Description of the condition

Stillbirth is a devastating event with enduring psychosocial consequences for parents, including anxiety and depression, guilt, complicated grief, social isolation, and relationship breakdown (Heazell 2016). Stillbirth also has profound economic impacts on parents, families, and the wider community (Heazell 2016; Ogwulu 2015). Globally, around 2.6 million babies are stillborn in the third trimester each year (Lawn 2016). While data‐capture issues persist in many parts of the world, it is known that the vast majority of these deaths (98%) occur in low‐ and middle‐income countries, and that over 40% occur in the intrapartum period – often associated with obstetric emergencies (Lawn 2016). Wide variation exists across and within countries, with stillbirth rates estimated to be below five per 1000 births in some high‐income countries (Flenady 2016), compared with approximately 32 per 1000 in sub‐Saharan Africa and South Asia (Lawn 2016).

There are many maternal and fetal conditions potentially associated with stillbirth. These conditions often co‐exist, and include maternal infections, non‐communicable diseases, nutrition and lifestyle factors, malaria, fetal growth restriction and advanced maternal age (Lawn 2016). In low‐ and middle‐income countries, limited access to skilled birth attendants and low rates of caesarean section are also believed to be important. Maternal undernutrition is prevalent in many low‐income countries, and contributes to various adverse pregnancy outcomes including fetal growth restriction (Black 2008a), which is an important risk factor for stillbirth. In high‐income countries, common risk factors for stillbirth include maternal overweight and obesity, advanced maternal age, primiparity and smoking (Flenady 2011).

A recent systematic review of stillbirth recurrence in high‐income countries including over three million women, reported an almost five‐fold increase in risk of stillbirth in the pregnancy following stillbirth from all causes (Lamont 2015). However, predicting recurrence risk in a specific pregnancy is difficult, as the risk depends on a variety of factors, particularly the aetiology of the index stillbirth. Where the death was related to placental insufficiency or a pre‐existing maternal condition, the recurrence risk is likely to be higher. Conversely, recurrence is unlikely for isolated events, such as maternal injury leading to placental abruption (Robson 2001).

When the cause of stillbirth is unexplained, the risk of recurrence is unclear (Lamont 2015). It is possible that recurrence following truly unexplained stillbirth is no higher than that of the general population (Onwude 2006; Robson 2001). While this may be reassuring for some women and their families, a history of stillbirth has been shown to be associated with higher frequencies of other complications in the next pregnancy, including increased rates of induced labour, elective and emergency caesarean birth, instrumental birth and other adverse outcomes, such as preterm birth, low birthweight, placental abruption, pre‐eclampsia, gestational diabetes (Black 2008b; Heinonen 2000; Robson 2001), chorioamnionitis, and neonatal death (Getahun 2009). Some of these outcomes may be in part due to care providers' and women's hypervigilance rather than inherent biological risk (Robson 2006).

Previous stillbirth is also commonly associated with intense anxiety and fear in the next pregnancy, with some women feeling a lack of confidence in their capacity to maintain a healthy pregnancy (Mills 2014). The fear of experiencing another loss may further increase risk, as stress during pregnancy has been associated with adverse pregnancy outcomes, such as preterm birth (Van den Bergh 2005) and low birthweight (Baibazarova 2013; Su 2015; Van den Bergh 2005), possibly mediated by placental function (O'Donnell 2009). Anxiety and fear may also prompt some parents to refrain from attachment to their baby (Mills 2014). Disorganised attachment has been observed in infants born subsequent to stillbirth, which may in turn increase these infants' risk of psychological and behavioural problems in childhood (Hughes 2001).

The global reduction in stillbirth rates has not matched that for maternal or neonatal mortality (Lawn 2016). A persisting issue facing providers of maternity care is therefore how to manage the next and subsequent pregnancies after a woman and her family experience a stillbirth. An Australian study of women who experienced an unexplained stillbirth found that women wanted high levels of surveillance and early birth in their next pregnancy (Robson 2009). Similarly, a survey of Australian obstetricians found that many health professionals were likely to recommend close surveillance and early delivery (Robson 2006). While early birth has some potential to reduce the rate of stillbirth, it may also be associated with iatrogenic (caused by treatment or diagnostic procedures) complications as alluded to earlier, including prematurity (and its associated adverse outcomes), failed induction, instrumental birth, emergency caesarean birth and postpartum haemorrhage (Paull 2013).

