International Stillbirth Research Alert

Issue 3, December 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: March-November 2008 )

Selected Studies

Other Key Papers:

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

Selected Studies

South Africa Every Death Counts Writing Group, Bradshaw D, Chopra M, Kerber K, Lawn JE, Bamford L, Moodley J, Pattinson R, Patrick M, Stephen C, Velaphi S. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet. 2008 Apr 12;371(9620):1294-304. Review. Erratum in: Lancet. 2008 Sep

The leaders of three reports on saving mothers, babies, and children in South Africa have come together to prioritise actions to save lives. South Africa is off-track for the health-related Millennium Development Goals – mortality in children younger than 5 years has increased, whereas maternal and neonatal mortality remain constant. This situation indicates the challenge of strengthening the health system because of high inequity and HIV/AIDS. Coverage of services is fairly high, but addressing the gaps in quality and equity is essential to increasing the number of lives saved. The South Africa Every death Counts Writing group state in this paper that addressing crosscutting health system and equity issues, and the prevention of mother-to-child transmission of HIV, would save tens of thousands of lives every year.

To assist in addressing these issues the next International Stillbirth Alliance conference is being held in South Africa in March 2009 in conjunction with the Perinatal Priorities Conference. For more information please go to the ISA website:

Korteweg FJ, Bouman K, Erwich JJ, Timmer A, Veeger NJ, Ravisé JM, Nijman TH,Holm JP. Cytogenetic analysis after evaluation of 750 fetal deaths: proposal for diagnostic workup.Obstet Gynecol. 2008 Apr;111(4):865-74.

While some studies recommend cytogenetic analysis for all fetal deaths, others advise testing for a selected population only. This study was conducted to estimate success rates for cytogenetic analysis in different tissues after intrauterine fetal death, as well as the value of cytogenetic testing in determining the cause of death. A cytogenetic analysis was performed on 750 fetal deaths and a multidisciplinary panel assessed the value of the test in determining cause. Overall, the results showed that cytogenetic analysis was valuable in determining the cause of 19% in the fetal deaths. Cytogenetics testing success rates were significantly higher (85%) for invasive testing (amniocentesis) than for postpartum tissues analysis (28%). While more abnormal chromosomes (38%) were identified in fetal deaths with morphological abnormalities, abnormal chromosomes were detected in 5% of infants who were morphologically normal. The researchers recommend a non-selective approach to cytogenetics testing using amniocentesis before labour.

Woods R. Long-term trends in fetal mortality: implications for developing countries. Bull World Health Organ. 2008 Jun;86(6):460-6

This paper discusses the problems of defining and measuring late-fetal mortality (stillbirths). It uses evidence from 11 developed countries to trace long-term trends in fetal mortality. Issues associated with varying definitions and registration practices are identified, as well as the range of possible rates, key turning points and recent convergence. The implications for developing countries are spelt out. They emphasise the possible limitations of WHO estimation methods and survey-based data by examining the cross-sectional associations among 187 countries in the year 2000. The important role of skilled birth attendants is emphasised in both data sets, but the different effects on maternal mortality and late-fetal mortality are also noted.

Aliyu MH, Salihu HM, Wilson RE, Alio AP, Kirby RS. The risk of intrapartum stillbirth among smokers of advanced maternal age. Arch Gynecol Obstet. 2008 Jul;278(1):39-45. Epub 2008 Jan 31.

The aim of this study was to determine the impact of advanced maternal age (>35 years) on the association between smoking during pregnancy for overall, antepartum and intrapartum stillbirth fetal deaths. A retrospective analysis of birth registry data of singleton births in Missouri from 1978 – 1997 including 1 436 628 births and 5 772 stillbirth was undertaken. The overall stillbirth rate (>20weeks gestation) was 4.00 per 1000. Mothers were categorised into two age group (younger - <35 years and older > 35 years). The probability of intrapartum stillbirth was greatest among older women who were smokers, followed by younger smokers, and lowest among younger non-smokers. The researchers concluded that the risk of intrapartum stillbirth associated with smoking in pregnancy is potentiated by the age of the mother.

Engel PJ, Smith R, Brinsmead MW, Bowe SJ, Clifton VL. Male sex and pre-existing diabetes are independent risk factors for stillbirth. Aust N Z J Obstet Gynaecol. 2008 Aug;48(4):375-83.

This Australian retrospective institution-based study aimed to determine whether the risk of stillbirth is associated with male fetal sex, fetal growth and maternal factors. 16 445 singleton births and 162 stillbirths were analysed using multiple logistic regression. The results showed that male sex (aOR 1.5;95% CI 1.01, 2.17), pre-existing diabetes (aOR 4.7;95% CI 1.58, 14.19), are independent risk factors for stillbirth.

