Research Projects


A-D E-H L-O P-S 

A-D

ANZSA Investigating Causes of Stillbirth: a prospective cohort study examining use and effectiveness of a comprehensive investigation protocol

Stillbirth is devastating to parents, their families and those who care for them. There has been no reduction in stillbirth rates for over two decades. Accurate cause of death data is the cornerstone of effective prevention and essential for parents facing this tragedy to understand what went wrong. However, the majority of stillbirths in Australia are not adequately investigated resulting in erroneous data on causation and a high proportion are ‘unexplained’.

This study addresses the call for better data on the causes of stillbirths from the NHMRC Maternity Services review and The Lancet Stillbirth Series and constitutes the major research agenda of the Australian and New Zealand Stillbirth Alliance (ANZSA). In this study we will identify causes of stillbirths in a large well-investigated cohort and improve the quality of data on stillbirths across Australia through identifying a cost-effective, evidence-based approach to stillbirth investigations.

SPECIFIC AIMS
Primary

1. To promote the use of the PSANZ clinical practice guidelines (CPGs) for the investigation and classification of stillbirth to a group of level two and three hospitals; to record which tests were done and the value placed on the results; and to use the expert clinical knowledge of a multi-disciplinary team to accurately classify the clinical cause of every stillbirth using the PSANZ Perinatal Death Classification (PDC).
2. To determine the sensitivity, specificity, positive and negative predictive values, and likelihood ratios for the PSANZ stillbirth investigation protocol and its individual tests; to compare diagnostic performance of the PSANZ protocol without autopsy compared to the PSANZ protocol with autopsy.
3. To measure the cost-effectiveness of the comprehensive PSANZ stillbirth investigation protocol compared with a selective approach based on presenting scenarios.

Secondary

1. To improve the consistency of classification across Australia and to contribute to the development of an international classification for stillbirths.
2. To establish a prospective internet-based register on test results of stillbirths to enable a continuous evaluation of the diagnostic tools and aetiologic factors.

View ANZSA Investigating causes of stillbirth Protocol Here

Hospitals Collaborating on the Stillbirth Investigations Protocol

Contact : Vicki Flenady

Classification Agreement Study

Accurate cause of stillbirth death data along with consistent application of stillbirth classification systems is important for developing effective prevention strategies. The PSANZ Clinical Practice Guidelines on Perinatal Mortality Audit were developed to aid accuracy and consistency of data on classification of stillbirth. However, uptake of these guidelines is low. Lack of high level evidence for the recommended investigations is thought to be a major reason for low compliance. A NSW study showed the need for education of hospital committees with regards to stillbirth classification.

Methods and Objectives

This study will compare the level of agreement in classification of stillbirth according to PSANZ Perinatal Death Classification between hospital review committees and expert panel review. This quality control exercise will identify areas for improvement and the feedback of the expert panel review to the hospital committees will provide a learning opportunity.

Investigators: Ibinabo Ibiebele, Vicki Flenady, Michael Coory, Fran Boyle

Contact: Ibinabo Ibiebele

Detection and management of decreased fetal movements in Australia and New Zealand: A survey of obstetric practice

Background:

Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM. Aims: To identify current practices and views of obstetricians in Australia and New Zealand regarding DFM.

Methods:

A postal survey of Fellows and Members, and obstetric trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Results:

Of the 1700 surveys distributed, 1066 (63%) were returned, of these, 805 (76% of responders) were currently practising and included in the analysis. The majority considered that asking women about fetal movement should be a part of routine care. Sixty per cent reported maternal perception of DFM for 12 h was sufficient evidence of DFM and 77% DFM for 24 h. KICK charts were used routinely by 39%, increasing to 66% following an episode of DFM. Alarm limits varied, the most commonly reported was < 10 movements in 12 h (74%). Only 6% agreed with the internationally recommended definition of < 10 movements in two hours. Interventions for DFM varied, while 81% would routinely undertake a cardiotocograph, 20% would routinely perform ultrasound and 20% more frequent antenatal visits. Conclusions: While monitoring fetal movement is an important part of antenatal care in Australia and New Zealand, variation in obstetric practice for DFM is evident. Large-scale randomised controlled trials are required to identify optimal screening and management options. In the interim, high quality clinical practice guidelines using the best available advice are needed to enhance consistency in practice including advice provided to women.

