Care, connection, and social distancing: The challenges of baby loss during the COVID-19 pandemic in Aotearoa New Zealand.

PROBLEM: The COVID-19 pandemic hindered access to routine healthcare globally, prompting concerns about possible increases in pregnancy loss and perinatal death. BACKGROUND: PUDDLES is an international collaboration exploring the impact of the COVID-19 pandemic on parents who experience pregnancy loss and perinatal death in seven countries, including Aotearoa New Zealand. AIM: To explore parents' experiences of access to healthcare services and support following baby loss during the COVID-19 pandemic in Aotearoa New Zealand. METHODS: We conducted in-depth, semi-structured interviews with 26 bereaved parents, including 20 birthing mothers, and six non-birthing parents (one mother and five fathers). Types of loss included 15 stillbirths, four late miscarriages, and one neonatal death. Participant ethnicities were broadly representative of Aotearoa New Zealand's multi-ethnic society. Data were analysed using Template Analysis. FINDINGS: Analysis revealed five themes relating to pandemic impact on bereaved parent's experiences. These were: 'Distanced and Impersonal care'; 'Navigating Hospital Rules'; Exclusion of Non-birthing Parents; 'Hindered Access to Social Support'; and 'Continuity of Relational Care'. DISCUSSION: The COVID-19 pandemic exacerbated isolation of bereaved parents through perceived impersonal care by healthcare professionals and restrictions on movement hindered access to social and cultural support. Compassionate bending of the rules by healthcare professionals and community postnatal visits by continuity of care midwives following the bereavement appeared to be mitigating factors. CONCLUSION: Social isolation is an added challenge for parents experiencing baby loss during a pandemic, which may be mitigated by flexible and compassionate care from healthcare professionals, especially continuity of care midwives.

Obstetrician views on Fetal Pillow® device use and research in Aotearoa New Zealand: A cross-sectional survey.

BACKGROUND: There is anecdotal evidence of Fetal Pillow® use, but no formal local information on clinician practices and perspectives. AIMS: To assess obstetrician use of the Fetal Pillow®, knowledge of relevant research, and interest in a proposed randomised controlled trial in Aotearoa New Zealand. MATERIALS AND METHODS: Anonymous cross-sectional survey of practising obstetricians and obstetric trainees in Aotearoa New Zealand distributed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RESULTS: Of 136 respondents (69% specialists and 31% trainees), 130 had heard of the Fetal Pillow® device, and 108 had used it at least once (43% more than ten times). The device was available in 17/21 units represented. The 108 users of the device reported this was most commonly on collegial advice (63%) or after personal experience of a difficult delivery (33%) and most (80%) believed it reduced maternal morbidity. Only around one-third of the 130 respondents who had heard of the device agreed there was adequate research demonstrating its efficacy for maternal (36%) and neonatal (30%) morbidity. The majority reported they would change practice in response to a randomised trial, although they were more likely to start use (81% of current non-users) than stop (53% of users). Most (70%) respondents agreed they would encourage patients to participate in a randomised trial. CONCLUSIONS: The Fetal Pillow® is available in most maternity units in Aotearoa New Zealand. The majority of obstetric clinicians believe it reduces maternal morbidity, while acknowledging the lack of scientific evidence. Most would support a randomised trial.

Maternal and neonatal morbidity associated with Fetal Pillow® use at full dilatation caesarean: A retrospective cohort.

OBJECTIVE: To investigate associations of the Fetal Pillow® with maternal and neonatal morbidity. DESIGN: Retrospective cohort. SETTING: Two tertiary maternity units, New Zealand. POPULATION OR SAMPLE: Full dilatation singleton, term, cephalic caesarean section, with three comparisons: at Unit A (1) before versus after introduction of the Fetal Pillow® (1 Jaunary 2016-31 October 2021); (2) with versus without the Fetal Pillow® after introduction (27 July 2017-31 October 2021); and (3) between Unit A and Unit B during the same time period (1 January 2019-31 October 2021). The Fetal Pillow® is unavailable at Unit B. METHODS: Cases were ascertained and clinical data were extracted from electronic clinical databases and records. Outcome data were adjusted and presented as adjusted odds ratios (aOR) with 95% CI. MAIN OUTCOME MEASURES: Primary outcome "any" uterine incision extension; secondary outcomes included major extension (into adjacent structures), and a composite neonatal outcome. RESULTS: In all, 1703 caesareans were included; 375 with the device and 1328 without. Uterine incision extension rates were: at Unit A before versus after introduction: 26.8% versus 24.8% (aOR 0.88, 95% CI 0.65-1.19); at Unit A with the Fetal Pillow® versus without: 26.1% versus 23.8% (aOR 1.14, 95% CI 0.83-1.57); and at Unit A versus Unit B: 24.2% versus 29.2% (aOR 0.73, 95% CI 0.54-0.99). No differences were found in major extensions, or neonatal composite outcome. CONCLUSIONS: Despite the relatively large size of this study, it could not rule out either a positive or a negative association between use of the Fetal Pillow® and uterine extensions, major uterine incision extensions, and neonatal morbidity. Randomised controlled trial evidence is required to assess efficacy.

