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Objective To understand why skilled birth attendance-an acknowledged strategy for reducing maternal deaths-has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions. Design Implementation research was conducted using an institutional ethnographic approach. Setting and population National programme and local community levels in Pakistan. Methods Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives ( CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together. Main outcomes Alignment of programme theory with real-world practice. Results Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public-private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography. Conclusions Greater attention to programme theory and the 'real-world' setting during design of maternal health strategies is needed to achieve consistent results in different contexts. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Both J, van Roosmalen J. The impact of Prevention of Mother to Child Transmission (PMTCT) programmes on maternal health care in resource-poor settings: looking beyond the PMTCT programme-a systematic review. BJOG 2010;117:1444-1450. Background There is increasing debate about the impact of scaled-up HIV/AIDS programmes on fragile healthcare systems in low-income countries. Objectives To contribute to the understanding of the relation between HIV/AIDS programmes and healthcare systems, this systematic review focuses on the impact of Prevention of Mother to Child Transmission (PMTCT) programmes on maternal health care. Search strategy Publications describing the effect of PMTCT programmes on maternal healthcare services were sought through computerised searches in five electronic databases. Selection criteria Abstracts of publications were evaluated for appropriateness for inclusion based on whether they met the inclusion criteria. Data collection and analysis Copies of all selected publications were obtained. A classification system was developed to group the relevant publications. Main results The findings show that empirical evidence of the effect of PMTCT programmes on maternal health care is scarce and further research is badly needed. Twenty-one studies that were included in the systematic review showed that PMTCT programmes are often semi-integrated in maternal health care with positive as well as negative effects on various aspects of maternal health care. Authors' conclusions It appears that PMTCT programmes miss the opportunity to have an overall positive effect on maternal health care because of their verticality. [ABSTRACT FROM AUTHOR]

Although Emergency Obstetric Care (EOC) is globally accepted as a key strategy to improve maternal health and reduce maternal mortality, there is still a lot of debate surrounding its use – What is EOC? Is it evidence-based? How can we measure it? How can we improve access to EOC? This paper attempts to answer these questions. Although there are no randomized controlled trials, there is strong evidence from quasi-experimental, observational and ecological studies that EOC should be a critical component of any programme to reduce maternal mortality. This paper also identifies the barriers to accessing EOC and proposes strategies to overcome them which could contribute to achieving Millennium Development Goal 5. [ABSTRACT FROM AUTHOR]

Background Pregnancy after perinatal death is characterised by elevated stress and anxiety, increasing the risk of adverse short-term and long-term outcomes. Objectives This metasynthesis aimed to improve understanding of parents' experiences of maternity care in pregnancy after stillbirth or neonatal death. Search strategy Six electronic databases were searched using predefined search terms. Selection criteria English language studies using qualitative methods to explore the experiences of parents in pregnancy after perinatal loss, were included subject to quality appraisal framework. Data collection and analysis Searches were initiated in December 2011 and finalised in March 2013. Studies were synthesised using an interpretive approach derived from meta-ethnography. Main results Fourteen studies were included in the synthesis, graded A (no or few flaws, high trustworthiness; n = 5), B (some flaws, unlikely to affect trustworthiness; n = 5) and C (some flaws, possible impact on trustworthiness; n = 4). Three main themes were identified; co-existence of emotions, helpful and unhelpful coping activities and seeking reasssurance through interactions. Conclusion Parents' experiences of pregnancy are profoundly altered by previous perinatal death; conflicted emotions, extreme anxiety, isolation and a lack of trust in a good outcome are commonly reported. Emotional and psychological support improves parents' experiences of subsequent pregnancy, but the absence of an evidence base may limit consistent delivery of optimal care within current services. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Bouvier-Colle M, Mohangoo A, Gissler M, Novak-Antolic Z, Vutuc C, Szamotulska K, Zeitlin J for The Euro-Peristat Scientific Committee. What about the mothers? An analysis of maternal mortality and morbidity in perinatal health surveillance systems in Europe. BJOG 2012;119:880-890. Objective To assess capacity to develop routine monitoring of maternal health in the European Union using indicators of maternal mortality and severe morbidity. Design Analysis of aggregate data from routine statistical systems compiled by the EURO-PERISTAT project and comparison with data from national enquiries. Setting Twenty-five countries in the European Union and Norway. Population Women giving birth in participating countries in 2003 and 2004. Methods Application of a common collection of data by selecting specific International Classification of Disease codes from the 'Pregnancy, childbirth and the puerperium' chapter. External validity was assessed by reviewing the results of national confidential enquiries and linkage studies. Main outcome measures Maternal mortality ratio, with distribution of specific obstetric causes, and severe acute maternal morbidity, which included: eclampsia, surgery and blood transfusion for obstetric haemorrhage, and intensive-care unit admission. Results In 22 countries that provided data, the maternal mortality ratio was 6.3 per 100 000 live births overall and ranged from 0 to 29.6. Under-ascertainment was evident from comparisons with studies that use enhanced identification of deaths. Furthermore, routine cause of death registration systems in countries with specific systems for audit reported higher maternal mortality ratio than those in countries without audits. For severe acute maternal morbidity, 16 countries provided data about at least one category of morbidity, and only three provided data for all categories. Reported values ranged widely (from 0.2 to 1.6 women with eclampsia per 1000 women giving birth and from 0.2 to 1.0 hysterectomies per 1000 women). Conclusions Currently available data on maternal mortality and morbidity are insufficient for monitoring trends over time in Europe and for comparison between countries. Confidential enquiries into maternal deaths are recommended. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Tunçalp Ö, Hindin MJ, Souza JP, Chou D, Say L. The prevalence of maternal near miss: a systematic review. BJOG 2012;119:653-661. Background Severe maternal morbidity or 'near miss' is a promising indicator to improve quality of obstetric care. Objectives To systematically review all available studies on 'near miss'. Search strategy Following a pre-defined protocol, our review covered articles between January 2004 and December 2010. We used a combination of the following terms: near miss morbidity, severe maternal morbidity, severe acute maternal morbidity, obstetric near-miss, maternal near miss, obstetric near miss, emergency hysterectomy, emergency obstetric hysterectomy, maternal complications, pregnancy complications, intensive care unit. Selection criteria Nearly 4000 articles were screened by title and abstract, and 153 articles were retrieved for full text evaluation. There were no language restrictions. Data collection and analysis Data extraction was performed using an instrument that included sections on study characteristics, quality of reporting, prevalence/incidence and the definition and identification criteria. Univariate analysis and meta-analysis for sub-groups were performed. Main results A total of 82 studies from 46 countries were included. Criteria for identification of cases varied widely. Prevalence rates varied between 0.6 and 14.98% for disease-specific criteria, between 0.04 and 4.54% for management-based criteria and between 0.14 and 0.92% for organ-based dysfunction based on Mantel criteria. The rates are higher in low-income and middle-income countries of Asia and Africa. Based on meta-analysis, the estimate of near miss was 0.42% (95% CI 0.40-0.44%) for the Mantel (organ dysfunction) criteria and 0.039% (95% CI 0.037-0.042%) for emergency hysterectomy. Our meta-regression results indicate that emergency hysterectomy rates have been increasing by about 8% per year. Authors' conclusions There is growing interest in the application of the maternal near-miss concept as an adjunct to maternal mortality. However, in the literature published before 2011 there was still important variation in the criteria used to identify maternal near-miss cases. The World Health Organization recently published criteria based on markers of management and of clinical and organ dysfunction which would enable systematic data collection on near miss and development of summary estimates. Comparing the rates over time and across regions, it is clear that different approaches are needed to lower the rates of near miss and that interventions must be developed with the local context in mind. [ABSTRACT FROM AUTHOR]

