OBJECTIVE To conduct a pilot study evaluating acceptability of pregnancy loss nomenclature amongst people with recent lived experience, and make recommendations for UK mass communication. DESIGN Electronic internet-based questionnaire. SETTING UK. POPULATION OR SAMPLE Service users who accessed UK healthcare for >1 experience(s) of pregnancy loss between 2021 and 2024 (n=391). METHODS Descriptive and inferential statistics. MAIN OUTCOME MEASURES Acceptability ratings for pregnancy loss nomenclature used diagnostically in UK healthcare settings. RESULTS Much nomenclature currently in use in UK pregnancy loss care was rated ‘unacceptable’ by a majority of study participants. Spontaneous abortion, incompetent cervix and cervical incompetence were among terminology rated as ‘unacceptable’ by >80% of the respondents rating terms for the process of loss. In contrast, pregnancy loss and ectopic pregnancy were rated ‘acceptable’ by >80% of respondents. As nomenclature for pregnancy loss outcomes, products, contents of the womb/uterus and tissue, were rated ‘unacceptable’ by >80% of respondents. Baby and ‘their given name’ were rated ‘acceptable’ by >80% of respondents across all gestational age brackets. Some terminology elicited mixed acceptability ratings. CONCLUSIONS Some pregnancy loss nomenclature attracted consensus acceptability or unacceptability ratings for respondents. The data inform evidence-based recommended alternatives which should be adopted for mass communications relating to pregnancy loss.

Objective To develop a prognostic model to predict pregnancy outcome in extremely early-onset fetal growth restriction (eFGR) using maternal characteristics, ultrasound parameters, and longitudinal biometry data. Design Retrospective cohort study. Setting Specialist fetal growth clinic at a tertiary centre and satellite clinics in the UK. Population Singleton pregnancies diagnosed with eFGR between 2009 and 2019, meeting Delphi consensus criteria and delivered before 33+0 weeks’ gestation (n = 182). Methods Maternal and ultrasound data were analysed to identify factors associated with fetal death in utero (FDIU) and perinatal mortality. Multivariable logistic regression and bootstrapped internal validation were used to develop and assess model performance. Longitudinal fetal growth trajectories were examined using multilevel mixed-effects linear regression. Main Outcome Measures Live birth to hospital discharge, FDIU, and neonatal or infant death. Results Gestational age at diagnosis, estimated fetal weight (EFW), umbilical artery end-diastolic flow (EDF), and uterine artery resistance index were significant predictors of FDIU (AUC 0.82). A model predicting overall perinatal death had moderate discrimination (AUC 0.75). Longitudinal analysis showed significantly slower fetal growth trajectories in pregnancies ending in FDIU, with early weight gain predictive of outcome. Conclusions A combination of gestational age, fetal biometry, and Doppler findings can predict adverse outcomes in eFGR. Longitudinal biometry adds prognostic value by enabling dynamic risk stratification. These findings support development of clinically applicable tools to inform counselling and management in eFGR.

Objective To develop a core outcome set for stillbirth care. Design Consensus development study. Setting International. Population 542 participants from 29 countries, including 381 parents or family members who have experienced stillbirth, 192 care professionals and researchers (31 of which identified as both parent and professional). Methods Modified Delphi method and Modified Nominal Group Technique. Results A long list of 108 potential outcomes was developed by combining outcomes reported in 240 stillbirth care studies with those derived from interviews of 40 parents and family members with lived experience of stillbirth. Following a two-round Delphi process with consensus meetings, stakeholders agreed upon 8 core outcomes to measure in all stillbirth care studies; an additional 11 outcomes for specific interventions or care were also decided. Core outcomes for all stillbirth care studies were life-threatening complications and maternal death, parents’ experience of respectful and supportive care, grief, mental health and emotional wellbeing, isolation, stigma, impact on work, impact on relationship with immediate family. Outcomes for studies assessing interventions to understand the cause of stillbirth (investigations): cause of death identified and parents’ understanding of cause of death. Outcomes in studies assessing subsequent pregnancy after stillbirth: antenatal complications for mother, antenatal complications for baby, survival of baby, neonatal outcomes and attachment to baby. Outcomes for when a stillbirth occurs in a multiple pregnancy: Survival of other baby/ies, preterm birth, pregnancy complications for baby/ies and neonatal outcomes. Conclusion This core outcome set for stillbirth care should now be used in future trials and systematic reviews to ensure that outcomes considered important by a range of stakeholders are addressed, and to minimise outcome reporting bias.

