cord abnormalities. Our analyses suggest specific avenues for future research.

Background: There is a disconnect between what maternity care providers consider should be done and what they actually do with respect to talking with their pregnant clients about reducing their risk of stillbirth. This suggests that they would benefit from receiving up-to-date knowledge about stillbirth, alongside education that provides them with strategies for talking about stillbirth with pregnant women. Objectives: To gain an understanding of maternity care provider (obstetricians and midwives) knowledge of stillbirth and determine whether delivering a half day workshop improves knowledge and results in intention to change practice. Design: A pre-post intervention study. Setting: Maternity care providers (Obstetricians, Midwives) working in the northern areas of Tasmania, Australia were asked, via questionnaire, about their knowledge of stillbirth both before and after attending a half-day workshop. Participants: Maternity care providers (n = 51) attended the workshop and 30 (59%) completed both the pre-workshop and post-workshop surveys. Methods: A four hour interactive workshop grounded in understanding the stillbirth experience. Participants were given up-to-date information about stillbirth risks and current prevention research as well as provided with an actionable step wise approach to talking about stillbirth prevention in pregnancy. Results: Stillbirth knowledge scores (total of 8-points) significantly increased following the workshop (pre: mean = 2.9 ± 1.5; post: mean = 4.7 ± 1.4 points, t 29 = 7.9

We examined whether sunlight affects hot flushes in working menopausal women and explored effect modification by shift work and season. In this prospective cohort study, daily hot flush score (outcome) was measured by the 7-day North Central Cancer Treatment Group Daily Vasomotor Symptoms Diary. Daily duration of sunlight (≥2000 lux) was recorded by the HOBO MX2202 pendant. Both variables were measured in two 7-day data collection phases. T0 data were collected during the Australian Summer (December 2017, January and February 2018); and T1 data were collected in the Australian winter (June, July and August 2018). Linear mixed effects model was used. Shift work and season were both confounders and effect modifiers. To detect a median effect size of R2 = 0.2, 34 women were required to achieve an effective sample size of 41. A total of 49 menopausal women were recruited, 11 shift and 38 day workers. Some 13 women had various missing observations. For shift workers, an hour increase in sunlight exposure was associated with a 1.4-point reduction in hot flush score (p = .016). This relationship was not significant for day workers (p = .185). The finding of this study suggests increased sunlight exposure might improve hot flushes in menopausal shift workers who are moderately bothered by hot flushes, but probably not in day workers. The possible role of shift-work associated circadian disruption on estrogen level in regard to elevated intensity and frequency of hot flush in menopausal women is discussed.

There is a wealth of evidence to say that sleep impacts maternal health during pregnancy, however, little has been published on fetal health and maternal sleep. This scoping review summarises current literature on maternal sleep including sleep disordered breathing, sleep quality, sleep duration and supine sleep position, as these relate to fetal outcomes specifically birth weight, growth, preterm birth and stillbirth. An overall interpretation of the studies evaluated shows that events occurring during maternal sleep such as obstructive sleep apnea, sleep disruption and sleep position may have a negative effect on the fetus resulting in altered growth, gestational length and even death. These effects are biologically and physically plausible. In conclusion, there is limited and often conflicting information on maternal sleep and fetal outcomes. However, existing evidence suggests that this is an important area for future research. This area is ripe for investigation if there is to be reduction in the physical, emotional, and financial burden of poor fetal outcomes related to maternal sleep. Refereed/Peer-reviewed

Study Objectives: To test whether a customized positional therapy device, PrenaBelt, would reduce time spent sleeping supine and evaluate any change in maternal or fetal parameters, in a group of healthy pregnant women in the third trimester of pregnancy. Methods: Participants underwent an in-home, overnight sleep study during late pregnancy (32-38 weeks). Participants were observed over 2 nights: 1 night when the PrenaBelt was not worn (nonintervention or control) and 1 night when it was (intervention). The intervention night was randomly allocated, and the study nights were consecutive. On the control night, participants were filmed using a night-capable (infrared) video camera, maternal sleep was measured by the Watch-PAT200, and the fetus was continuously monitored using the Monica AN24. On the intervention night, video, maternal, and fetal monitoring were repeated with the addition of the mother wearing the PrenaBelt. Results: A total of 25 healthy pregnant women were studied. Four had missing data for the Watch-PAT or Monica, and eight had missing or disrupted video data. Video-determined time in bed was not significantly different during intervention and control nights (P = .196, r = −.23). Median time spent supine during the intervention night was reduced from 48.3 minutes, to 28.5 minutes during the control night (P = .064, r = −.33). The difference in the proportion of time spent supine was significant (P = .039). There was no significant difference in objectively estimated sleep time (P = .651, r = −.07). Improvement was observed in both maternal and fetal parameters during the intervention night with an increase in median minimum maternal oxygen saturations (control = 91.6%,intervention = 92.4%, P = .006, r = −.42), fewer maternal oxygen desaturations (control = 7.1, intervention = 5.9, P = .095, r = −.26), and fewer fetal heart rate decelerations (control = 14.0, intervention = 10.4, P = .045, r = −.31) compared to the control night. Conclusions: Results provide preliminary evidence that an intervention to reduce supine sleep in late pregnancy may provide maternal and fetal health benefits, with minimal effect on maternal perception of sleep quality and objectively estimated sleep time. Further research to explore relationships between objectively determined maternal sleep position, maternal respiratory indices, and fetal well-being is warranted. Refereed/Peer-reviewed

