A voice for women's health

Maternity


HAVING A BABY AT MIDDLEMORE HOSPITAL WHEN YOU ARE YOUNG, MAORI AND/OR PACIFIC
 At the beginning of the year Counties Manukau Health (CMH) released a report it had commissioned Pacific Perspectives Ltd to prepare on what is working well and where improvements can be made in the maternity care being provided at Middlemore Hospital. The project was specifically focused on the experiences of Maori and Pacific mothers, teen mothers and women of childbearing age who live in areas of high socio-economic deprivation.
 
The report is called “Maternity Care Experiences of Teen, Young, Maori, Pacific and Vulnerable Mothers at Counties Manukau Health” and follows the independent maternity review in 2012 which found that unborn and newborn babies were dying at higher rates in South Auckland than the national average. The 96-page document makes for grim and at times very emotional reading and it is painfully clear that Middlemore Hospital often gives their young Maori and Pacific mothers a very hard time. The mothers interviewed said they felt unwelcome and their needs and concerns were ignored by a system that is focused on trying to make them comply with their unreasonable expectations.  
 
Five key themes
Counties Manukau Health identified five key themes that they wanted the views of mothers on. They were:
- Accessing and engaging early in pregnancy
- Using the primary birthing units – Botany Downs, Pukekohe and Papakura
- Accessing appropriate advice and affordable contraception in a timely manner
- Developing strategies to reduce smoking in pregnant women
- Developing culturally appropriate interventions to reduce pre-pregnancy obesity. 

Dissatisfied mothers
A number of focus groups and face to face interviews were held in a variety of settings with young, Maori and Pacific women, as well as women living in economically deprived areas who had given birth at Middlemore hospital. All groups expressed dissatisfaction with maternal care provided by Counties Manukau Health. The report states that “the dissatisfaction relates to:

Perceived attitudes of staff towards mothers, for example vulnerable young mothers felt interactions with staff stereotyped, judged and stigmatised them.

Labour, delivery and the period immediately after delivery were mentioned as times when young mothers felt they needed support and care of health professionals and their families. However the predominant CMH culture was focused on timeliness and efficiency. Mothers perceived they received a service, rather than nurturing and care. The service failed to utilise family support. We were told of many cases when births occurred at night, partners and families were sent home, (or charged an unaffordable fee to stay the night). This left vulnerable young women alone in an unfamiliar environment with staff who could not or would not respond to their needs due to other work pressures. We noted that mothers who had also delivered at Auckland District Health Board (ADHB) facilities, described a marked contrast in their experience of the maternal care services provided at ADHB. In particular staff attitudes were different, including welcoming families and going the “extra mile” to make them feel comfortable and provide care and support in the period immediately after delivery; 

Women with English as a second language and/or with low health literacy were not able to access additional resources to meet their needs; 

Interworkforce rivalry and patch protection were obvious to mothers and their families. Mothers described tensions between private LMCs and hospital staff, with LMCs acting as advocates for them against hospital staff who were perceived as focused on discharging mothers home early; and hospital staff who criticised the actions and competence of LMCs. This impacted on their confidence and trust in the services, and their willingness to engage for future needs.” 

Shared Care
Women have been reporting on the problems with the Shared Care service since it was first established. Shared Care is unique to CMH and was developed in response to a shortage of private LMCs. Under the Shared Care service women receive most of their antenatal care from a GP, but are also entitled to three antenatal visits with a DHB-employed community midwife. Care during labour and birth is provided by a CMH-employed midwife. GPs that provide Shared Care are not required to have specific training in antenatal care and are not required to have a postgraduate Diploma in Obstetrics and Gynaecology. This is and has always been totally unacceptable.
 
What is also unacceptable is that the women who go to Shared Care for their initial maternity visit are not told about their other options, ie they can choose a self-employed midwife as their LMC, “due to financial incentives” that CMH provides to the Shared Care GPs. The report states “although doctors were the first contact for young mothers to confirm their pregnancy and their main source of information regarding different antenatal care options, they provide very little information and guidance. Women were unsure about the different options of maternity care, how to make choices and how to access the different types of care.”
 