Objective – To evaluate parents’ psychological distress and emotional suppression in the antenatal and postnatal periods of a pregnancy following a perinatal death. Design – Questionnaire. Setting – Tertiary Maternity Unit in the UK. Sample – Parents who were pregnant and attending a specialist antenatal clinic for pregnancy after loss. Methods – Partners and mothers completed questionnaire measures which evaluated their levels of depression, anxiety, post-traumatic stress (PTS) and emotional suppression at 23 and 32 weeks’ gestation, and 6 weeks postnatally. Levels were plotted over time and examined to determine if there were significant changes between time points. The proportion of partners and mothers scoring above threshold for each measure was identified, and differences in scores between mothers and partners were examined. Main outcome measures – Psychological distress and emotional suppression Results – Parents’ depression levels significantly decreased after the birth of a live baby and anxiety levels significantly decreased for mothers but not partners. PTS did not change across the course of a pregnancy, and symptoms continued into the postnatal period for mothers. Partners are more likely to hide their emotions during pregnancy than mothers. Conclusion – Both parents who have experienced a prior perinatal death are likely to experience high levels of psychological distress in a subsequent pregnancy which may continue into the postnatal period. Specialist mental health support offered within a dedicated pregnancy after loss service is one way to support parents. Further research is needed to determine whether psychological distress impacts on parent-child bonding.

Abstract Objectives: Women experiencing reduced fetal movements (RFM) have an increased risk of adverse pregnancy outcome (APO). Single-population studies may introduce bias and limiting generalisability. This study aimed to identify factors most strongly associated with APO, including stillbirth, fetal growth restriction (FGR), and admission to neonatal intensive care unit in women with RFM. Design and settings: Individual-level data from multiple sites in Manchester and Leicester were synthesised and analysed. Population or Sample: 1,175 women between 28 +0 and 41 +0 weeks’ gestation with singleton pregnancies. Methods: Factors associated with APO were assessed by two-stage individual participant data meta-analysis (IPD-MA). Main Results: 7.7% of RFM pregnancies ended in APO, with the most common complication being FGR (birthweight ≤3 rd centile) in 4.6%. Maternal past medical history (adjusted Odds Ratio, aOR = 2.28, 95% CI 1.08-4.83) and smoking status (aOR = 2.52, 95% CI 1.20-5.29) were most strongly associated with APO. Estimated fetal weight (EFW) percentile (aOR = 0.97, 95% CI 0.96-0.99) and maternal age (aOR = 1.05, 95% CI 1.01-1.09) were also significant risk factors, though high heterogeneity between studies in EFW percentile was observed (I 2 = 76.84%, Tau 2 = 0.0004, Q-statistic p-value = 0.0007). Conclusions: IPD-MA allowed amalgamation of patient-level data across studies, and more accurate and reliable associations were found by accounting for heterogeneity. Further work is required to investigate the model’s generalisability across diverse populations and settings. Funding: This study received no specific funding. Keywords: Individual Participant Data Meta-Analysis; Adverse pregnancy outcome; Stillbirth; Fetal Growth Restriction; Perinatal mortality; Decreased Fetal Movement