Diabetes in pregnancy: Women's views of care in a multi-ethnic, low socioeconomic population with midwifery continuity-of-care.

BACKGROUND: Diabetes in pregnancy is diagnosed in 6% of pregnancies annually in Aotearoa-New Zealand, disproportionately affecting multi-ethnic, low socio-economic women. Little is known about the care experience of this population within the model of midwifery continuity-of-care, including views of telehealth care. AIM: Increase understanding of the experience of diabetes in pregnancy care, including telehealth, among multi-ethnic, low socio-economic women receiving midwifery continuity-of-care. METHODS: Qualitative interview study with primarily indigenous and migrant women who had diabetes in pregnancy and gave birth 6-18 months previously. Interviewers were matched with participants by ethnicity. Transcripts were analysed using Framework analysis. RESULTS: Participants were 19 women (5 Maori, 5 Pacific Peoples, 5 Asian, 4 European). Data analysis revealed three key themes: 1) 'shock, shame, and adjustment' to the diagnosis 2) 'learning to manage diabetes in pregnancy' and 3) 'preparation for birth and beyond' to the postpartum period. DISCUSSION: Receiving the diagnosis of diabetes in pregnancy was a shock. Managing diabetes during pregnancy was particularly challenging for indigenous and migrant women, who wished for better access to culturally appropriate dietary and lifestyle information. Women appreciated having options of telehealth and face-to-face consultations. Preparation for birth and postpartum diabetes follow-up were areas requiring significant improvement. Challenges were mitigated through care from a consistent diabetes specialist midwife and community-based midwifery continuity-of-care. CONCLUSION: Midwives were the backbone of diabetes in pregnancy care for this multi-ethnic, low socio-economic population. Care could be improved with more culturally appropriate diet and lifestyle information, better birth preparation, and expanded postpartum diabetes support.

A validation of placental pathology reports by ethnicity in New Zealand, through systematic analysis of histological slides.

INTRODUCTION: Reliability studies of placental examination have shown differing interobserver agreement for certain pathological features, a lack of uniform reporting criteria and variable experience among pathologists. In previous analyses we have shown that placental pathology differs by ethnicity. This validation study was performed to investigate whether bias related to ethnicity is a feature of placental pathology reporting in New Zealand (NZ). METHODS: 199 of 1726 eligible perinatal death cases between 2008 and 2017 were selected at random for this audit-type study, including 51 cases from South Asian, Maori and NZ European ethnicity and 46 cases from Pacific mothers. Stored histology slides were blinded and re-examined by an experienced perinatal pathologist, and linked to the corresponding original pathology report. Interobserver agreement (overall, by ethnicity and by gestational age) was described by proportional differences and kappa coefficients. RESULTS: Total interobserver agreement between original placental reporting and the validation review was 89.7 %, which differed by pathological feature. There was generally more underreporting than overreporting (3.6 % and 6.7 %, respectively). There was little disagreement by ethnicity (decidual vasculopathy [p = 0.03]), although there were more differences by gestational age (villous morphology [p < 0.01], chorioamnionitis [p = 0.03], high-grade villitis of unknown etiology [p < 0.01], and placental haemorrhage [p = 0.03]). DISCUSSION: No systematic bias in placental pathology reporting in NZ was identified by ethnicity or gestational age, as observed differences could be related to the underlying prevalence of pathology. We identified more underreporting than overreporting of pathology in the original reports, emphasizing the importance of placental investigation by specialised perinatal pathologists.

Does fetal size affect maternal perception of fetal movements? Evidence from an individual participant data meta-analysis.

