International Stillbirth Research Alert

Issue 2, March 2008


This Stillbirth Research Alert is a collaborative activity of the International Stillbirth Alliance and the Australian and New Zealand Stillbirth Alliance – ANZSA*.
The aim of this alert is to provide plain language summaries of recent key papers on stillbirth. For further details about the Alert, ISA and ANZSA,
please go to the ISA website :

(*ANZSA is the ANZ regional office of ISA)

Research Alert Index  ( Search period: January-February 2008 )

1. Conference proceedings
2. Overviews/Guidelines
3. Risk factors/Causes
4. Investigation/audit/classification
5. Bereavement
6. Intervention/Prevention

1. Conference proceedings

The ISA conference was held in Oslo on the 5-7 November 2008. The proceedings of this conference, General Assembly minutes and summaries of scientific meetings will all be published on the ISA website ( shortly.

2. Overviews/Guidelines

No publications in this category were found in the search.

3. Risk factors/Causes

Ghosh GS, Gudmundsson S. “Nuchal cord in post-term pregnancy - relationship to suspected intrapartum fetal distress indicating operative intervention.” J Perinat Med. 2008 Jan 23; [Epub ahead of print]

A nuchal cord occurs when the umbilical cord wraps 360˚ around the fetal neck. A study was conducted to determine if Doppler ultrasound examination for nuchal cord could improve the outcome of post-term pregnancies. A nuchal cord was identified in 34% of the monitored pregnancies. However, there were no significant differences between the pregnancies with and without a nuchal cord. The results of the study suggested that Doppler ultrasound of nuchal cord would not be a useful tool for improving the outcome of post-term pregnancies. A larger sample size may be required to confirm the results from the study.

Lee YM, Wylie BJ, Simpson LL, D'Alton ME. “Twin chorionicity and the risk of stillbirth.” Obstet Gynecol. 2008 Feb;111(2 Pt 1):301-8.

When a woman is pregnant with twins, the risk of stillbirth and other obstetric complications is increased. This study compares in utero survival between two different types of twins, monochorionic-diamniotic and dichorionic-diamniotic. A dichorionic-diamniotic twin pregnancy occurs when each cell develops separately its own placenta (chorion) and its own sac (amnion). Monochorionic-diamniotic twins are twins who share one placenta, but each have their own amniotic sacs.

Data from 1000 consecutive twin pairs was analysed, giving the results that monochorionic-diamniotic twins were at a higher risk of stillbirth than dichorionic-diamniotic twins, with rates of 3.6% and 1.1% respectively.

Black M, Shetty A, Bhattacharya S. “Obstetric outcomes subsequent to intrauterine death in the first pregnancy.” BJOG. 2008 Jan;115(2):269-74.

The objective of this study was to examine the obstetric outcomes in the pregnancy subsequent to intrauterine death compared to those pregnancies that followed a previous live birth.

The results of this study showed that while women with a previous stillbirth have a live birth in the subsequent pregnancy, they are still a high-risk group with an increased incidence of adverse maternal and neonatal outcomes, such as pre-eclampsia, placental abruption and prematurity in comparison to women who have had a previous live birth.

Rawlinson WD, Hall B, Jones CA, Jeffery HE, Arbuckle SM, Graf N, et al. “Viruses and other infections in stillbirth: what is the evidence and what should we be doing?” Pathology. 2008 Feb;40(2):149-60.

The exact causes of almost half of all stillbirths are unknown. Recent evidence suggests that some of cases of stillbirth may have viruses contributing to the babies death, either alone or in combination with other infections. This article describes some of the causes of stillbirth including clinical, epidemiological as well as viral and other infectious agents. It summarise some of the recent molecular techniques used to detect the presence of any infection in the placenta and/or stillborn baby. These tests can identify several infectious agents such as Cytomegalovirus, Varicella Zoster Virus, Herpes Viruses and others. Finally the article describes whether the actual infectious agent causes the death of the baby or whether there maybe other interacting causes of the baby’s death. These tests may assists to assign a correct cause of death for some of these stillborn babies. Having a correct diagnosis is a benefit to assists parents in their decision making for future pregnancies.