Objective: To describe and explore 'gut instinct' that something was wrong in women who identified that they experienced gut instinct during pregnancy. Method: A case-control study utilising an international web-based questionnaire. Stillborn cases ( n = 146) and liveborn controls ( n = 234) answered the gut instinct question within 30 days of the pregnancy ending. Of those, 84 cases and 27 controls also provided qualitative comment data. Descriptive statistics were used for the question, with a fixed option and summative content analysis was used to analyse the comment data. Findings: In all, 110 (75%) of the stillborn cases answered "yes" to the gut instinct question vs only 28 (12%) of the controls who had a livebirth meaning the risk of stillbirth was 22.5 fold higher in those who experience "gut instinct" than in those who do not experience this feeling. Four themes were identified from the comment data namely: When the gut instinct occurred; How the gut instinct made the woman feel; Dreams and other related phenomena; Reassured by someone or something. Conclusions: Women who had a stillborn baby reported a "gut instinct" that something was wrong more frequently than mothers of a live born baby. Our findings may be influenced by recall negativity bias, and a prospective study is needed to confirm or refute our findings. The possibility that "maternal intuition" exists during pregnancy and responds to changes in fetal or placental health merits further exploration. Implications for practice: Maternity care providers should be alert to the woman when she expresses intuitive feelings, as well as asking her to report her concerns and act appropriately to assess and manage fetal wellbeing. Refereed/Peer-reviewed

Background Accessibility of water immersion for labour and/or birth is often dependent on the care provider and also the policies/guidelines that underpin practice. With little high quality research about the safety and practicality of water immersion, particularly for birth, policies/guidelines informing the practice may lack the evidence necessary to ensure practitioner confidence surrounding the option thereby limiting accessibility and women’s autonomy. Aim The aims of the study were to determine how water immersion policies and/or guidelines are informed, who interprets the evidence to inform policies/guidelines and to what extent the policy/guideline facilitates the option for labour and birth. Method Phase one of a three-phase mixed-methods study critically analysed 25 Australian water immersion policies/guidelines using critical discourse analysis. Findings Policies/guidelines pertaining to the practice of water immersion reflect subjective opinions and views of the current literature base in favour of the risk-focused obstetric and biomedical discursive practices. Written with hegemonic influence, policies and guidelines impact on the autonomy of both women and practitioners. Conclusion Policies and guidelines pertaining to water immersion, particularly for birth reflect opinion and varied interpretations of the current literature base. A degree of hegemonic influence was noted prompting recommendations for future maternity care policy and guidelines’. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

Problem Information that women receive about the importance of monitoring fetal movements and what to do if there are changes is inconsistent and may not be evidence based. Background This paper reports a summary of the kind of messages a group of South Australian midwives (n = 72) currently give pregnant women. Methods Comment data from two questions in a larger survey asking (1) what information midwives routinely provide to women about fetal movements and (2) their practice regarding advice they give to women reporting reduced fetal movements. Data were analysed using summative content analysis. Findings Four main recurring words and phrases were identified. With respect to information midwives give all women about monitoring fetal movements, recurring words were “10”, “normal”, “kick charts” and “when to contact” their care-provider. Recurrent words and phrases arising from answers to the second question about advice midwives give to women reporting reduced fetal movement were “ask questions,” “suggest fluids,” “monitor at home and call back” or “come in for assessment”. Discussion These findings suggest that a group of South Australian midwives are providing pregnant women with inconsistent information, often in conflict with best practice evidence. Conclusion As giving correct, evidence based information about what to do in the event of an episode of reduced fetal movement may be a matter of life or death for the unborn baby it is important that midwives use existing guidelines in order to deliver consistent information which is based on current evidence to women in their care.

