BACKGROUND:Advancements in neonatal and paediatric intensive care have improved survival of children born very preterm or with complex health conditions. However, many of these children will subsequently require admission to paediatric intensive care. How families navigate experiences and knowledge across these different admissions remains poorly understood. AIM:To explore the experiences of parents with a child admitted to both a neonatal unit (NNU) and a paediatric intensive care unit (PICU) with a focus on the development of parental knowledge. STUDY DESIGN:We conducted an exploratory qualitative study. Semi-structured interviews were conducted with 18 parents of 15 children who experienced admission to both NNU and PICU. Participants were recruited via national charities and interviewed remotely. Data were analysed using inductive content analysis, focussing on parents' temporal experiences. FINDINGS:Parents described knowing their child as a dynamic state evolving throughout the NNU to the PICU. In the NNU, parents initially learned to know their child through hands-on care, often facilitated by staff, though physical and emotional barriers sometimes hindered bonding. Discharge from NNU was a key transition moment, with some parents feeling confident while others felt uncertain about managing their child's healthcare needs at home without the support of staff and medical equipment. At PICU admission, parents brought experiential knowledge, the value of which was not always recognised by healthcare professionals. This lack of acknowledgement sometimes led to missed opportunities for provision of safe care. During PICU stays, parents wanted their expertise respected and integrated into care, particularly for children requiring ongoing specialist care, which was often provided by families, outside of PICU. CONCLUSIONS:Parental knowledge of their child, and their previous experiences, is vital to support safe care delivery but sometimes overlooked. Recognising parents as expert and equal partners in care can potentially improve safety, communication and family-centred practice. RELEVANCE FOR CLINICAL PRACTICE:Neonatal and paediatric healthcare teams should actively acknowledge and incorporate parental expertise during and when transitioning between NNU and PICU. Parents' experiences provide additional insights, which provide opportunities for better care. Improved communication across neonatal and paediatric services may enhance outcomes and parental confidence.

Objective: This study aimed to increase understanding of the signs and symptoms that lead pregnant people to seek hospital care in the second trimester of pregnancy. In addition, we aimed to describe management and follow up, to record pregnancy outcomes, and to gather information about symptoms and signs related to second trimester pregnancy loss. Methods: This prospective audit in seven geographically dispersed sites across the UK collected data over two weeks (7th March-20th March 2022 inclusive) on all unscheduled secondary care attendances between 14 and 21 completed weeks' gestation. Data on the number of patients booked at each unit within this 8-week second trimester gestational age range were collected. Descriptive analyses identified common patterns and associations with second trimester pregnancy loss. Results: Of 8,585 patients in the second trimester of their pregnancy, 283 presented acutely at least once over the two-week period (3.3 %) Of these, 19 patients experienced a second trimester pregnancy loss (7 % of those presenting in the second trimester). There were a broad range of presentations and diagnoses and a lack of standardisation of investigation and management of patients. Logistic regression identified associations between previous first trimester miscarriage (OR 2.95 95 % CI 1.15, 7.60), previous first trimester termination of pregnancy (OR 7.00 95 % CI 2.45, 19.98), and presentation with increased vaginal discharge (OR 3.82 CI 1.24, 11.7) with second trimester pregnancy loss. Conclusions: This study has identified that a significant number of pregnant people attend hospital and reattend in the second trimester of pregnancy, with a worrying lack of standardisation of both investigation and management, and a broad range of presenting symptoms and diagnoses. Patients who present in the second trimester have a high rate of second trimester pregnancy loss and the preliminary associations identified would benefit from further research in a larger scale study.