Toal M, Keating S, Machin G, Dodd J, Lee Adamson S, Windrim RC, Kingdom JCP. “Determinants of adverse perinatal outcome in high-risk women with abnormal uterine artery Doppler images.” American Journal of Obstetrics and Gynecology 2008;198:330.e1-330.e7.

The placenta is essential for successful pregnancy. These investigators looked at placental shape and texture using ultrasound at 19-23 weeks gestation to predict poor pregnancy outcomes including stillbirth. They looked at 60 patients with abnormal blood flow in the uterine artery which is associated with poor pregnancy outcome. They found that abnormal placental size and shape was associated with lower birthweight, increased risk of preterm delivery and stillbirth. The population under study had a high rate of pregnancy complications and 83% had evidence of placental abnormality on microscopic assessment of the placentas. They concluded that placental size and shape might be able to predict which women are at risk of pregnancy complications. The researchers also stated that present imaging of the placenta has significant limitations.

Strandberg-Larsen K, Nielsen NR, Gronbaek M, Andersen PK, Olsen J, Andersen AM. “Binge drinking in pregnancy and risk of fetal death.” Obstet Gynecol. 2008 Mar;111(3):602-9.

Drinking is considered binge drinking when there is an intake of five or more drinks on one single occasion. This study examines whether the frequency and timing of binge drinking episodes during the first 16 weeks of pregnancy increase the risk of fetal death.

89 201 women from 1996 to 2002 participated in this study, and results showed that while binge drinking three or more times during pregnancy is associated with an increased risk of stillbirth, neither the frequency nor timing of binge drinking was associated with an increased risk of spontaneous abortion.

Huang L, Sauve R, Birkett N, Fergusson D, van Walraven C. “Maternal age and risk of stillbirth: a systematic review.” CMAJ. 2008 Jan 15;178(2):165-72.

The number of women who delay childbirth to their late 30s and beyond has increased significantly over the past several decades, and studies regarding the relation between older maternal age and the risk of stillbirth have yielded inconsistent conclusions. This paper is a systematic review of previous publications on maternal age and risk of stillbirth to explore whether older maternal age is associated with an increased risk of stillbirth.
After analysing the data from the relevant articles found, results showed that women with advanced maternal age have an increased risk of stillbirth, but the magnitude of the increased risk is not clear.

4. Investigation/audit/classification

Papiernik E, Zeitlin J, Delmas D, Draper ES, Gadzinowski J, Künzel W, Cuttini M, Di Lallo D, Weber T, Kollée L, Bekaert A, Bréart G; MOSAIC Research Group. “Termination of pregnancy among very preterm births and its impact on very preterm mortality: results from ten European population-based cohorts in the MOSAIC study.” BJOG. 2008 Feb;115(3):361-8.

MOSAIC stands for Models of OrganiSing Access to Intensive Care for very preterm babies. Ten regions from nine European countries participated in this study.

The objective was to determine the impact of pregnancy termination, and causes for termination, on mortality rates in Europe by evaluating births during 22-31 weeks. The existing regional differences in policies and reporting procedures for screening of congenital anomalies and the legality and timing of pregnancy terminations led to the inability to adequately compare study results. International reporting policies are needed so that comparisons can be made.

Walsh CA, McMenamin MB, Foley ME, Daly SF, Robson MS, Geary MP. “Trends in intrapartum fetal death, 1979-2003.” Am J Obstet Gynecol. 2008 Jan;198(1):47 e1-7.

This study was undertaken to analyse trends in intrapartum fetal death and rates of perinatal autopsy over a 25 year period (1979-2003) in Dublin, Ireland.

Results of this long-term study shows that there was a significant decrease in the rate of intrapartum fetal death in the 25 year period studied. This has primarily resulted from a reduction in deaths attributable to intrapartum hypoxia, of which rates have fallen dramatically. Also found in this study was the concerning outcome that rates of perinatal autopsy had also fallen significantly from 1979-2003.

5. Bereavement

Bryant H. “Maintaining patient dignity and offering support after miscarriage.” Emerg Nurse. 2008 Feb;15(9):26-9.

The care received by women and their partners at the time of miscarriage has a major impact on their grieving process. Nurses who attend to women during this time therefore need to meet both the physical and psychological needs of the women they are caring for. They also need to meet and understand the needs of their partners as well as any attending extended family members. Time, respect and information should be given to all.