This chapter outlines strategies midwives can use to raise awareness of stillbirth with women during pregnancy. It focuses on how to empower women to get to know, protect and advocate for their unborn baby. The other main challenge is providing sensitive, evidence-informed midwifery care once a stillbirth has occurred. The chapter discusses the importance of building a strong relationship between the midwife and the bereaved family from the time of diagnosis, through labour and following the birth. It also focuses on communication, privacy and shared decision-making and provides three core principles of care when a baby dies, namely communication, and facilitating privacy, and shared decision-making. There are four main challenges that have identified with respect to including a discussion about ways of reducing the risk of stillbirth during antenatal care provision, namely, breaking silence, ongoing discussion, changing habits and imparting knowledge. Good communication is considered a core competency of the qualified midwife, by most midwifery professional bodies globally.

Background: Water immersion for labour and birth is an option that is increasingly favoured by women.Australian water immersion policies and guidelines commonly specify that practitioners, such as midwives, must undertake further education and training to become accredited. Method: A three-phase mixed methods approach was used. Phase one used critical discourse analysis to determine who or what informs policies and guidelines related to water immersion for labour and/or birth. Phase two examined policy and guideline informants’ experiences of the development of policies/guidelines, whilst phase three surveyed Australian midwives’ views and experiences of water immersion and their use of and/or involvement in the development of policies and guidelines. Findings: Practitioner accreditation for the facilitation of water immersion was a common finding across all phases of the study. An examination of policies and guidelines found that practitioners, namely midwives, were required to meet additional training requirements to facilitate water immersion.Participants of phases two and three identified and discussed accreditation as a significant challenge to the option of water immersion, particularly where there were inconsistencies across documents and in the interpretation of their content. Conclusion: The need for practitioners to be accredited to facilitate water immersion was identified as a major barrier to availability and therefore, women’s ability to access the option. Given these findings, the need for accreditation should be challenged. Refereed/Peer-reviewed

Stillbirth is a global public health issue affecting over 2.6 million women at or beyond 28 weeks’ gestation each year.1 Raising awareness of decreased or reduced fetal movements (RFM) among pregnant women and clinicians is one existing strategy intended to reduce risk of stillbirth.2, 3, 4 RFM is strongly linked to stillbirth,4 yet suboptimal care for women with RFM is a commonly reported contributing factor to stillbirth.5, 6 Women frequently report that clinicians have not listened to their concerns about RFM and many delay reporting.4, 7 Misinformation about fetal movements is commonplace. For example, women are often told that RFM at term is to be expected due to the baby ‘running out of room’ or that RFM can be corrected by the woman drinking a glass of water. Such information can delay presentation with RFM. Reducing delayed presentation for RFM may increase the window of opportunity for meaningful assessment and intervention. Practice improvement initiatives aimed at raising awareness of RFM are widely accepted as an important prevention strategy for stillbirth.7 The recent AFFIRM trial results show that a package of care targeting women and clinicians did not reduce stillbirth rates, and increased interventions and neonatal admissions.8 The title of the editorial ‘encouraging awareness of fetal movement is harmful' does not accurately reflect the AFFIRM trial findings.9 It is important to look beyond the headlines and try to understand what this well-conducted trial is telling us in this complex area.

Decision-making pervades all aspects of midwifery practice across the world. Midwifery is informed by a number of decision-making theories, but it is sometimes difficult to marry these theories with practice. This book provides a comprehensive exploration of decision-making for midwives irrespective of where in the world they practice or in which model of care. The first part critically reviews decision-making theories, including the Enhancing Decision-making Assessment in Midwifery (EDAM) tool, and their relevance to midwifery. It explores the links between midwifery governance, including professional regulation and the law, risk and safety and decision-making as well as how critical thinking and reflection are essential elements of decision-making. It then goes on to present a number of diverse case studies, demonstrating how they interrelate to and impact upon optimal midwifery decision-making. Each chapter presents examples that show how the theory translates into practice and includes activities to reinforce learning points. Bringing together a diverse range of contributors, this volume will be essential reading for midwifery students, practising midwives and midwifery academics.