Surkan PJ, Rådestad I, Cnattingius S, Steineck G, Dickman PW. Events after stillbirth in relation to maternal depressive symptoms: a brief report. Birth. 2008 Jun;35(2):153-7.

This study explored how infant bonding and maternal actions after a stillbirth can be associated with ensuring depressive symptoms. 314 (83%) of the 380 Swedish speaking women who had a singleton stillbirth registered in the Swedish Medical Birth Register in 1991 completed a postal questionnaire 3 years after the stillbirth. The questions included the actions taken to bond with the baby such as seeing, holding, kissing, dressing, or caressing the infant, keeping tokens of remembrance, as well as questions surrounding procedures at the hospital, further pregnancies and the birth order of stillbirth infant. Results suggest that a mother being with the stillborn baby for as long as they wished reduces the risk of depressive symptoms. Birth order of the stillbirth may influence her later depressive symptomatology- an increased risk was shown for women having a stillborn baby in a third, forth or later pregnancy were at increased risk. Compared with mothers who became pregnant again within 6 months those who did not have a subsequent pregnancy were at higher risk of depressive symptoms at 3 years’ follow up.

Warland J, McCutcheon H, Baghurst P. Maternal blood pressure in pregnancy and stillbirth: a case-control study of third-trimester stillbirth. Am J Perinatol. 2008 May;25(5):311-7. Epub 2008 Apr 28.

High blood pressure is a well known and well researched risk factor for perinatal mortality, however little research has been conducted on the adverse effects of low maternal blood pressure during pregnancy. The objective of this study is to determine whether low blood pressure during pregnancy increases the risk of fetal death. Blood pressure recordings of 124 women whose pregnancies resulted in stillbirth were compared to blood pressures of 243 women whose pregnancies resulted in a liveborn infant. Results showed that women with low blood pressure (three or more mean arterial pressures values < 83 mmHg) or borderline low blood pressure (diastolic blood pressure 60 to 70mm Hg) were at a greater risk of stillbirth. The researchers concluded that maternal hypotension may be a contributory risk factor for stillbirth.

Walsh CA, Vallerie AM, Baxi LV. Etiology of stillbirth at term: a 10-year cohort study. J Matern Fetal Neonatal Med. 2008 Jul;21(7):493-501.

This study aimed to examine etiological factors contributing to intrauterine fetal death in term pregnancies. 29,908 term infants (37+0- 41+6 weeks) born at a tertiary-referral institution in New York over a ten year period 1996 – 2005 were included. 55 term stillbirths were identified and included giving a fetal death rate of 1.8/1000 at-risk pregnancies. This rate had not changed significantly over the study period. Placental/cord factors accounted for 25% of stillbirths which was unchanged over the ten year period. Almost 50% of term stillbirths occurred in women with suboptimal antenatal care. The overall proportion of unexplained stillbirth was 51% however a downward trend was shown over the study period. The researchers noted that a classification of unexplained stillbirth often resulted from an incomplete diagnostic work-up and called for a complete work-up to minimize the incidence of unexplained stillbirth.

Gordon A, Jeffery HE.
Classification and description of stillbirths in New South Wales, 2002-2004. Med J Aust. 2008 Jun 2;188(11):645-8.

Classification of stillbirth is essential for both understanding and future prevention. The purpose of this study was to describe the pattern of stillbirths by cause and gestation period in New South Wales since the introduction of the Perinatal Society of Australia and New Zealand perinatal death classification (PSANZ-PDC). The study was also designed to assess the agreement between local hospital committees and the Perinatal Outcomes Working Party (POWP) of the NSW Department of Health Ministerial Maternal and Perinatal Committee.
All 258045 births in NSW and all 1264 stillbirths classified by the POWP from 2002 to 2004 were used in this study. Results showed that the most common classification was unexplained antepartum death which comprised 41.5% of the cohort and 60% of the stillbirths of equal to or greater than 37 weeks’ gestation. These unexplained stillbirths were more likely to have an autopsy than explained stillbirths.

Other Key Papers:

1. Conference proceedings

International Stillbirth Alliance Conference 2008 Proceedings

2. Overviews/Guidelines


3. Risk factors/Causes/Epidemiology

Joseph KS.
The fetuses-at-risk approach: clarification of semantic and conceptual

BMC Pregnancy Childbirth. 2008 Mar 26;8:11. Review.

Wood SL, Chen S, Ross S, Sauve R.
The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy.
BJOG. 2008 May;115(6):726-31.

Nicopoullos JD.
The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy.
BJOG. 2008 Sep;115(10):1324; author reply 1325-6. No abstract available.

Cohain JS.
The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy.
BJOG. 2008 Sep;115(10):1324-5; author reply 1325-6. No abstract available.

