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Pathways of association between maternal haemoglobin and stillbirth: path-analysis of maternity data from two hospitals in England.

ABSTRACT: OBJECTIVE:To investigate the mechanisms that link maternal haemoglobin concentration with stillbirth. DESIGN:A retrospective cohort analysis using anonymised maternity data from two hospitals in England. SETTING:The Royal Wolverhampton NHS Trust and Guy's and St Thomas' NHS Foundation Trust. STUDY POPULATION:12?636 women with singleton pregnancies ?24 weeks of gestation giving birth in the two hospitals during 2013-2015. METHOD:A conceptual framework of hypothesised pathways through birth weight-for-gestational age and maternal infection including potential confounders and other risk factors was developed and examined using path-analysis. Path-analysis was performed by fitting a set of regression equations using weighted least squares adjusted for mean and variance. Goodness-of-fit indices were estimated. MAIN OUTCOME MEASURES:Coefficient of association (?) for relationship between each parameter, and direct, indirect and total effects via the postulated pathways. RESULTS:The path-model showed a significant adjusted indirect negative effect of maternal haemoglobin on stillbirth mediated via birth weight-for-gestational age (standardised estimate (SE)=-0.01; 95%?CI=-0.01?to -0.001; P=0.028). The effect through maternal infection was not significant at P<0.05 (SE=0.001; 95%?CI=-0.004?to 0.01; P=0.610). There was a residual direct negative effect of maternal haemoglobin on stillbirth (SE=-0.12; 95%?CI -0.23 to -0.02; P=0.020) after accounting for the two pathways. Total indirect SE=-0.004; 95%?CI -0.01 to 0.003; P=0.267; total direct and indirect SE=-0.13; 95%?CI -0.23 to -0.02; P=0.016. The goodness-of-fit indices showed a good fit between the model and the data. CONCLUSION:While some of the influence on risk of stillbirth acts through low birth weight-for-gestational age, the majority does not. Several new mechanisms have been suggested for how haemoglobin may be exerting its influence on the risk of stillbirth possibly involving genetic, epigenetic and/or alternative obstetric and nutritional pathologies, but much more research is needed.

SUBMITTER: Nair M

PROVIDER: S-EPMC5892753 | biostudies-literature | 2018 Apr

REPOSITORIES: biostudies-literature

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Pathways of association between maternal haemoglobin and stillbirth: path-analysis of maternity data from two hospitals in England.

Nair Manisha M Knight Marian M Robinson Susan S Nelson-Piercy Catherine C Stanworth Simon J SJ Churchill David D

BMJ open 20180407 4

<h4>Objective</h4>To investigate the mechanisms that link maternal haemoglobin concentration with stillbirth.<h4>Design</h4>A retrospective cohort analysis using anonymised maternity data from two hospitals in England.<h4>Setting</h4>The Royal Wolverhampton NHS Trust and Guy's and St Thomas' NHS Foundation Trust.<h4>Study population</h4>12 636 women with singleton pregnancies ≥24 weeks of gestation giving birth in the two hospitals during 2013-2015.<h4>Method</h4>A conceptual framework of hypoth ...[more]

PMID: 29627813

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Project description:INTRODUCTION:The UK Department of Health have targeted a reduction in stillbirth by 50% by 2025; to achieve this, the first version of the Saving Babies' Lives Care Bundle (SBLCB) was developed by NHS England in 2016 to improve four key areas of antenatal and intrapartum care. Clinical practice guidelines are a key means by which quality improvement initiatives are disseminated to front-line staff. METHODS:Seventy-five clinical practice guidelines covering the four areas of antenatal and intrapartum care in the first version of SBLCB were obtained from 19 maternity providers. The content and quality of guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Maternity health professionals in participating organisations were invited to participate in an anonymous survey to determine perceptions toward and experiences of the use of clinical practice guidelines using a series of Likert scales. RESULTS:Unit guidelines showed considerable variation in quality with median scores of 50%-58%. Only 4 (5.6%) guidelines were recommended for use in clinical practice without modifications, 54 (75.0%) were recommended for use subject to modifications and 12 (16.7%) were not recommended for use. The lowest scoring domains were 'rigour of development', 'stakeholder involvement' and 'applicability'. A significant minority of unit guidelines omitted recommendations from national guidelines. The majority of staff believed that clinical practice guidelines standardised and improved the quality of care but over 30% had insufficient time to use them and 24% stated they were unable to implement recommendations. CONCLUSION:To successfully implement initiatives such as the SBLCB change is needed to local clinical practice guidelines to reduce variation in quality and to ensure they are consistent with national recommendations . In addition, to improve clinical practice, adequate time and resources need to be in place to deliver and evaluate care recommended in the SBLCB.