Importance There are wide disparities in neonatal mortality rates (NMRs, deaths <28 days of life after live birth per 1000 live births) between countries in Europe, indicating potential for improvement. Comparing country-specific patterns of births and deaths with countries with low mortality rates can facilitate the development of effective intervention strategies. Objective To investigate how these disparities are associated with the distribution of gestational age (GA) and GA-specific mortality rates. Design, Setting, and Participants This was a cross-sectional study of all live births in 14 participating European countries using routine data compiled by the Euro-Peristat Network. Live births with a GA of 22 weeks or higher from 2015 to 2020 were included. Data were analyzed from May to October 2023. Exposures GA at birth. Main Outcomes and Measures The study investigated excess neonatal mortality, defined as a rate difference relative to the pooled rate in the 3 countries with the lowest NMRs (Norway, Sweden, and Finland; hereafter termed the top 3). The Kitagawa method was used to divide this excess into the proportion explained by the GA distribution of births and by GA-specific mortality rates. A sensitivity analysis was conducted among births 24 weeks' GA or greater. Results There were 35 094 neonatal deaths among 15 123 428 live births for an overall NMR of 2.32 per 1000. The pooled NMR in the top 3 was 1.44 per 1000 (1937 of 1 342 528). Excess neonatal mortality compared with the top 3 ranged from 0.17 per 1000 in the Czech Republic to 1.82 per 1000 in Romania. Excess deaths were predominantly concentrated among births less than 28 weeks' GA (57.6% overall). Full-term births represented 22.7% of the excess deaths in Belgium, 17.8% in France, 40.6% in Romania and 17.3% in the United Kingdom. Heterogeneous patterns were observed when partitioning excess mortality into the proportion associated with the GA distribution vs GA-specific mortality. For example, these proportions were 9.2% and 90.8% in France, 58.4% and 41.6% in the United Kingdom, and 92.9% and 7.1% in Austria, respectively. These associations remained stable after removing births under 24 weeks' GA in most, but not all, countries. Conclusions and Relevance This cohort study of 14 European countries found wide NMR disparities with varying patterns by GA. This knowledge is important for developing effective strategies to reduce neonatal mortality.

Introduction In the UK, 1600 babies die every year before, during or immediately after birth at 20–28 weeks’ gestation. This bereavement has a similar impact on parental physical and psychological well-being to late stillbirth (>28 weeks’ gestation). Improved understanding of potentially modifiable risk factors for late stillbirth (including supine going-to-sleep position) has influenced international clinical practice. Information is now urgently required to similarly inform clinical practice and aid decision-making by expectant mothers/parents, addressing inequalities in pregnancy loss between 20 and 28 weeks.Methods and analysis This study focuses on what portion of risk of pregnancy loss 20–28 weeks’ gestation is associated with exposures amenable to public health campaigns/antenatal care adaptation. A case–control study of non-anomalous singleton baby loss (via miscarriage, stillbirth or early neonatal death) 20+0 to 27+6 (n=316) and randomly selected control pregnancies (2:1 ratio; n=632) at group-matched gestations will be conducted. Data is collected via participant recall (researcher-administered questionnaire) and extraction from contemporaneous medical records. Unadjusted/confounder-adjusted ORs will be calculated. Exposures associated with early stillbirth at OR≥1.5 will be detectable (p<0.05, β>0.80) assuming exposure prevalence of 30%–60%.Ethics and dissemination NHS research ethical approval has been obtained from the London—Seasonal research ethics committee (23/LO/0622). The results will be presented at international conferences and published in peer-reviewed open-access journals. Information from this study will enable development of antenatal care and education for healthcare professionals and pregnant people to reduce risk of early stillbirth.Trial registration number NCT06005272.