Gyte G, Dodwell M, Newburn M, Sandall J, Macfarlane A, Bewley S.
An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003.
BJOG. 2008 Sep;115(10):1321-2; author reply 1322. No abstract available.

Gardosi J.
Risk of intrapartum-related perinatal mortality in booked home births.
BJOG. 2008 Aug;115(9):1185-6; author reply 1186. No abstract available.

Steer P.
An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003. Editor-in-Chief's reply.
BJOG. 2008 Aug;115(9):1185. No abstract available.

Rowe R, Stewart M, Puddicombe D.
Perinatal outcomes in birth centers.
Birth. 2008 Mar;35(1):85; author reply 86. No abstract available.

Davey MA, King JF.
Perinatal outcomes in birth centers.
Birth. 2008 Mar;35(1):85-6; author reply 86. No abstract available.

Sameshima H, Ikenoue T; Miyazaki Perinatal Data Group.
Risk factors for perinatal deaths in Southern Japan: population-based analysis from 1998 to 2005.
Early Hum Dev. 2008 May;84(5):319-23. Epub 2007 Sep 27.

Cecatti JG, Correa-Silva EP, Milanez H, Morais SS, Souza JP.
The associations between inter-pregnancy interval and maternal and neonatal outcomes in Brazil.
Matern Child Health J. 2008 Mar;12(2):275-81. Epub 2007 Jun 6.

Alderliesten ME, Stronks K, van Lith JM, Smit BJ, van der Wal MF, Bonsel GJ,
Bleker OP.
Ethnic differences in perinatal mortality. A perinatal audit on the role of
substandard care.

Eur J Obstet Gynecol Reprod Biol. 2008 Jun;138(2):164-70. Epub 2007 Nov 5.

Kalter HD, Khazen RR, Barghouthi M, Odeh M.
Prospective community-based cluster census and case-control study of stillbirths and neonatal deaths in the West Bank and Gaza Strip.
Paediatr Perinat Epidemiol. 2008 Jul;22(4):321-33.

Ronsmans C, Chowdhury ME, Alam N, Koblinsky M, El Arifeen S.
Trends in stillbirths, early and late neonatal mortality in rural Bangladesh: the role of public health interventions.
Paediatr Perinat Epidemiol. 2008 May;22(3):269-79.

Weck RL, Paulose T, Flaws JA.
Impact of environmental factors and poverty on pregnancy outcomes.
Clin Obstet Gynecol. 2008 Jun;51(2):349-59. Review.

Kinzler WL, Vintzileos AM.
Fetal growth restriction: a modern approach.
Curr Opin Obstet Gynecol. 2008 Apr;20(2):125-31. Review.

Pedersen NG, Figueras F, Wøjdemann KR, Tabor A, Gardosi J.
Early fetal size and growth as predictors of adverse outcome.
Obstet Gynecol. 2008 Oct;112(4):765-71.

Aydin Y, Berker D, Direktör N, Ustün I, Tütüncü YA, Işik S, Delibaşi T,
Guler S.
Is insulin lispro safe in pregnant women: Does it cause any adverse outcomes on infants or mothers?
Diabetes Res Clin Pract. 2008 Jun;80(3):444-8. Epub 2008 Mar 21.

Bell R, Bailey K, Cresswell T, Hawthorne G, Critchley J, Lewis-Barned N;
Northern Diabetic Pregnancy Survey Steering Group.
Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes.

BJOG. 2008 Mar;115(4):445-52.

Rasheeda CA, Navaneethan U, Jayanthi V.
Liver disease in pregnancy and its influence on maternal and fetal mortality: a prospective study from Chennai, Southern India.
Eur J Gastroenterol Hepatol. 2008 Apr;20(4):362-4. No abstract available.

Michalowicz BS, DiAngelis AJ, Novak MJ, Buchanan W, Papapanou PN, Mitchell
DA, Curran AE, Lupo VR, Ferguson JE, Bofill J, Matseoane S, Deinard AS Jr, Rogers
Examining the safety of dental treatment in pregnant women.
J Am Dent Assoc. 2008 Jun;139(6):685-95.

Jellesen R, Strandberg-Larsen K, Jørgensen T, Olsen J, Thulstrup AM,
Andersen AM.
Maternal use of oral contraceptives and risk of fetal death.
Paediatr Perinat Epidemiol. 2008 Jul;22(4):334-40.
PMID: 18578746 [PubMed - indexed for MEDLINE]

Odibo AO, Gray DL, Dicke JM, Stamilio DM, Macones GA, Crane JP.
Revisiting the fetal loss rate after second-trimester genetic amniocentesis: a single center's 16-year experience.
Obstet Gynecol. 2008 Mar;111(3):589-95.