Shared Care was therefore not an informed choice made by the women. Their experience of Shared Care was one of long waiting times, rushed appointments, and a lack of continuity of care after discharge from hospital – some mothers had no follow-up care, others were seen many weeks after discharge and/or had an insufficient number of postnatal visits. The service was perceived by women to be medically focused and inflexible.
 
This helps to explain why on average 190 women in CMH per year do not have any antenatal care and just over a third of women book very late in pregnancy.           
 
It has all been said before
The authors of the report also note that their desktop review of previous reports indicated that these views were already well documented. The MSCC can confirm this as we were receiving calls about many of the issues described in the report a decade and more ago, especially those related to Shared Care.
 
 The stories

Factors preventing early engagement
Many teens were scared of a positive result: 
“I was three and a half months when I found out… I was in denial because I didn’t want to find out I was pregnant. I had no symptoms I just missed my period hoping it would come the next month.”
 
“I didn’t want to know, I just pretended it wasn’t happening, but deep down I knew.”
 
Older mothers said:
“I usually don’t. I just get me a midwife when I’m about six months.”
 
Then there is the story of a Pacific mother who was encouraged to attend prenatal sessions with her LMC. To get to her first check up she had to catch two buses, and it took her two hours with children in tow. Once there it took 15 minutes to complete the checks. The mother was told “you’re fine” and sent home. She did not attend subsequent checks.
 
Low Health Literacy
This was particularly an issue for Pacific mothers of all ages.
 “She told me I had to find a midwife and I was like what is this word? I have never heard this word before.”
 
“I was told I have to go here and here and here and I was like, why do I have to go to all these places. In Raro I saw one person; it gave me a sore head to think of all these new things.”
 
Religious and cultural beliefsPacific women know very little about the symptoms of pregnancy even with subsequent pregnancies:
 
“There’s no way we would talk about anything like that in our family, no-one in my culture does, you have to find out from your friends.”
 
Interworkforce rivalry
Interworkforce rivalry and patch protection were obvious to mothers and families:
 “I had a show and bad cramps, I waited three days and the baby still didn’t come. I couldn’t sleep or anything. I rang the hospital and they kept saying don’t come, it’s not time. I finally rang my own midwife because I was scared, I was worried I would be too tired to push this baby out. My midwife met me at the hospital and she told them off. I heard them argue up in there.”
 
History of State/Government intervention
Vulnerable mothers described difficulties with any mainstream service because of historical and on-going relationships with CYF, the Police, and Work and Income.
 
“When I told her my age she looked at me funny and I was a bit terrified because she asked me who’s my supporters and I was worried in case she was going to get CYF.”
 
“They (Social Service provider) sent someone to help me; it took them two years to get through my door.”
 
Barriers to access
Mothers highlighted significant issues with the continuity of care.
 
“I never had a midwife, due to when I did have a midwife she was very judgemental because of my age being pregnant young … so I felt uncomfortable so I just basically looked after myself through the whole 9 months and gave birth in my own bath tub, I didn’t go to hospital … I just did it on my own.”
 
“The day I gave birth to my daughter my midwife didn’t come and didn’t see me until three weeks later. They gave me someone else when I was in labour and I was like “who the hell are you?’ ”
 
Staff attitudes and lack of cultural competency
The lack of compassion is incredible.
 
“So I had my baby at midnight and she told me I could stay until I went to the toilet. At 4am I went to the toilet and she told me to leave. It was the middle of winter and I am sitting in the foyer waiting for my mum to come back and pick me up with my new baby. My mum only just left two hours before because they said she can’t stay the night. I was thinking of her petrol.”
 
“I was looking out the hospital window in my room and I could see my mum sitting in the dark at Middlemore train station and we were both crying.”
 