Project description:BackgroundAround 1 in 150 babies are stillborn or die in the first month of life in the UK. Most women conceive again, and subsequent pregnancies are often characterised by feelings of stress and anxiety, persisting beyond the birth. Psychological distress increases the risk of poor pregnancy outcomes and longer-term parenting difficulties. Appropriate emotional support in subsequent pregnancies is key to ensure the wellbeing of women and families. Substantial variability in existing care has been reported, including fragmentation and poor communication. A new care package improving midwifery continuity and access to emotional support during subsequent pregnancy could improve outcomes. However, no study has assessed the feasibility of a full-scale trial to test effectiveness in improving outcomes and cost-effectiveness for the National Health Service (NHS).MethodsA prospective, mixed-methods pre-and post-cohort study, in two Northwest England Maternity Units. Thirty-eight women, (≤ 20 weeks' gestation, with a previous stillbirth, or neonatal death) were offered the study intervention (allocation of a named midwife care coordinator and access to group and online support). Sixteen women receiving usual care were recruited in the 6 months preceding implementation of the intervention. Outcome data were collected at 2 antenatal and 1 postnatal visit(s). Qualitative interviews captured experiences of care and research processes with women (n = 20), partners (n = 5), and midwives (n = 8).ResultsOverall recruitment was 90% of target, and 77% of women completed the study. A diverse sample reflected the local population, but non-English speaking was a barrier to participation. Study processes and data collection methods were acceptable. Those who received increased midwifery continuity valued the relationship with the care coordinator and perceived positive impacts on pregnancy experiences. However, the anticipated increase in antenatal continuity for direct midwife contacts was not observed for the intervention group. Take-up of in-person support groups was also limited.ConclusionsWomen and partners welcomed the opportunity to participate in research. Continuity of midwifery care was supported as a beneficial strategy to improve care and support in pregnancy after the death of a baby by both parents and professionals. Important barriers to implementation included changes in leadership, service pressures and competing priorities.Trial registrationISRCTN17447733 first registration 13/02/2018.

Project description:ObjectiveTo assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England.DesignA retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle.ResultsThe total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18-1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07-1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21-1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32-1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle.ConclusionsImplementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention.Trial registrationThe study was registered on (NCT03231007); www.clinicaltrials.gov.

Project description:The United Kingdom has one of the highest rates of stillbirth in Europe, resulting in approximately 4,000 stillbirths every year. Potentially modifiable risk factors for late stillbirths are maternal age, obesity and smoking, but the population attributable risk associated with these risk factors is small.Recently the Auckland Stillbirth Study reported that maternal sleep position was associated with late stillbirth. Women who did not sleep on their left side on the night before the death of the baby had double the risk compared with sleeping on other positions. The population attributable risk was 37%. This novel observation needs to be replicated or refuted.Case control study of late singleton stillbirths without congenital abnormality. Controls are women with an ongoing singleton pregnancy, who are randomly selected from participating maternity units booking list of pregnant women, they are allocated a gestation for interview based on the distribution of gestations of stillbirths from the previous 4 years for the unit. The number of controls selected is proportional to the number of stillbirths that occurred at the hospital over the previous 4 years.Interviewer administered questionnaire and data extracted from medical records.415 cases and 830 controls. This takes into account a 30% non-participation rate, and will detect an OR of 1.5 with a significance level of 0.05 and power of 80% for variables with a prevalence of 57%, such as non-left sleeping position.Mantel-Haenszel odds ratios and unconditional logistic regression to adjust for potential confounders.The hypotheses to be tested here are important, biologically plausible and amenable to a public health intervention. Although this case-control study cannot prove causation, there is a striking parallel with research relating to sudden infant death syndrome, where case-control studies identified prone sleeping position as a major modifiable risk factor. Subsequently mothers were advised to sleep babies prone ("Back to Sleep" campaign), which resulted in a dramatic drop in SIDS. This study will provide robust evidence to help determine whether such a public health intervention should be considered.NCT02025530.

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Pathways of association between maternal haemoglobin and stillbirth: path-analysis of maternity data from two hospitals in England.

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Pathways of association between maternal haemoglobin and stillbirth: path-analysis of maternity data from two hospitals in England.

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