OBJECTIVE:To compare stillbirth rates and risks for small for gestational age (SGA), large for gestational age (LGA) and appropriate for gestational age (AGA) pregnancies at 24-44 completed weeks of gestation using a birth-based and fetuses-at-risk approachs. DESIGN:Population-based, multi-country study. SETTING:National data systems in 15 high- and middle-income countries. POPULATION:Live births and stillbirths. METHODS:A total of 151 country-years of data, including 126 543 070 births across 15 countries from 2000 to 2020, were compiled. Births were categorised into SGA, AGA and LGA using INTERGROWTH-21st standards. Gestation-specific stillbirth rates, with total births as the denominator, and gestation-specific stillbirth risks, with fetuses still in utero as the denominator, were calculated from 24 to 44 weeks of gestation. MAIN OUTCOME MEASURES:Gestation-specific stillbirth rates and risks according to size at birth. RESULTS:The overall stillbirth rate was 4.22 per 1000 total births (95% CI 4.22-4.23) across all gestations. Applying the birth-based approach, the stillbirth rates were highest at 24 weeks of gestation, with 621.6 per 1000 total births (95% CI 620.9-622.2) for SGA pregnancies, 298.4 per 1000 total births (95% CI 298.1-298.7) for AGA pregnancies and 338.5 per 1000 total births (95% CI 337.9-339.0) for LGA pregnancies. Applying the fetuses-at-risk approach, the gestation-specific stillbirth risk was highest for SGA pregnancies (1.3-1.4 per 1000 fetuses at risk) prior to 29 weeks of gestation. The risk remained stable between 30 and 34 weeks of gestation, and then increased gradually from 35 weeks of gestation to the highest rate of 8.4 per 1000 fetuses at risk (95% CI 8.3-8.4) at ≥42 weeks of gestation. The stillbirth risk ratio (RR) was consistently high for SGA compared with AGA pregnancies, with the highest RR observed at ≥42 weeks of gestation (RR 9.2, 95% CI 15.2-13.2), and with the lowest RR observed at 24 weeks of gestation (RR 3.1, 95% CI 1.9-4.3). The stillbirth RR was also consistently high for SGA compared with AGA pregnancies across all countries, with national variability ranging from RR 0.70 (95% CI 0.43-0.97) in Mexico to RR 8.6 (95% CI 8.1-9.1) in Uruguay. No increased risk for LGA pregnancies was observed. CONCLUSIONS:Small for gestational age (SGA) was strongly associated with stillbirth risk in this study based on high-quality data from high- and middle-income countries. The highest RRs were seen in preterm gestations, with two-thirds of the stillbirths born as preterm births. To advance our understanding of stillbirth, further analyses should be conducted using high-quality data sets from low-income settings, particularly those with relatively high rates of SGA.

Background Despite concerns about worsening pregnancy outcomes resulting from healthcare restrictions, economic difficulties and increased stress during the COVID-19 pandemic, preterm birth (PTB) rates declined in some countries in 2020, while stillbirth rates appeared stable. Like other shocks, the pandemic may have exacerbated existing socioeconomic disparities in pregnancy, but this remains to be established. Our objective was to investigate changes in PTB and stillbirth by socioeconomic status (SES) in European countries.Methods The Euro-Peristat network implemented this study within the Population Health Information Research Infrastructure (PHIRI) project. A common data model was developed to collect aggregated tables from routine birth data for 2015-2020. SES was based on mother's educational level or area-level deprivation/maternal occupation if education was unavailable and harmonized into low, medium and high SES. Country-specific relative risks (RRs) of PTB and stillbirth for March to December 2020, adjusted for linear trends from 2015 to 2019, by SES group were pooled using random effects meta-analysis.Results Twenty-one countries provided data on perinatal outcomes by SES. PTB declined by an average 4% in 2020 {pooled RR: 0.96 [95% confidence intervals (CIs): 0.94-0.97]} with similar estimates across all SES groups. Stillbirths rose by 5% [RR: 1.05 (95% CI: 0.99-1.10)], with increases of between 3 and 6% across the three SES groups, with overlapping confidence limits.Conclusions PTB decreases were similar regardless of SES group, while stillbirth rates rose without marked differences between groups.