The research also highlighted that the women they interviewed very rarely complain about the service they received even when it is very bad. Others issues discussed with the mothers included accessing affordable and appropriate contraception, reducing or stopping smoking during pregnancy, and developing culturally appropriate nutritional interventions to reduce pre-pregnancy obesity.
 
Recommendations
The report includes a number of recommendations on how to achieve quality in maternity care across culturally diverse populations, doing something urgently abut the poor service to teen, young, Maori, Pacific and other vulnerable mothers, the need to consider the whole maternity care system when making changes, and reviewing the mechanisms used by CMH for patient and consumer input.
 
The MSCC considers that similar problems exist with the maternity services provided to these groups of mothers in West Auckland, and recommends that Waitemata DHB undertakes a similar survey of women who have given birth at Waitakere Hospital.
 
The Counties Manukau Health report is available at:
www.countiesmanukau.health.nz/News_Publications/Reports/maternitycarereview/default.htm


March 2013


MATERNITY CARE IN COUNTIES MANUKAU FAILS MOTHERS & BABIES

The report of the review of maternity care in the Counties Manukau DHB area was released on 15 November 2012. Commissioned by the Counties Manukau DHB, the Maternity Care Review Panel was chaired by Professor Ron Paterson and panel members included Anne Candy, Siniua Lilo, Professor Lesley McCowan, Dr Ray Naden and Maggie O’Brien.
 
In the Chairman’s Foreword, Ron Paterson stated that many women with high needs do not have access to an adequate standard of maternity care, and that decisive action is needed to address the underlying population health factors that contribute to Counties Manukau’s high rates of perinatal mortality.
 
Nothing new
The contributing factors to the rate of perinatal mortality and morbidity in Counties Manukau identified in the report are not new to many of the health professionals and consumer groups who have been involved in maternity care in the Auckland region over the past decade. Attempts have been made over the years to draw attention to the concerns of women about the state of maternity care in South Auckland and to get the DHB or the Ministry of Health to act. The general public knew almost nothing about the problems because, unlike other DHBs, the vast majority of items about maternity services in the Counties Manukau DHB meeting agenda papers took place behind closed doors.

What finally led to the commissioning of this review was the 5th Annual Report of the National Perinatal and Maternal Mortality Review Committee (PMMRC) which identified that Counties Manukau had a significantly higher perinatal mortality rate than the rest of New Zealand, particularly among Maori and Pacific women.
 
Access to LMC midwives and continuity of care
One of the issues identified by the review was that pregnant women in Counties Manukau do not have the same level of access to self-employed midwives that women in other DHBs do.
 
Only 51% of pregnant women in Counties Manukau have their primary maternity care provided by an LMC midwife. There are a number of reasons behind the low numbers of LMC midwives providing care in South Auckland. Many women in this area are living in poverty, have few resources and when they are pregnant they present with complex health, financial and social needs. Because the Section 88 funding mechanism is a one-size-fits-all payment system which has no financial incentives to provide the extra care that these women need, self-employed midwives are understandably reluctant to take on these women and provide LMC care.
 
The other models of care available in South Auckland are what are referred to as case-loading DHB midwives, and shared care in which maternity care is shared between a GP and the Counties Manukau DHB midwifery team. Neither of these two models of care provides the same level of continuity of care that LMC midwifery care does, and there have been complaints about the shared care arrangement for many years. There are concerns about the knowledge, expertise and skills of the GPs providing shared maternity care in South Auckland, some of whom are not appropriately qualified to provide maternity care. It is doubtful as to whether they engaged in continuing medical education activities that focus on providing primary maternity care, and whether they are vocationally registered.
 
The maternity care provided by this shared care model is substandard and the maternity groups have been aware for some years that pregnant women were not being advised of their options by the shared care GPs. Women have rung complaining about the care they received, their lack of choices, being seen by different doctors and midwives during their antenatal visits, and the unacceptably few postnatal visits.   
 