INTRODUCTION: Maternal perception of fetal movements during pregnancy are reassuring; however, the perception of a reduction in movements are concerning to women and known to be associated with increased odds of late stillbirth. Prior to full term, little evidence exists to provide guidelines on how to proceed unless there is an immediate risk to the fetus. Increased strength of movement is the most commonly reported perception of women through to full term, but perception of movement is also hypothesized to be influenced by fetal size. The study aimed to assess the pattern of maternal perception of strength and frequency of fetal movement by gestation and customized birthweight quartile in ongoing pregnancies. A further aim was to assess the association of stillbirth to perception of fetal movements stratified by customized birthweight quartile. MATERIAL AND METHODS: This analysis was an individual participant data meta-analyses of five case-control studies investigating factors associated with stillbirth. The dataset included 851 cases of women with late stillbirth (>28 weeks' gestation) and 2257 women with ongoing pregnancies who then had a liveborn infant. RESULTS: The frequency of prioritized fetal movement from 28 weeks' gestation showed a similar pattern for each quartile of birthweight with increased strength being the predominant perception of fetal movement through to full term. The odds of stillbirth associated with reduced fetal movements was increased in all quartiles of customized birthweight centiles but was notably greater in babies in the lowest two quartiles (Q1: adjusted OR: 9.34, 95% CI: 5.43, 16.06 and Q2: adjusted OR: 6.11, 95% CI: 3.11, 11.99). The decreased odds associated with increased strength of movement was present for all customized birthweight quartiles (adjusted OR range: 0.25-0.56). CONCLUSIONS: Increased strength of fetal movements in late pregnancy is a positive finding irrespective of fetal size. However, reduced fetal movements are associated with stillbirth, and more so when the fetus is small.

An in-depth analysis of perinatal related mortality among women of South Asian ethnicity in Aotearoa New Zealand.

BACKGROUND: International and national New Zealand (NZ) research has identified women of South Asian ethnicity at increased risk of perinatal mortality, in particular stillbirth, with calls for increased perinatal research among this ethnic group. We aimed to analyse differences in pregnancy outcomes and associated risk factors between South Asian, Maori, Pacific and NZ European women in Aotearoa NZ, with a focus on women of South Asian ethnicity, to ultimately understand the distinctive pathways leading to adverse events. METHODS: Clinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, while national maternity and neonatal data, and singleton birth records from the same decade, were linked using the Statistics NZ Integrated Data Infrastructure for all births. Pregnancy outcomes and risk factors for stillbirth and neonatal death were compared between ethnicities with adjustment for pre-specified risk factors. RESULTS: Women of South Asian ethnicity were at increased risk of stillbirth (aOR 1.51, 95%CI 1.29-1.77), and neonatal death (aOR 1.51, 95%CI 1.17-1.92), compared with NZ European. The highest perinatal related mortality rates among South Asian women were between 20-23 weeks gestation (between 0.8 and 1.3/1,000 ongoing pregnancies; p < 0.01 compared with NZ European) and at term, although differences by ethnicity at term were not apparent until ≥ 41 weeks (p < 0.01). No major differences in commonly described risk factors for stillbirth and neonatal death were observed between ethnicities. Among perinatal deaths, South Asian women were overrepresented in a range of metabolic-related disorders, such as gestational diabetes, pre-existing thyroid disease, or maternal red blood cell disorders (all p < 0.05 compared with NZ European). CONCLUSIONS: Consistent with previous reports, women of South Asian ethnicity in Aotearoa NZ were at increased risk of stillbirth and neonatal death compared with NZ European women, although only at extremely preterm (< 24 weeks) and post-term (≥ 41 weeks) gestations. While there were no major differences in established risk factors for stillbirth and neonatal death by ethnicity, metabolic-related factors were more common among South Asian women, which may contribute to adverse pregnancy outcomes in this ethnic group.

Placental pathology findings in perinatal deaths from 28 weeks gestation in Aotearoa New Zealand.

INTRODUCTION: Women of South Asian ethnicity are overrepresented in adverse pregnancy outcome across high-income countries, including those related to placental dysfunction. It has been hypothesised that placental aging occurs at earlier gestation in South Asian pregnancies. We aimed to identify differences in placental pathology among perinatal deaths ≥28 weeks gestation, between South Asian, Maori and New Zealand (NZ) European women in Aotearoa NZ, with a focus on women of South Asian ethnicity. METHODS: Placental pathology reports and clinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, blinded, and analysed by an experienced perinatal pathologist using the Amsterdam Placental Workshop Group Consensus Statement criteria. RESULTS: 790 of 1161 placental pathology reports, 346 preterm (28+0 to 36+6 weeks) and 444 term (≥37+0 weeks) deaths, met the inclusion criteria. Among preterm deaths, South Asian women had higher rates of maternal vascular malperfusion compared with Maori (aOR 4.16, 95%CI 1.55-11.15) and NZ European (aOR 2.60, 95%CI 1.10-6.16). Among term deaths, South Asian women had higher rates of abnormal villous morphology compared with Maori (aOR 2.19, 95%CI 1.04-4.62) and NZ European (aOR 2.12, 95%CI 1.14-3.94), mostly due to increased rates of chorangiosis (36.7%, compared to 23.3% and 21.7%, respectively). DISCUSSION: Differences in placental pathology by ethnicity were observed among preterm and term perinatal deaths. While we suspect differing underlying causal pathways, these deaths may be associated with maternal diabetic and red blood cell disorders among South Asian women, leading to a hypoxic state in-utero.