Privacy and time are especially important and simple measures can be taken to ensure that they are achieved in any Emergency Department. Locks and “engaged” signs on doors, with the examination couch facing away from the door can have extremely positive benefits to the woman, as can adequate screening and proper draping.

Staff should also have proper training, access to relevant leaflets and a positive line of referral to work to. They should also ensure that sanitary products and examination trolleys are kept “topped up” and refilled after every patient.

These simple measures can help to ensure that women, their partners and their families experiencing miscarriage are treated with the dignity and respect that they both need and deserve.

Chan MF, Lou F, Arthur DG, Cao F, Wu LH, Li P, Sagara-Rosemeyer M; Chung LYF, Lui L. “Investigating factors associate to nurses' attitudes towards perinatal bereavement care.” J Clin Nurs. 2008 Feb;17(4):509-18.

Death is a taboo subject in Chinese Culture and is not routinely discussed. Open displays of emotion are not widely seen, which may lead bereaved parents not openly showing their need for support.

Hospitals in Hong Kong have recently developed perinatal bereavement support to offer bereaved parents emotional care. This study was designed to explore nurses’ attitudes towards perinatal bereavement care and to examine factors associated with such attitudes.

Key findings include:
1. A need for increased knowledge and experience around perinatal bereavement.
2. A need for improved communication skills and greater support from colleagues.
3. The nurses themselves need psychological help and support to enable them to support the bereaved parents.
4. The nurses need to be able to discuss and debrief their experiences with their colleagues.
5. Supportive care practices need to be understood, implemented and practiced by all nurses, with a mentoring approach being a key factor in this.

In Addition it was found that:
1. Most nurses had a positive attitude towards caring for bereaved parents.
2. More than 89% of the nurses agreed that parents should have time to grieve and recognized that perinatal bereavement support provided psychological and emotional support to the parents.
3. Most nurses believed that they should be well informed so that they can help the parents to make informed choices.
4. Most of the nurses recognized that they needed further training to provide this care.

Stratton K, Lloyd L. “Hospital-based interventions at and following miscarriage: literature to inform a research-practice initiative.” Aust N Z J Obstet Gynaecol. 2008 Feb;48(1):5-11. Review.

Miscarriage is a common form of reproductive loss with an estimated one in five pregnancies resulting in this. Because of this, it is often under acknowledged by the community and health professionals, leading to dissatisfaction with care following miscarriage. Evidence suggests that the care provided in hospital can have a significant effect on the emotional and physical recovery from a miscarriage, so this literature review aims to determine any evidence-based guidelines for hospital-based medical and psychological services following a miscarriage.

Barr P, Cacciatore J. “Problematic emotions and maternal grief.” Omega (Westport). 2007-2008;56(4):331-48.

This study examines the relation of personality proneness to “problematic social emotions” – envy, jealousy, shame and guilt to maternal grief following a miscarriage, stillbirth, neonatal death or infant/child death.
441 women participated in this study and results showed that all four problematic emotions correlated with maternal grief - particularly envy, jealousy and guilt.

6. Intervention/Prevention

Ortendahl M, Nasman P. “Quitting smoking is perceived to have an effect on somatic health among pregnant and non-pregnant women.” J Matern Fetal Neonatal Med. 2008 Apr;21(4):239-46

A group of 80 women in Bulgaria was interviewed about how they expected that continued smoking would affect their health in the future. The group included pregnant and non-pregnant women and among both the pregnant and the non-pregnant women were women with the intention to quit smoking and women not having the intention to quit. The women were asked for the probability of health consequences related to their own physical health, consequences related to the pregnancy and consequences related to mood and social relations.

The greatest effect of intending to quit smoking on expected future health consequences was found in the consequences related to the physical health. The factor of pregnancy did not have a great influence on these results. The authors conclude that the effect of smoking on the physical health of women should be stressed in health promotion, also for pregnant women.

Heazell AE, Green M, Wright C, Flenady VJ, Frøen JF. “Midwives' and obstetricians' knowledge and management of women presenting with decreased fetal movements.” Acta Obstetricia et Gynecologica Scandinavica. 2008;87(3):331-339.