BACKGROUND:Reducing avoidable stillbirth is a global priority. The stillbirth rate in England compares unfavourably to that of some other high-income countries. Poorly-managed episodes of altered fetal movement have been highlighted as a key contributor to avoidable stillbirth, and strategies introduced in England in 2016 to reduce perinatal mortality included recommendations for the management of reduced fetal movement. Despite a downward trend in stillbirth rates across the UK, the effects of policies promoting awareness of fetal movement remain uncertain. OBJECTIVE:To provide in-depth knowledge of how practice and clinical guidance relating to altered fetal movement are perceived, enacted and experienced by midwives and obstetricians, and explore the relationship between recommended fetal movement care and actual fetal movement care. DESIGN:A focused ethnographic approach comprising over 180 h of observation, 15 interviews, and document analysis was used to explore practice at two contrasting UK maternity units. SETTINGS:Antenatal services at two UK maternity units, one in the Midlands and one in the North of England. PARTICIPANTS:Thirty-six midwives, obstetricians and sonographers and 40 pregnant women participated in the study across 52 observed care episodes and relevant unit activity. Twelve midwives and three obstetricians additionally participated in formal semi-structured interviews. METHODS:Fieldnotes, interview transcripts, policy documents, maternity notes and clinical guidelines were analysed using a modified constant comparison method to identify important themes. RESULTS:fetal movement practice was mostly consistent and in line with guideline recommendations. Notwithstanding, most midwives and obstetricians had concerns about this area of care, including challenges in diagnosis, conflicting evidence about activity, heightened maternal anxiety, and high rates of monitoring and intervention in otherwise low-risk pregnancies. To address these issues, midwives spent considerable time reassuring women through information and regular monitoring, and coaching them to perceive fetal movement more accurately. CONCLUSIONS:Practice relating to altered fetal movement might be more uniform than in the past. However, a heightened focus on fetal movement is associated by some midwives and obstetricians with potential harms, including increased anxiety in pregnancy, and high rates of monitoring and intervention in pregnancies where there are no 'objective concerns'. Challenges in diagnosing a significant change in fetal movement with accuracy might mean that interventions and resources are not being directed towards those pregnancies most at risk. More research is needed to determine how healthcare professionals can engage in conversations about fetal movement and stillbirth to support safe outcomes and positive experiences in pregnancy and birth. REGISTRATION:Not registered. TWEETABLE ABSTRACT:Midwives and obstetricians take #reducedfetalmovement seriously but worry this 'unreliable' symptom increases anxiety, monitoring and intervention in many 'low risk' pregnancies.

OBJECTIVE:Currently used estimates of survival are nearly 10 years old and relate to only those babies admitted for neonatal care. Due to ongoing improvements in neonatal care, here we update estimates of survival for singleton and multiple births at 22+0 to 31+6 weeks gestational age across the perinatal care pathway by gestational age and birth weight.DESIGN:Retrospective analysis of routinely collected data.SETTING:A national cohort from the UK and British Crown Dependencies.PATIENTS:Babies born at 22+0 to 31+6 weeks gestational age from 1 January 2016 to 31 December 2020.INTERVENTIONS:None.MAIN OUTCOME MEASURES:Survival to 28 days.RESULTS:Estimates of neonatal survival are provided for babies: (1) alive at the onset of care during the birthing process (n=43 763); (2) babies where survival-focused care was initiated (n=42 004); and (3) babies admitted for neonatal care (n=41 158). We have produced easy-to-use survival charts for singleton and multiple births. Generally, survival increased with increasing gestational age at birth and with increasing birth weight. For all births with a birthweight over 1000 g, survival was 90% or higher at all three stages of care.CONCLUSIONS:Survival estimates are a vital tool to support and supplement clinical judgement within perinatal care. These up-to-date, national estimates of survival to 28 days are provided based on three stages of the perinatal care pathway to support ongoing clinical care. These novel results are a key resource for policy and practice including counselling parents and informing care provision.