Placental pathology findings amongst extremely preterm perinatal deaths in Aotearoa New Zealand.

INTRODUCTION: Women of South Asian ethnicity are overrepresented in adverse pregnancy outcomes across high-income countries, including placental dysfunction and antepartum haemorrhage. As the burden of mortality is highest for extremely preterm infants, we aimed to identify any differences in placental pathology among perinatal deaths from 20+0 to 27+6 weeks gestation between South Asian, Maori and New Zealand (NZ) European women in Aotearoa NZ, with a focus on women of South Asian ethnicity. METHODS: Placental pathology reports and clinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, blinded and analysed by an experienced perinatal pathologist using the Amsterdam Placental Workshop Group Consensus Statement criteria. South Asian ethnicity was classified as Indian, Fijian Indian, South African Indian, Sri Lankan, Pakistani and Bangladeshi. RESULTS: 886 of 1571 placental pathology reports met the inclusion criteria. Women of South Asian ethnicity were significantly more likely to show features of histologic chorioamnionitis (aOR 1.87, 95%CI 1.19-2.94) and chorionic vasculitis (aOR 1.92, 95%CI 1.13-3.29), than NZ European and Maori women respectively. 13 of 15 (87%) of South Asian mothers with a diabetic disorder were identified with chorioamnionitis, compared to 1 in 5 (20%) of Maori and 5 in 12 (41%) of NZ European women. Cord hyper-coiling was also more common among South Asian pregnancies, compared to NZ European (aOR 1.98, 95%CI 1.10-3.56). DISCUSSION: Differences in placental pathology by ethnicity were observed among extremely preterm perinatal deaths. Underlying metabolic disorders and an associated pro-inflammatory environment may play an important role in the causal pathway leading to these deaths in women of South Asian ethnicity.

Risk factors for late preterm and term stillbirth: A secondary analysis of an individual participant data meta-analysis.

OBJECTIVE: Identify independent and novel risk factors for late-preterm (28-36 weeks) and term (≥37 weeks) stillbirth and explore development of a risk-prediction model. DESIGN: Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors. SETTING: An IPD database from five case-control studies in New Zealand, Australia, the UK and an international online study. POPULATION: Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257). METHODS: Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second-hand smoking, antenatal-care utilisation, and detailed fetal movement and sleep variables. MAIN OUTCOME MEASURES: Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth. RESULTS: After model building, 575 late-stillbirth cases and 1541 controls from three contributing case-control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hiccoughs, increasing strength, frequency or vigorous fetal movements) aOR of stillbirth. Poor antenatal-care utilisation increased risk while more-than-adequate care was protective. The area-under-the-curve was 0.84 (95% CI 0.82-0.86). CONCLUSIONS: Similarities in risk factors for late-preterm and term stillbirth suggest the same approach for risk-assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal-care utilisation could be valuable in late-stillbirth risk assessment.

A comprehensive methodology report for maternity and perinatal mortality research in the New Zealand Integrated Data Infrastructure.

AIM: The highest quality perinatal data in New Zealand is collected and collated by the Perinatal and Maternal Mortality Review Committee (PMMRC) and is made available to a limited number of researchers. Therefore, maternity, and perinatal mortality studies are generally performed on Government-held data. This report offers an alternative approach with in-depth justification for the methodology, while simultaneously improving the understanding of the data sources. METHOD: A standardised method for creating a comprehensive maternity dataset within the Statistics New Zealand Integrated Data Infrastructure (IDI) was developed and a validation dataset was created to include all births between 2008 and 2017. RESULTS: A close approximation to the PMMRC annual report data was found, with 4.0% over-reporting of perinatal deaths and 0.05% over-reporting of live births in the IDI dataset. Several variables, including important pregnancy risk factors, were validated for use. Limitations to the datasets were explored and additional tables in the IDI were proposed, to include variables on pregnancy complications, ethnicity and country of birth, and socio-economic data. CONCLUSION: This methodological report describes an opportunity for standardised, high-quality maternity research in New Zealand using the IDI, including a variety of national data sources. Recommendations for further enhancement of these resources have been offered.

