Priority Area Four

Improving knowledge of causes and contributors to stillbirth

Priority Area Four leads: Professor Vicki Flenady, Professor Jeremy Oats, Ms Jessica Sexton

Knowledge of the causes and contributing factors in stillbirth is crucially important to parents to understand why their baby died and is also the cornerstone of future prevention of stillbirths. Contributing factors relating to care are identified in a small, but important, proportion of stillbirths. Currently, data quality to understand the important contributors for stillbirth is often suboptimal due to under-investigation, inadequate classification and clinical audit of the circumstances surrounding the death.

Priority area four focuses on developing an evidence-based stillbirth investigation protocol and enhancing the existing Perinatal Society of Australia and New Zealand stillbirth and neonatal deaths classification system and audit mechanisms. The CRE is linking with the Australian Institute of Health and Welfare (AIHW) through its recently established National Maternal and Perinatal Mortality Advisory Group to optimise future implementation. With international collaborators (through ISA and WHO) it will also inform the development of international solutions.

  • Current practices, views and experiences of perinatal mortality audit - survey of hospitals

    Study Team: Vicki Flenady, David Ellwood, Dell Horey, Fran Boyle, Madeline Forbes, Johanna Laporte

    The aim of this survey is to better understand perinatal mortality review processes and bereavement support across maternity services in Australia. In this study we will help identify factors contributing to stillbirth. Findings from this study will inform the development of implementation strategies to prevent stillbirth and to improve the quality of care for families after a stillbirth or neonatal death.

  • Interventions for investigating and identifying the causes of stillbirth: a Cochrane systematic review

    Study Team: Aleena M Wojcieszek, Emily Shepherd, Philippa Middleton, Glenn Gardener, David A Ellwood, Elizabeth M McClure, Katy Gold, Yee Khong, Bob Silver, Jan Jaap Erwich, Vicki Flenady

    Understanding of the causes of stillbirth is at the cornerstone of prevention. Diagnostic tests aim to find the causes of stillbirth, but there are a myriad of tests available and no consensus on the best approach to using these tests. This review assesses the effect of different tests, protocols or guidelines for investigating and identifying the causes of stillbirth on outcomes for parents - including psychosocial outcomes, economic costs, and rates of diagnosis of the causes of stillbirth.

    The review has been published in the Cochrane Database of systematic reviews and can be accessed here.

  • Investigating the causes of stillbirth; a prospective cohort study examining use and effectiveness of a comprehensive investigation protocol

    Study Team: Vicki Flenady, Glenn Gardener, David Ellwood, Adrian Charles, Michael Coory, Louisa Gordon, Kassam Mahomed, Yee Khong, Alison Kent

    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 are:

    1. To describe the causes and contributing factors to stillbirth in a well investigated cohort
    2. To evaluate the procedures involved in establishing and maintaining a stillbirth research data collection system, including independent expert panel review, compliance with Perinatal Society of Australia and New Zealand (PSANZ) stillbirth investigation protocol and data quality
    3. To determine agreement between hospital review committees and the expert panel with regards to classification of causes of stillbirth using the PSANZ Perinatal Death Classification (PDC).
  • Ending preventable stillbirths scorecard for high-income countries (HIC Scorecard)

    Study Team: Vicki Flenady, Susannah Leisher, Hannah Blencowe, Paula Quigley, Madeline Forbes 


    In 2018 the Stillbirth Advocacy Working Group (SAWG), founded by the Partnership for Maternal, Child, and Newborn Health and co-chaired by the London School of Hygiene & Tropical Medicine and the International Stillbirth Alliance, developed a scorecard to track progress against the Call to Action that was presented in the final paper of the Lancet's Ending Preventable Stillbirths series. The SAWG aims to promote use of the Scorecard to track each component of the Lancet's Call to Action, including meeting the Every Newborn Action Plan global stillbirth rate target, as well as reducing equity divides in sub-national stillbirth rates, increasing access to and quality of antenatal and intrapartum care and family planning, improving the quality of post-stillbirth bereavement care, and reducing stigma associated with stillbirth. 

    Following on from this work, the Stillbirth CRE is developing an adaptation of the Scorecard for use in high-income countries and settings (HIC). The aim of the "Ending Preventable Stillbirths Scorecard for High-Income Countries" is to provide a tool for the global community, including national governments, UN bodies, bilateral organisations, parent organisations, donors and NGOs, to track progress against the Ending Preventable Stillbirths Call to Action, in particular highlighting areas where insufficient progress is being made and where further investments and actions are needed. New indicators for high income settings have been identified, from sources such as the indicator list for the United States' Healthy People 2020 national health objectives. A draft version of the HIC Scorecard has been trialled the US, the UK, and Australia to assess the feasibility and utility of each indicator, and incorporated comments into the draft.