Contact: Vicki Flenady

Published paper:

FLENADY, V., MacPHAIL, J., GARDENER, G., CHADHA, Y., MAHOMED, K., HEAZELL, A., FRETTS, R. and FRØEN, F. (2009), Detection and management of decreased fetal movements in Australia and New Zealand: A survey of obstetric practice. Australian and New Zealand Journal of Obstetrics and Gynaecology, 49: 358–363. doi: 10.1111/j.1479-828X.2009.01026.x

E-H

Epidemiology of unexplained fetal deaths in Queensland

In Australia, the unexplained antepartum fetal deaths (UAFD) rate is approximately 2 per 1000 births and contributes 30% to all fetal deaths. The relative contribution of to the total fetal deaths appears to be on the increase. In the vast number of these deaths, the death occurs unexpectedly towards the end of pregnancy when, had the baby been born alive, the chance of survival is high. The rate of UAFD is approximately six times the current rate of Sudden Infant Death Syndrome (SIDS) in Australia. Despite this, little research has been undertaken in this area.

Methods and Objectives:

Using routinely collected population base data, the study will describe the epidemiology of fetal death in Queensland. These analyses will provide valuable information on which to base the development of initiatives aimed at reducing the risk of antepartum fetal death.

Investigators: Ibinabo Ibiebele, Vicki Flenady, Michael Coory, Fran Boyle, Adrian Charles, Gordon Smith

Contact: Ibinabo Ibiebele

L-O

My Baby's Movements: a stepped wedge cluster randomised controlled trial to raise maternal awareness of fetal movements during pregnancy

Specific aims of the MBM Trial

To develop, and assess the effects of, a personalised interactive mobile phone software program (MBM), using smart phones or SMS (Short Message Service), provided to pregnant women as part of their antenatal care, compared to women receiving routine antenatal care alone on: 1) Stillbirth rates; 2) maternal psychosocial outcomes and health services utilisation; 3) women’s and clinician’s and views on fetal movements (FM) information provided and knowledge of FM; and 4) economic impact.

Objectives
Primary

1) To develop and pilot test MBM among a sample of women attending antenatal care at the Mater Mothers' Hospital and surrounds (pilot study).
2) To provide women, attending for antenatal care at the participating hospitals, access to MBM, and to provide an educational program for clinicians on its use, using a stepped wedge randomised trial design.
3) To assess the effects of MBM on reporting DFM and on stillbirth and other important pregnancy outcomes using routinely collected perinatal data.
4) To undertake an economic evaluation of MBM.

Secondary

1) To conduct a clinical audit during the control and intervention phases to determine proportion of women presenting with DFM, delays in presentation, and outcome of clinical assessment.
2) To undertake cross sectional surveys of women attending for antenatal care and clinical staff during the control and intervention phase to determine acceptability of DFM information, knowledge about DFM, and a follow-up survey at 6 months postpartum regarding psychosocial outcomes, general health and health service utilisation.
3) Through the MBM Tool, survey women after the birth of the baby to determine the acceptability of MBM in general and fetal movement counting component.

My Baby's Movements Trial Protocol

Hospitals collaborating on My Baby's Movements

Contact: Vicki Flenady

P-S

Parental Consent Study

Autopsy is the gold standard for stillbirth investigation; however, rates of perinatal autopsy have been declining. Approaches to communication and consent for autopsy should be evidence based; however, these are currently based on supposition of parent’s wishes.
The autopsy consent process is a difficult process for parents and clinicians alike. Parents are required to gain an understanding of detailed procedures while in a state of grief. Studies have shown that parents enduring powerful negative experiences may not recall information given to them. Clinicians may also be reluctant to place additional burden on parents or may feel ill equipped to approach parents for consent. Parents may regret decisions about autopsy, and this may be due to inadequate information or poor communication.

Methods and Objectives:

This qualitative study using in-depth telephone interviews is nested within a larger sequential mixed-methods design study. This study will employ qualitative interviews to determine parent’s views and experiences on autopsy to inform clinical practice.

Investigators: Ibinabo Ibiebele, Fran Boyle, Vicki Flenady, Michael Coory

Contacts: Ibinabo Ibiebele