The inadequate level of maternity care being provided in South Auckland has been allowed to continue for a number of years and this has undoubtedly contributed to self-employed midwives not wanting to work there. It should not have taken a PMMRC report to finally galvanise Counties Manukau DHB into action, if indeed they have been galvanized into action.
 
MOH responsibility
The Ministry of Health must also share some of the responsibility for the current situation. The Ministry has permitted the Counties Manukau DHB to continue flouting the maternity service requirements that other DHBs were required to meet. Concerns about the situation in Counties Manukau have been expressed at both national and regional meetings during the past decade. When exceptions to maternity service requirements are permitted it is of course the mothers and babies who suffer the consequences.
 
Increase in Section 88 funding
The increase in Section 88 funding that midwives obtained this year was insufficient and will do nothing to improve the LMC midwifery shortage in South Auckland. The NZ College of Midwives made extensive submiss-ions to the Ministry about the need to increase the Section 88 fees as there had been no fee increase since 2007. The result was a small increase in fees for first trimester care and for postnatal care. It is woefully inadequate and does little to cover the increased workload midwives have to take on. It also will not cover the extra maternity care and support needed by mothers in South Auckland who have complex health and social needs.
 
Mothers in Counties Manukau
The report notes that 14% of all births in New Zealand are to women residing in Counties Manukau. Approximately 8,500 babies are born each year to women living in the CMDHB area, of whom more than 50% are born to Maori or Pacific mothers, and to mothers who predominantly live in areas of high socioeconomic deprivation. Maori and Pacific mothers are more likely to have a stillborn baby or to lose a baby in the neonatal period compared to European mothers.       
 
The report notes that Counties Manukau has more women with high health needs during pregnancy than any other part of the country. These include obese women, smokers, teenage mothers and older mothers who have had several pregnancies. However, in one of two reports produced for the CMDHB, researcher Dr Catherine Jackson, commented that “ethnicity was not an independent risk factor for perinatal death, ie it is not being Maori or Pacific that places you at higher risk. It is the increased odds of exposure to risk factors such as smoking, obesity, premature birth, etc.”
 
While the review was commissioned by the CMDHB and the report was focused on the issues and the needs of the women in South Auckland, there were many factors described in the report that also apply to women in West Auckland.
 
All women are vulnerable
The Panel interviewed staff and self-employed LMC midwives and asked about services provided to vulnerable women. They were repeatedly told that “all women are vulnerable.” The report notes that Dr Jackson concluded that 81% of women who delivered at CMDHB facilities during 2007-2009 would be classified as high risk based on the PMMRC criteria, but cautioned that this serves to highlight “the limitations of a high-risk approach in a population that is predominantly high risk.”
 
It is essential that all CMDHB women are provided with high quality maternity care, not just those singled out as being “vulnerable.” Improving services to all women avoids stigmatising or marginalising particular groups of women who are assessed, labelled and subsequently assigned to receive special services. All women are entitled to a high standard of maternity care, including continuity of care, not just those identified as “most vulnerable.”

The recommendations
The report contains a raft of recommendations for improving both maternity care and reproductive health services in Counties Manukau. Many of the recommendations have the word “urgent” attached to them.
 
The Panel makes a strong statement at the beginning of the report about “the critical importance of providing care in a culturally appropriate manner.” One of the recommendat-ions refers to the need to ensure “that educational material and information is provided in a variety of languages, that the maternity workforce better reflects the wider community, and that maternity care is provided in a manner that more appropriately meets the needs and requirements of different cultural groups.”  

