Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England

Objectives: To investigate the factors associated with sudden infant death syndrome (SIDS) from birth to age 2 years, whether recent advice has been followed, whether any new risk factors have emerged, and the specific circumstances in which SIDS occurs while cosleeping (infant sharing the same bed or sofa with an adult or child). Design: Four year population based case-control study. Parents were interviewed shortly after the death or after the reference sleep (within 24 hours) of the two control groups. Setting: South west region of England (population 4.9 million, 184 800 births). Participants: 80 SIDS infants and two control groups weighted for age and time of reference sleep: 87 randomly selected controls and 82 controls at high risk of SIDS (young, socially deprived, multiparous mothers who smoked). Results: The median age at death (66 days) was more than three weeks less than in a study in the same region a decade earlier. Of the SIDS infants, 54% died while cosleeping compared with 20% among both control groups. Much of this excess may be explained by a significant multivariable interaction between cosleeping and recent parental use of alcohol or drugs (31% v 3% random controls) and the increased proportion of SIDS infants who had coslept on a sofa (17% v 1%). One fifth of SIDS infants used a pillow for the last sleep (21% v 3%) and one quarter were swaddled (24% v 6%). More mothers of SIDS infants than random control infants smoked during pregnancy (60% v 14%), whereas one quarter of the SIDS infants were preterm (26% v 5%) or were in fair or poor health for the last sleep (28% v 6%). All of these differences were significant in the multivariable analysis regardless of which control group was used for comparison. The significance of covering the infant’s head, postnatal exposure to tobacco smoke, dummy use, and sleeping in the side position has diminished although a significant proportion of SIDS infants were still found prone (29% v 10%). Conclusions: Many of the SIDS infants had coslept in a hazardous environment. The major influences on risk, regardless of markers for socioeconomic deprivation, are amenable to change and specific advice needs to be given, particularly on use of alcohol or drugs before cosleeping and cosleeping on a sofa

Perinatal Mortality Rate as a Quality Indicator of Healthcare in Al-Dakhiliyah Region, Oman

Objectives: This study aimed to provide insight into the causes of stillbirths and early neonatal deaths and identify better intervention strategies. Methods: This was a retrospective study during a 7-year period (January 2003 to December 2009) of all stillbirths and early neonatal deaths at the Nizwa regional referral hospital in Al-Dakhiliyah region, Oman. Results: Of a total 27,668 births, there were 244 stillbirths and 157 early neonatal deaths. The perinatal mortality rate (PMR) was 14.49/1,000 births. The period-specific rates were 17.23/1,000 in 2003, 18.33/1,000 in 2004, 15.20/1,000 in 2005, 12.20/1,000 in 2006, 12.46/1,000 in 2007 and 12.09/1000 in 2008. This decline in the death rate was significant (P = <0.005). The rate rose in 2009 to 15.63/1,000, mostly from an increase in early neonatal deaths (congenital anomalies). The most common identifiable cause of stillbirth was congenital anomalies (18.82%), in which central nervous system anomalies were most common. Other causes include abruptio placentae (13%), cord accidents (12%), and intrauterine growth restriction (IUGR), while the cause remained unknown in 22.59%. Congenital anomalies accounted for 53.50% of early neonatal deaths followed by prematurity (23.56%) and birth asphyxia (5.73%). Extremes of maternal age were related to higher PMRs. Conclusion: An overall improvement in the stillbirths and neonatal death rates was witnessed; however, further improvement is warranted for common avoidable fetal and maternal risk factors. Extra care needs to be provided for women who are at risk of developing complications such as gestational diabetes, pregnancy-induced hypertension, IUGR, etc

Recurrence rates for SIDS - the importance of risk stratification

Objective: To investigate the importance of stratification by risk factors in computing the probability of a second SIDS in a family. Design: Simulation Study Background: The fact that a baby dies suddenly and unexpectedly means that there is a raised probability that the baby’s family have risk factors associated with Sudden Infant Death Syndrome (SIDS). Thus one cannot consider the risk of a subsequent death to be that of the general population. The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI)6 identified three major social risk factors: smoking, age1, and unemployed/unwaged as major risk factors. It gave estimates of risk for families with different numbers of these risk factors. We investigate whether it is reasonable to assume that, conditional on these risk factors, the risk of a second event is independent of the risk of the first and as a consequence one can square the risks to get the risk of two SIDS in a family. We have used CESDI data to estimate the probability of a second SID in a family under different plausible scenarios of the prevalence of the risk factors. We have applied the model to make predictions in the Care of Next Infant (CONI) study7. Results: The model gave plausible predictions. The CONI study observed 18 second SIDS. Our model predicted 14 (95% prediction interval 7 to 21). Conclusion: When considering the risk of a subsequent SIDS in a family one should always take into account the known risk factors. If all risks have been identified, then conditional on these risks, the risk of two events is the product of the individual risks However for a given family we cannot quantify the magnitude of the increased risk because of other possible risk factors not accounted for in the model

