Stillbirth in Australia 1: The road to now: Two decades of stillbirth research and advocacy in Australia

Stillbirth is a major public health problem with an enormous mortality burden and psychosocial impact on parents, families and the wider community both globally and in Australia. In 2015, Australia’s late gestation stillbirth rate was over 30% higher than that of the best-performing countries globally, highlighting the urgent need for action. We present an overview of the foundations which led to the establishment of Australia’s NHMRC Centre of Research Excellence in Stillbirth (Stillbirth CRE) in 2017 and highlight key activities in the following areas: Opportunities to expand and improve collaborations between research teams; Supporting the conduct and development of innovative, high quality, collaborative research that incorporates a strong parent voice; Promoting effective translation of research into health policy and/or practice; and the Regional and global work of the Stillbirth CRE. We highlight the first-ever Senate Inquiry into Stillbirth in Australia in 2018. These events ultimately led to the development of a National Stillbirth Action and Implementation Plan for Australia with the aims of reducing stillbirth rates by 20% over the next five years, reducing the disparity in stillbirth rates between advantaged and disadvantaged communities, and improving care for all families who experience this loss.     

Stillbirth in Australia 6: The future of stillbirth research and education

The first five papers in the Stillbirths in Australia series have described the current state of stillbirth research and education in Australia, as well as the national approach being adopted to prevention. This final paper in the series asks ‘where to from here?’. What does the next 5–10 years hold for those of us working in this field and how much more can be achieved? There are signs that we are moving in the right direction with a national prevention program about to rollout to add to the gains of the last two decades, and evidence of a more consistent approach to bereavement care. However, we must sharpen our equity lens and ensure that all groups are included in these efforts.     

Stillbirth in Australia 2: Working together to reduce stillbirth in Australia: The Safer Baby Bundle initiative

The rate of late gestation stillbirth in Australia is unacceptably high. Up to one third of stillbirths are preventable, particularly beyond 28 weeks’ gestation. The aim of this second paper in the Stillbirth in Australia series is to highlight one key national initiative, the Safer Baby Bundle (SBB), which has been led by the Centre of Research Excellence in Stillbirth in partnership with state health departments. Addressing commonly identified evidence practice gaps, the SBB contains five elements that, when implemented together, should result in better outcomes than if performed individually. This paper describes the development of the SBB, what the initiative aims to achieve, and progress to date. By collaborating with Departments of Health and other partners to amplify uptake of the SBB, we anticipate a reduction of at least 20% in Australia’s stillbirth rate after 28 weeks’ gestation is achievable.     

Stillbirth in Australia 3: Addressing stillbirth inequities in Australia: Steps towards a better future

Persistent disparities in stillbirth risk and care are present in Australia. Eliminating these disparities is possible with a commitment to enhancing and scaling up models of culturally safe maternity care shown to be effective for Aboriginal and Torres Strait Islander women and those of migrant and refugee backgrounds. Campaigns to improve public awareness of stillbirth also play an important role in reducing stillbirth risk and consequences. To achieve reach and impact in communities at risk, messaging needs to be framed around the social and cultural context of women’s lives. Here we describe important initiatives underway within the Stillbirth Centre of Research Excellence to develop a coordinated national approach to stillbirth prevention and care in communities that bear a disproportionate burden of stillbirth.     

Stillbirth in Australia 5: Making respectful care after stillbirth a reality: The quest for parent-centred care

Stillbirth is a tragedy that can leave parents feeling powerless and vulnerable. Respectful and supportive bereavement care is essential to reducing adverse psychosocial impact. Initiatives of the Australian Centre of Research Excellence in Stillbirth are designed to improve care after stillbirth. At their heart are the voices of perinatally bereaved parents and support organisations and shared decision making between parents and health care providers. Priorities in future perinatal bereavement care research include ensuring appropriate care for population groups who experience higher rates of stillbirth and addressing implementation challenges to best practice in respectful and supportive bereavement care within our health systems.     

Breaking through the silence in antenatal care: Fetal movement and stillbirth education

BackgroundFetal movements are a key indicator of fetal health. Research has established significant correlations between altered fetal activity and stillbirth. However, women are generally unaware of this relationship. Providing pregnant women with information about the importance of fetal movements could improve stillbirth rates. However, there are no consistent fetal movements awareness messages globally for pregnant women.AimsThis study aimed to explore the antenatal care experiences of Australian mothers who had recently had a live birth to determine their knowledge of fetal movements, the nature and source of that information.MethodsAn online survey method was used for 428 women who had a live birth and received antenatal care in Australia. Women’s knowledge of fetal movements, stillbirth risk, and the sources of this knowledge was explored.FindingsA large proportion of participants (84.6%; n = 362) stated they had been informed by health care professionals of the importance of fetal movements during pregnancy. Open-ended responses indicate that fetal movements messages are often myth based. Awareness that stillbirth occurs was high (95.2%; n = 398), although, 65% (n = 272) were unable to identify the current incidence of stillbirth in Australia.ConclusionWomen who received antenatal care have high-awareness of fetal movements, but the information they received was inconsistent. Participants knew stillbirth occurred but did not generally indicate they had obtained that knowledge from health care professionals. We recommend a consistent approach to fetal movements messaging throughout pregnancy which focuses on stillbirth prevention.     

