National action to reduce the pain and silence of stillbirth

The care Australians receive throughout their pregnancy journey is set to improve with the release of the first national standard on stillbirth*.

Each year, more than 2000 Australian families experience the tragic and painful loss of a baby to stillbirth. In the past two decades, statistics have remained steady with, on average, six babies stillborn every day.ⁱ

The Stillbirth Clinical Care Standard, developed by the Australian Commission on Safety and Quality in Health Care, was launched at the 2022 Annual National Stillbirth Forum in Brisbane.

The new standard has guidance on better care for women before and during pregnancy, encourages open discussions about investigations after a stillbirth and urges wide-ranging support after perinatal loss.

Aiming to reduce the stillbirth rate and the stigma attached to the experience, the standard provides a pathway to closing the equity gaps from cultural and geographic barriers.

The standard responds to a recommendation in the Australian Government’s National Stillbirth Action and Implementation Planⁱⁱ and is aligned with the Safer Baby Bundle programⁱⁱⁱ, which both aim to reduce rates of late-gestation stillbirth (after 28 weeks).

Clinical lead for the standard Associate Professor Liz Marles, Clinical Director at the Commission and a general practitioner, said Australia was on a ‘positive trajectory’ to address this public health issue, which is reinforced by the endorsement of 26 peak bodies and healthcare organisations.

“Stillbirth is the most common form of perinatal death in Australia, accounting for 7 in every 1000 births. Yet for many families, the experience of stillbirth remains hidden because of stigma and a culture of silence,” she said.

“The Commission’s national standard will be the catalyst for real change to reduce the risk of stillbirth and help ease the grief for bereaved women and families.

“For the first time, this standard embeds stillbirth guidance into our maternity care that extends across the pregnancy journey. This begins when a family is planning for a baby, continues through pregnancy and, sadly, in instances where a baby dies before birth, can involve a search for reasons for the death.”

For many parents, Marles said understanding what may have led to the loss can be a helpful part of living with the death of their baby and may help with planning future pregnancies.

“Stillbirth is a profoundly devastating experience. Families can struggle to navigate those first few hours and days after stillbirth. The standard highlights the importance of clinicians speaking openly with families about their experience and options for tests to understand why it may have happened,” she said.

The standard also seeks to ensure cultural safety and improve equity in care, particularly for Aboriginal and Torres Strait Islander women and those living in very remote areas, where the stillbirth rates are much higher — 11 and 12 deaths, respectively, in every 1000 births.

“We need to recognise that women from diverse backgrounds, including Aboriginal and Torres Strait Islander women, may be less inclined to seek care from healthcare services that do not provide culturally safe care, which can prevent them from accessing maternity care. The way we provide care must take individual needs into account,” Marles said.

A hidden tragedy: six stillbirths a day

According to Professor David Ellwood, Professor of Obstetrics & Gynaecology at Griffith University and Co-Director of the Centre of Research Excellence in Stillbirth (Stillbirth CRE), the standard is vitally important because it clearly defines expected care for women in pregnancy and after stillbirth.

“We can do more in Australia to reduce our stillbirth rate, particularly for late-gestation stillbirths, which is almost 50% higher than in countries with the lowest rates worldwide, including the Netherlands, Finland and Denmark.^iv In recent years, several countries have had success in reducing stillbirth rates, and Australia can learn from these initiatives to inform our approach to stillbirth prevention.

“There are immense benefits to expanding our understanding of the causes of stillbirth — through appropriate clinical conversations, relevant assessments during pregnancy and clinical investigations after stillbirth, such as autopsy,” Ellwood said.

“While not all stillbirths can be prevented, research shows that in 20–30% of cases, the death may have been avoided had high-quality care been provided.^v This highlights the value of investigating why stillbirths are happening and then examining the evidence to improve our health response.”

Professor Caroline Homer AO, Co-Program Director of Maternal, Child and Adolescent Health at the Burnet Institute and President of the Perinatal Society of Australia and New Zealand, is also an advocate of the new standard.

“The Stillbirth Clinical Care Standard is critical because for the first time, it provides the benchmark to ensure that Australian women and families get the best care — both to reduce preventable stillbirth and to provide the very best bereavement care,” she explained.

“We all want to reduce the number of families who face the unimaginable grief of losing a baby. It’s time for us to talk more openly with women about how to reduce the risk of stillbirth, such as using safe sleeping positions after 28 weeks of pregnancy and supporting women to stop smoking.”

Homer added, “The care provided to parents after a stillbirth should be compassionate and sensitive to their needs. Many things can help grieving families, which may include spending time with their baby, organising mementos such as photos or meaningful rituals such as a memorial service.

“The standard also addresses the importance of supporting parents with practical arrangements related to the death of their baby and ensuring access to follow-up care and support after they leave hospital.”

The Hon. Ged Kearney MP, Assistant Minister for Health and Aged Care, launched the new clinical care standard at the 2022 Annual National Stillbirth Forum.

^{*In Australia, stillbirth is when a baby dies after 20 weeks of pregnancy or weighing 400 grams or more.}

^{i Australian Institute of Health and Welfare. Stillbirth and neonatal deaths in Australia 2017 and 2018. Canberra: AIHW; 2021.}

^{ii Department of Health, National Stillbirth Action and Implementation Plan; Dec 2020.}

^{iii Centre of Research Excellence in Stillbirth. Safer Baby Bundle handbook and resource guide: working together to reduce stillbirth. Australia: Centre of Research Excellence in Stillbirth; 2019.}

^{iv Flenady V, Wojcieszek AM, Middleton P, Ellwood D, Erwich JJ, Coory M, et al. Stillbirths: recall to action in high-income countries. Lancet. 2016;387(10019):691–702.}

^{v Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, et al. Stillbirths: the way forward in high-income countries. Lancet. 2011;377(9778):1703–17}

Image credit: iStock.com/TolikoffPhotography