Major epidemiological changes in sudden infant death syndrome : a 20-year population-based study in the UK

Background Results of case-control studies in the past 5 years suggest that the epidemiology of sudden infant death syndrome (SIDS) has changed since the 1991 UK Back to Sleep campaign. The campaign's advice that parents put babies on their back to sleep led to a fall in death rates. We used a longitudinal dataset to assess these potential changes. Methods Population-based data from home visits have been collected for 369 consecutive unexpected infant deaths (300 SIDS and 69 explained deaths) in Avon over 20 years (1984—2003). Data obtained between 1993 and 1996 from 1300 controls with a chosen “reference” sleep before interview have been used for comparison. Findings Over the past 20 years, the proportion of children who died from SIDS while co-sleeping with their parents, has risen from 12% to 50% (p<0·0001), but the actual number of SIDS deaths in the parental bed has halved (p=0·01). The proportion seems to have increased partly because the Back to Sleep campaign led to fewer deaths in infants sleeping alone—rather than because of a rise in deaths of infants who bed-shared, and partly because of an increase in the number of deaths in infants sleeping with their parents on a sofa. The proportion of deaths in families from deprived socioeconomic backgrounds has risen from 47% to 74% (p=0·003), the prevalence of maternal smoking during pregnancy from 57% to 86% (p=0·0004), and the proportion of pre-term infants from 12% to 34% (p=0·0001). Although many SIDS infants come from large families, first-born infants are now the largest group. The age of infants who bed-share is significantly smaller than that before the campaign, and fewer are breastfed. Interpretation Factors that contribute to SIDS have changed in their importance over the past 20 years. Although the reasons for the rise in deaths when a parent sleeps with their infant on a sofa are still unclear, we strongly recommend that parents avoid this sleeping environment. Most SIDS deaths now occur in deprived families. To better understand contributory factors and plan preventive measures we need control data from similarly deprived families, and particularly, infant sleep environments

Stillbirth and loss: family practices and display

This paper explores how parents respond to their memories of their stillborn child over the years following their loss. When people die after living for several years or more, their family and friends have the residual traces of a life lived as a basis for an identity that may be remembered over a sustained period of time. For the parent of a stillborn child there is no such basis and the claim for a continuing social identity for their son or daughter is precarious. Drawing on interviews with the parents of 22 stillborn children, this paper explores the identity work performed by parents concerned to create a lasting and meaningful identity for their child and to include him or her in their families after death. The paper draws on Finch's (2007) concept of family display and Walter's (1999) thesis that links continue to exist between the living and the dead over a continued period. The paper argues that evidence from the experience of stillbirth suggests that there is scope for development for both theoretical frameworks

The development of social class sensitive proxies for infant mortality at the PCT level: An appraisal of candiate indicators for the commission for health improvement

The main aim of the work is to identify social class-sensitive proxies for infant mortality at Primary Care Trust level that could be used in the CHI performance ratings process for PCTs in 2003/4

3.2 million stillbirths: epidemiology and overview of the evidence review

More than 3.2 million stillbirths occur globally each year, yet stillbirths are largely invisible in global data tracking, policy dialogue and programme implementation. This mismatch of burden to action is due to a number of factors that keep stillbirths hidden, notably a lack of data and a lack of consensus on priority interventions, but also to social taboos that reduce the visibility of stillbirths and the associated family mourning. Whilst there are estimates of the numbers of stillbirths, to date there has been no systematic global analysis of the causes of stillbirths. The multiple classifications systems in use are often complex and are primarily focused on high-income countries. We review available data and propose a programmatic classification that is feasible and comparable across settings. We undertook a comprehensive global review of available information on stillbirths in order to 1) identify studies that evaluated risk factors and interventions to reduce stillbirths, 2) evaluate the level of evidence for interventions, 3) place the available evidence for interventions in a health systems context to guide programme implementation, and 4) elucidate key implementation, monitoring, and research gaps. This first paper in the series outlines issues in stillbirth data availability and quality, the global epidemiology of stillbirths, and describes the methodology and framework used for the review of interventions and strategies

Association between reduced stillbirth rates in England and regional uptake of accreditation training in customised fetal growth assessment