Knowing your audience: Investigating stillbirth knowledge and perceptions in the general population to inform future public health campaigns

BackgroundThe prevalence of stillbirth in many high income countries like Australia has remained unchanged for over 30 years. The 2018 Australian government Senate Select Committee on Stillbirth Research and Education highlighted the need for a public health campaign to encourage public conversations and increase awareness. However, there is little evidence about the community’s knowledge and perceptions towards pregnancy and stillbirth, nor their aspirations for a public health campaign.AimsTo assess the general knowledge, perceptions, myths and attitudes towards stillbirth to inform future public health campaigns.MethodsAustralian participants (n = 344; predominately women n = 294 (85.5%)) were recruited via Facebook.com. They completed a cross-sectional online survey designed to assess their knowledge of pregnancy and stillbirth, with additional questions on socio-demographic characteristics.ResultsStillbirth knowledge and awareness of incidence was low in this sample. Prominent myths, such as baby runs out of room in the uterus (n = 112, 33%) and baby slows down when preparing for labour (n = 24, 27%) were endorsed. Only 25% (n = 85) knew the prevalence of stillbirth in Australia (six per day). Almost two-thirds (n = 205; 62%) agreed that there needs to be a public health campaign, however one in five (n = 65; 20%) were concerned that talking about stillbirth with pregnant women may cause them to worry.Discussion and conclusionOur findings reinforce the need for a targeted campaign, which educates the general population about the definition and prevalence of stillbirth, stillbirth risks and modifiable health behaviours. Appropriate messaging should target pregnant women during antenatal care as well as their support and care systems (family, friends, and care providers).     

城镇不同社会医疗保险待遇人群死亡率交叉现象研究

本文使用中国老人健康长寿影响因素研究(Chinese Longitudinal Healthy Lon-gevity Survey,CLHLS),2002～2005年调查数据对我国不同社会医疗保险待遇的老年人口的死亡率交叉现象进行了研究。运用离散时间的死亡风险分析,文章的发现支持选择性死亡的理论,即无社会医疗保险的人群,60岁时死亡率一直高于享受医保人群,使得无医保人群中强健的个体幸存下来;随着年龄的增长,这种选择机制的作用逐渐表现为死亡率逆转,即无医保人群的平均死亡率在大约96岁以后开始低于享受医保人群。研究显示,我国享受社会医疗保险的老年的生存优势一直存在至96岁高龄,医疗保险对于老年人口的健康有着显著而长远的积极影响。     

The impact of mass media family planning promotion on contraceptive behavior of women in Ghana

This paper examines the influence of media messages about family planning, and attitudes toward media promotion of family planning, on contraceptive behavior of married women in Ghana. It also examines the problem of reverse causation that arises in studies of this nature when the data used provide no information on the temporal order of the actual time that respondents were exposed to family planning information in the mass media and the time of adoption of contraceptive behavior. The results show that exposure to media messages on contraception exerts strong impact on current practice of, and intention to use, contraception. Women who had heard or seen advert on contraceptive brands, and women who favor broadcast of family planning messages in the media, are significantly more likely to adopt birth control behavior than women who had not heard or seen, and women who do not favor broadcast of such media messages, respectively. Regarding the problem of reverse causation, the study demonstrates that while being exposed to media messages significantly affects a woman's contraceptive behavior, the reverse does not seem to be the case. The policy implications of these results and how mass media could be used to promote family planning in Ghana are discussed.     