Fetal movements: A framework for antenatal conversations.

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.

Grouping women of South Asian ethnicity for pregnancy research in New Zealand.

BACKGROUND: The New Zealand (NZ) Ministry of Health ethnicity data protocols recommend that people of South Asian (SAsian) ethnicity, other than Indian, are combined with people of Japanese and Korean ethnicity at the most commonly used level of aggregation in health research (level two). This may not work well for perinatal studies, as it has long been observed that women of Indian ethnicity have higher rates of adverse pregnancy outcomes, such as perinatal death. It is possible that women of other SAsian ethnicities share this risk. AIMS: This study was performed to identify appropriate groupings of women of SAsian ethnicity for perinatal research. MATERIALS AND METHODS: National maternity and neonatal data, and singleton birth records between 2008 and 2017 were linked using the Statistics NZ Integrated Data Infrastructure. Socio-demographic risk profiles and pregnancy outcomes were compared between 15 ethnic groups. Recommendations were made based on statistical analyses and cultural evaluation with members of the SAsian research community. RESULTS: Similarities were observed between women of Indian, Fijian Indian, South African Indian, Sri Lankan, Bangladeshi and Pakistani ethnicities. A lower-risk profile was seen among Japanese and Korean mothers. Risk profiles of women of combined Indian-Maori, Indian-Pacific and Indian-New Zealand European ethnicity more closely represented their corresponding non-Indian ethnicities. CONCLUSIONS: Based on these findings, we suggest a review of current NZ Ministry of Health ethnicity data protocols. We recommend that researchers understand the risk profiles of participants prior to aggregation of groups in research, to mitigate risks associated with masking differences.

A better understanding of the association between maternal perception of foetal movements and late stillbirth-findings from an individual participant data meta-analysis.

BACKGROUND: Late stillbirth continues to affect 3-4/1000 pregnancies in high-resource settings, with even higher rates in low-resource settings. Reduced foetal movements are frequently reported by women prior to foetal death, but there remains a poor understanding of the reasons and how to deal with this symptom clinically, particularly during the preterm phase of gestation. We aimed to determine which women are at the greatest odds of stillbirth in relation to the maternal report of foetal movements in late pregnancy (≥ 28 weeks' gestation). METHODS: This is an individual participant data meta-analysis of all identified case-control studies of late stillbirth. Studies included in the IPD were two from New Zealand, one from Australia, one from the UK and an internet-based study based out of the USA. There were a total of 851 late stillbirths, and 2257 controls with ongoing pregnancies. RESULTS: Increasing strength of foetal movements was the most commonly reported (> 60%) pattern by women in late pregnancy, which were associated with a decreased odds of late stillbirth (adjusted odds ratio (aOR) = 0.20, 95% CI 0.15 to 0.27). Compared to no change in strength or frequency women reporting decreased frequency of movements in the last 2 weeks had increased odds of late stillbirth (aOR = 2.33, 95% CI 1.73 to 3.14). Interaction analysis showed increased strength of movements had a greater protective effect and decreased frequency of movements greater odds of late stillbirth at preterm gestations (28-36 weeks' gestation). Foetal hiccups (aOR = 0.45, 95% CI 0.36 to 0.58) and regular episodes of vigorous movement (aOR = 0.67, 95% CI 0.52 to 0.87) were associated with decreased odds of late stillbirth. A single episode of unusually vigorous movement was associated with increased odds (aOR = 2.86, 95% CI 2.01 to 4.07), which was higher in women at term. CONCLUSIONS: Reduced foetal movements are associated with late stillbirth, with the association strongest at preterm gestations. Foetal hiccups and multiple episodes of vigorous movements are reassuring at all gestations after 28 weeks' gestation, whereas a single episode of vigorous movement is associated with stillbirth at term.

Modification of maternal late pregnancy sleep position: a survey evaluation of a New Zealand public health campaign.