Background: Late stillbirth, that which occurs ≥28 weeks gestation, affects 1.3-8.8 per 1,000 births in high-income countries. Of concern, most occur in women without established risk factors. Identification of potentially modifiable risk factors that relate to maternal behaviours remains a priority in stillbirth prevention research. This study aimed to investigate, in an international cohort, whether maternal sleep practices are related to late stillbirth. Methods: An internet-based case-control study of women who had a stillbirth ≥28 weeks’ gestation within 30 days prior to completing the survey (n=153) and women with an ongoing third-trimester pregnancy or who had delivered a live born child within 30 days (n=480). Bivariate and multiple logistic regression was used to determine unadjusted and adjusted odds ratios (OR and aOR respectively) with 95% confidence intervals (95%CI) for stillbirth. Results: Sleeping >9 hours per night in the previous month was associated with stillbirth (aOR 1.75, 95%CI 1.10-2.79), as was waking on the right side (aOR 2.27, 95%CI 1.31-3.92). Non-restless sleep in the last month was also found to be associated with stillbirth (aOR 1.73, 95%CI 1.03-2.99), with good sleep quality in the last month approaching significance (aOR 1.64, 95%CI 0.98-2.75). On the last night of pregnancy, not waking more than one time was associated with stillbirth (aOR 2.03, 95%CI 1.24-3.34). No relationship was found with going to sleep position during pregnancy, although very few women reported settling in the supine position (2.4%). Conclusions: Long periods of undisturbed sleep are associated with late stillbirth. Physiological studies of how the neuroendocrine and autonomic system pathways are regulated during sleep in the context of late pregnancy are warranted.

Objectives: We investigated how women, seeking care due to decreased movements, had paid attention to fetal movements and if the method of monitoring was associated with pregnancy outcome. Methods: A questionnaire was distributed to women from gestational week 28, who had sought care due to decreased fetal movements in Stockholm between January 1st and December 31st , 2014. Women were included in the study if the examination did not reveal any signs of a compromised fetus requiring immediate intervention. Birth outcome and sociodemographic data were collected from the obstetric record register. Results: There were 29 166 births in Stockholm in 2014, we have information from 2683 women who sought care for decreased fetal movements. The majority (96.6%) of the women stated that they paid attention to fetal movements. Some women observed fetal movements weekly (17.2%) and 69.5% concentrated on fetal movements daily (non-structured group). One in ten (9.9%) used counting methods daily for observing fetal movements (structured group). Women in the structured group more often had caesarean section before onset of labor (RR 1.6, 95% CI 1.2–2.2) and a lower risk of their baby being transferred to neonatal nursery (RR 0.25, 95% CI 0.03–0.94) compared to women in the non-structured group. Conclusions: Women, who had a daily and structured approach to awareness of fetal movements, were more likely to have a caesarean section but their babies were less likely to be transferred to a neonatal nursery as compared with women who used a non-structured method daily. Refereed/Peer-reviewed

Objective The objective of this study was to explore the views, experiences, perceptions of and access to water immersion for labor and birth in Australia. Design A sequential exploratory mixed methods study commenced in 2016. The first phase involved an online survey. The second phase is due to commence in 2019 and will involve focus groups and interviews. This paper presents a subset of results from phase one that asked women to self-rate the benefits and risks associated with water use on Likert-scales and for those who had a previous birth not involving water, how the two experiences compared. Participants A total of 740 Australian women who had used water immersion for labor and/or birth rated the benefits against 7-point Likert scales and 736 responded to 5-point Likert scales relating to commonly cited concerns surrounding the option. Results Women highly rated water immersion against all benefits. Benefits that were most highly rated (by numbers of ‘entirely agree’ on 7-point Likert scales) included sense of safety (80.14%), an alert baby (75.00%), a positive birth experience (72.70%), water as soothing (72.03%) and freedom of movement (71.35%). Women were most concerned (by selecting ‘somewhat’ to ‘extremely concerned’ on 5-point Likert scales) about being told to get out of the water when they did not want to (n = 120/736, 16.30%), their contractions going away (n = 76/736, 10.33%) and unsupportive staff (n = 65/736, 8.83%). More than 90% (n = 682/740) of women mostly to entirely agreed that they would recommend water immersion to others. Women rated water immersion as more comfortable, more satisfying and more relaxing when compared to previous births that they had that did not involve water. Key conclusions Women value water immersion for labor and birth. They have very little to no concern for the most common adverse events as documented in the literature. Implications for practice The results add to the growing evidence base surrounding water immersion for labor and birth. Whilst there remains ongoing debate about the safety of water immersion, women's experiences should be considered alongside outcome data. The results of this study may assist policy makers and clinicians in their advocacy and support of women who choose water immersion. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