Please cite this paper as: de Graaf J, Schutte J, Poeran J, van Roosmalen J, Bonsel G, Steegers E. Regional differences in Dutch maternal mortality. BJOG 2012;119:582-588. Objective To study regional differences in maternal mortality in the Netherlands. Design Confidential inquiry into the causes of maternal mortality. Setting Nationwide. Population A total of 3 108 235 live births and 337 maternal deaths. Methods Data analysis of all maternal deaths in the period 1993-2008. Main outcome measure Maternal mortality. Results The overall national maternal mortality ratio was 10.8 per 100 000 live births. In the 12 provinces of the Netherlands, the maternal mortality ratio ranged from 6.2 in Noord Brabant to 16.3 per 100 000 live births in Zeeland. In the four largest cities, maternal mortality varied from 9.3 in Amsterdam to 21.0 in Rotterdam. At a national level, the most frequent direct cause was pre-eclampsia. Increased risks for maternal mortality were found for women living in deprived neighbourhoods (RR 1.41), women from non-Western origin (RR 1.59), and women who were 35 years or older (RR 1.61). Conclusion There are significant variations in maternal mortality ratios in the Netherlands between cities, provinces, and neighbourhoods. In addition, higher maternal mortality was observed in women of non-Western origin and in women who were 35 years of age or older. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Saucedo M, Deneux-Tharaux C, Bouvier-Colle M. Understanding regional differences in maternal mortality: a national case-control study in France. BJOG 2012;119:573-581. Objectives To assess the risk of postpartum maternal death associated with region, and to examine whether the quality of care received by the women who died differed by region. Design A national case-control study. Setting France. Population Selected from recent nationwide surveys, 328 postpartum maternal deaths from 2001 through 2006 as cases; and a representative sample ( n = 14 878) of women who gave birth in 2003 as controls. Methods Crude and adjusted odds ratios (aOR) of maternal death associated with region were calculated with logistic regression, and the quality of care for women who died was compared according to region with chi-square tests or Fisher's exact tests. Main outcome measures Risk of postpartum maternal death associated with region, and quality of care. Results After adjustment for maternal age and nationality, the risk of maternal death was higher in the Ile-de-France region (aOR 1.6, 95% CI 1.2-2.0) and the overseas districts (aOR 3.5, 95% CI 2.4-5.0) than in the group for the rest of continental France. In both regions, the excess risk of death from haemorrhage, amniotic fluid embolism and hypertensive disorders was significant. In continental France, after further controlling for women's obstetric characteristics, the risk of maternal death in Ile-de-France remained higher (aOR 1.8. 95% CI 1.3-2.6). The women in the cases groups received suboptimal care more frequently in Ile-de-France than in the other continental regions (64% versus 43%, P = 0.01). Conclusions These results suggest that quality of care and organisation of health services may play a role in the differential risk of maternal mortality between regions in France. Research on severe maternal morbidity and its determinants is needed to clarify the mechanisms involved. [ABSTRACT FROM AUTHOR]