Inclusion and exclusion criteria for publicly-funded homebirth in Australia: A scoping review

BackgroundThere are fifteen publicly-funded homebirth programs currently operating in Australia. Suitability for these programs is determined by a series of inclusion and exclusion criteria.AimThe aim of this scoping review is to identify common inclusion and exclusion criteria for publicly-funded homebirth programs and other related factors that affect access to these programs.MethodsA Google search was conducted for publicly-funded homebirth programs listed on the National Publicly-funded Homebirth Consortium website. Public websites, documents, and policies were analysed to identify inclusion and exclusion criteria for these programs.FindingsEleven of the 15 publicly-funded homebirth programs mention the availability of homebirth on their health service website, with varying levels of information about the inclusion and exclusion criteria available. Two of the programs with no information on their health service website are covered by a state-wide guideline. Additional details were sought directly from programs and obtaining further information from some individual homebirth programs was challenging. Variation in inclusion and exclusion criteria exists between programs. Common areas of variation include restrictions relating to Body Mass Index, parity, age, English language ability, tests required during pregnancy, and gestation at booking to the homebirth program.ConclusionThe inclusion and exclusion criteria for a publicly-funded homebirth program determines women’s access to the program. Limited publicly available information regarding inclusion and exclusion criteria for many publicly-funded homebirth programs is likely to limit women’s awareness of and access to these programs.     

The BLOSSoM study: Burnout after perinatal LOSS in Midwifery. Results of a nation-wide investigation in Italy

BackgroundRespectful care of bereaved parents after stillbirth plays a pivotal role in enabling the grieving process and reducing the traumatic impact of this life-changing event. Unfortunately, professionals and midwives, in particular, are often emotionally unprepared and frequently left alone when dealing with these stressful events.AimThe BLOSSoM (Burnout after perinatal LOSS in Midwifery) study aims to address the levels of professional burnout in Italian midwives and evaluate the psychological impact of bereavement care on professionals.MethodsWeb-based cross-sectional study, including socio-demographic questionnaire, survey on the knowledge of guidelines for stillbirth management and two psychometric tests: Maslach Burnout Inventory (MBI) and Impact of Event Scale - Revised (IES-R).FindingsOf 445 female midwives, mean age 35.1 (SD 9.9), working years 11.2 (SD 10.2), 149 (33.4%) reported specific training on stillbirth and 420 (94.6%) highlighted the need for further training and support. Medium to high levels of burnout (Emotional Exhaustion) were present in 65 midwives (15.9%) with a high prevalence of Reduced Personal Accomplishment (292, 64.2%). ‘Communicating the diagnosis of death’ was considered the hardest task, followed by ‘assisting the meeting with the baby’; 109 midwives (24.5%) reported high IES-R scores (>30), suggesting symptoms of PTSD related to stillbirth events; a good level of knowledge of guidelines favoured Personal Accomplishment (OR 0.3 [0.1 – 0.6]). The number of stillbirths assisted by midwives was not associated with burnout levels.ConclusionMidwives are particularly at risk of developing professional burnout, as early as after five years of work, with a significant association with the psychological impact exerted by stressful events (stillbirth).     

Voices of the unheard: A qualitative survey exploring bereaved parents experiences of stillbirth stigma

BackgroundEvery year, 2.6 million babies are stillborn worldwide. Despite these figures, stillbirth remains a relatively ignored public health issue. The wider literature suggests that this is due to the stigma associated with stillbirth. The stigma of stillbirth is seen as possibly one of the greatest barriers in reducing stagnant stillbirth rates and supporting bereaved parents. However, empirical evidence on the extent, type, and experiences of stillbirth stigma remain scarce.AimThis study aimed to explore the stigma experiences of bereaved parents who have endured a stillbirth.MethodsAn online survey of closed and open-questions with 817 participants (n = 796 female; n = 17 male) was conducted in high-income countries.FindingsBased on self-perception, 38% of bereaved parents believed they had been stigmatised due to their stillbirth. Thematic data analysis revealed several themes consistent with Link and Phelan’s stigma theory- labelling, stereotyping, status loss and discrimination, separation, and power. One more theme outside of this theory- bereaved parents as agents of change was also discovered.ConclusionBereaved parents after stillbirth may experience stigma. Common experiences included feelings of shame, blame, devaluation of motherhood and discrimination. Bereaved parents also reported the silence of stillbirth occurred during their antenatal care with many health care providers not informing them about the possibility of stillbirth. Further research needs to be undertaken to explore further the extent and type of stigma felt by bereaved parents after stillbirth, and how stigma is impacting the health care professional disseminating and distributing resources to pregnant women.     

快速城市化背景下城市公共服务需求偏好研究——以上海为例

近年来,我国进入快速城市化阶段,城市人口快速膨胀,人口结构复杂化,居民对公共服务的需求多样化。本文以上海市为例,通过问卷数据,从人口学视角,通过回归分析不同人群公共服务的偏好。结果显示,当前居民对公共服务的需求不仅有数量增加,对质量、服务水平及环境都有所要求;同时人口区域结构对公共服务的需求具有显著影响,人口自然结构、社会结构的影响较小,区域公共服务差异、户籍性质造成的身份差异是影响公共服务需求的主导因素。     

Public Policies and Suicide Rates in the American States

We are interested in the relationship between public policies and outcomes measuring quality of life. There is no outcome more final than the ending of one’s own life. Accordingly, we test the relationship between public policy regimes and suicide rates in the American states. Controlling for other relevant factors (most notably a state’s stock of social capital), we find that states with higher per capita public assistance expenditures tend to have lower suicide rates. This relationship is of significant magnitude when translated into potential lives saved each year. We also find that general state policy liberalism and the governing ideologies of state governments are linked to suicide rates. In response to a growing literature on the importance of non-political factors such as social connectedness in determining quality of life, these findings demonstrate that government policies remain important determinates as well.