Problem Undergraduate education for midwives in the area of stillbirth may be lacking. Background When a baby dies the families are usually cared for, at some stage in their pregnancy or birth journey, by midwives, however, midwives may not be adequately prepared to care for them. Aim The aim of this study was to investigate the current content of stillbirth education in undergraduate midwifery curricula in Australia. Methods Nineteen midwifery program leaders from each of the Australian Universities that deliver undergraduate midwifery education were invited to respond to an online survey regarding content related to stillbirth risk, prevention and/or bereavement care. There were 10 complete surveys. Quantitative survey data were analysed and described using percentages, and data from the free text comments collected verbatim. Findings Responses indicated that there is a diverse inclusion of material relating to the topic of stillbirth, with different approaches to teaching the content and the amount of time devoted to the topic is relatively small. Discussion This small study in scoping curricula from participating Australian Universities indicated that more could be done to strengthen stillbirth related content. Stillbirth is a complex issue and therefore it is important for midwives to understand not only bereavement care but also the physiological underpinnings of issues that could be an antecedent cause or precursor for stillbirth. Conclusion There is room to improve and standardise appropriate stillbirth curriculum nationally. It is imperative that midwives are able to provide sensitive and knowledgeable care to all women and their families.

Background Water immersion for labour and birth is consistently challenged as a practice lacking support from high quality evidence. Despite this, the option is available to Australian women. Practitioners are guided by policies and guidelines however, given the research paucity, questions surround the way in which water immersion policies and guidelines are informed. Aims The aims of the study were to determine how water immersion policies and/or guidelines are informed and to what extent the policy/guideline facilitates the option of water immersion for labour and birth with respect to women’s choice and autonomy. Methods Phase two of a three phase mixed methods study used critical, post structural interpretive interactionism to examine the process of development and implementation of water immersion policies and guidelines from informant’s experience. Semi-structured interviews were conducted with 12 Australian participants. Findings Participants highlighted that the lack of randomised controlled trials had resulted in other forms of evidence being drawn upon to inform water immersion policies and guidelines. This was influenced in part by individual interpretations of evidence with medical views taking precedence. This sometimes resulted in policy and guideline documents that were restrictive with this impacting on women’s ability to access the option. Conclusion Perceived limitations of research and the subsequent translation of this perceived paucity of evidence into policies and guidelines, has impacted on women’s ability to exercise choice and autonomy with respect to water immersion and indeed, on the professional autonomy of practitioners who wish to facilitate it.

Changes in fetal movement are associated with increased risk of stillbirth after 28 weeks of pregnancy. The majority of studies have focussed on maternal perception of reduced fetal movements, which is associated with stillbirth via placental dysfunction. Recent studies have also described an association between a single episode of excessive fetal movements and late stillbirth. We present a hypothesis that a sudden episode of excessive fetal activity indicates fetal compromise relating to underlying disturbance of the in utero environment, which if it persists can lead to fetal death. The origin of the excessive fetal movements is unknown; they may represent fetal seizures induced by asphyxia or infection, an attempt to release cord entanglement or a change in fetal behaviour (inducing signs of distress) in response to a noxious stimulus. It is also possible that an increase in maternal anxiety may lead to increased perception of fetal activity. Current evidence regarding excessive fetal movements is sparse; there is no clinical guidance regarding how reporting of this symptom might relate to a fetus at risk and which management might reduce the risk of subsequent stillbirth. This could be addressed by prospective observational studies of mothers presenting with excessive fetal movements which could both explore the underlying pathophysiology and determine which investigations could identify fetal compromise in this population. The presence of fetal seizures or umbilical cord entanglement could be evaluated at the time of presentation by cardiotocography and ultrasonography of the fetus and cord. Exposure to infection or noxious stimuli could be evaluated by maternal history and measurement of maternal blood for inflammatory markers or toxins. Maternal anxiety could be assessed by validated anxiety scores. Fetal outcome following excessive fetal movements can be recorded after birth. In addition, the presence of perinatal asphyxia can be assessed using Apgar scores, assessment of fetal acidaemia or measurement of stress-related factors in umbilical cord blood. The placenta and cord can be systematically examined for signs of hypoxia, infection or umbilical cord compression. Such studies would provide evidence regarding the underlying cause of excessive fetal movement and how this symptom might relate to in utero compromise and stillbirth. Ultimately, this approach will determine whether excessive fetal movements can be used alongside reduced fetal movements as a tool to reduce the perinatal mortality rate. Refereed/Peer-reviewed