INTRODUCTION: A 'Sleep-On-Side When Baby's Inside' public health campaign was initiated in New Zealand in 2018. This was in response to evidence that maternal supine going-to-sleep position was an independent risk factor for stillbirth from 28 weeks' gestation. We evaluated the success of the campaign on awareness and modification of late pregnancy going-to-sleep position through nationwide surveys. METHODS AND ANALYSIS: Two web-based cross-sectional surveys were conducted over 12 weeks in 2019-2020 in a sample of (1) pregnant women ≥28 weeks, primary outcome of going-to-sleep position; and (2) health professionals providing pregnancy care, primary outcome of knowledge of going-to-sleep position and late stillbirth risk. Univariable logistic regression was performed to identify factors associated with supine going-to-sleep position. DISCUSSION: The survey of pregnant women comprised 1633 eligible participants. Going-to-sleep position last night was supine (30, 1.8%), non-supine (1597, 97.2%) and no recall (16, 1.0%). Supine position had decreased from 3.9% in our previous New Zealand-wide study (2012-2015). Most women (1412, 86.5%) had received sleep-on-side advice with no major resultant worry (1276, 90.4%). Two-thirds (918, 65.0%) had changed their going-to-sleep position based on advice, with most (611 of 918, 66.5%) reporting little difficulty. Supine position was associated with Maori (OR 5.05, 95% CI 2.10 to 12.1) and Asian-non-Indian (OR 4.20, 95% CI 1.27 to 13.90) ethnicity; single (OR 10.98, 95% CI 4.25 to 28.42) and cohabitating relationship status (OR 2.69, 95% CI 1.09 to 6.61); hospital-based maternity provider (OR 2.55, 95% CI 1.07 to 6.10); education overseas (OR 3.92, 95% CI 1.09 to 14.09) and primary-secondary level (OR 2.80, 95% CI 1.32 to 6.08); and not receiving sleep-on-side advice (OR 6.70, 95% CI 3.23 to 13.92). The majority of health professionals (709 eligible participants) reported awareness of supine going-to-sleep position and late stillbirth risk (543, 76.6%). CONCLUSION: Most pregnant women had received and implemented sleep-on-side advice without major difficulty or concern. Some groups of women may need a tailored approach to acquisition of going-to-sleep position information.

Associations between consumption of coffee and caffeinated soft drinks and late stillbirth-Findings from the Midland and North of England stillbirth case-control study.

OBJECTIVE: The consumption of caffeinated drinks and soft drinks is widespread in society, including by pregnant women. Data regarding the association of caffeine intake and stillbirth are varied. We aimed to investigate the degree of consumption of caffeinated drinks or soft drinks in the last four weeks of pregnancy in women who experienced a late stillbirth compared to women with ongoing live pregnancies at similar gestation. Influences on maternal caffeine intake and soft drink consumption during pregnancy were also investigated. STUDY DESIGN: A case-control study undertaken in 41 maternity units in the United Kingdom. Cases were women who had a singleton non-anomalous stillbirth ≥28 weeks' gestation (n = 290) and controls were women with an ongoing pregnancy at the time of interview (n = 729). Data were collected using an interviewer-administered questionnaire which included questions regarding consumption of a variety of caffeinated drinks and soft drinks in the last four weeks of pregnancy as well as other behaviours (e.g. cigarette smoking). RESULTS: Multivariable analysis adjusting for co-existing demographic and behavioural factors found the consumption of instant coffee, energy drinks and cola were associated with increased risk of stillbirth. There was an independent association between caffeine intake and late stillbirth (adjusted Odds Ratio 1.27, 95 % Confidence Interval (95 %CI) 1.14, 1.43 for each 100 mg increment/day). 15 % of cases and 8% of controls consumed more than the World Health Organisation (WHO) recommendation (>300 mg of caffeine/day; aOR 2.30, 95 % CI 1.40, 4.24). The population attributable risk for stillbirth associated with >300 mg of caffeine/day was 7.4 %. The majority of respondents reduced caffeine consumption in pregnancy. Midwives and internet resources were the most frequently used sources of information which influenced maternal behaviour with regard to soft drinks and caffeine, and this did not differ between cases and controls. CONCLUSIONS: Women should be informed that consumption of caffeine during pregnancy is associated with increased risk of stillbirth, particularly at levels greater than recommended by the WHO (>300 mg/day). Recommendations from midwives and internet-based resources are likely to be the most effective means to influence maternal behaviour.

Associations between symptoms of sleep-disordered breathing and maternal sleep patterns with late stillbirth: Findings from an individual participant data meta-analysis.

BACKGROUND AND OBJECTIVES: Sleep-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. METHODS: Data 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. RESULTS: In 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. CONCLUSION: A 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.

Stillbirth research: Recruitment barriers and participant feedback.

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.