Please cite this paper as: van den Akker T, Bemelmans M, Ford N, Jemu M, Diggle E, Scheffer S, Zulu I, Akesson A, Shea J. HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi. BJOG 2012;119:431-438. Objective To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-to-child transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services. Design Descriptive analysis. Setting Thyolo District, with a population of 600 000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004. Population Women attending reproductive health services care in 2005 and 2010. Methods Review of facility records and databases for routine monitoring. Main outcome measures Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care. Results There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40, 95% CI 4.25-4.55). Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52). Conclusions During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Fox R, Walker J. Draycott T. Medical simulation for professional development-science and practice. BJOG 2011;118 (Suppl. 3): 1-4. From the earliest days of medical practice, when surgeons used cadavers to explore the possibilities of surgical intervention, simulation has been employed to advance the practice of health care. In the last 10 years, technological advances have allowed for a wider availability and greater realism of simulation, and this has encouraged a great expansion in its use. Simulation aims to create a virtuous cycle of professional development to improve patient outcomes. Although it seems eminently logical to believe that simulation will result in better outcomes, there is a need to test these new training interventions rigorously to be sure of their worth and to understand any limitations. The purpose of this BJOG supplement is to examine in depth several paradigms of medical simulation within maternity care and gynaecology, in different settings, looking at what can be achieved and how. In this opening review, we look at the potential use of medical simulation in broad terms and describe the types of evidence that can be employed to support its use. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Ayres-de-Campos D, Deering S, Siassakos D. Sustaining simulation training programmes - experience from maternity care. BJOG 2011;118 (Suppl. 3): 22-26. There is little scientific evidence to support the majority of simulation-based maternity training programmes, but some characteristics appear to be associated with sustainability. Among these are a clear institutional-level commitment to the course, strong leadership in course organisation, a curriculum relevant to clinical practice, a nonthreatening learning environment, the establishment of multiprofessional training and the use of simulators appropriate to the learning objectives. There is still some debate on whether simulation-based sessions should be carried out in dedicated training time outside normal working hours or in ad-hoc drills that are run during clinical sessions, whether they should be located in clinical areas, simulation centres, or both, and whether or not they should include standardised generic teamwork training sessions. In this review, we discuss the main characteristics that appear to make a simulation-based training programme a sustainable initiative. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Crofts J, Winter C, Sowter M. Practical simulation training for maternity care-where we are and where next. BJOG 2011; 118 (Suppl. 3): 11-16. Improving maternal and perinatal care is a global priority. Practical simulation training for maternity care might prevent many of these deaths. There have been numerous evaluation studies published on the effectiveness of simulation training for obstetric emergencies, with increasing evidence that it is associated with improvement in clinical outcomes. Evidence has begun to move from subjective assessment of participants' experiences towards objective assessment of clinical outcomes. However, the results are not entirely consistent and, at present, all of the evidence associating training with improvements in clinical outcomes relates to neonatal outcomes. This review summarises recent progress in the evaluation of the effectiveness of simulation training for maternity care in both high- and low-resource settings, and presents a vision for ensuring that practical simulation training for maternity care can become an effective tool to reduce global maternal and perinatal morbidity and mortality. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Edwards C, Saha S. From home to hospital, a continuum of care: making progress towards Millennium Development Goals 4 and 5 in rural Bangladesh. BJOG 2011;118 (Suppl. 2):88-92. The Lutheran Aid to Medicine in Bangladesh (LAMB) health and development project in rural Bangladesh has developed an integrated maternal and child healthcare system providing appropriate, accessible and affordable health services for the poor, through a home-to-hospital, continuum-of-care approach. LAMB is thus an example of how high-quality maternity health services accessible to women of all socio-economic classes in a rural context can be provided, making progress towards Millennium Development Goals 4 and 5. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Siddiqui G, Hussein R, Dornan J. Dying to give birth: the Pakistan Liaison Committee's strategies to improve maternal health in Pakistan. BJOG 2011; 118 (Suppl. 2): 96-99. Pakistan has one of the worst maternal mortality ratios worldwide: 260-490 women die for every 100 000 live births in Pakistan. The Pakistan Liaison Group (PLG) was formed to work with and through the international office of the Royal College of Obstetricians and Gynaecologists (RCOG). It works with the RCOG representative committee in Pakistan to improve the health of women. It aims to contribute to improving maternal morbidity and mortality through strategies directed at improving the education and training of health professionals. In addition, the PLG aims to promote changes in the legislature to allow for the notification of maternal deaths so that accurate figures can be obtained, and so that health parameters can be accurately assessed and, in the long term, a confidential enquiry into maternal deaths can be initiated. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Bhandari A, Gordon M, Shakya G. Reducing maternal mortality in Nepal. BJOG 2011;118 (Suppl. 2):26-30. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Chowdhury S, Banu LA, Chowdhury TA, Rubayet S, Khatoon S. Achieving Millennium Development Goals 4 and 5 in Bangladesh. BJOG 2011;118 (Suppl. 2):36-46. Bangladesh has made commendable progress in achieving Millennium Development Goals (MDGs) 4 and 5. Since 1990, there has been a remarkable reduction in maternal and child mortality, with an estimated 57% reduction in child mortality and 66% in maternal mortality. This review highlights that, whereas Bangladesh is on track for achieving MDG 4 and 5A, progress in universal access to reproductive health (5B) is not yet at the required pace to achieve the targets set for 2015. In addition, Bangladesh needs to further enhance activities to improve newborn health and promote skilled attendance at birth. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Senanayake H, Goonewardene M, Ranatunga A, Hattotuwa R, Amarasekera S, Amarasinghe I. Achieving Millennium Development Goals 4 and 5 in Sri Lanka. BJOG 2011;118 (Suppl. 2):78-87. Sri Lanka has an exemplary record in maternal and child health care. Provision of free education for over 60 years has helped to empower women. Medical care is accessible and provided free of charge. The maternal mortality ratio and the other indices of maternal and neonatal health have shown uninterrupted improvement since 1930. Midwives and the policy to increase their presence has been the key to success. Public health midwives provide care at the doorstep. Institutional midwives carry out the vast majority of deliveries, of which 99% occur in hospitals. Although on target with the Millennium Development Goals, some challenges that still remain are maternal death from postpartum haemorrhage and unsafe abortion, and perinatal deaths due to congenital abnormalities and prematurity. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Bhuiyan A, Goodall D. The role of the South Asia Federation of Obstetrics and Gynaecology (SAFOG) in South Asia. BJOG 2011; 118 (Suppl. 2): 22-25. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Feng X, Zhu J, Zhang L, Song L, Hipgrave D, Guo S, Ronsmans C, Guo Y, Yang Q. Socio-economic disparities in maternal mortality in China between 1996 and 2006. BJOG 2010;117:1527-1536. Objective China's economic reforms have raised concerns over rising inequalities in maternal mortality, but it is not known whether the gap across socio-economic regions has increased over time. Design A population-based, longitudinal, ecological correlation study. Setting China. Sample Records from the National Maternal and Child Mortality Surveillance System between 1996 and 2006. Methods We report levels, causes and timing of maternal deaths, and examine crude and adjusted time trends in the overall and cause-specific maternal mortality ratio in five socio-economic regions (using Poisson regression). We examine whether socio-economic disparities have widened over time using concentration curves. Main outcome measures All-causes and cause-specific maternal mortality ratios. Results Maternal mortality (MMR) declined by 6% per year (yearly rate ratio, RR, 0.94; 95% CI 0.93-0.96). The decline was most pronounced in the wealthiest rural type-I counties (RR 0.89; 95% CI 0.85-0.93), and in the poorest rural type-IV counties (RR 0.90; 95% CI 0.82-1.00). There were declines in almost all causes of maternal death. Postpartum haemorrhage (PPH) was by far the leading cause of maternal death (32%, 997/3164). The decline in MMR was largely explained by the increased uptake of institutional births. Concentration curves suggest that wealth-related regional inequalities did not increase over time. Conclusions China's extraordinary economic growth has not adversely affected disparities in MMR across socio-economic regions over time, but poor rural women remain at disproportionate risk. Other emerging economies can learn from China's focus on the supply and quality of maternity services along with more general health systems strengthening. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Deneux-Tharaux C, Dupont C, Colin C, Rabilloud M, Touzet S, Lansac J, Harvey T, Tessier V, Chauleur C, Pennehouat G, Morin X, Bouvier-Colle M, Rudigoz R. Multifaceted intervention to decrease the rate of severe postpartum haemorrhage: the PITHAGORE6 cluster-randomised controlled trial. BJOG 2010;117:1278–1287. Objective Decreasing the prevalence of severe postpartum haemorrhages (PPH) is a major obstetrical challenge. These are often considered to be associated with substandard initial care. Strategies to increase the appropriateness of early management of PPH must be assessed. We tested the hypothesis that a multifaceted intervention aimed at increasing the translation into practice of a protocol for early management of PPH, would reduce the incidence of severe PPH. Design Cluster-randomised trial. Population 106 maternity units in six French regions. Methods Maternity units were randomly assigned to receive the intervention, or to have the protocol passively disseminated. The intervention combined outreach visits to discuss the protocol in each local context, reminders, and peer reviews of severe incidents, and was implemented in each maternity hospital by a team pairing an obstetrician and a midwife. Main outcome measures The primary outcome was the incidence of severe PPH, defined as a composite of one or more of: transfusion, embolisation, surgical procedure, transfer to intensive care, peripartum haemoglobin decrease of 4 g/dl or more, death. The main secondary outcomes were PPH management practices. Results The mean rate of severe PPH was 1.64% (SD 0.80) in the intervention units and 1.65% (SD 0.96) in control units; difference not significant. Some elements of PPH management were applied more frequently in intervention units—help from senior staff ( P = 0.005), or tended to - second-line pharmacological treatment ( P = 0.06), timely blood test ( P = 0.09). Conclusion This educational intervention did not affect the rate of severe PPH as compared with control units, although it improved some practices. [ABSTRACT FROM AUTHOR]