Abstract Background Lower socioeconomic status (SES) is strongly associated with adverse perinatal health outcome, such as preterm birth and stillbirth. We investigated whether the caesarean section (CS) rate, which may reflect a greater prevalence of maternal health complications, was also higher in disadvantaged populations. Methods The study uses aggregate routine birth data from European countries collected with the Euro-Peristat federated analysis protocol. We analysed CS rates (total births by CS/total births) by SES from 2015 to 2020. Mothers’ education level (primary/lower secondary; upper secondary; postsecondary) was the preferred SES indicator; if unavailable, parents’ occupation or area-based deprivation scores were used and harmonised into three groups (low, medium, high). Results 17 countries provided data on maternal education, 5 on area-based deprivation, 1 on parents’ occupation. CS rates ranged from 16.7% (Lithuania) to 48.5% (Cyprus) in the low SES group and from 16.8% (the Netherlands) to 55.2% (Cyprus) in the high SES group. Patterns across SES groups were diverse, with greater use of CS in higher SES groups (Croatia: 19.6%, 24.1%, 26.7% and Ireland: 30.3%, 33.4%, 35.5% for low, medium and high SES respectively), whereas elsewhere, more disadvantaged SES groups had higher CS rates: Italy: 37.1%, 35.2%, 33.7%, Denmark: 22.0%, 21.9%; 19.8% and Luxembourg: 34.5%, 33.2%, 29.9%. In some countries, rates were similar across groups (France: 21.3%, 20.7%, 21.3% and the Netherlands: 17.2%, 17.0%, 16.8%). Risk ratios of CS in low versus high SES groups ranged from 0.74 (95% CI R0.70-0.77) in Croatia to 1.15 (95% CI 1.12-1.19) in Luxembourg. Conclusions Our results do not show that CS was consistently associated with social disadvantage. Instead, we found surprising variations in the SES gradient between countries, raising questions about CS practices and their interaction with maternal characteristics in European countries.

OBJECTIVE:To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021. DESIGN:Population-based, multi-country analysis. SETTING:National data systems in 23 middle- and high-income countries. POPULATION:Liveborn infants. METHODS:Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, <10th centile), appropriate (10th-90th centiles), or large (LGA, >90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types. MAIN OUTCOME MEASURES:Prevalence of six newborn types. RESULTS:We analysed 165 017 419 live births and the median prevalence of small types was 11.7% - highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries. CONCLUSIONS:The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries.