Understanding staff views and experiences of a clinical practice change to reduce stillbirth in South Asian women: A cross-sectional survey

BackgroundIn July 2017, Victoria’s largest maternity service implemented a new clinical practice guideline to reduce the rates of term stillbirth in women of South Asian background.AimTo capture the views and experiences of clinical staff following the implementation of the new clinical guideline.MethodsCross sectional survey of clinical staff providing maternity care in August 2018, 12 months post implementation. Staff were asked to provide their agreement with ten statements assessing: perceived need for the guideline, implementation processes, guideline clarity, and clinical application. Open-ended questions provided opportunities to express concerns and offer suggestions for improvement. The frequency of responses to each question were tabulated. Open ended responses were grouped together to identify themes.FindingsA total of 120 staff completed the survey, most (n = 89, 74%) of whom were midwives. Most staff thought the rationale (n = 95, 79%), the criteria for whom they applied (83%, n = 99), and the procedures and instructions within the guideline were clear (74%, n = 89). Staff reported an increase in workload (72%, n = 86) and expressed concerns related to rationale and evaluation of the guidelines, lack of education for both staff and pregnant South Asian women, increased workload and insufficient resources, patient safety and access to care. Challenges relating to shared decision making and communicating with women whose first language is not English were also identified.DiscussionThis study has identified key barriers to and opportunities for improving implementation and highlighted additional challenges relating to new clinical guidelines which focus on culturally and linguistically diverse women.     

人口因素对公共医疗服务效率的影响——区域差异与动态变化

本文基于2002～2010年我国31个省市的面板数据,在DEA—Tobit两阶段分析框架下研究了人口因素对我国区域公共医疗服务效率的动态影响。首先,通过数据包络分析方法（DEA）测算了各省份医疗卫生体系的综合技术效率、纯技术效率和规模技术效率。在此基础上,利用受限因变量Tobit模型对效率值及人口规模、人口密度、受教育程度、城市化率等人口因素之间的关系进行了检验。研究结果表明：人口规模、人口密度与医疗体系的综合服务效率显著正相关,尽管受教育程度和城市化率与综合效率关系并不明显,但是对医疗体系的规模效率和纯技术效率仍然存在显著影响。     

城市流动人口聚居社区的公共政策与社区服务分析——五城市流动人口聚居社区调查

本文基于五城市流动人口聚居社区的调查资料,采用描述性分析的方法,首先通过对五城市流动人口聚居社区流动人口与社区城市户籍居民的对比分析,考察城市流动人口聚居社区管理与服务的状况;然后在分析的基础上提出对于相关公共政策和社区服务问题的一些思考.     

流动人口计划生育公共服务评估及创新——基于五地市的调查

基于对五地市的调查,本研究对流动农村人口计生公共服务实施情况进行了分析评估.综合政策认知、接受的人口计生公共服务项目、服务需求、服务满意度等方面情况的调查结果,发现:当前流动人口计生公共服务还存在服务内容不丰富、服务方式不科学、政策执行不到位、保障机制不健全、管理机制不协调、服务不均等等诸多问题和制约.转变政府公共服务职能和理念、拓展服务内容、丰富服务方式、完善保障机制有助于提升流动人口计生公共服务的水平和效能.     

Public policy and the labor market adjustment of new immigrants to Australia

Two separate cohorts of immigrants to Australia are compared in order to assess the potential role of immigrant selection criteria, labor market conditions, and income-support policy in facilitating the labor market adjustment of new arrivals. Although these two cohorts entered Australia only five years apart, their initial labor market outcomes varied dramatically. The results indicate that changes in immigration policy may have led to increased human capital endowments that in turn resulted in higher participation rates and reduced unemployment. At the same time, improvement in Australian labor market conditions and changes in income-support policy over the 1990s – which most likely altered the returns to human capital – were probably instrumental in reinforcing the effects of tighter immigrant selection criteria. As much as half of the fall in unemployment rates among women and one third the decline among men appears to have occurred as the result of changes in the returns to demographic and human capital characteristics. Responsible editor:Christoph M. Schmidt