Description of the intervention

The care and management of women in the next and subsequent pregnancies following stillbirth may be different to the care of women who have never been pregnant, or who have never had a complicated pregnancy. It is possible that a number of management decisions will be required; some guided by causes, circumstances or risk factors associated with the prior stillbirth (Monari 2010; Paull 2013; Reddy 2007; Robson 2010; Saade 2011). Therefore, while individual interventions may be assessed to care for women in the next and subsequent pregnancies following stillbirth, it is also likely that interventions assessed may include the use of different management algorithms, protocols, guidelines, or models of care, combining multiple interventions in order to optimise care and improve outcomes.

Care prior to subsequent pregnancies might first focus on counselling on stillbirth recurrence risk for parents considering a subsequent pregnancy after stillbirth, to provide information and decision‐making support on:

• interpregnancy interval; pre‐conception health.

Alternatively, or in addition, care prior to or during subsequent pregnancies might focus on managing/addressing specific defined causes and/or circumstances of the index stillbirth, such as interventions to treat, manage or address:

• diabetes; hypertensive disorders; thyroid disorders; acquired or inherited thrombophilia; systemic lupus erythematosus; blood group antibodies; hyperhomocysteinaemia; chronic infectious conditions (toxoplasmosis, syphilis); periodontal disease; preterm labour; and cervical insufficiency.

Care could also be focused on addressing the presence of modifiable high‐risk behaviours or risk factors, such as interventions to reduce:

• obesity; smoking; alcohol use.

In the case of unexplained stillbirth and also where causes, circumstances or risk factors have been identified, care may focus on fetal surveillance and timing and mode of birth, such as:

• maternal assessment of fetal movements; regular non‐stress testing; early and/or regular ultrasound surveillance (to assess fetal growth, placental size or structure amniotic fluid index, Doppler assessment of uterine or umbilical flow); and/or

• elective induction of labour; elective caesarean birth; early birth; intrapartum monitoring.

Care prior to or during subsequent pregnancies might also focus on specific psychosocial needs, such as:

• specialised antenatal classes for bereaved parents; peer‐support programs and grief counselling; and additional antenatal visits and/or therapies to address anxiety, depression, and maternal‐infant attachment.

How the intervention might work

Interventions for care prior to and during subsequent pregnancies following stillbirth are likely to be highly diverse, addressing a range of risk factors, conditions, and aspects of care. First, counselling on stillbirth recurrence risk may facilitate informed decision‐making for parents considering a pregnancy subsequent to stillbirth (Paull 2013). Such counselling may include information on interpregnancy interval, preconception‐health, and the costs and benefits of delaying a subsequent pregnancy in each unique case. For some parents, delaying conception may enable additional time to deal with grief before entering another pregnancy, and may reduce anxiety in the subsequent pregnancy (Davis 1989; Hughes 1999). For women who do become pregnant, understanding the cause of the index stillbirth (if known) will enable the development of an individualised management plan in the subsequent pregnancy to directly address the cause and therefore reduce the likelihood of recurrence. For pre‐existing maternal conditions that are likely to recur (e.g. diabetes), stabilisation of the condition may reduce stillbirth recurrence risk. Cessation of smoking and pre‐conception interventions addressing maternal overweight and obesity may also reduce risk (Monari 2010). Where no cause of death for the index stillbirth has been identified, frequent monitoring may enable early detection of developing complications and may prompt expedited birth where appropriate (Robson 2010). Interventions designed to improve maternal mental health may reduce stress in pregnancy, lessening the likelihood of adverse effects such as low birthweight and preterm birth, while also enhancing maternal‐fetal attachment. Additional antenatal visits, for example, may provide parents with more opportunities for reassurance, and have been welcomed by parents in pregnancies subsequent to stillbirth or neonatal death (Mills 2014).

Why it is important to do this review

Despite the known stillbirth recurrence risk and far‐reaching impacts of stillbirth on subsequent pregnancies and beyond, there is a paucity of information on care prior to and during these pregnancies to improve health outcomes. Women pregnant subsequent to stillbirth comprise a small but unique group who require specialised and individualised care both clinically and psychosocially.