ABSTRACTObjectiveTo examine the contribution of preterm birth and size-for-gestational age in stillbirths using six ‘newborn types’.DesignPopulation-based multi-country analyses.SettingBirths collected through routine data systems in 12 countries.Sample119,644,788 total births from 22+0to 44+6weeks gestation identified from 2000 to 2020.MethodsWe included 605,557 stillbirths from 22+0weeks gestation from 12 countries. We classified all births, including stillbirths, by six ‘newborn types’ based on gestational age information (preterm, PT, <37+0weeks vs term, T, ≥37+0weeks) and size-for-gestational age defined as small (SGA, <10thcentile), appropriate (AGA, 10th-90thcentiles), or large (LGA, >90thcentile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21ststandards.Main Outcome MeasuresDistribution of stillbirths, stillbirth rates and rate ratios according to six newborn types.Results605,557 (0.50%) of the 119,644,788 total births resulted in stillbirth after 22+0weeks. Most stillbirths (74.3%) were preterm. Around 21.0% were SGA types (PT+SGA (16.0%), T+SGA (5.0%)) and 14.3% were LGA types (PT+LGA (10.1%), T+LGA (4.2%)). The median rate ratio (RR) for stillbirth was highest in PT+SGA babies (RR=78.8, interquartile range (IQR), 68.2, 111.5) followed by PT+AGA (RR=24.5, IQR, 19.3, 29.4), PT+LGA (RR=23.0, IQR,13.7, 29.0) and T+SGA (RR=5.5, IQR, 5.0, 6.0) compared with T+AGA. Stillbirth rate ratios were similar for T+LGA vs T+AGA (RR=0.7, IQR, 0.7, 1.1). At the population level, 21.5% of stillbirths were attributable to small-for-gestational-age.ConclusionsIn these high-quality data from high/middle income countries, almost three quarters of stillbirths were born preterm and a fifth were small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, and also patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.FundingThe Children’s Investment Fund Foundation, 1803-02535KEY FINDINGS1.WHAT WAS KNOWN?Stillbirth (pregnancy loss after 22+0weeks) is a devastating outcome. Global estimates indicating 1.9 million late gestation stillbirths (≥28+0weeks) worldwide in 2021 underestimate the overall burden. Many of the pathways to stillbirth result in fetal death before term (preterm stillbirth, <37+0weeks of gestational age). In addition, babies with fetal growth restriction (frequently assessed using the proxy small for gestational age (SGA, <10thcentile)) are at higher risk of stillbirth than their appropriately grown peers. Stillbirths are therefore more likely to be low birthweight (LBW, <2,500g). Being large for gestational age (LGA, >90thcentile) at term may also be associated with increased risk of stillbirth.2.WHAT WAS DONE THAT IS NEW?Combining information on gestational age (preterm (PT), or term (T)) and attained size for-gestational-age (small-for-gestational-age (SGA), appropriate-for-gestational age (AGA), large-for-gestational age (LGA)) we defined six ‘newborn types’: four small (PT+SGA, PT+AGA, PT+LGA, T+SGA), one large (T+LGA), and one reference (T+AGA). We compiled livebirth and stillbirth data from 15 high- and middle-income countries as part of the Vulnerable Newborn Collaboration. A total of 119,039,231 livebirths and 605,557 stillbirths ≥22+0weeks from 12 countries between 2000 and 2020 met the inclusion criteria. We examined the distribution of stillbirths by these ‘newborn types’, and calculated type-specific stillbirth rates and rate ratios.3.WHAT WAS FOUND?Most stillbirths (74.3%) were preterm, compared to fewer than 1-in-10 (9.0%) livebirths. A fifth (21.0%) of stillbirths were SGA compared to 1-in-20 (5.4%) livebirths. Preterm SGA had 78.8 times higher stillbirth rates compared to term AGA (Rate ratio (RR)=78.8, interquartile range (IQR), 68.2,111.5). Overall, preterm types had a 25 times higher stillbirth rate than term types (RR=25.0, IQR,20.1, 29.5). At the population level, over a fifth of stillbirths (21.5%) were attributable to being SGA, indicating a substantial impact of growth restriction on stillbirth in these settings. 14.3% of stillbirths and 17.5% of livebirths were LGA. There was no evidence of increased stillbirth rates for LGA types. The distribution of these ‘newborn types’ are similar amongst stillbirths and neonatal deaths.4.WHAT NEXT?Categorisation of all births, including stillbirths, into these ‘newborn types’ was analytically possible using routinely collected data in these 12 upper-middle- or high-income contexts and led to programmatic relevant findings. However, as the majority (98%) of the world’s stillbirths are in low-and middle-income countries, more data are needed to improve understanding of patterns in stillbirths in a wider range of contexts, especially in settings with higher rates of intrapartum stillbirth and those with very high SGA rates such as South Asia. Further analyses, including assessing gestational age-specific risk, could provide more information on pathways to stillbirth and enable targeted interventions to underlying causes such as infection and obstetric complications. When analysing these vulnerability pathways, omitting stillbirths neglects an important part of the burden and its effects on families and society.

Objectives To explore the effect of changes in national clinical recommendations in 2019 that extended provision of survival focused care to babies born at 22 weeks’ gestation in England and Wales. Design Population based cohort study. Setting England and Wales, comprising routine data for births and hospital records. Participants Babies alive at the onset of care in labour at 22 weeks+0 days to 22 weeks+6 days and at 23 weeks+0 days to 24 weeks+6 days for comparison purposes between 1 January 2018 and 31 December 2021. Main outcome measures Percentage of babies given survival focused care (active respiratory support after birth), admitted to neonatal care, and surviving to discharge in 2018-19 and 2020-21. Results For the 1001 babies alive at the onset of labour at 22 weeks' gestation, a threefold increase was noted in: survival focused care provision from 11.3% to 38.4% (risk ratio 3.41 (95% confidence interval 2.61 to 4.45)); admissions to neonatal units from 7.4% to 28.1% (3.77 (2.70 to 5.27)), and survival to discharge from neonatal care from 2.5% to 8.2% (3.29 (1.78 to 6.09)). More babies of lower birth weight and early gestational age received survival focused care in 2020-21 than 2018-19 (46% to 64% at <500g weight; 19% to 31% at 22 weeks+0 days to 22 weeks+3 days). Conclusions A change in national guidance to recommend a risk based approach was associated with a threefold increase in 22 weeks’ gestation babies receiving survival focused care. The number of babies being admitted to neonatal units and those surviving to discharge increased.