Decreased fetal movements are associated with increased risk of stillbirth and intrauterine growth restriction; this study investigated views of 129 obstetricians and 94 midwives in the UK about decreased fetal movements using a postal questionnaire.

The primary finding of this study was that there was wide variation in clinical practice. The majority of respondents enquired about the presence of fetal movements after 28 weeks gestation, but there was little agreement on a definition of decreased fetal movements with a maternal perception of decreased movements for 24 h gaining the greatest acceptance. Few practitioners used formal fetal movement counting, with the majority of respondents stating they were ineffective in the prevention of IUGR or IUFD and led to increased intervention. There was large variation in the knowledge of associations with DFM and management of women presenting with DFM. The variation in practice may result from a lack of robust evidence on which to base the provision of care. More research is needed to provide evidence to direct the management of women presenting with DFM.

Mbonye AK, Bygbjerg IC; Magnussen P. “Intermittent preventive treatment of malaria in pregnancy: the incremental cost-effectiveness of a new delivery system in Uganda.” Trans R Soc Trop Med Hyg. 2008 Jul;102(7):685-93. Epub 2008 May 29.

Malaria is the leading cause of morbidity and mortality in Uganda, mainly affecting pregnant women and young children. This study was undertaken to determine whether traditional birth attendants, drug-shop vendors, community reproductive-health workers or adolescent peer mobilisers could administer intermittent preventive treatment for malaria to pregnant women.

Supplementation with Multiple Micronutrients Intervention Trial (SUMMIT) Study Group, Shankar AH, Jahari AB, Sebayang SK, Aditiawarman, Apriatni M, Harefa B, Muadz H, Soesbandoro SD, Tjiong R, Fachry A, Shankar AV, Atmarita, Prihatini S, Sofia G. “Effect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial.” Lancet. 2008 Jan 19;371(9608):215-27.

In developing countries, nutrient supplementation for pregnant women is generally restricted to provision of iron and folic acid, as there is little evidence of the effects of multiple micronutrients on fetal loss and infant death. This study investigates the effect of maternal supplementation with multiple micronutrients compared with iron and folic acid on fetal loss and infant death, randomly assigning 262 midwives to distribute supplements to 31 290 pregnant women. Results showed that multiple micronutrients can reduce the incidence of early infant mortality and other adverse obstetric outcomes.


Volume 32, Issue 4, Pages 231-322 (August 2008) of Seminars in Perinatology has an extremely relevant and valuable selection of studies on topics such as stillbirth, fetal movement and fetal growth restriction. Some articles found in this issue are “Epidemiology of Stillbirth and Fetal Central Nervous System Injury.” (Salihu HM), “Management of decreased fetal movements.” (Frøen JF et al.) and “Antepartum testing for women with previous stillbirth.” (Weeks, JW).

Volume 22, Issue 4, Pages 313-359 (July 2008) of the Journal of Paediatric and Perinatal Epidemiology features an important collection of studies such as “Maternal use of oral contraceptives and risk of fetal death.” (Jellesen R et al.), “The impact of past pregnancy experience on subsequent perinatal outcomes” (Hutcheon JA et al.) and “Health-risk behaviours: examining social disparities in the occurrence of stillbirth” (Goy J et al.)

Volume 35, Issue 3 (September 2008) of the Journal of Obstetric and Gynecology Clinics in North America includes a number of articles and studies on prenatal care such as “Nutrition During Pregnancy” (Cox JT) and “Childbirth Education and Birth Plans” (Bailey JM).

Volume 199, Issue 3, pages 209-326 (September 2008) of the American Journal of Obstetrics and Gynecology includes studies on a broad range of topics under stillbirth, for example “Biophysical profile in the treatment of intrauterine growth-restricted fetuses who weigh <1000 g” (Kaur S et al.), “Identifying the causes of stillbirth: a comparison of four classification systems” (Vergani P et al.) and “Risk factors for uteroplacental vascular compromise and inflammation” (Baker M et al.).



We would like to acknowledge the volunteers and staff who gave generously of their time in compiling this Alert: Elizabeth Flenady, Liam Flenady, Jeroen Meewisse, Caron Millard, Dawn Thomas, William Rawlinson, Jonathon Howard, Alex Heazell, and ISA secretariat Anais Gschwind and Yanlin Liu. 

International Stillbirth Alliance (c) 2008