Please cite this paper as: de Graaf J, Ravelli A, Visser G, Hukkelhoven C, Tong W, Bonsel G, Steegers E. Increased adverse perinatal outcome of hospital delivery at night. BJOG 2010;117:1098–1107. Objective To determine whether delivery in the evening or at night and some organisational features of maternity units are related to perinatal adverse outcome. Design A 7-year national registry-based cohort study. Setting All 99 Dutch hospitals. Population From nontertiary hospitals ( n = 88), 655 961 singleton deliveries from 32 gestational weeks onwards, and, from tertiary centres ( n = 10), 108 445 singleton deliveries from 22 gestational weeks onwards. Methods Multiple logistic regression analysis of national perinatal registration data over the period 2000–2006. In addition, multilevel analysis was applied to investigate whether the effects of time of delivery and other variables systematically vary across different hospitals. Main outcome measures Delivery-related perinatal mortality (intrapartum or early neonatal mortality) and combined delivery-related perinatal adverse outcome (any of the following: intrapartum or early neonatal mortality, 5-minute Apgar score below 7, or admission to neonatal intensive care). Results After case mix adjustment, relative to daytime, increased perinatal mortality was found in nontertiary hospitals during the evening (OR, 1.32; 95% CI, 1.15–1.52) and at night (OR, 1.47; 95% CI, 1.28–1.69) and, in tertiary centres, at night only (OR, 1.20; 95% CI, 1.06–1.37). Similar significant effects were observed using the combined perinatal adverse outcome measure. Multilevel analysis was unsuccessful; extending the initial analysis with nominal hospital effects and hospital–delivery time interaction effects confirmed the significant effect of night in nontertiary hospitals, whereas other organisational effects (nontertiary, tertiary) were taken up by the hospital terms. Conclusion Hospital deliveries at night are associated with increased perinatal mortality and adverse perinatal outcome. The time of delivery and other organisational features representing experience (seniority of staff, volume) explain hospital-to-hospital variation. [ABSTRACT FROM AUTHOR]