Background: Reducing avoidable stillbirth is a global priority. The stillbirth rate in England compares unfavourably to that of some other high-income countries. Poorly-managed episodes of altered fetal movement have been highlighted as a key contributor to avoidable stillbirth, and strategies introduced in England in 2016 to reduce perinatal mortality included recommendations for the management of reduced fetal movement. Despite a downward trend in stillbirth rates across the UK, the effects of policies promoting awareness of fetal movement remain uncertain.Objective: To provide in-depth knowledge of how practice and clinical guidance relating to altered fetal movement are perceived, enacted and experienced by maternity clinicians.Design: A focused ethnographic approach comprising over 180 hours of observation, 16 interviews, and document analysis was used to explore practice at two contrasting UK maternity units. Settings: Antenatal services at two UK maternity units, one in the Midlands and one in the North of England. Participants: Thirty-seven midwives, obstetricians and sonographers and 40 pregnant women participated in the study across 52 observed care episodes and relevant unit activity. Twelve midwives and three obstetricians additionally participated in formal semi-structured interviews.Methods: Fieldnotes, interview transcripts, policy documents, maternity notes and clinical guidelines were analysed using a modified constant comparison method to identify important themes.Results: Although clinicians adhered closely to clinical guidelines for the management of altered fetal movement, most had concerns about this area of practice, including challenges in (self-)diagnosis, conflicting evidence about fetal activity, heightened maternal anxiety, and high rates of monitoring and intervention in otherwise low-risk pregnancies. To address these issues, clinicians spent considerable time reassuring women through information and regular monitoring, and coaching them to perceive fetal movement more accurately.Conclusions: Practice relating to altered fetal movement might be more uniform than in the past, with a high level of adherence to fetal movement guidelines. However, a heightened focus on fetal movement is associated by some clinicians with potential harms, including increased maternal anxiety (which could make the symptom less reliable), and high rates of monitoring and intervention in pregnancies where there are no ‘objective concerns’. Challenges in diagnosing a significant change in fetal movement with accuracy might mean that interventions and resources are not being directed towards those pregnancies most at risk. More research is needed to determine how fetal movement and stillbirth should be discussed and managed to support safer outcomes, maternal mental wellbeing, and positive experiences of pregnancy and birth.

Objective To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000-2020.Design Population-based, multi-country study.Setting National data systems in 15 middle- and high-income countries.Methods We used individual-level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm [PT] versus term [T]) and size-for-gestational age (small [SGA], <10th centile, appropriate [AGA], 10th-90th centile or large [LGA], >90th centile) according to INTERGROWTH-21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types.Main outcome measures Mortality of six newborn types.Results Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range [IQR] 45.6-73.9), PT + AGA (median 34.3, IQR 23.9-37.5) and PT + LGA (median 28.3, IQR 18.4-32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5-54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2-388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7-342.8) compared with those between 2500 g and 4000 g as a reference group.Conclusion Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co-existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.

OBJECTIVE:We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020. DESIGN:Population-based, multi-country study. SETTING:National healthcare systems. POPULATION:Liveborn infants. METHODS:We used individual-level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th-90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500-3999 g. INTERGROWTH 21st served as the reference population. MAIN OUTCOME MEASURES:Prevalence and neonatal mortality risks. RESULTS:Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%-22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77-0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%-13.3%), with 1.2% (IQR 0.7%-2.0%) ≥4500 g and with 0.2% (IQR 0.1%-0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69-0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10-2.11) and ≥5000 g (RR 4.54, 95% CI 2.58-7.99), compared with birthweights of 2500-3999 g, with the highest risk observed in the first 7 days of life. CONCLUSIONS:In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