Other recommendations include:
- encourage women who are healthy and have a normal pregnancy to opt for midwifery care and to birth at a primary birthing unit
- seek an urgent review by the Ministry of Health of the section 88 funding mechanism for LMCs nationally, in order to create incentives to provide care for women who have clinical or social risk factors
- encourage midwives to work as self-employed practitioners in the CMDHB region and increase the number of LMCs available
- review, as a matter of urgency, the current delivery and funding of family
- planning services in the CMDHB area, with a view to increasing access to these services, particularly for young and “at-risk” women
- consider the establishment of a local non-surgical termination of pregnancy service at Counties Manukau
improve access to pregnancy-related ultrasound scanning
implement an integrated maternity information system
 
The prioritisation of the vulnerable
There are four recommendations concerning vulnerable women:
- establish a set of criteria to define and identify the most socially and medically vulnerable pregnant women
- establish a vulnerable women’s multi-disciplinary group to refer vulnerable women to
- consider ways in which those identified as most vulnerable can be provided with continuity of care
- urgently consider the development of comprehensive social worker and/or community health worker support services, to assist pregnant women to address the social factors that impact on their health status.
 
The report also stresses the importance of getting women to attend “a full pregnancy assessment appointment” with a midwife or GP in the first 10 weeks of pregnancy. About 25% of pregnant women in Counties Manukau do not have any antenatal care and this group has the highest perinatal mortality rate.
 
However, until a system of high quality, culturally appropriate maternity care is established in Counties Manukau pregnant women will remain isolated from the services they need. Defining them as one of those in the “most socially and medically vulnerable” group is also unlikely to win them over. 
 

A copy of the External Review of Maternity Care in the Counties Manukau District is available at:
http://www.cmdhb.org.nz/News_Publications/Reports/report-external-maternitycare-review.pdf

December 2012



NZ’s maternity hospitals – how are they doing at keeping birth normal? 
The Ministry of Health has just released a report with statistical information that enables the general public and mothers and their families in particular to see how their local secondary or tertiary maternity hospital is performing when it comes to keeping birth normal.

The report covers births in 2009 and is a first in that it is focused on maternity clinical indicators for women aged between 20 and 34 who are expecting their first baby and who have had a normal pregnancy uncomplicated by any health problems in either the baby or the mother. These women should therefore expect to have a normal birth with few if any medical interventions. As the report puts it, using this standard definition “allows the separate assessment of a group of women for whom interventions and outcomes should be similar.” (1)

The clinical indicators are based on Australasian clinical indicators, are evidence-based and cover a range of procedures and outcomes for mothers and their babies. They include spontaneous vaginal birth, instrumental vaginal birth, caesarean section, induction of labour, intact lower genital tract, episiotomy and no tear, third or fourth degree tear and no episiotomy, episiotomy and third or fourth degree tear, use of general anaesthetic for caesarean section, blood transfusion, premature birth.
  
However, what the statistics reveal is that the rate of interventions between various DHBs and between individual secondary and tertiary hospitals varies enormously, and such significant variation “among a group of women who would be expected to have similar outcomes needs to be investigated.” Women’s health groups around the country now need to put pressure on their local hospital to do something about the high intervention rates occurring in some hospitals.

Spontaneous vaginal birth
This indicator measures the proportion of first-time mothers having a spontaneous vaginal birth. “It is expected to encourage maternity service providers to review, evaluate and make necessary changes to clinical practice aimed at supporting women to achieve an unassisted birth.” (2)

For Auckland the rates of spontaneous vaginal births were 56.1% at North Shore Hospital, 61.3% at Auckland City Hospital, 69.5% at Waitakere Hospital and 70.2% at Middlemore Hospital.

Christchurch had the lowest rate at 50.7%, Southland had 57.6%, Wairarapa Hospital had 58.1% and Waikato had 58.5%.

Instrumental vaginal birth
This indicator is to assist service providers evaluate the use of ventouse and forceps in their hospitals, and if their rates are significantly higher than their peer group at a national level, they will need to examine the rate of maternal and perinatal morbidity.

For Auckland the rates of first-time mothers undergoing an instrumental vaginal birth were 18.8% at Auckland City Hospital, 17% at North Shore Hospital, 15.4% at Middlemore Hospital and 10.2% at Waitakere Hospital.

Christchurch had the highest rate at 26.4%, Waikato had 24.2%, Southland had 19.4%, and Dunedin Hospital had 18.3%.

