Caution needed when implementing national stillbirth program
Caution must be used when implementing the recently launched Safer Baby Bundle, so that population-level reductions in the stillbirth rate are not offset by healthcare-induced harm to healthy babies, according to the authors of a Perspective published online today by the Medical Journal of Australia.
The Safer Baby Bundle is a national program that aims to reduce stillbirth in Australia by 20% by 2023. It is made up of five components:
- supporting women to stop smoking in pregnancy
- improving awareness of a safe maternal sleeping position
- improving decision making about timing of birth
- improving the detection and management of fetal growth restriction (FGR)
- raising awareness and improving care for women with decreased fetal movements (DFM).
Professor Euan Wallace, CEO of Safer Care Victoria and colleagues, wrote that although whole-of-population level programs were important and effective, there was potential for harm.
"Of these five components, the latter two have the potential to increase early delivery," Wallace and colleagues wrote.
"FGR is the strongest contributor to the burden of stillbirth. Improving the detection of FGR is central to any program aiming to reduce stillbirth," they wrote. "But increasing FGR detection may also cause harm. In Victoria, a greater focus on improving the detection of FGR quadrupled the number of babies delivered early for suspected FGR, from 741 in 2000 to 2996 in 2017. The number and proportion of these babies with a birthweight in the 10th centile or greater increased from 307 (41%) to 1597 (53%). Striving to increase the sensitivity of FGR detection decreased specificity. This is a problem because unwarranted early delivery is harmful to both immediate perinatal and longer term developmental outcomes."
Detecting decreased fetal movements as a method of predicting stillbirth was also potentially problematic, Wallace and colleagues wrote.
"Women who report DFM have a 2.4-fold increased risk of stillbirth. However, translating this into an effective intervention has been challenging. Thirty years ago, it was shown that the use of formal fetal movement counting charts failed to reduce stillbirth. More recently, a large randomized controlled trial—the AFFIRM trial—assessed a care package for women presenting with DFM. In over 400 000 women attending 33 health services in the UK, increasing the awareness of DFM and standardizing the care of those women presenting with DFM did not significantly reduce stillbirth.
"Despite clear guidance for clinicians about what investigations to offer women with DFM and under what circumstances delivery was merited, there was an increase in the rates of induction of labor and cesarean delivery, with an additional 500 babies born between 32 and 34 weeks' gestation and 5000 more born between 34 and 37 weeks' gestation. The number of babies requiring admission to a neonatal unit also increased. The fact that most women with DFM will go on to give birth to a healthy baby suggests that the care package assessed by AFFIRM needs to be better targeted to women at risk," Wallace and colleagues wrote.
The authors concluded that until more "discriminatory screening tools" were developed, caution was needed so that "population-level reductions in the stillbirth rate are not offset by iatrogenic harm" to healthy babies.
"It is crucial that the potential for unintended harm is made explicit and that measures of unnecessary early delivery are used to monitor progress of the Safer Baby Bundle implementation in Australia," they concluded.