OBJECTIVE:To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'. DESIGN:Population-based multi-country analyses. SETTING:Births collected through routine data systems in 13 countries. SAMPLE:125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020. METHODS:We included 635 107 stillbirths from 22+0 weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0 weeks versus term, T, ≥37+0 weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards. MAIN OUTCOME MEASURES:Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types. RESULTS:635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0 weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age. CONCLUSIONS:In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Abstract Background Socioeconomic status (SES) is strongly associated with perinatal health outcomes, perpetuating intergenerational health inequalities. Our aim was to assess the utility of population data in Europe to monitor social inequalities in key perinatal health indicators. Methods Using the PHIRI federated analysis protocol to aggregate routine birth data from across Europe, we collected data on selected perinatal health indicators by SES from 2015 to 2020. Mothers’ education level (primary/lower secondary; upper secondary; postsecondary) was the preferred SES indicator; if unavailable, parents’ occupation or area-based deprivation scores were provided. The International Standard Classification of Occupations was used to group parents’ occupations into 4 categories, while area-based deprivation scores were measured in quintiles. For each country, we calculated risk ratios (RR) for preterm birth, stillbirth, neonatal death and caesarean delivery (CD) comparing the most with the least disadvantaged group Results 17 countries provided data on maternal education, 5 on area-based deprivation, 1 on parents’ occupation and 2 could not provide data. For preterm birth, stillbirth and neonatal death, lower SES was associated with worse outcomes with most RR between lowest and highest groups in the range of 1.5 to 3.0. In contrast, in some countries, such as Croatia, Latvia, Lithuania and Spain, CD rates were higher for socially advantaged groups whereas the gradient was reversed in others (Denmark, Luxembourg, the Netherlands and Italy). Conclusions European countries can provide perinatal health indicators by SES, revealing marked socioeconomic inequalities in perinatal health. The differing SES gradient between countries for CD raise questions about care organization and clinical practice. Further exploration of the harmonization of differing SES measure across countries is required, while countries that do not monitor SES data should aim to improve existing systems.

ObjectivesTo investigate inequalities in stillbirth rates by ethnicity to facilitate development of initiatives to target those at highest risk.DesignPopulation-based perinatal mortality surveillance linked to national birth and death registration (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK).SettingUK.Participants4 391 569 singleton births at ≥24+0 weeks gestation between 2014 and 2019.Main outcome measuresStillbirth rate difference per 1000 total births by ethnicity.ResultsAdjusted absolute differences in stillbirth rates were higher for babies of black African (3.83, 95% CI 3.35 to 4.32), black Caribbean (3.60, 95% CI 2.65 to 4.55) and Pakistani (2.99, 95% CI 2.58 to 3.40) ethnicities compared with white ethnicities. Higher proportions of babies of Bangladeshi (42%), black African (39%), other black (39%) and black Caribbean (37%) ethnicities were from most deprived areas, which were associated with an additional risk of 1.50 stillbirths per 1000 births (95% CI 1.32 to 1.67). Exploring primary cause of death, higher stillbirth rates due to congenital anomalies were observed in babies of Pakistani, Bangladeshi and black African ethnicities (range 0.63–1.05 per 1000 births) and more placental causes in black ethnicities (range 1.97 to 2.24 per 1000 births). For the whole population, over 40% of stillbirths were of unknown cause; however, this was particularly high for babies of other Asian (60%), Bangladeshi (58%) and Indian (52%) ethnicities.ConclusionsStillbirth rates declined in the UK, but substantial excess risk of stillbirth persists among babies of black and Asian ethnicities. The combined disadvantage for black, Pakistani and Bangladeshi ethnicities who are more likely to live in most deprived areas is associated with considerably higher rates. Key causes of death were congenital anomalies and placental causes. Improved strategies for investigation of stillbirth causes are needed to reduce unexplained deaths so that interventions can be targeted to reduce stillbirths.