Caesarean section
The purpose of this indicator is to encourage maternity service providers to evaluate whether caesarean sections were performed on the right women at the right place and at the right time. “The longer-term aim is to reduce the risks associated with an unnecessary caesarean section, reduce the number of women at risk of a subsequent caesarean section and reduce the number of women who experience difficulties with their second and subsequent births as a consequence of a primary caesarean section.” 

For Auckland the rates of first-time mothers undergoing a caesarean section were 23.2% at North Shore Hospital, 19.8% at Auckland City Hospital, 13.9% at Waitakere Hospital and 13.4% at Middlemore Hospital.

Wairarapa Hospital had the highest rate at 27.9%, Wairau had 25.7%, Grey Base Hospital had 24%, Southland had 23% and Christchurch had 22.4%.

Induction of labour
This indicator will assist maternity service providers to evaluate the effects of inducing labour in low-risk women, effects which include caesarean section, postpartum haemorrhage and episiotomy.

For Auckland the rates of first-time mothers undergoing an induction of labour were 9.1% at Auckland City Hospital, 5.6% at North Shore Hospital, 2.4% at Middlemore Hospital and 1.9% at Waitakere Hospital.

Southland had the highest rate of inductions at 13.1%, Grey Base Hospital had 10%, Wellington had 8.1% and Waikato had 6.1%.

Episiotomy
This indicator aims to encourage further investigation to ensure that risks to the mother as well as the infant are assessed before undertaking an episiotomy, risks that include bleeding, infection and maternal morbidity.

For Auckland the rates of first-time mothers undergoing an episiotomy without mention of a third or fourth degree tear were 28.7% at Auckland City Hospital, 23.9% at North Shore Hospital, 19.4% at Middlemore Hospital and 13.6% at Waitakere Hospital.

Christchurch had the highest rate of episiotomies at 32.9%, Wairarapa Hospital had 29%, Wellington had 28.9%, and Palmerston North had 25.1%.

Keeping birth normal
The statistical information contained in this 71-page report reveals that there is a significantly high rate of variation in the intervention rates for low-risk mothers giving birth to their first baby after an uncomplicated pregnancy. Far too many secondary and tertiary maternity hospitals are doing far too little to stem the growing tide of interventions in the normal birth process, interventions that result in significant risks to the future health and well-being of both mother and baby.  
In Auckland, North Shore Hospital has continued to countenance unnecessarily high rates of intervention in the birth process for decades, higher even in some cases than those at National Women’s at Auckland City Hospital. There have been concerns for over two decades about the maternity services provided at North Shore Hospital, and over the past five years Waitemata DHB has attempted to hide North Shore Hospital’s poor performance by producing annual maternity reports that combine the rates of intervention for both Waitakere and North Shore hospitals.

Nationally, women in Southland, Christchurch and the Waikato may also want to question their local maternity hospitals about their high intervention rates and firmly request to be a part of initiatives that seek to identify and implement improvements to the maternity services provided in their local hospitals. 

References

1. Ministry of Health. “NZ Maternity Clinical Indicators 2009.” March 2012.
2. MOH. “NZ Maternity Clinical Indicators 2009.” March 2012. Page 7.
3. MOH. “NZ Maternity Clinical Indicators 2009.” March 2012. Pages 7-8.


March 2012


COUNTING THE COST OF STILLBIRTHS

On the 14th April 2011 The Lancet published a series of ground-breaking online articles on an issue that is not only invisible in the majority of societies around the world but is ignored on international policy, programme and investment agendas. The issue is stillbirth, a devastating event for millions of women and their families every year, and one that the series of articles in The Lancet identified as one of the most shamefully neglected areas of public health.

Stillbirth is not counted in the Millennium Development Goals; it is not counted by the United Nations (UN); nor is it counted in the Global Burden of Disease figures. This despite the fact that in 2008 there were an estimated 2.65 million stillbirths with over a million of them occurring intrapartum – during labour and birth. The international definition of stillbirth is the death of a baby after 28 weeks gestation.