Background In high-resource settings around 20% of maternal deaths are attributed to women who fail to receive adequate antenatal care. Epidemiological evidence suggests many of these women belong to marginalised groups often living in areas of relative deprivation. Reasons for inadequate antenatal attendance have yet to be fully evaluated. Objectives To identify the factors affecting access to antenatal care for marginalised pregnant women living in developed countries. Search strategy We included qualitative studies from developed countries published in English language journals (1980–2007). Selection criteria Qualitative studies exploring the views of marginalised women living in developed countries who either failed to attend for any antenatal care or did so late or irregularly. Data collection and analysis Eight studies fulfilled the selection criteria and were synthesised in accord with the techniques derived from meta-ethnography. Main results Initial access is influenced by late pregnancy recognition and subsequent denial or acceptance. Continuing access appears to depend on a strategy of weighing up and balancing out of the perceived gains and losses. Personal resources in terms of time, money and social support are considered alongside service provision issues including the perceived quality of care, the trustworthiness and cultural sensitivity of staff and feelings of mutual respect. Conclusions A nonthreatening, nonjudgemental antenatal service run by culturally sensitive staff may increase access to antenatal care for marginalised women. Multiagency initiatives aimed at raising awareness of, and providing access to, antenatal care may also increase uptake. [ABSTRACT FROM AUTHOR]

The authors comment on the paper "Prevalence and predictors of antidepressant use in a cohort of pregnant women," by É. Ramos, D. Oraichi, É. Rey, L. Blais and A. Bérard. They acknowledged the study's importance and timeliness to the treatment of depression during pregnancy. The finding that the prescription rate for antidepressant medication decreased during pregnancy may be explained by the reduction of the pharmacological management of depression by 50 to 80 percent.

There are many projects to help reform maternity care in the former Soviet Union (FSU). Doctors and other health workers are visiting, conducting research in and offering clinical assistance to many such countries. Some understanding of the practices in these regions will help them prepare for, and plan, maternity reforms. This paper outlines key features of the maternity care systems in place in the FSU. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Mathai M. To ensure maternal mortality is reduced, quality of care needs to be monitored and improved alongside increasing skilled delivery coverage rates. BJOG 2011; 118 (Suppl. 2): 12-14. [ABSTRACT FROM AUTHOR]

The paper from Nowotny et al. ( I BJOG i 2019;126:1437-44) in I BJOG i once again shines a light on the potential role of legal liability indemnifiers (organisations that provide insurance protection against malpractice claims) to improve maternity care. Litigation claims provide a very narrow lens on care and there can be missed opportunities to learn from positive deviance (Liberati et al. I Soc Sci Med i 2019;223:64-72). These issues notwithstanding, medico-legal claims provide an important perspective on maternity care and reducing litigation costs is an international priority. [Extracted from the article]

The article offers a commentary from the authors to a paper published within the issue about core outcome sets (COS) for postpartum haemorrhage (PPH). They specifically addressed the issue about the role of COS as barrier to research as it drives researchers to abandon their preferred study design, arguing that COS facilitates focused and relevant research. The standardisation of baseline characteristics for optimal comparability of studies is suggested.

Objective: To explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth. Design: The study is based on data from the Babies Born Better online survey, version 2. Setting: The maternity care system in Norway. Study population: Women who gave birth in Norway between 2013 and 2018. Method: Descriptive statistics were used to describe sample characteristics and to compare data from the B3 survey with national data from the Medical Birth Registry of Norway. The open‐ended questions were analysed with an inductive thematic analysis. Main outcome measures: Themes developed from two open‐ended questions. Results: The final sample included 8401 women. There were no obvious differences between the sample population and the national population with respect to maternal age, marital status, parity, mode of birth and place of birth, except for the proportion of planned home births. Four themes and one overarching theme were identified; Compassionate and Respectful Care, A Family Focus, Sense of Continuity and Consistency, and Sense of Security. Overarching theme: Coherence in Childbearing. Conclusions: Norwegian women across all birth settings emphasise maternity care that authentically focuses on both socio‐cultural and psychological aspects of care, and physical and clinical factors. If the positive aspects of care identified in this study are adopted at all levels of the maternity care system and from all care providers, there is a high chance that most women will have a safe outcome, and a strong sense of coherence related to a positive birth and motherhood experience. Having a baby is a pivotal life changing experience and not just a clinical event, according to a survey of 8400 women in Norway. Positive birth and motherhood experiences depend on maternity staff who are both skilled and kind. Having a baby is a pivotal life‐changing experience and not just a clinical event, according to a survey of 8400 women in Norway. Positive birth and motherhood experiences depend on maternity staff who are both skilled and kind. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Mahmud G, Zaman F, Jafarey S, Khan RL, Sohail R, Fatima S. Achieving Millennium Development Goals 4 and 5 in Pakistan. BJOG 2011;118 (Supp. 2):69-77. Pakistan is a signatory of many international development strategies including the Millennium Development Goals, and the government is committed to achieving a reduction in infant mortality rate from 72 to <55 per 1000 live births, the newborn mortality rate from 55 to <40 per 1000 live births and the maternal mortality rate from 276 per 100 000 to 140 per 100 000 live births by 2015. Maternal, newborn and child health play a key role in reducing poverty and promoting social and economic development. Improvement in maternal and child health is a priority agenda of the Government of Pakistan. [ABSTRACT FROM AUTHOR]