Background: Nurses working in the neonatal intensive care unit (NICU) who care for dying infants and their families say they do not necessarily have the expertise or the specific training to provide quality end-of-life-care (EOLC). Purpose: The purpose of this review was to critically appraise the existing qualitative literature regarding nurses' experiences when caring for infants during end of life in the NICU and to identify barriers and enablers to provide quality EOLC. Search Strategy: A literature search was conducted using CINAHL and OVID databases. Studies that explored nurses' experiences when caring for infants who were dying or when lifesaving care was withdrawn were retrieved and 15 studies were thematically analyzed. Results: Five major themes emerged: advocating for the dying infant, building close relationships with the family, providing an appropriate care environment, nurses' emotional responses to dying or death, and professional inadequacy in EOLC. Implications for Practice: Nurses face multiple challenges when providing EOLC including moral dilemmas and feelings of professional inadequacy. Avoidance was a common strategy used by nurses to cope with the stress associated with EOLC. Managers can foster quality EOLC by implementing education sessions about infant mortality, EOLC, advocacy, team communication, and self-care practices. Implications for Research: Research could evaluate the effectiveness of EOLC education sessions to build nurses' competence and confidence in advocacy and EOLC clinical skills Refereed/Peer-reviewed

Background Stillbirth after 28 weeks gestation affects between 1.3–8.8 per 1000 births in high-income countries. The majority of stillbirths in this setting occur in women without established risk factors. Identification of risk factors which could be identified and managed in pregnancy is a priority in stillbirth prevention research. This study aimed to evaluate women’s experiences of fetal movements and how these relate to stillbirth. Methods An international internet-based case–control study of women who had a stillbirth ≥28 weeks’ gestation within 30 days prior to completing the survey (n = 153) and women with an ongoing pregnancy or a live born child (n = 480). The online questionnaire was developed with parent stakeholder organizations using a mixture of categorical and open–ended responses and Likert scales. Univariate and multiple logistic regression was used to determine crude (unadjusted) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). Summative content analysis was used to analyse free text responses. Results Women whose pregnancy ended in stillbirth were less likely to check fetal movements (aOR 0.54, 95% CI 0.35–0.83) and were less likely to be told to do so by a health professional (aOR 0.55, 95% CI 0.36–0.86). Pregnancies ending in stillbirth were more frequently associated with significant abnormalities in fetal movements in the preceding two weeks; this included a significant reduction in fetal activity (aOR 14.1, 95% CI 7.27–27.45) or sudden single episode of excessive fetal activity (aOR 4.30, 95% CI 2.25–8.24). Cases described their perception of changes in fetal activity differently to healthy controls e.g. vigorous activity was described as “frantic”, “wild” or “crazy” compared to “powerful” or “strong”. Conclusions Alterations in fetal activity are associated with increased risk of stillbirth. Pregnant women should be educated about awareness of fetal activity and reporting abnormal activity to health professionals. Electronic supplementary material The online version of this article (10.1186/s12884-017-1555-6) contains supplementary material, which is available to authorized users.

Background There is little published research that has examined practitioners’ views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. Aims The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. Methods Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. Findings Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women’s informed choice. Conclusion Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

This article reviews three new and emerging risk factors for stillbirth that may be modifiable or might identify a compromised fetus. We focus on fetal movements, maternal sleep, and maternal diet. Recent studies have suggested than a sudden increase in vigorous fetal activity may be associated with increased risk of stillbirth. We review the papers that have reported this finding and discuss the implications as well as potential future directions for research. There is emerging literature to suggest that maternal sleep position may be a risk for stillbirth, especially if the woman settles to sleep supine. This risk is biologically plausible. How this knowledge may be utilized to assist stillbirth reduction strategies is discussed. Finally, we examine the somewhat limited literature regarding maternal diet and pregnancy outcome. Introducing probiotics into the diet may prove useful, but further work is required. The possible next steps for research are considered, as well as some potential intervention strategies that may ultimately lead to stillbirth reduction. Refereed/Peer-reviewed

Objective: To determine if the way caregivers offer opportunities to see and hold a stillborn baby impacts a mother's feelings about the experience of seeing and holding her newborn. Design and setting: A web questionnaire hosted by the Swedish National Infant Foundation from March 2008 to April 2010. Findings: When mothers were presented the baby as a normal part of birth without being asked if they wanted to see, they more often reported that the experience was comfortable compared to mothers who were asked if they wanted to see the baby 86% vs. 76% (p=