Objective: To assess the effect that accreditation training in fetal growth surveillance and evidence-based protocols had on stillbirth rates in England and Wales. Design: Analysis of mortality data from Office of National Statistics. Setting: England and Wales, including three National Health Service (NHS) regions (West Midlands, North East and Yorkshire and the Humber) which between 2008 and 2011 implemented training programmes in customised fetal growth assessment. Population: Live births and stillbirths in England and Wales between 2007 and 2012. Main: outcome measure Stillbirth. Results: There was a significant downward trend (p=0.03) in stillbirth rates between 2007 and 2012 in England to 4.81/1000, the lowest rate recorded since adoption of the current stillbirth definition in 1992. This drop was due to downward trends in each of the three English regions with high uptake of accreditation training, and led in turn to the lowest stillbirth rates on record in each of these regions. In contrast, there was no significant change in stillbirth rates in the remaining English regions and Wales, where uptake of training had been low. The three regions responsible for the record drop in national stillbirth rates made up less than a quarter (24.7%) of all births in England. The fall in stillbirth rate was most pronounced in the West Midlands, which had the most intensive training programme, from the preceding average baseline of 5.73/1000 in 2000–2007 to 4.47/1000 in 2012, a 22% drop which is equivalent to 92 fewer deaths a year. Extrapolated to the whole of the UK, this would amount to over 1000 fewer stillbirths each year. Conclusions: A training and accreditation programme in customised fetal growth assessment with evidence-based protocols was associated with a reduction in stillbirths in high-uptake areas and resulted in a national drop in stillbirth rates to their lowest level in 20 years

Facility-based stillbirth review processes used in different countries across the world: a systematic review

Background: Facility-based stillbirth review provides opportunities to estimate incidence, evaluate causes and risk factors for stillbirths, and identify any issues related to the quality of pregnancy and childbirth care which require improvement. Our aim was to systematically review all types and methods of facility-based stillbirth review processes used in different countries across the world, to examine how stillbirth reviews in facility settings are being conducted worldwide and to identify the outcomes of implementing the reviews. Moreover, to identify facilitators and barriers influencing the implementation of the identified facility-based stillbirth reviews processes by conducting subgroup analyses. Methods: A systematic review of published literature was conducted by searching MEDLINE (OvidSP) [1946-present], EMBASE (OvidSP) [1974-present], WHO Global Index Medicus (globalindexmedicus.net), Global Health (OvidSP) [1973–2022 Week 8] and CINAHL (EBSCOHost) [1982-present] from their inception until 11 January, 2023. For unpublished or grey literature, the WHO databases, Google Scholar and ProQuest Dissertations & Theses Global were searched, as well as hand searching the reference lists of included studies. MESH terms encompassing “∗Clinical Audit”, “∗Perinatal Mortality”, “Pregnancy Complications”, and “Stillbirth” were used with Boolean operators. Studies that used a facility-based review process or any approach to evaluate care prior to stillbirth, and explained the methods used were included. Reviews and editorials were excluded. Three authors (YYB, UGA, and DBT) independently screened and extracted data, and assessed the risk of bias using an adapted JBI's Checklist for Case Series. A logic model was used to inform the narrative synthesis. The review protocol was registered with PROSPERO, CRD42022304239. Findings: A total of 68 studies from 17 high-income (HICs) and 22 low-and-middle-income countries (LMICs) met the inclusion criteria from a total of 7258 identified records. These were stillbirth reviews conducted at different levels: district, state, national, and international. Three types were identified: audit, review, and confidential enquiry, but not all desired components were included in most processes, which led to a mismatch between the description of the type and the actual method used. Routine data from hospital records was the most common data source for identifying stillbirths, and case assessment was based on stillbirth definition in 48 out of 68 studies. Hospital notes were the most common source of information about care received and causes/risk factors for stillbirth. Short-term and medium-term outcomes were reported in 14 studies, but impact of the review process on reducing stillbirth, which is more difficult to establish, was not reported in any study. Facilitators and barriers in implementing a successful stillbirth review process identified from 14 studies focused on three main themes: resources, expertise, and commitment. Interpretation: This systematic review's findings identified that there is a need for clear guidelines on how to measure the impact of implementation of changes based on outputs of stillbirth reviews and methods to enable effective dissemination of learning points in the future and promoting them through training platforms. In addition, there is a need to develop and adopt a universal definition of stillbirth to facilitate meaningful comparison of stillbirth rates between regions. The key limitation of this review is that while using a logic model for narrative synthesis was deemed most appropriate for this study, sequence of implementing a stillbirth review in the real world is not linear, and assumptions are often not met. Therefore, the logic model proposed in this study should be interpreted with flexibility when designing a stillbirth review process. The generated learnings from the stillbirth review processes inform the action plans and allow facilities to consider where the changes should happen to improve the quality of care in the facilities, enabling positive short-term and medium-term outcomes. Funding: Kellogg College, University of Oxford, Clarendon Fund, University of Oxford, Nuffield Department of Population Health, University of Oxford and Medical Research Council (MRC)