Most intrapartum stillbirths are associated with obstetric emergencies, whereas deaths during the third trimester of pregnancy are associated with maternal infections and foetal growth restriction.

In the first of six papers about stillbirth entitled “Stillbirths: why they matter,” Dr J Frederik Froen and his colleagues report:
“To be registered, counted and recognised also has profound humane implications. Although stillbirth can be as devastating as a child’s death, often the baby is known and mourned solely by the parents. Even in high-resource settings in which psychological support might be available, one in five mothers has appreciable long-term depression, anxiety, or post-traumatic stress disorder after a stillbirth. Fathers are also affected by negative psycho-social consequences. When compared with the leading global causes of death in all age categories, all-cause stillbirths would rank fifth among the global health burdens – before diarrhoea, HIV/AIDS, tuberculosis, traffic accidents, and any form of cancer.” (1)

The focus on maternal health
Over the past few decades there has been an increasing focus on maternal and child health which has seen a number of significant initiatives and interventions. Despite this, stillbirths have been ignored and the loss of these babies remains largely invisible.

For example, in September 2010, the UN summarised the commitments to improve maternal and child health by seven UN agencies, 36 countries, and more than 75 non-governmental organisations (NGOs) and professional organisations: stillbirth is not mentioned in any of them.

Stillbirths linked to deprivation
98% of stillbirths occur in countries of low and middle incomes, and within high-income countries disadvantaged populations have a much greater risk of stillbirth than affluent populations. The five major causes of stillbirths in low and middle income countries are childbirth complications, maternal infections during pregnancy (syphilis), maternal disorders (especially hypertension), maternal under-nutrition and foetal growth restriction, and congenital abnormalities. 

The variation in stillbirth rates across and within high-income countries indicate that further reduction in stillbirth is possible in these countries as well. While stillbirth rates have declined dramatically from around 1940, over recent times the decline has slowed or even stalled. (2) 

In most countries the causes of stillbirths are inseparable from those that result in the deaths of pregnant women and their newborn babies. The Millennium Development Goals estimate that there are 350,000 maternal deaths and 3.6 million neonatal deaths every year. In countries with high mortality rates, emergency obstetric care has the greatest effect on these deaths, as well as on stillbirths. (3)

High-income countries
In high-income countries the familiar link between low socioeconomic status and adverse outcomes are starkly evident with large increases in the risk of stillbirth in minority populations. Inuit-inhabited areas of Canada have almost three times the rate of stillbirths as compared to the rest of Canada. Indigenous Australia women have almost twice the risk of non-indigenous women, as do African-American women in the USA when compared with white women. Reports from the UK and New Zealand reveal a similar scenario. (2)   

Other risk factors
Smoking is a major contributor to stillbirths in some disadvantaged populations. For example, among indigenous Australian and Canadian women smoking contributes to about 20% of stillbirths compared with 4-7% overall in high-income countries.

Obesity is another major and potentially modifiable risk factor for stillbirths.  

Other risk factors include:
• A maternal age of more than 35 years
• Alcohol consumption during pregnancy
• A first pregnancy
• A previous caesarean birth
• A multiple pregnancy
• Use of reproductive technology
• Lack of antenatal care

Call to action
The sixth paper in the series calls for high-income countries to eliminate all preventable stillbirths and close equity gaps. By 2020 low income and middle income countries should aim to have reduced their current stillbirth rates by at least 50%.

However, first stillbirths need to be recognised by all countries and the UN as a major public health issue. Then each stillbirth must be counted.

References
1. J. Frederik Froen et al. “Stillbirths: why they matter.” www.thelancet.com 14 April 2011.
2. Vicki Flenady et al. "Stillbirths: the way forward in high-income countries.” www.thelancet.com 14 April 2011.
3. Robert Pattinson et al. “Stillbirths: how can health systems deliver for mothers & babies?” www.thelancet.com 14 April 2011.
 
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