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Background Prioritisation of stillbirth research in high-income countries is required to address preventable stillbirth. However, concern is raised by ethics committees, maternity providers and families, when pregnant and bereaved women are approached to participate. Our aim was to 1) assess factors influencing recruitment in a multicentre case-control stillbirth study and 2) gain insight into how women felt about their participation. Methods Eligible women were contacted through maternity providers from seven New Zealand health regions in 2011-2015. Cases had a recent singleton non-anomalous late stillbirth (≥28 weeks’ gestation). Controls were randomly selected and matched for region and gestation. Participants were interviewed by a research midwife and given a feedback form asking their views about participation. Feedback was evaluated using thematic analysis. Results 169 (66.5%) of 254 eligible cases and 569 (62.2%) of 915 eligible controls were recruited. Non-participants consisted of 263 (22.5% of eligible) women who declined, 108 (9.2% of eligible) uncontactable women, and 60 (5.1% of eligible) women declined by the maternity provider, with no significant differences between the proportion of non-participating cases and controls in each of these three categories. The majority (63.2%) of women did not provide a specific reason for non-participation. Written feedback was provided by 111 participants (cases 15.3%, controls 14.9%) and all described their involvement positively. Feedback themes identified were ‘motivation to participate,’ ‘ease of participation,’ and ‘post-participation positivity.’ Conclusion Identification of recruitment barriers and our reassuring participant feedback may assist women’s participation in future research and support progress towards stillbirth prevention.

Background and objectivesSleep-disordered breathing (SDB) affects up to one third of women during late pregnancy and is associated with adverse pregnancy outcomes, including hypertension, diabetes, impaired fetal growth, and preterm birth. However, it is unclear if SDB is associated with late stillbirth (≥28 weeks' gestation). The aim of this study was to investigate the relationship between self-reported symptoms of SDB and late stillbirth.MethodsData were obtained from five case-control studies (cases 851, controls 2257) from New Zealand (2 studies), Australia, the United Kingdom, and an international study. This was a secondary analysis of an individual participant data meta-analysis that investigated maternal going-to-sleep position and late stillbirth, with a one-stage approach stratified by study and site. Inclusion criteria: singleton, non-anomalous pregnancy, ≥28 weeks' gestation. Sleep data ('any' snoring, habitual snoring ≥3 nights per week, the Berlin Questionnaire [BQ], sleep quality, sleep duration, restless sleep, daytime sleepiness, and daytime naps) were collected by self-report for the month before stillbirth. Multivariable analysis adjusted for known major risk factors for stillbirth, including maternal age, body mass index (BMI kg/m2), ethnicity, parity, education, marital status, pre-existing hypertension and diabetes, smoking, recreational drug use, baby birthweight centile, fetal movement, supine going-to-sleep position, getting up to use the toilet, measures of SDB and maternal sleep patterns significant in univariable analysis (habitual snoring, the BQ, sleep duration, restless sleep, and daytime naps). Registration number: PROSPERO, CRD42017047703.ResultsIn the last month, a positive BQ (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 1.02-2.04), sleep duration >9 hours (aOR 1.82, 95% CI 1.14-2.90), daily daytime naps (aOR 1.52, 95% CI 1.02-2.28) and restless sleep greater than average (aOR 0.62, 95% CI 0.44-0.88) were independently related to the odds of late stillbirth. 'Any' snoring, habitual snoring, sleep quality, daytime sleepiness, and a positive BQ excluding the BMI criterion, were not associated.ConclusionA positive BQ, long sleep duration >9 hours, and daily daytime naps last month were associated with increased odds of late stillbirth, while sleep that is more restless than average was associated with reduced odds. Pregnant women may be reassured that the commonly reported restless sleep of late pregnancy may be physiological and associated with a reduced risk of late stillbirth.