Objectives To estimate the national incidence of eclampsia in the UK and to describe the management and associated outcomes since the introduction of magnesium sulphate. Design A population-based descriptive study using the newly established UK Obstetric Surveillance System (UKOSS). Setting All 229 hospitals with consultant-led maternity units in the UK. Population All women in the UK delivering between February 2005 and February 2006. Methods Prospective case identification through the monthly mailing of UKOSS. Main outcome measures Incidence and mortality rates with 95% confidence intervals. Results Data collection was complete for 94% of women. The incidence of eclampsia was 2.7 cases per 10 000 births (95% CI 2.4–3.1). Thirty-eight percent of women had established hypertension and proteinuria in the week before their first fit. Ninety-nine percent of women were treated with magnesium sulphate. No women in the study died. Fifty-four women (26%) had recurrent fits. One hundred and nineteen women (56%) were admitted to intensive care or obstetric high dependency units for a median of 2 days (range 1–9). Twenty-two women (10%) were reported to have other severe morbidity after the eclamptic episode. Outcomes were known for 222 infants (204 singletons and 18 twins). Eight infants were stillborn and five died in the neonatal period (perinatal mortality 59/1000 births [95% CI 32–98]). Conclusions The incidence of eclampsia and its complications have decreased significantly in the UK since 1992, following the introduction of management guidelines for eclampsia and pre-eclampsia. These results are consistent with the findings of the randomised controlled trials of magnesium sulphate. This study has shown the practical benefits of the incorporation of research evidence into practice. [ABSTRACT FROM AUTHOR]

The coronavirus (COVID-19) pandemic has resulted in rapid changes in many areas of healthcare worldwide.1 Some organisational and governance controls on innovation have been relaxed, to enable rapid adaptation to changing circumstances. A resilient maternity care system The COVID-19 pandemic exposed vulnerabilities in both countries' maternity care systems, particularly in terms of hospital and staff capacities. "Never waste a crisis": a commentary on the COVID-19 pandemic as a driver for innovation in maternity care. [Extracted from the article]

The authors discuss an analysis of legal maternity claims across the globe. They highlight a new report entitled "Ten Years of Maternity Claims" published by the British National Health Service Litigation Authority (NHSLA). They state that the report contains more than 5000 claims for the last ten years.

A letter to the editor is presented in response to the article "BJOG (International Journal of Obstetrics & Gynaecology)," published in the April 2007 issue.

The article cites a report entitled "Global women's health: current clinical trials in low and middle-income countries." It provides an overview of an international women's health conference focusing on the current clinical trials in low and middle-income countries. Information about women's health interventions as well as the World Health Organization's International Clinical Trials Registry Platform is provided.

Objective: The aim of this study is to identify items of economic evaluation guidelines that are frequently not complied within obstetric economic evaluations and to search for reasons for non-adherence.Design: Scoping review and qualitative study.Setting: Literature on economic evaluations in obstetric care and interviews with experts.Population or Sample: The sample included 229 scientific articles and five experts.Methods: A systematic literature search was performed. All types of literature about economic evaluations in obstetric care were included. The adherence to guidelines was assessed and articles were qualitatively analysed on additional information about reasons for non-adherence. Issues that arose from the scoping review were discussed with experts.Main Outcome Measures: Adherence to guideline items of the included economic evaluations studies. Analytical themes describing reasons for non-adherence, resulting from qualitative analysis of articles and interviews with experts.Results: A total of 184 economic evaluations and 45 other type of articles were included. Guideline items frequently not complied with were time horizon, type of economic evaluation and effect measure. Reasons for non-adherence had to do with paucity of long-term health data and assessing and combining outcomes for mother and child resulting from obstetric interventions.Conclusions: This study identified items of guidelines that are frequently not complied with and the reasons behind this. The results are a starting point for a broad consensus building on how to deal with these challenges that can result in special guidance for the conduct of economic evaluations in obstetric care.Tweetable Abstract: Non-adherence to guidelines in obstetric economic evaluation studies: the difficulties in detail. [ABSTRACT FROM AUTHOR]

Objective: The coronavirus disease 2019 (COVID-19) pandemic is disrupting health services worldwide. We aimed to evaluate the provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID-19 pandemic.Design: Interview-based national survey.Setting: Women's healthcare units in the National Health Service.Population: Junior doctors in obstetrics and gynaecology.Methods: Participants were interviewed by members of the UK Audit and Research in Obstetrics and Gynaecology trainees' collaborative between 28 March and 7 April 2020. We used a quantitative analysis for closed-ended questions and a thematic framework analysis for open comments.Results: We received responses from 148/155 units (95%), most of the participants were in years 3-7 of training (121/148, 82%). Most completed specific training drills for managing obstetric and gynaecological emergencies in women with COVID-19 (89/148, 60.1%) and two-person donning and doffing of Personal Protective Equipment (PPE) (96/148, 64.9%). The majority of surveyed units implemented COVID-19-specific protocols (130/148, 87.8%), offered adequate PPE (135/148, 91.2%) and operated dedicated COVID-19 emergency theatres (105/148, 70.8%). Most units reduced face-to-face antenatal clinics (117/148, 79.1%) and suspended elective gynaecology services (131/148, 88.5%). The 2-week referral pathway for oncological gynaecology was not affected in half of the units (76/148, 51.4%), but half reported a planned reduction in oncology surgery (82/148, 55.4%).Conclusion: The provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID-19 pandemic seems to be in line with current guidelines, but strategic planning is needed to restore routine gynaecology services and ensure safe access to maternity care in the long term.Tweetable Abstract: Provision of obstetrics and gynaecology services during the acute phase of COVID-19 is in line with current guidelines, strategic planning is needed to restore routine services and ensure safe access to care in the long term. [ABSTRACT FROM AUTHOR]