Alijotas-Reig J, Casellas-Caro M, Ferrer-Oliveras R, Llurba-Olive E,
Hermosilla E, Vilardell-Tarres M, Cabero-Roura L.
Are anti-beta-glycoprotein-I antibodies markers for recurrent pregnancy loss in lupus anticoagulant/anticardiolipin seronegative women?
Am J Reprod Immunol. 2008 Sep;60(3):229-37.

Clark DA.
Immunological factors in pregnancy wastage: fact or fiction.
Am J Reprod Immunol. 2008 Apr;59(4):277-300. Review.

Warren JE, Silver RM.
Genetics of pregnancy loss.
Clin Obstet Gynecol. 2008 Mar;51(1):84-95. Review.

Lagerberg RE.
Malaria in pregnancy: a literature review.
J Midwifery Womens Health. 2008 May-Jun;53(3):209-15. Review.

Syridou G, Spanakis N, Konstantinidou A, Piperaki ET, Kafetzis D, Patsouris
E, Antsaklis A, Tsakris A.
Detection of cytomegalovirus, parvovirus B19 and herpes simplex viruses in cases of intrauterine fetal death: association with pathological findings.
J Med Virol. 2008 Oct;80(10):1776-82.

Menghrajani P, Osterheld MC.
Significance of hemorrhagic endovasculitis in placentae from stillbirths.
Pathol Res Pract. 2008;204(6):389-94. Epub 2008 Mar 5.

Redline RW.
Placental pathology: a systematic approach with clinical correlations.
Placenta. 2008 Mar;29 Suppl A:S86-91. Epub 2007 Oct 22. Review.

Parast MM, Crum CP, Boyd TK.
Placental histologic criteria for umbilical blood flow restriction in unexplained stillbirth.
Hum Pathol. 2008 Jun;39(6):948-53. Epub 2008 Apr 21.

Sinha P, Kuruba N.
Ante-partum haemorrhage: an update.
J Obstet Gynaecol. 2008 May;28(4):377-81. Review.

4. Investigation/audit/classification

Varli IH, Petersson K, Bottinga R, Bremme K, Hofsjö A, Holm M, Holste C, Kublickas M, Norman M, Pilo C, Roos N, Sundberg A, Wolff K, Papadogiannakis N.
The Stockholm classification of stillbirth.
Acta Obstet Gynecol Scand. 2008;87(11):1202-12.

Ego A, Subtil D, Grange G, Thiebaugeorges O, Senat MV, Vayssiere C, Zeitlin
Should parity be included in customised fetal weight standards for identifying small-for-gestational-age babies? Results from a French multicentre study.
BJOG. 2008 Sep;115(10):1256-64.

Alderliesten ME, Stronks K, Bonsel GJ, Smit BJ, van Campen MM, van Lith JM,
Bleker OP.
Design and evaluation of a regional perinatal audit.
Eur J Obstet Gynecol Reprod Biol. 2008 Apr;137(2):141-5.

Vergani P, Cozzolino S, Pozzi E, Cuttin MS, Greco M, Ornaghi S, Lucchini V.
Identifying the causes of stillbirth: a comparison of four classification

Am J Obstet Gynecol. 2008 Sep;199(3):319.e1-4.

5. Bereavement

Bergner A, Beyer R, Klapp BF, Rauchfuss M.
Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping.
J Psychosom Obstet Gynaecol. 2008 Jun;29(2):105-13.

Gold KJ, Kuznia AL, Hayward RA.
How physicians cope with stillbirth or neonatal death: a national survey of obstetricians.
Obstet Gynecol. 2008 Jul;112(1):29-34.

6. Intervention/Prevention

Coleman T.
Reducing harm from tobacco smoke exposure during pregnancy.
Birth Defects Res C Embryo Today. 2008 Mar;84(1):73-9. Review.

Figueras F, Eixarch E, Gratacos E, Gardosi J.
Predictiveness of antenatal umbilical artery Doppler for adverse pregnancy outcome in small-for-gestational-age babies according to customised birthweight centiles: population-based study.
BJOG. 2008 Apr;115(5):590-4.

Grandone E, De Stefano V, Rossi E, Cappucci F, Colaizzo D, Margaglione M.
Antithrombotic prophylaxis during pregnancy in women with deficiency of natural anticoagulants.
Blood Coagul Fibrinolysis. 2008 Apr;19(3):226-30.



We would like to acknowledge the volunteers and staff who gave generously of their time in compiling this Alert: Elizabeth Flenady, Liam Flenady, Anais Gschwind, Madeleine Elder, Laura Koopmans, Vicki Flenady, and Yanlin Liu. 

International Stillbirth Alliance (c) 2008