  • Development and implementation of an international classification systems for optimal reporting of the causes of stillbirths and neonatal deaths

    Study Team: Vicki Flenady, Susannah Leisher, Glenn Gardener, Kara Warrilow, Madeline Forbes


    To test the recently developed classification system for causes of stillbirths and neonatal deaths in data-rich settings (high-income and upper-middle income countries). 


    1. To test a new system that combines key features of best performing HIC classification systems into a single system that reflects recent research:

    • Ensuring alignment with the principles of the newly developed ICD-PM
    • Reflecting expert-consensus characteristics of an effective global system
    • Reflecting our analysis of systems currently in use and their alignment with the critical characteristics
    • Incorporating recent findings on placental contributors to death

    2. Fine-tune the classification system and data collection tool by classifying 20 cases by the Australian and Netherlands team.
    3. Refine the system and data collection tool such that it is ready for wide-scale performance testing across 10 countries.
    4. Following fine-tuning, test the system on 1000 cases (250 stillbirths and 250 neonatal deaths) across all 10 country groups independently classified by five multidisciplinary panels. Of these 1000 cases, 200 will be tested in all teams to measure agreement of the system.
    5. Refine the system prior to global adoption.

  • Every Baby counts: implementing high quality investigation and audit for stillbirths and neonatal deaths

    Study Team: Vicki Flenady, David Ellwood, Adrienne Gordon, Euan Wallace, Jonathan Morris, Fran Boyle, Dell Horey, Emily Callander, Yee Khong, Jeremy Oats

    Poor quality data on causes of stillbirth is a significant barrier to future prevention efforts. The proportion of unexplained stillbirth may be overestimated by 50% as a result of inadequate investigation, audit and classification. Our survey for The Lancet Ending Preventable Stillbirths Series indicates room for improvement in stillbirth investigation, with 50% of parents feeling that not everything possible had been done to find out why their baby died. Substandard care contributing to stillbirth is evident across Australia. High quality audit can reduce stillbirth but only if linked to practice improvement initiatives.

    We have now updated the PSANZ Guideline on care around stillbirth and neonatal death to include the best available evidence for determining the causes of stillbirth and neonatal deaths through an evidence-based stillbirth investigation protocol, enhancements to the classification of causes and substandard care. Our aim is to implement and evaluate a package to promote best practice in stillbirth investigation. An on-line audit database developed as part of the Investigating the causes of stillbirth; a prospective cohort study examining use and effectiveness of a comprehensive investigation protocol will be refined to measure performance of the implementation strategies.

    Expected outcomes: Acceptability and feasibility of the recommended audit process and improvement in quality of care, including stillbirth investigations, classification and audit and addressing substandard care factors; a reduction in unexplained stillbirth.

  • Improving knowledge of causes and contributors to stillbirth in Papua New Guinea

    Study Team: Caroline Homer, Josh Vogel through the Burnet Institute

    It is known that 98% of stillbirths occur in low- and middle-income countries (LMIC). Australia’s nearest neighbour, PNG and our other close Pacific Island nations (Solomon Islands and Vanuatu) bear the burden of high stillbirth rates. Unfortunately, due to poor data collection processes the full impact of stillbirth in these nations is not realised. In LMICs, stillbirths are largely attributable to preventable or treatable conditions that occur either in conjunction with, or as a result of pregnancy, including malaria, syphilis, anaemia, diabetes, hypertension, pre-eclampsia and post-term pregnancy. Other risk factors for stillbirth, such as young maternal age, short inter-pregnancy interval, indoor air pollution and interpersonal violence against women during pregnancy also play a role. Many of these risk factors could be addressed through universal access to good-quality antenatal and intrapartum care. Modelling has suggested that up to 45% of all stillbirths could be prevented if a package of 10 proven antenatal and intrapartum interventions (including basic and emergency obstetric care) was made widely available. However, it is unknown whether these interventions would address the key issues in a country like PNG or whether they would even be feasible.

    The proposed research supports the ‘Improving knowledge of causes and contributors to stillbirth’ priority through an analysis of at least 40 stillbirths in PNG which have been collected as part of two recent and ongoing studies. This analysis will support the development of a larger project which will be developing and testing a feasible bundle of interventions to address preventable stillbirth in PNG and similar low resource countries.