Objective: The aim of this article is to describe the incidence and characteristics of pregnancy-related death in low- and middle-resource settings, in relation to the availability of key obstetric resources.Design: This is a secondary analysis of a stepped-wedge cluster randomised controlled trial.Setting: This trial was undertaken at ten sites across eight low- and middle-income countries in sub-Saharan Africa, India and Haiti.Population: Institutional-level consent was obtained and all women presenting for maternity care were eligible for inclusion.Methods: Pregnancy-related deaths were collected prospectively from routine data sources and active case searching.Main Outcome Measures: Pregnancy-related death, place, timing and age of maternal death, and neonatal outcomes in women with this outcome.Results: Over 20 months, in 536 233 deliveries there were 998 maternal deaths (18.6/10 000, range 28/10 000-630/10 000). The leading causes of death were obstetric haemorrhage (36.0%, n = 359), hypertensive disorders of pregnancy (20.6%, n = 206), sepsis (14.1%, n = 141) and other (26.5%, n = 264). Approximately a quarter of deaths occurred prior to delivery (28.4%, n = 283), 35.7% (n = 356) occurred on the day of delivery and 35.9% (n = 359) occurred after delivery. Half of maternal deaths (50.6%; n = 505) occurred in women aged 20-29 years, 10.3% (n = 103) occurred in women aged under 20 years, 34.5% (n = 344) occurred in women aged 30-39 years and 4.6% (n = 46) occurred in women aged ≥40 years. There was no measured association between the availability of key obstetric resources and the rate of pregnancy-related death.Conclusions: The large variation in the rate of pregnancy-related death, irrespective of resource availability, emphasises that inequality and inequity in health care persists.Tweetable Abstract: Inequality and inequity in pregnancy-related death persists globally, irrespective of resource availability. [ABSTRACT FROM AUTHOR]

Objective: To examine whether a method for raising women's awareness of fetal movements, Mindfetalness, can affect pregnancy outcomes.Design: Cluster-randomised controlled trial.Setting: Sixty-seven maternity clinics in Stockholm, Sweden.Population: Women with singleton pregnancy with birth from 32 weeks' gestation.Methods: Women registered at a clinic randomised to Mindfetalness were assigned to receive a leaflet about Mindfetalness (n = 19 639) in comparison with routine care (n = 20 226). Data were collected from a population-based register.Main Outcome Measures: Apgar score <7 at 5 minutes after birth, visit to healthcare due to decrease in fetal movements. Other outcomes: Apgar score <4 at 5 minutes after birth, small-for-gestational-age and mode of delivery.Results: No difference (1.1 versus 1.1%, relative risk [RR] 1.0; 95% CI 0.8-1.2) was found between the Mindfetalness group and the Routine care group for a 5-minute Apgar score <7. Women in the Mindfetalness group contacted healthcare more often due to decreased fetal movements (6.6 versus 3.8%, RR 1.72; 95% CI 1.57-1.87). Mindfetalness was associated with a reduction of babies born small-for-gestational-age (RR 0.95, 95% CI 0.90-1.00), babies born after gestational week 41+6 (RR 0.91, 95% CI 0.83-0.98) and caesarean sections (19.0 versus 20.0%, RR 0.95; 95% CI 0.91-0.99).Conclusions: Mindfetalness did not reduce the number of babies born with an Apgar score <7. However, Mindfetalness was associated with the health benefits of decreased incidence of caesarean section and fewer children born small-for-gestational-age.Tweetable Abstract: Introducing Mindfetalness in maternity care decreased caesarean sections but had no effect on the occurrence of Apgar scores <7. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the author discusses various reports within the issue on topics including the influence of time and day and presence of a senior obstetrician in the labour ward on neonatal outcomes at Austrian hospitals, an approach used to develop indicators for comparing the performance of maternity units in Great Britain, and the hospital cost variation of childbirth hospitalization in California.

Objective: To develop core outcome sets (COS) for studies evaluating interventions for (1) prevention and (2) treatment of postpartum haemorrhage (PPH), and recommendations on how to report the COS.Design: A two-round Delphi survey and face-to-face meeting.Population: Healthcare professionals and women's representatives.Methods: Outcomes were identified from systematic reviews of PPH studies and stakeholder consultation. Participants scored each outcome in the Delphi on a Likert scale between 1 (not important) and 9 (critically important). Results were discussed at the face-to-face meeting to agree the final COS. Consensus at the meeting was defined as ≥ 70% of participants scoring the outcome as critically important (7-9). Lectures, discussion and voting were used to agree how to report COS outcomes.Main Outcome Measures: Outcomes from systematic reviews and consultations.Results: Both Delphi rounds were completed by 152/205 (74%) participants for prevention and 143/197 (73%) for treatment. For prevention of PPH, nine core outcomes were selected: blood loss, shock, maternal death, use of additional uterotonics, blood transfusion, transfer for higher level of care, women's sense of wellbeing, acceptability and satisfaction with the intervention, breastfeeding, and adverse effects. For treatment of PPH, 12 core outcomes were selected: blood loss, shock, coagulopathy, hysterectomy, organ dysfunction, maternal death, blood transfusion, use of additional haemostatic intervention, transfer for higher level of care, women's sense of wellbeing, acceptability and satisfaction with the intervention, breastfeeding, and adverse effects. Recommendations were developed on how to report these outcomes where possible.Conclusions: These COS will help standardise outcome reporting in PPH trials.Tweetable Abstract: Core outcome sets for PPH: nine core outcomes for PPH prevention and 12 core outcomes for PPH treatment. [ABSTRACT FROM AUTHOR]

Objective: To develop a core metric set to monitor the quality of maternity care.Design: Delphi process followed by a face-to-face consensus meeting.Setting: English maternity units.Population: Three representative expert panels: service designers, providers and users.Main Outcome Measures: Maternity care metrics judged important by participants.Methods: Participants were asked to complete a two-phase Delphi process, scoring metrics from existing local maternity dashboards. A consensus meeting discussed the results and re-scored the metrics.Results: In all, 125 distinct metrics across six domains were identified from existing dashboards. Following the consensus meeting, 14 metrics met the inclusion criteria for the final core set: smoking rate at booking; rate of birth without intervention; caesarean section delivery rate in Robson group 1 women; caesarean section delivery rate in Robson group 2 women; caesarean section delivery rate in Robson group 5 women; third- and fourth-degree tear rate among women delivering vaginally; rate of postpartum haemorrhage of ≥1500 ml; rate of successful vaginal birth after a single previous caesarean section; smoking rate at delivery; proportion of babies born at term with an Apgar score <7 at 5 minutes; proportion of babies born at term admitted to the neonatal intensive care unit; proportion of babies readmitted to hospital at <30 days of age; breastfeeding initiation rate; and breastfeeding rate at 6-8 weeks.Conclusions: Core outcome set methodology can be used to incorporate the views of key stakeholders in developing a core metric set to monitor the quality of care in maternity units, thus enabling improvement.Tweetable Abstract: Achieving consensus on core metrics for monitoring the quality of maternity care. [ABSTRACT FROM AUTHOR]