Objective To identify outcomes that are important to families, to inform the development of a core outcome set for stillbirth care research. Design Qualitative interview study. Setting A national study in the United Kingdom. Population A diverse sample of parents with a personal history of stillbirth were interviewed. Methods Data collection, coding and analysis were influenced by a modified Grounded Theory approach. Parents’ lived experiences of stillbirth were translated into outcomes for the purpose of developing a core outcome set. Results Forty parents and family members were interviewed. Analysis identified 343 potential care outcomes, 298 (87%) of which have not been previously reported by stillbirth care studies. Outcomes were organised into four major care outcome themes: 1) Clinical 2) Mental health and wellbeing 3) Social and family 4) Future pregnancy and children. Short- and long-term outcomes related to the labour, birth, investigations to understand why a baby had died, stillbirth in a multiple pregnancy, postpartum, psychological and subsequent pregnancy care were reported. Outcomes infrequently measured in previous stillbirth care research yet discussed by most participants were social isolation, impact on occupation and need for mental health support. Parents spoke of the importance of counselling to help them understand their grief, however, the provision of this service was reported to be varied throughout the UK. Conclusion A comprehensive outcome inventory has now been constructed, from which the final core outcome set will be determined. Future care should be developed and evaluated using outcomes that directly relate to the lived experiences of parents and families exposed to stillbirth.

Objective: To compare the carbon footprint of caesarean and vaginal birth. Design: Life cycle assessment. Setting: Tertiary maternity units and home births in the UK and the Netherlands Methods: A life cycle assessment, including: equipment use, energy, analgesia, hospital stay, waste, sterilisation and laundry, was conducted using primary data combined with data from published sources. Main Outcome Measures: ‘Carbon footprint’ (in kgCO 2e) Results: Excluding analgesia, the carbon footprint of a caesarean birth in the UK was 31.21 kgCO 2e, compared with 12.47 kgCO 2e for vaginal birth in hospital and 7.63 kgCO 2e at home. In the Netherlands the carbon footprint of a caesarean was higher (32.96 kgCO 2e), but lower for vaginal birth in hospital and home (10.74 and 6.27 kgCO 2e respectively). Emissions associated with analgesia for vaginal birth were: 0.08 kgCO 2e (opioid analgesia), 0.75 kgCO 2e (remifentanil), 1.2 kgCO 2e (epidural) and 237.33 kgCO 2e (nitrous oxide with oxygen). Differences in analgesia use resulted in a lower average carbon footprint for vaginal birth in the Netherlands than the UK (11.64 vs. 193.26 kgCO 2e). Conclusion: The carbon footprint of a caesarean is higher than for vaginal birth if analgesia is excluded, but this is very sensitive to the analgesia used; use of nitrous oxide with oxygen multiplies the carbon footprint of vaginal birth 25-fold. Alternative methods of pain relief or nitrous oxide destruction systems would lead to a substantial improvement in carbon footprint. Although clinical need and maternal choice are paramount, protocols should consider the environmental impact of different choices.

Objectives To investigate the risk of stillbirth in relation to; 1) a previous CD compared to those following a vaginal birth (VB); and 2) vaginal birth after caesarean (VBAC) compared to a repeat CD. Design Population-based cohort study. Setting The Swedish Medical Birth registry Population Women with their first and second singletons between 1982 and 2012. Methods Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). Main outcome measures Stillbirth (antepartum and intrapartum fetal death). Results Of the 1,771,700 singleton births from 885,850 women,117,114 (13.2%) women had a CD in the first pregnancy, and 51,755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR:1.37 [95% CI, 1.23–1.52]) in women with a previous CD compared to VB. The odds of intrapartum stillbirth was higher in previous pre-labour CD group (aOR:2.72 [95% CI, 1.51–4.91]) than the previous in-labour CD group (aOR:1.35 [95% CI, 0.76–2.40,]), although not statistically significant in the latter case. No increased odds was found for intrapartum stillbirth in women who had VBAC (aOR:0.99 [95% CI, 0.48–2.06]) compared to women who had a repeat CD, whereas women with antepartum stillbirth were more likely to have a VBAC (aOR:4.49 [95% CI, 3.55–5.67]). Conclusions This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help health care providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.

Background A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which has been identified as an important research priority. Objectives To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth. Search strategy Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021. Selection criteria Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention. Data collection and analysis Interventions, outcomes reported, definitions and outcome measurement tools were extracted. Main results 40 randomised and 200 non-randomised studies were included. 58 different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. 242 outcome measurement instruments were used, with 0-22 tools per outcome. Conclusions Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.