Background: Maternal supine going-to-sleep position has been associated with increased risk of late stillbirth (≥28 weeks), but it is unknown if the risk differs between right and left side, and if some pregnancies are more vulnerable. Methods: Systematic searches were undertaken for an individual-level participant data (IPD) meta-analysis of case–control studies, prospective cohort studies and randomised trials undertaken up until 26 Jan, 2018, that reported data on maternal going-to-sleep position and stillbirth. Participant inclusion criteria included gestation ≥28 weeks', non-anomalous, singleton pregnancies. The primary outcome was stillbirth. A one-stage approach stratified by study and site was used for the meta-analysis. The interaction between supine going-to-sleep position and fetal vulnerability was assessed by bi-variable regression. The multivariable model was adjusted for a priori confounders. Registration number: PROSPERO, CRD42017047703. Findings: Six case–control studies were identified, with data obtained from five (cases, n = 851; controls, n = 2257). No data was provided by a sixth study (cases, n = 100; controls, n = 200). Supine going-to-sleep position was associated with increased odds of late stillbirth (adjusted odds ratio [aOR] 2.63, 95% CI 1.72–4.04, p

BACKGROUND For parents who experience stillbirth, knowing the cause of their baby's death is important. A post mortem examination is the gold standard investigation, but little is known about what may influence parents' decisions to accept or decline. AIM We aimed to identify factors influencing maternal decision-making about post mortem examination after late stillbirth. METHODS In the New Zealand Multicentre Stillbirth Study, 169 women with singleton pregnancies, no known abnormality at recruitment, and late stillbirth (≥28weeks gestation), from seven health regions were interviewed within six weeks of birth. The purpose of this paper was to explore factors related to post mortem examination decision-making and the reasons for declining. We asked women if they would make the same decision again. RESULTS Maternal decision to decline a post mortem (70/169, 41.4%) was more common among women of Māori (adjusted odds ratio (aOR) 4.99 95% confidence interval (CI) 1.70-14.64) and Pacific (aOR 3.94 95% CI 1.47-10.54) ethnicity compared to European, and parity two or more (aOR 2.95 95% CI 1.14-7.62) compared to primiparous. The main reason for declining was that women 'did not want baby to be cut'. Ten percent (7/70) who declined said they would not make this decision again. No woman who consented regretted her decision. CONCLUSION Ethnic differences observed in women's post mortem decision-making should be further explored in future studies. Providing information of the effect of post mortem on the baby's body and the possible emotional benefits of a post mortem may assist women faced with this decision in the future.

Importance Supine maternal position in the third trimester is associated with reduced uterine blood flow and increased risk of late stillbirth. As reduced uterine blood flow is also associated with fetal growth restriction, this study explored the association between the position in which pregnant women went to sleep and infant birth weight. Objective To examine the association between supine position when going to sleep in women after 28 weeks of pregnancy and lower birth weight and birth weight centiles. Design, Setting, and Participants Prespecified subgroup analysis using data from controls in an individual participant data meta-analysis of 4 case-control studies investigating sleep and stillbirth in New Zealand, Australia, and the United Kingdom. Participants were women with ongoing pregnancies at 28 weeks’ gestation or more at interview. Main Outcomes and Measures The primary outcome was adjusted mean difference (aMD) in birth weight. Secondary outcomes were birth weight centiles (INTERGROWTH-21st and customized) and adjusted odds ratios (aORs) for birth weight less than 50th and less than 10th centile (small for gestational age) for supine vs nonsupine going-to-sleep position in the last 1 to 4 weeks, adjusted for variables known to be associated with birth size. Results Of 1760 women (mean [SD] age, 30.25 [5.46] years), 57 (3.2%) reported they usually went to sleep supine during the previous 1 to 4 weeks. Adjusted mean (SE) birth weight was 3410 (112) g among women who reported supine position and 3554 (98) g among women who reported nonsupine position (aMD, 144 g; 95% CI, −253 to −36 g;P = .009), representing an approximate 10-percentile reduction in adjusted mean INTERGROWTH-21st (48.5 vs 58.6; aMD, −10.1; 95% CI, −17.1 to −3.1) and customized (40.7 vs 49.7; aMD, −9.0; 95% CI, −16.6 to −1.4) centiles. There was a nonsignificant increase in birth weight at less than the 50th INTERGROWTH-21st centile (aOR, 1.90; 95% CI, 0.83-4.34) and a 2-fold increase in birth weight at less than the 50th customized centile (aOR, 2.12; 95% CI, 1.20-3.76). Going to sleep supine was associated with a 3-fold increase in small for gestational age birth weight by INTERGROWTH-21st standards (aOR, 3.23; 95% CI, 1.37-7.59) and a nonsignificant increase in small for gestational age birth weight customized standards (aOR, 1.63; 95% CI, 0.77-3.44). Conclusions and Relevance This study found that going to sleep in a supine position in late pregnancy was independently associated with reduced birth weight and birth weight centile. This novel association is biologically plausible and likely modifiable. Public health campaigns that encourage women in the third trimester of pregnancy to settle to sleep on their side have potential to optimize birth weight.

Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19 439 late gestation ( 28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20-30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities.

In this chapter an overview of death within New Zealand contemporary society is presented as a background to the rituals and funerary practices of our diverse population. A brief outline of some of New Zealand’s history is offered alongside discussion on religious affiliation and practice. Māori myths and legends are also presented; these form a backdrop to the systems and approaches to death and mourning for our indigenous population. From this “Macro” viewpoint, we then focus on the “Meso” or more detailed practices within the culture of death in New Zealand, primarily the tangihanga or Māori funerary ritual. This unique ritual provides a framework for understanding death from a Māori perspective and has remained a constant funerary ritual since colonisation in the nineteenth century. Finally we discuss baby and infant loss in New Zealand, offering a “Micro” perspective on a prevalent yet under acknowledged mortality statistic. Case studies of two bereaved mothers and their experiences of mourning and funerary practices following the loss of their precious babies are presented as a means of illustrating the “Macro”, “Meso” and “Micro” perspectives of death, grief and culture in relation to baby and infant loss in New Zealand in the twenty-first century.

The Board of the International Stillbirth Alliance (ISA) would like to thank and to congratulate The Lancet on publishing its Stillbirths Series. Stillbirth has a profound eff ect on mothers, fathers, family, and care providers. The Comment by Zoe Mullan and Richard Horton includes a photograph of a couple with their stillborn baby, which clearly illustrates the enormity of this loss and gives hope that the invisibility of stillbirth, which has held back progress for so long, is now over. ISA was pleased to contribute to the activities of the 69 authors, from more than 50 institutions across 18 countries, to produce this series through a grant from the Gates Foundation. ISA was founded on the dream of three mothers of stillborn babies who shared a vision to make a diff erence in the stillbirth cause. Their dream was to create an organisation that would combine the knowledge of health-care professionals with the passion of families to advance stillbirth research, medical care, and bereavement services. ISA now has 47 member organisations in 14 countries and works to link people around the world to address stillbirth. Through annual conferences combining bereavement care, clinical practice, and research in stillbirth prevention, ISA brings people together from all backgrounds to share knowledge and foster col laboration. ISA has made a commit ment to address the call for action in this Series through each annual conference. Parents are central to the work of ISA. Many ISA organisations are parentbased, established by those who have suff ered the loss of a child through stillbirth. Many of these organisations focus on bereavement support and promoting awareness and many also support and undertake research. Our Parent Advisory Committee is made up of these member organisations. We believe that a large proportion of the huge global burden of stillbirths is potentially preventable, and through the collaboration of global partners this can be realised. To effect this change, resources are required. These resources need to support the provision of care to prevent stillbirth, to ensure best practice in our provision of care, and to fund research to address the losses that occur despite best practice. ISA implores funding agencies to support activities that address the call to action of The Lancet’s Stillbirths Series.