The author comments on a paper by R. S. Geary et al about the need to reform and improve system of maternity care. Topics include a brief description of obstetric practice in the past century, an increase in U.S. maternal mortality rate in the first part of the 20th century, and the launch of the National Maternity and Perinatal Audit (NMPA) by National Health Service (NHS) maternity services across England, Scotland and Wales to reform maternity care.

The authors support the World Health Organization (WHO) model of intrapartum care for a positive childbirth experience and for transforming care of women and babies for improved health and well-being. They discuss the guiding principles for intrapartum care and outline recommended practices for positive childbirth experience. They stress the need for healthcare systems to implement the WHO model of care in accordance with a human rights-based approach. They

Hospital administrative data are attractive for comparing performance of maternity units because of their often large sample sizes, lack of selection bias and the relatively low costs of accessing these data compared with conducting primary data collection. However, using administrative data to develop indicators can also present challenges including varying data quality, the limited detail on clinical risk factors and a lack of structural and user experience measures. This review illustrates how to develop performance indicators for maternity units using hospital administrative data, including methods to address the challenges that administrative data pose.Tweetable Abstract: How to develop maternity indicators from administrative data. [ABSTRACT FROM AUTHOR]

Background: Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention.Objectives: To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM.Search Strategy: We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016.Selection Criteria: Reports of stillbirth causes in unselective cohorts.Data Collection and Analysis: Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC).Main Results: Eighty-five reports from 50 countries (489 089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes.Conclusions: There is a paucity of quality information on causes of stillbirth globally. Improving investigation of stillbirths and standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings.Funding: HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611).Tweetable Abstract: Urgent need to improve data on causes of stillbirths across all settings to meet global targets.Plain Language Summary: Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards. [ABSTRACT FROM AUTHOR]

Objective: Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions.Design: We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered.Setting and Population: Pregnancies in SSA in 2012.Methods: For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates.Main Outcome Measures: Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions.Results: Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth.Conclusions: Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries.Tweetable Abstract: Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery. [ABSTRACT FROM AUTHOR]

Objective: To report maternal sleep practices in women who experienced a stillbirth compared with controls with ongoing live pregnancies at similar gestation.Design: Prospective case-control study.Setting: Forty-one maternity units in the United Kingdom.Population: Women who had a stillbirth after ≥ 28 weeks' gestation (n = 291) and women with an ongoing pregnancy at the time of interview (n = 733).Methods: Data were collected using an interviewer-administered questionnaire that included questions on maternal sleep practices before pregnancy, in the four weeks prior to, and on the night before the interview/stillbirth.Main Outcome Measures: Maternal sleep practices during pregnancy.Results: In multivariable analysis, supine going-to-sleep position the night before stillbirth had a 2.3-fold increased risk of late stillbirth [adjusted Odds Ratio (aOR) 2.31, 95% CI 1.04-5.11] compared with the left side. In addition, women who had a stillbirth were more likely to report sleep duration less than 5.5 hours on the night before stillbirth (aOR 1.83, 95% CI 1.24-2.68), getting up to the toilet once or less (aOR 2.81, 95% CI 1.85-4.26), and a daytime nap every day (aOR 2.22, 95% CI 1.26-3.94). No interaction was detected between supine going-to-sleep position and a small-for-gestational-age infant, maternal body mass index, or gestational age. The population-attributable risk for supine going-to-sleep position was 3.7% (95% CI 0.5-9.2).Conclusions: This study confirms that supine going-to-sleep position is associated with late stillbirth. Further work is required to determine whether intervention(s) can decrease the frequency of supine going-to-sleep position and the incidence of late stillbirth.Tweetable Abstract: Supine going-to-sleep position is associated with 2.3× increased risk of stillbirth after 28 weeks' gestation.Plain Language Summary: Stillbirth, the death of a baby before birth, is a tragedy for mothers and families. One approach to reduce stillbirths is to identify factors that are associated with stillbirth. There are few risk factors for stillbirth that can be easily changed, but this study is looking at identifying how mothers may be able to reduce their risk. In this study, we interviewed 291 women who had a stillbirth and 733 women who had a live-born baby from 41 maternity units throughout the UK. The mothers who had a stillbirth were interviewed as soon as practical after their baby died. Mothers who had a live birth were interviewed during their pregnancies at the same times in pregnancy as when the stillbirths occurred. We did not interview mothers who had twins or who had a baby with a major abnormality. Mothers who went to sleep on their back had at least twice the risk of stillbirth compared with mothers who went to sleep on their left-hand side. This study suggests that 3.7% of stillbirths after 28 weeks of pregnancy were linked with going to sleep lying on the back. This study also shows that the link between going-to-sleep position and late stillbirth was not affected by the duration of pregnancy after 28 weeks, the size of the baby, or the mother's weight. Women who got up to the toilet once or more at night had a reduced risk of stillbirth. This is the largest of four similar studies that have all shown the same link between the position in which a mother goes to sleep and stillbirth after 28 weeks of pregnancy. Further studies are needed to see whether women can easily change their sleep position in late pregnancy and whether changing the position a mother goes to sleep in reduces stillbirth. [ABSTRACT FROM AUTHOR]